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136 Cards in this Set

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Pre-eclamptic woman, BP 170/110, headache, proteinuria 1.2g. Which of the following NOT to use for control of her hypertension:
A. Magnesium
B. SNP
C. GTN
D. Hydralazine
E. Metoprolol
A. Magnesium - not for control of HTN

Severe PET as > 160/110 + headache and proteinuria.
Management of PET:
- early diagnosis, control of BP, prevention of convulsions and timely delivery, strict fluid balance

BP control:
Maintain MAP 100-140 (130/90-170/110). Sudden drop can compromise placental perfusion. Drugs used:
- Hydralazine 5mg increments or infusion
- Labetalol 50mg increments IV or 100mg PO q30min
- Methyldopa 1-3g PO per day
- Nifedipine 20mg PO (drops BP ++ with magnesium)
- SNP infusion - may cause excessive hypotension, good for emergencies, risk of cyanide toxicity to fetus
- GTN - as above, risk of methaemoglobinaemia

Magnesium is NOT for control of BP. It is for prevention of fits and treatment. 4g loading + 1g/h infusion
Male with a Haemoglobin of 8G% and reticulocyte count 10%. Possible diagnosis:
A. Untreated pernicious anaemia
B. Aplastic anaemia
C. Acute leukaemia
D. Anaemia of chronic disease
E. Hereditary spherocytosis
E. Spherocytosis
Commonest organism causing meningitis post spinal:
A. Staph epidermidis
B. Staph salivarius
C. Staph aureus
D. Strep pneumoniae
E. ?
B. Staph salivarius
Baer, Post Dural Puncture Bacterial meningitis, Anaesth 2006
Third, most of the organisms that cause PDPM are
commensals of the mouth and upper airway. These observations
support the droplet mechanism for the pathogenesis
of most cases of PDPM. That is, the aerosolized
organism that enters the CSF during dural puncture originates
in the upper airway of medical personnel.
Exponential decline / definition of time constant (with various options)
A. time for exponential process to reach log(e) of its initial value
B. Time until exponential process reaches zero
C. Time to reach 37% of initial value
D. Time to reach half if its initial value
E. 69% of half life
C. Time to decrease by 67%, or to 1/e
(This is a very old repeat) Relative humidity – air fully saturated at 20 %. What is the relative humidity at 37 degrees ?
A. 20
B. 30
C. 40
D. 50
E. 60%
C. 40%
A 50 year old man with multiple fractures. The BEST parameter to monitor volume resuscitation is:
A. Heart rate
B. LVEDV
C. PCWP
D. RVEDV
E. Changes in R atrial pressure during inspiration
NFI - Source says Changes in RAP with inspiration.
Normalisation of RVEDV and SvO2 --> better outcomes
Readily available = HR RR UO BP Pulse pressure LOC
HR altered by anxiety pain and stress
Invasive
Maertz et al

Reference for answer: Echo derived parameters of fluid responsiveness "the dynamic parameters e.g. inspiratory decrease in RAP, expiratory decrease in arterial systolic pressure, respiratory changes in pulse pressure (etc)...predict fluid responsiveness better than static parameters".
Anaphylaxis to rocuronium. Which is most likely to cause coss-reactivity ?
A. Vecuronium
B. Pancuronium
C. Atracurium
D. Cisatracurium
E. None of the above -cross reactivity too variable to predict
E. Variable cross reactivity
Ref: AAGBI Anaphylaxis 2009 "
AAGBI
60% of anaphylaxis in anaesthesia = NBMD
Miv- and atracurium are associated with histamine / non-allergy reaction
Sux is most likely, Roc close behind
Cross sensitivity is relatively common, probably because of their quaternary ammonium group.
If anaphylaxis to an NMBA is suspected, the patient should undergo skin prick testing with all the NMBAs in current use. If a patient demonstrates a positive skin prick test (SPT) to an NMBA, the patient should be warned against future exposure to all NMBAs if possible. If it is mandatory to use an NMBA during anaesthesia in the future, it would seem appropriate to permit the use of an NMBA which has a negative skin test, accepting that a negative skin test does not guarantee that anaphylaxis will not occur.
Hypotension post propofol induction in elderly patient. More pronounced / profound than in younger patient. Reason ?
A. Concentric LVH associated with ageing and therefore preload dependent
B. Because of increased lean body mass
C. Decreased cardiac output with ageing
D. Increased sensiticity to all anaesthetic agents, thus relative overdose is common
E. Decreased liver blood flow with ageing, decrease drug clearance and increased drug concentration
A. Concentric LVH so preload dependent - we also overdose often due to slow circulation time and lower Vd but the agents are vasodilatory and hence the hypotension
Predictive factors for mortality in elderly patient (except):
A. Aortic stenosis
B. Diabetes mellitus
C. Elevated Creatinine
D. Cognitive dysfunction
E. Type of surgery
D. Cognitive dysfunction

Minimising perioperative adverse events in the elderly, BJA 2001
The best clinical indicator of SEVERE AS
A. Presence of thrill
B. Mean Gradient 30mmHg
C. Area 1.2 cm2
D. Slow rising pulse and ESM radiating to carotids
E. Shortness of breath
A. Thrill
CEACCP
Three cardinal symptoms - angina, syncope and dyspnoea. Do not correlate well to severity of stenosis.
50% of pts with angina with have CAD too.
Examination: arterial pulse slow rising and of low volume - if severe low systolic and pulse pressures.
Lag may be felt between apex and carotid - presence of precordial thrill is reasonably specific for severe AS.

Symptomatic / < 1cm2 / > 40mmHg mean gradient = AHA
Elderly patient. Indications for pre Femoro-Popliteal Bypass angiogram include all EXCEPT:
A. Severe heart failure
B. Suspicion of L main disease
C. Symptomatic tachyarrhythmia
D. Unstable angina
E. Stable angina with positive thallium
E. AICM "Preoperative evaluation of Vascular patients" includes arrhythmia as reason for angiography (& the others).
How do you minimise risk of intravenous cannulation with epidural insertion ?
A. Injection saline through epidural needle before catheter insertion
B. Lie patient lateral
C. Do CSE
D. Thread catheter slowly
E.
A. Inject saline through needle before catheter

Detection of intravascular epidural catheter placement:
A review
D. N. BELL*, K. LESLIE†
Department of Anaesthesia and Pain Management, Royal Melbourne Hospital, Melbourne, Victoria, Australia

Says N saline through catheter helps - but going for E all of the above!
Timing of peak respiratory depression post intrathecal 300 mcg morphine:
A. < 3.5 hours (think it was one hour)
B. 3.5 – 7.5 hours (then three hours)
C. 7 - 12.5 hours (then 7.5 - 12.5 hrs)
D. 12.5 -18 hours
E. > 18 hours
B. 3.5-7.5 hr
CEACCP
Morphine-induced late onset respiratory depression occurs between 3.5 and 12 h after injection with a peak at 6 h
Patient with aortic dissection. Blood pressure 150/90. Best drug to control BP:
A. Captopril
B. Esmolol
C. GTN
D. Hydralazine
E. SNP
B. Esmolol - Beta blockers

CEACCP:
*Mortality 1-2% per hour during first 48 hours
ECG shows ischaemia in 20% - image pre-thrombolysis!
Manage: type A and complicated type B --> Surgery
Reduce force of LV contraction, reducing shear forces - beta blockers and labetalol can be used. SNP, GTN or Hydralazine if further decrease in BP can be used.
Type of dissection – which is classically for NON-operative management:
A. DeBakey Type I
B. DeBakey Type II
C. Stanford A
D. Stanford B
E. Stanford C
D. Stanford B - A is for surgical management, B for medical

CEACCP - Dx/Mx of Aortic Dissection
Stanford A involves ascending aorta but may extend into arch and descending aorta
Type B involves descending aorta only, dissection distal to left subclavian artery origin
DeBakey -
Type I involves ascending aorta, arch, descending aorta
Type II - confined to ascending aorta
Type III - descending aorta distal to left subclavian artery (IIIa up to diaphragm, IIIb beyond)
TURP – patient under spinal. Confused. ABG: Na+ 117 / normal gas exchange. Treatment ?
A. 10 ml 20% Saline as fast push IV
B. 3% NS 100 ml/h
C. Normal saline 200 ml/h
D. Frusemide 40 mg IV
E. Fluid restrict 500 ml/day
B. Since it says gas exchange ok (i.e. no pulmonary odema) and has severe hyponatraemia, for 3%NS

Clinical diagnosis based on symptoms and signs ass with excessive absorption of irrigation fluid into circulation; acute changes in intravascular volume, plasma solute conc's, osmolality.
Mild-mod TURP syndrome may occur 1-8% - overall mortality 0.2-0.8%. Presents 15 min-24 hr after operation. Severe syndrome (rare) has mortality up to 25%.
Glycine 1.5% --> restlessness, headache, inc RR, visual disturbances --> if more severe get resp distress, hypoxia, APO, N&V, conusion, convulsions, coma
Fluid absorbed at 10-30ml/min. 5-20% absorb > 1L. Some places add ethanol and breath test!
Increased absorption if:
- higher pressure irrigation fluid (bag height)
- low venous pressures (low bP or volume)
- prolonged surgery
- large blood loss (lots of open veins)
- capsule or bladder perforated
Effects and Rx:
Acute volume change --> hypotension, bradycardia
Low sodium/osmol --> headache, LOC, N&V, seizures, coma [cerebral oedema, raised ICP]
acute decrease of Na to < 120mmol/l should be treated with hypertonic saline*
Rx: stop surgery, stop IV fluids, respiration, support circulation, anticonvulsants/magnesium as required. check UEC, Hb. Diuretics to treat APO. 3% saline if severe hyponatraemia or severe symptoms. Slow rate of correction (1mmol/L/hr in first 24 h). Admit HDU/ICU and invasive monitoring.
Male undergoing trans-sphenoidal surgery. Now Na+ 155mmol/l and thirsty with polydypsia. Treatment:
A. Desmopressin (DDAVP)
B. Fluid restrict
C. Aldosterone
D.
A. DDAVP for diabetes insipidus


Results from absolute or relative lack of ADH in response to normal physiologic triggers such as hyperosmolarity
Central or nephrogenic
Typically polyuria is compensated for by thirst and excess consumption of fluid to match output

Usual features are:
Hypertonic plasma with hypotonic urine
Plasma ~ high normal > 290 – 300
Urine 50 – 200 mosm/L
High Volume Urine output:
> 4 – 6 L/day or > 3ml/kg for 4 - 6 consecutive hours

TREATMENT
Determines if central or nephrogenic
• 10mcg DDAVP nasally
• 1mcg DDAVP S/C or IV
Central will be associated with 50% increase in urine osmolality

DDAVP
1 – 4 mcg/hr IV continuous
10 – 40 mcg intranasal
Duration 12 – 24 hr intranasal
The STRONGEST stimulus for ADH secretion:
A. High serum osmolality
B. Low serum osmolality
C. Hypovolaemia
D. High serum Na
E.
C. Volume wins - sensitive to 1-2% change in osmolarity or 10% change in volume, but volume response is STRONGER
Stellate ganglion block. Needle entry next to SCM muscle at C6. Which direction to advance needle ?
A. C3
B. C4
C. C5
D. C6
E. C7
D. C6
Ref: Anaesthesia UK site
http://www.frca.co.uk/article.aspx?articleid=100538

Indications:

Pain syndromes
Complex regional pain syndrome type I and II
Refractory angina
Phantom limb pain
Herpes zoster
Shoulder/hand syndrome
Angina

Vascular insufficiency
Raynaud's syndrome
Scleroderma
Frostbite
Obliterative vascular disease
Vasospasm
Trauma
Emboli

Method:
...The needle is directed onto the tubercle, and then redirected medially and inferiorly toward the body of C6. After the body is contacted, the needle is withdrawn 1-2 mm. This brings the needle out of the belly of the longus colli muscle, which sits posterior to the ganglion and runs along the anterolateral surface of the cervical vertebral bodies. The needle is then held immobile....
Thermoneutral zone in 1 month old infant ?
A. 26 – 28 degrees Celcius
B. 28 – 30 degrees Celcius
C. 30 – 32 degrees Celcius
D. 32 – 34 degrees Celcius
E. 34-46 degrees celcius
D. 32-24 deg's (34-36 for younger neonate)
Neonatal Physiology, AICU 2008

Thermal stress is the extra energy required to maintain normothermia. It can occur with a normal core temperature as the neonate uses extra energy to maintain normothermia. Thermal stress can also occur if a baby is overheated because energy must be used to lose heat. The thermoneutral environment therefore minimizes neonatal energy requirements in maintaining a normal core temperature of 36.5–37.5°C rectal (axilla is 0.5–1.0°C lower). The thermoneutral temperature range varies with age and whether the baby is wearing clothes or not. The range for a naked term baby at 1 week is 32.0–33.5°C and 24.0–27.0°C when the baby is clothed. In comparison, a 30-week gestation baby’s range is 34.0–35.0°C naked and 28.0–30.0°C clothed. The point at which an increase in metabolic rate is required to maintain normothermia is defined as the critical temperature.
A 60 year old man describes orthopnoea. On examination: pansystolic murmur (at LSE)/ displaced apex beat. Likely diagnosis ?
A. Mitral regurgitation
B. ?
C.
D.
E.
Um...MR?
A 4 year old child with VSD (repaired when 2 years old) for dental surgery. What antibiotic prophylaxis do the guidelines recommend?
A. Amoxycillyn orally
B. Amoxycillin IV
C. Cephazolin IV
D. Amoxycillin / gentamicin
E. No antibiotics required
E. AHA guidelines say after 6 months nil required if no leak

+ Anaesthetic implications of CHD (AIC 2003)
A 4 year old child with Arthrogrophysis multiplex congenita for dental surgery. Jaw rigidity post induction. Likely cause ?
A. Temporomandibular joint involvement/ TMJ rigidity
B. Inadequate depth of anaesthesia
C. Inadequate muscle relaxation/ inadequate sux
D. Masseter spasm
E. ?
A. Hrm. Not learning that one too much. No increased risk MH.
Arthrogryposis multiplex congenita refers to a variety of conditions that involve congenital limitation of joint movement. Intelligence is relatively normal except when the arthrogryposis is caused by a disorder or syndrome that also affects intelligence.
There are two major types of arthrogryposis multiplex congenita (AMC):
Amyoplasia (classic arthrogryposis): Multiple symmetric contractures occur in the limbs.
Distal arthrogryposis: The hands and feet are involved, but the large joints are spared.
Etiology
Any condition that impairs in utero movement for > 3 wk can result in AMC. Causes may involve
Physical limitation of movement (eg, due to uterine malformations, multiple gestations, oligohydramnios)
Maternal disorders (eg, multiple sclerosis, impaired uterine vascularity)
Fetal disorders (eg, neuropathies; myopathies, including muscular dystrophies; connective tissue abnormalities; impaired fetal vascularity; anterior horn cell disease)
More than 35 specific genetic disorders (eg, spinal muscular atrophy type I, trisomy 18) have been linked to AMC.
Symptoms and Signs
Deformities are prominent at birth. AMC is not progressive; however, the condition that causes it (eg, muscular dystrophy) may be. Affected joints are contracted in flexion or extension. In classic AMC, shoulders are sloped, adducted, and internally rotated; the elbows are extended; and the wrists and digits are flexed. Hips may be dislocated and are usually slightly flexed. Knees are extended; feet are often in the equinovarus position. Leg muscles are usually hypoplastic, and limbs tend to be tubular and featureless. Soft-tissue webbing sometimes occurs over ventral aspects of the flexed joints. The spine may be scoliotic. Except for slenderness of the long bones, the skeleton appears normal on x-rays. Physical disabilities may be severe. As noted, some children may have primary CNS dysfunction, but intelligence is usually unimpaired.
Endotracheal intubation during surgery may be difficult because children have small immobile jaws. Other abnormalities that rarely accompany arthrogryposis include microcephaly, cleft palate, cryptorchidism, and cardiac and urinary tract abnormalities.
A 78 year old man with past difficult intubation for arm surgery. Supraclavicular block with 25 mls 0.5% bupivacaine. Shortly after begins convulsing. INITIAL management?
A. Midazolam 5mg
B. Intralipid 20% 1.5 ml/kg
C. Thiopentone 150mg
D. Suxamethonium 50mg
E. Propofol 50mg
A. Midaz. or thio but Midaz usually there and less paperwork now! Intralipid is for cardiac symptoms.

Treatment priorities for LAST include airway management, circulatory support, and promoting the diminution of the systemic effects of local anesthetics. Unlike the case for treatment of "conventional" cardiac arrest, the key to successful care of LAST patients is recognizing the primacy of airway management. As reported by Moore and colleagues a half century ago,10,44 prevention of hypoxia and acidosis by immediate restoration of oxygenation and ventilation can either halt progression to CV collapse and seizure or facilitate resuscitation. Subsequent laboratory investigations confirm this concept.45 If seizures occur, they should be rapidly controlled to prevent injury to the patient and acidosis. The Panel recommends that benzodiazepines are the ideal drugs to treat seizures because they have limited potential for cardiac depression. In the absence of readily available benzodiazepine, propofol or thiopental are acceptable alternatives; however, their potential for worsening existing hypotension or cardiac depression requires using the lowest effective dose. ASRA practive advisory on LA toxicity
Advantages of bronchial blockers over double lumen tubes:
A. Able to achieve lobar isolation
B. Lower cuff pressure
C. Quicker deflation of isolated lung
D. Pneumonectomy
E. Lower incidence of malposition
A. Lobar isolation *by default.

Campos, Thoracic Anaesthesia, DLT versus bronchial blockers
Therefore, the use of a bronchial blocker is more advantageous than the DLTs for difficult airways (nasal and
oral), rapid sequence induction, or in patients with an
existing tracheostomy who require lung isolation [15].
In contrast, the depth of insertion of a bronchial blocker is
not an issue as long as the tip of the single-lumen
endotracheal tube is at least 2cm above the tracheal
carina, so the bronchial blocker can be manipulated into
the desired bronchus.
For an absolute lung separation or sleeve pneumonectomy, the use of a right or left-sided DLT is the best choice.
Bronchial blockers are a better choice for patients with
difficult airways, for selective lobar ventilation, or
wherever postoperative mechanical ventilation is contemplated
Patient for pneumonectomy. Pre op FEV1 2.4. (Predicted 4.5L) FVC given as well. For R lower lobectomy. Postoperative predicted FEV1 ?
A. 1.3
B. 1.5
C. 1.7
D. 1.9
E. 2.2
C. Because of how many segments there are...to follow.
(Can also use slinger 30/42 x 1.24 = 1.7)

CEACCP article (2006), we can calculate a predicted post-op FEV1 (ppoFEV1) by calculating how many broncho-pulmonary segments of lung will remain after surgery. The starting number varies depending on the text/classification you use, but this article suggests 19 lung segments in total - 10 on the right (RUL=3, RML=2, RLL=5), and 9 on the left (LUL=3, Lingula=2, LLL=4). Given that the right lung is physically and functionally larger than the left this makes sense. Therefore for a right lower lobectomy we will be removing 5 segments, and therefore be left with 14 segments. The ppoFEV1 will be 14/19 x 2.4L = 0.7368 x 2.4L = 1.77L.
Post accidental dural puncture with epidural needle. Headache. Which does NOT fit ?
A. Epidural blood patch 30-50% effective
B. Unlikely to be related to epidural if purely occipital headache
C. Caffeine mildly effective in reducing headache
D. Subdural haematoma can rarely occur with PDPH
E. (?something about photophobia)
I think B now

Paech, Epidural blood patch, CanJAnaes 2005
Therapeutic 95%
Prophylactic 30-75%

Although: Although initial relief from an EBP is high, many parturients
experience only a partial reduction in the
severity of PDPH and the frequency of recurrence or
exacerbation is significant (about 30%).5,6 Women
should be informed that the chance of a "cure" (complete
relief) with a single EBP is at best 50% and that
in up to 40% of cases a second EBP is required

So - is it another one then?
The BJA CEACCP article from 2001 states that "The headache does not occur in any specific distribution within the cranium".
Cell saver. Which does NOT get filtered ?
A. Foetal cells
B. Free Hb
C. Platelets
D. Clotting factors
E. Microaggregates of leukocytes
A. Fetal cells. But they've shown it's no worse than labour/delivery and the UK College recommends for LSCS now.

CEACCP:
Red cells are retained, while the plasma, platelets, heparin, free haemoglobin, and inflammatory mediators are discarded with the wash solution.
Cell salvage is increasingly used in the UK in obstetrics in the
management of major obstetric haemorrhage. Concerns about amniotic fluid embolism, fetal debris contamination, and rhesus sensitization previously limited such use. However to date, there have been no proven cases of amniotic fluid embolism caused by reinfusion of salvaged blood in the literature. There is increasing evidence supporting the safety of cell salvage in obstetrics, and this has been approved by NICE.7 In pregnancies involving an Rh-negative mother and an Rh-positive fetus, a Kleihauer test should be performed in the immediate post-partum period. This will allow the calculation of the appropriate dose of anti-D immunoglobulin (usually 125 IU ml21 of fetal blood) if required.
You are on a humanitarian aid mission in the developing world. Drawover vaporiser apparatus described being used. Given 400 mm tubing, OMV or diamedica vaporiser, 200mm tubing attached to self-inflating bag. Which other ONE piece of equipment is ESSENTIAL to make this system functional?
A. Halothane
B. In-line Waters' Cannister [1]
C. Non-rebreathing valve
D. Oxygen source
E. Ventilator
C. Can use air instead of O2
Regarding post craniotomy pain:
A. Local infiltration proven to reduce long-term pain
B. Local more painful than discrete nerve blocks
C. Local infiltration more efficacious than discrete nerve blocks
D. Local infiltration more efficacious than opioid analgesia
E. Local infiltration more efficacious with clonidine included
A. LA good. Clonidine useless.

Pain following craniotomy, Anaesth 2005
Acute pain book, page 243

Scalp infiltration with 0.25% bupivacaine with 1 :
200 000 epinephrine has been shown to reduce immediate
pain postoperatively [25]. Furthermore, when 0.75%
ropivacaine was used for infiltration, pain relief can last
up to 48 h postoperatively. This may be related to a preemptive mechanism of pain relief
A 60 year old female is undergoing hysterectomy. Gabapentin reduces postoperative:
A. Nausea
B. Vomiting
C. Sedation
D. Pruritus
E. Constipation
A. Nausea. Going to have to try this!

Stupid Pain book doesn't let me copy, but it says "blah blah...reduced opioid consumption...NNT for nausea 25...after hysterectomy...improved pain relief, opioid sparing, nausea was less"
Burns dressings. The following is proven to be of analgesic benefit:
A. Morphine gel
B. Biosynthetic dressings
C. Dexmedetomidine IV
D. Lignocaine IV
E. Cognitive/Distraction technique
B. biosynthetic dressings then...If the pain book says, then it must be!

9.3.1
The choice of dressing has an effect on time to healing and pain during dressing change: biosynthetic dressings have been found to be superior.
Subtenon’s block. What is the worst position to insert block?
A. Inferonasal
B. Inferotemporal
C. Superonasal
D. Supertemporal
E. Medial / canthal
Any spot really okay but apparently more muscle insertion points medially so E?
Liposuction. Infiltration of lignocaine with 1:200,000 adrenaline. Peak plasma concentration of lignocaine occurs at:
A. 1 hour
B. 3 hours
C. 18 hours
D. 24 hours
E. 30 mins
C. As per Novel uses of LA CEACCP. Up to 35mg/kg lignocaine used!
Tumescent analgesia
The high hydrostatic pressure within the tissues is also thought to be responsible for the delayed systemic absorption and hence delayed and reduced peak plasma concentrations of local anaesthetic, despite the very large doses being used. Doses as high as 22–57 mg kg21 of lidocaine
Child-Pugh score. Components ?
A. Bilirubin / albumen / INR (yes INR, not PT), ascites, encephalopathy
B. Various other options including AST/ALT, GGT, PT
C. ?
D. ?
E. ?
A. Child-Pugh:
Clinical or biochemical variable
Points scored for increasing abnormality 1 / 2 / 3
The Pugh modification of Child’s classification is used to estimate the risk of mortality in patients with liver disease undergoing surgery. Points from each variable are added to make the total score. A total score of 5 or 6 is considered Child’s class A and is associated with a low operative mortality risk (<5%); a total score of 7–9 (Child’s class B) carries a moderate risk (25%) and total score of 10–15 (Child’s class C) carries a high risk (>50%). Although this
classification was originally used in patients undergoing portosystemic shunts, the variables included have been shown to be predictive of outcome for all types of abdominal surgery in patients with liver disease. Other predictors of poor outcome include malnutrition, emergency surgery, sepsis, and blood loss.

A. Encephalopathy (grade)
None = 1
Minimal (1 and 2) = 2
Advanced (3 and 4) = 3
B. Ascites
None = 1
Easily controlled = 2
Poorly controlled = 3
C. Serum bilirubin (mg dl21)
<2.0 =1
2.0–3.0 =2
>3.0 = 3
D. Serum albumin (g dl21)
> 3.5 = 1
2.8–3.5 = 2
< 2.8 = 3
E. Prothrombin time (s .control)
1–4 =1
4–6 =2
>6 = 3
Which is NOT a disadvantage of drawover vaporiser versus plenum vaporiser:
A. Temperature compensation
B. Cannot use sevoflurane
C. Small volume reservoir
D. Flow compensation
E.
B. Modifications mean yes you can
Acute renal failure. Which is not an indication for dialysis ?
A. Hyperkalaemia
B. Metabolic alkalosis
C. Hypernatraemia
D. Uraemic pericarditis
E. APO
C. Hypernatraemia? Usually metabolic acidosis is the issue but some references say "severe acid-base disturbances"
Chronic alcohol use. Which is not an associated complication ?
A. AF
B. hypertriglyceridemia
C. Macrocytosis
D. Nephrotic syndrome
E. Pancreatic Ca
D. As it causes cardiomyopathy, fat/fatty liver, delayed RBC maturation and pancreatic Ca.
CEACCP Alcohol and the Anaesthetist
Chest xray shown of patient post Left pneumonectomy with heart swung to left side. Management:
A. Increase PEEP
B. Roll onto right side
C. Turn on suction to left pleural catheter
D. Lung biopsy
E.
B. Gravity is your friend :)
Salicylate poisoning:
A. Respiratory acidosis
B. Metabolic acidosis (/ don’t think this was an option - ak )(yep i think it was- mm)
C. Increased CO2 (production)
D. High output renal failure
E. Hyperthermia (/ pretty sure this option was HYPOthermia - too late)
B. Get resp alkalosis and metabolic acidosis (non-anion gap)
New onset atrial fibrillation in a 10 week pregnant lady. BP 150/90, HR 160, SaO2 92%. Moderate mitral stenosis on TTE, no thrombus seen. Emergency doctor gave her anticoagulant (not specified what). Most appropriate management:
A. Verapamil
B. Labetalol 20mg iv to 300mg
C. Amiodarone 300mg IV
D. Synchronised biphasic cardioversion with 70-100 Joule
E. Oral digoxin -1000mcg then 500mcg 6 hrs later
Depends what sats of 92% mean. Probably a shock therefore D. Otherwise digoxin is recommended.
Patient post anterior cervical fusion. Patient in recovery. Confused and combative. Nurse concerned about haematoma Taken to theatre: Most appropriate way of securing airway:
A. Gas induction / laryngoscopy / intubate
B. Awake tracheostomy
C. Awake fibreoptic intubation using minimal sedation
D. Thiopentone, suxamethonium, direct laryngoscopy and intubation
E. retrograde intubation
A. As per CEACCP article on C spine surgery. Try heliox, Dex and neb adrenaline; reintubation may be difficult, in a semi-sitting posture. Options are AFOI, or direct laryngoscopy after sevo and oxygen may be easier. If that 'combative' not sure.

CEACCP "Cervical spine surgery"
- Surgery designed to relieve compression of spinal cord or nerve roots (osteophytes, congenital, tumour, infection etc); may be due to instability or trauma/C spine injury.
- Instability can be asymptomatic (atlanto-axial subluxation), or symptomatic. AAS is seen in Down sundrome, RA, infection of head/neck.
Prevention of neurological deterioration during anaesthesia:
- maintaining spinal cord perfusion - BP
- cord monitoring - SEP, Motor
Airway Mx: in unstable C spines, chin lift and jaw thrust can cause as much displacement as laryngoscopy, some say awake is best, no evidence. In line stabilisation is sensible, LMA/Glidescope etc,
Beware of difficult airway
Postop airway obstruction = haematoma, swelling, usually within 6 hr, especially after anterior-posterior cervical surgery. Diagnostic points:
1. Stridor unusual
2. Pts say 'can't breathe' and want to sit up
3. Oximetry may be normal until very late
4. Drain in neck doesn't prevent swelling
Sux is hazardous is myelopathic patients due to K+
Young asthmatic male in emergency department. RR 26, pCO2 27, SAO2 92%, struggling talking in sentences. Given nebulised salbutamol, and ipratropium, 200mg IV hydrocortisone. After 30 minutes - no improvement. Further management:
A. IV salbutamol
B. IV aminophylline
C. IV magnesium
D. Intubate and ventilate
E. ?
C. Ahh the wonder drug. If he is okay with nebs then stick to them before IV salbutamol, aminophylline not indicated anymore and he's not quite at I&V state.
Management:
* oxygen
* nebulised salbutamol - only 10% reaches bronchioles, continue until significant clinical response or serious side effects
* neb ipratropium bromide
* steroids - PO as efficacious as long as can swallow
* IV MgSO4 - single dose of 1.2-2g over 20 min has been shown to be safe and effective --> bronchodilates
* IV bronchodilators - consider in ventilated pts and those with life threatening asthma or aminophylline (lots of side effects)

Who should be ventilated? as high incidence of complications
* Coma, resp or cardiac arrest, severe refractory hypoxaemia.
* worsening +++, fatigue, somnolence, compromised, pneumothorax
[Pre-O2, RSI, expect hypotension, slow hand ventilation, no PEEP, low rate and low I:E ratio]
Called to emergency department to review a 20 y/o male punched in throat at a party. Some haemoptysis / hoarse / soft voice. Next step in management:
A. CT to rule out thyroid cartilage fracture
B. XR to rule out fractured hyoid
C. Rapid sequence induction / laryngoscopy / intubation
D. Awake fibreoptic intubation
E. Nasendoscopy by ENT in emergency department
E. See what you're dealing with.
How quickly does the CO2 rise in the apnoeic patient ?
A. 1 mmHg per min
B. 2 mmHg per min
C. 3 mmHg per min
D. 4 mmHg per min
E. 5 or ?8 mmHg per min
C. 3mmHg/min
Apparently Miller

Long-standing T6 paraplegia. All present EXCEPT ?
A. Flaccid paralysis
B. Poikilothermia
C. Autonomic hypereflexia
D. Labile BP
E. Hyperkalaemia with suxamethonium
A. Flaccid paralysis - after 8 weeks or so you have increased muscle tone and contractures.
OHA
Return of muscle tone and reflexes after perhaps 3 days to 8 weeks
Rest are longer term (i.e. 9 months)
Young female patient for tonsillectomy with history of bleeding tendency. Which is the most likely cause?
A. Factor V Leiden
B. Protein C deficiency
C. Haemophilia B (Christmas disease)
D. Antithrombin III deficiency
E. Lupus anticoagulant
C. Rest are pro-coagulant and she would clot clot clot.

Genetic

Bleeding disorders
• Haemophilia A, B, C
• von Willebrand disease
• Factors II, V, VII, X deficiency (common pathway proteins)
• Factor XIII and fibrinogen deficiency

Hypercoagulable diseases
• A ntithrombin III deficiency
• Protein C and S deficiency

Acquired
Prohaemorrhagic
• L iver diseases
• Drugs: vitamin K deficiency, warfarin, heparin
• Haemodilution and massive transfusion
• Disseminated intravascular coagulation
• Hyperfibrinolysis
• Venom-induced coagulopathy

Prothrombotic
• Heparin-induced thrombocytopenia
• Antiphospholipid antibody syndrome (‘lupus anticoagulant’)
• Microvascular thrombosis: thrombotic microangiopathy,
coumarin-induced skin necrosis
Amniotic fluid embolism. Cause of death in first half hour ?
A. Pulmonary hypertension
B. Malignant arrhythmia
C. Pulmonary oedema
D. Hypovolaemic shock
E.
A. Like a big PE as per OHA - "within the first 30 minutes, intense pulmonary vasoconstriction occurs and is associated with right heart failure, hypoxia, hypercarbia and acidosis"

ATOTW Amniotic Fluid Embolus
*Mortality 20-40%
*1:8-80000
Based on echocardiography studies in the acute setting, the haemodynamic response to AFE is thought to be biphasic. Initially there is thought to be severe pulmonary hypertension secondary to pulmonary vasoconstriction, which can precipitate right heart failure. This vasoconstriction may extend to the systemic circulation which can account for the transient hypertension that is occasionally seen. If the patient survives this acute insult then it can be followed by left heart failure. This left heart failure is probably secondary to a combination of a shift of the interventricular septum secondary to right heart failure, myocardial depression by activated mediators and myocardial ischaemia secondary to the initial hypoxia. Hypotension is attributed to the left heart failure but may also be contributed to by a distributive vasodilatory process, arrhythmia or haemorrhage.
Hypocalcaemia – earliest sign:
A. Tingling of face and hands
B. Chvostek’s sign
C. Carpopedal spasm
D.
E.
A
A. Tingling
Elderly COAD patient. On home oxygen. 24 hours of worsening condition. Various blood gases given:
A. paO2 > 50, paCO2 70 HCO3 30 etc…
B.
C.
D.
E.
Likely to see hypoxia / raised CO2 (normal for them probably 50-60, hence greater), high bicarb to indicate chronicity of CO2 retention...
Visual loss with pupillary reflexes retained. Likely cause ?
A. Retinal detachment
B. Occipital mass
C. Frontal mass
D. Chiasmal mass
E. Optic neuritis
B
Cortical blindess = visual loss but with retained pupillary reflexes and normal fundoscopy. Caused by pathology in the occipital lobes.
This damage is most often caused by loss of blood flow to the occipital cortex from either unilateral or bilateral posterior cerebral artery blockage (ischemic stroke). A patient with cortical blindness often has little or no insight that they have lost vision, a phenomenon known as Anton's Syndrome or Anton-Babinski syndrome.
http://www.iveyeye.ca/pdfs/acute_visual_loss.pdf
Retinal detachment – an extensive retinal detachment involving the macular area would produce acute visual loss and this patient will complain of flashing lights followed by a large number of floaters and then a shade or blind covering the visual field. An afferent pupillary defect is usually present. The diagnosis is confirmed by ophthalmoscopy through a dilated pupil, and retina appears elevated with folds and the choroidal background is indistinct.
Optic Neuritis: Optic Neuritis is inflammation of the optic nerve and is usually associated with multiple sclerosis in a significant number. The visual acuity is markedly reduced and an afferent pupillary defect is present. The optic disc initially appears hyperemic and swollen. The visual acuity usually recovers; however, repeated episodes of optic neuritis may lead to permanent loss of
vision.
Nerve block for anaesthesia over anterior 2/3 of ear?
A. C2
B. Mandibular nerve
C. Maxillary nerve
D. Ophthalmic nerve
E. Vagus
B.
Four sensory nerves supply the external ear: (1) greater auricular nerve, (2) lesser occipital nerve, (3) auricular branch of the vagus nerve, and (4) auriculotemporal nerve. (Emedicine)
The greater auricular nerve is a branch of the cervical plexus. It innervates the posteromedial, posterolateral, and inferior auricle.
The lesser auricular nerve innervates a small portion of the helix.
The auricular branch of the vagus nerve innervates the concha and most of the area around the auditory meatus.
The auriculotemporal nerve is a branch of the mandibular branch of the trigeminal nerve. It innervates the anterosuperior and anteromedial aspect of the auricle.
The external auditory canal and tympanic membrane have separate innervation.
http://emedicine.medscape.com/article/82698-overview
Complex regional pain syndrome. What proportion of patients have motor involvement ?
A. 0 %
B. 25 %
C. 50 %
D. 75 %
E. 95 %
D.
Blue book 2005

CRPS type I (reflex sympathetic dystrophy) is diagnosed where there is no evidence of a precipitating nerve injury
CRPS Type II (causalgia) where a nerve injury is present.

Motor / trophic changes
- motor dysfunction 57-98%
- weakness 75-95%
- limited range of movement 80-88%
- incoordination 47%
- tremor 48%
- spasm 13%
- dystonia 14%
- myoclonus 4-20%

See powerpoint Summary in files
Malignant hyperthermia. The number of people in the community at any given time with a predisposition is called the:
A. Prevalence
B. Incidence
C.
D.
E.
Prevalence = measures how much of some disease or condition there is in a population at a particular point in time.
Incidence = the rate of occurrence of new cases of a disease or condition.

Incidence of MH (per wiki) is 1:15000 anaesthetics for children and adolescents and 1:50-150000 anaesthetics for adults.
Prevalence for susceptabiity may be as high as 1:2000
Patient with Hx COAD and suspected pneumonia – clinical findings supporting R pneumonia on examination:
A. R Dull percussion note & increased vocal resonance
B. R Dull percussion note & decreased vocal resonance
C. R Decreased air entry
D. Tracheal deviation to left
E. Tracheal deviation to right
A
Pneumonia = dull percussion note (consolidation doesn't transmit sound as well as air), decreased breath sounds, may be bronchial breath sounds, increased vocal resonance (through consolidated lung)
Thallium scan:
A. High negative predictive value
B. High positive predictive value
C. Not as good as a dobutamine stress echocardiography
A.
AHA/ACCHA Guidelines:
The 2 main techniques used in preoperative evaluation of
patients undergoing noncardiac surgery who cannot exercise
are to increase myocardial oxygen demand (by pacing or
intravenous dobutamine) and to induce hyperemic responses
by pharmacological vasodilators such as intravenous dipyridamole
or adenosine. The most common examples presently
in use are DSE and intravenous dipyridamole/adenosine
myocardial perfusion imaging with both thallium-201 and
technetium-99m.
From the 2007 AHA guidelines,
'because of a very high sensitivity of abnormal stress nuclear imaging studies for detecting patients at risk for perioperative cardiac events, the negative predictive value of a normal scan has remained uniformly high at approximately 99% for MI or cardiac death'.
IE. NEGATIVE = MORE LIKELY NOT GOING TO RUN INTO TROUBLE!
Thallium scanning in coronary artery disease (CAD) using radioactive thallium-201(201-Tl) is a widely available technique which is sensitive, accurate and noninvasive. It detects CAD accurately in patients with:
atypical chest pain and a positive exercise ECG or
typical chest pain and a negative exercise ECG.
A 50 y/o male diabetic admitted to intensive care with pneumonia. Intubated and ventilated. Extensive results given. BP 80/-, HR 120, CVP 4, PCWP 6, SvO2 69% PaO2 80, BE -4 pH 7.2. Management:
A. Blood transfusion
B. Bicarbonate infusion
C. Fluid resuscitation
D. Adrenaline infusion
E. Insulin infusion
C. Fluids. Low CVP, hypotensive, tachycardic, low PCWP.
Acidosis could be diabetic or lactate .

No reason for Blood unless low Hb.
Bicarb contraindicated in DKA as need to breathe off excess CO2
Adrenaline - if non-responsive to fluid
Insulin - depends if hyperglycaemic
Young female having cholecystectomy. Venous air embolus:
A. Mechanical ventilation and PEEP is part of treatment strategy
B. Most likley to occur at initial gas insufflation, but can occur at any time
C. Inert gas (argon, xenon) is safer
D.
B. Classically due to insufflation of CO2 via a hasson cannula, but cut surfaces e.g. of liver may permit entry of gas. "This complication develops principally during the induction of pneumoperitoneum, particularly in patients with previous abdominal surgery." Miller 7th ed. p. 2188.

Two preconditions must exist for venous air embolism to occur: (1) a direct communication between a source of air and the vasculature and (2) a pressure gradient favoring the passage of air into the circulation. Severity depends on volume of gas (20ml/kg, or 2-3ml into cerebral circulation), rate of accumulation (rapid entry puts a strain on RV, and if increases PAP can lead to RV outflow obstruction), and patient's position at time of event.

Tachyarrhythmias common; bradyarrhythmias can occur, + "Mill wheel" murmur - A temporary loud, machinerylike, churning sound due to blood mixing with air in the right ventricle, best heard over the precordium (a late sign)

Positioning: Generally, if the patient is in a sitting position, gas will travel retrograde via the internal jugular vein to the cerebral circulation, leading to neurologic symptoms secondary to increased intracranial pressure. In a recumbent position, gas proceeds into the right ventricle and pulmonary circulation, subsequently causing pulmonary hypertension and systemic hypotension.

Incidence - 10% for cervical laminectomy (prone) - 80% in posterior fossa (Fowler's (sitting)).
VAE pose a risk whenever wound is > 5cm about RA
Inert gases NOT safer - CO2 safest as dissolves fastest

TREATMENT = ABC; place patient in left lateral and trendeleburg position; remove air from CVC if possible (see VAE CEACCP)
LUSCS for failure to progress. Spinal is inserted uneventfully. Next day the patient has foot drop. The most likely cause is?
A. epidural haematoma
B. lumbosacral palsy
C. sciatic nerve palsy
D. common peroneal palsy
B. It's never us ;) CEACCP 2003:
"Postpartum foot drop is caused by damage to the lumbosacral trunk or, less frequently, the common peroneal nerve. The lumbosacral trunk (L4, L5) is compressed between the ala of the sacrum and the descending fetal head. It may also occur during a forceps delivery. The result is a unilateral foot drop with loss of sensation and/or paraesthesia along the lateral calf and foot."
"Common peroneal nerve damage may occur due to improper or prolonged positioning during lithotomy and the sensory deficit may be limited to the dorsum of the foot."
Epidural haematomas extremely rare (1:168,000 from review in Anaesthesiology 2006; 105: 394)and obstetric palsies are much more common than complications related to neuraxial blocks.
Sciatic nerve injury would cause a foot drop but would also affect knee flexion (hamstrings) and all muscles in lower leg and foot.
Common peroneal nerve palsy less likely in this case as there is no mention of stirrups or 'excessive knee holding'
Severe pre-eclampsia. WORST treatment option:
A. Magnesium
B. Nifedipine
C. Metoprolol
D. SNP
E.
D? C. ??
Magnesium if questions says about hypertension
Beta blockers could tip into LVF and APO however SIG says some B blockers (metoprolol, pindolol, propranolol) are ok.
SNP is rarely used and not recommended due to hypotension, paradoxical bradycardia with severe PET and unknown risk of fetal cyanide toxicity
In pregnancy the dural sac ends at:
A. T12
B. L2
C. L4
D. S2
E. S4
D. No different to normal.

CEACCP Applied epidural anatomy
Septic elderly man. Given lots of obs but essentially mixed venous oxygen sat 65%, lactate 4, MAP low. Mx.
A transfuse
B fluid bolus
C Noradrenaline
B. Points to inadequate perfusion --> needs resuscitation, especially if septic. Then maybe to squeezers (which can worsen lactate).
Oxygen
Fluid resuscitation
Pregnant woman presents with narrow complex tachycardia HR 190, stable BP 100/60. No response to vagal manoevures. Management?
A. Adenosine 6mg
B. DCR
C. Amiodarone
D. Atenolol
E. ?
A. Adenosine or shock if unstable

BJA 2004 "SVT in Pregnancy"
Drug use in labour or LSCS can precipitate SVT. Careful with synto, and ephedrine.
Regional anaesthesia --> decreased filling and may precipitate. Ensure aortocaval tilt is used.
Adenosine, a naturally occurring purine nucleotide,
transiently depresses sinus node activity and slows atrioventricular conduction, and is effective in terminating SVT.
It is rapidly metabolized with an elimination half-life of less
than 10 s, making it ideally suitable for use in pregnancy.
Numerous case reports,and a retrospective study,
suggest that adenosine is safe and effective.

If adenosine fails, other antiarrhythmics may be indicated and the risk of their use should be weighed against the risk of continuing SVT. Beta-blockers have been used extensively in pregnancy, to treat maternal hypertension and cardiac problems, and are generally well tolerated. They are the agents of choice in Wolf-Parkinson-White syndrome, where AV nodal blocking drugs may lead to acceleration of conduction through the accessory pathway and the arrhythmia being sustained. Verapamil, a calcium channel-blocking agent, is as effective as adenosine in converting an SVT to sinus rhythm. Peripheral vasodilation and negative inotropy are unwanted side-effects. There are reports of its safe use in pregnancy for treatment of SVT. Digoxin has been used in all stages of gestation for maternal and fetal indications without causing harm.
Amiodarone is perhaps best avoided because of its potential teratogenic effects and reports of fetal toxicity, but again there are reports of its safe use during pregnancy.
Synchronized electrical cardioversion may become necessary for SVT resistant to pharmacological therapy, particularly if hypotension develops. Direct current electrical shock has been used at all stages in pregnancy without significant complication. The amount of current reaching the fetus is thought to be negligible. However, transient fetal dysrhythmia has been described, and monitoring of fetal heart rate during maternal cardioversion is advisable. Implantable devices have been successfully used during pregnancy for malignant tachyarrhythmias. Both temporary and permanent endocardial pacing has been used in pregnancy, although mainly in the treatment of bradyarrhythmias.
Which gives the BEST seal?
A LMA classic
B Proseal
C Intubating LMA
D. ?
E. ?
B. If it is referring to airway seal = Proseal. CEACCP 1:2, 2011
From the LMA website / product information:
LMA Classic - Seal pressure up to 20cm H20
LMA Supreme™ - measured oropharyngeal leak pressures up to 37 cm H2O
LMA Flexible™ - oropharyngeal seal pressures up to 20 cm H2O
LMA Fastrach - Seal pressures up to 20 cm H2O
LMA ProSeal™ - leak pressures up to 32 cm H2O

(Oesophageal seat = ILMA; Concerning the risk of aspiration, the use of devices with an additional esophageal drainage lumen might be superior for use in patients with an increased risk of aspiration. The Combitube, Easytube, and intubating laryngeal mask Fastrach showed the best capacity to withstand an increase of esophageal pressure.)
Lady on citalopram. Which drug is relatively contraindicated?
A Tramadol
B. ?
Serotonin syndrome - review...
A 30yo Male. 5 hour operation. Arms abducted to 60 degrees. Head turned slightly to left side. Post op numb palm/thumb/index finger/middle finger and lateral half of ring finger. Numb ventral forearm. Weak finger grip. Weak elbow flexion. Most likely nerve injured?
A. median nerve
B. musculocutanous nerve
C. upper trunk of brachial plexus
D. ?brachial plexus stretch
E.
?C.

A. Median nerve doesn't supply elbow flexion (this is upper arm - brachialis (musculocutaneous), brachioradialis (radial), biceps (musculocutaneous)
B. coracobrachialis, brachialis and biceps brachi but not median nerve sensory
C. Think it must be to encompass m/cutaneous + median
D. ?
Diastolic dysfunction is NOT caused by:
A Adrenaline
B Aortic stenosis
C Hypertension
D myocardial fibrosis
E ?
A. Adrenaline

Left ventricular (LV) diastolic dysfunction refers to abnormalities of diastolic distensibility, filling, or relaxation, regardless of whether LV ejection fraction (LVEF) is normal or abnormal and whether the patient is symptomatic or not.
The major causes of diastolic dysfunction include:
chronic hypertension
hypertrophic cardiomyopathy
aortic stenosis
coronary artery disease
restrictive cardiomyopathy (a rare condition in which the heart muscle is infiltrated, and made stiff, by abnormal cells, protein, or scar tissue. The most common cause of restrictive cardiomyopathy is amyloidosis, a disease in which protein-like substance is deposited within the body's tissues. Other causes include sarcoidosis and haemochromatosis.)
aging (Whether age alone causes stiffening of the ventricles, or whether such stiffening is related to "subclinical hypertension" or some other definable medical condition, is not yet worked out.)

See CEACCP
An 18 yo with Fontan circulation undergoing exploratory laparotomy. On ICU vent, sats 70%. Which ventilator parameter would you INCREASE to improve his sats?
A. Bilevel pressure
B. Expiratory time
C. Inspiratory time
D. Peak inspiratory pressure
E. PEEP
B. Expiratory time

CEACCP
Low respiratory rates, short inspiratory times, low PEEP,
and tidal volumes of 5–6 ml kg21 usually allow adequate pulmonary
blood flow, normocarbia, and a low PVR.

Also article on "Grown up congenital heart disease"
A 7 kg Infant with tetralogy of fallot, post BT-shunt. Definitive repair at later date. Paralysed and ventilated. Sats 85% baseline, now 70%, best treatment:
A. Increase FiO2 from 50 - 100%
B. Esmolol 70 mcg
C. Phenylephrine 35 mcg
D. Morphine 1 mg
E. 1/2 NS with 2.5% dex 70 mls
C. Phenylephrine - will increase SVR and L pressures, reducing R-L shunt.

(increase FiO2 won't change if big shunt)
http://lifeinthefastlane.com/2010/04/cardiovascular-curveball-009/

Frank Shann's dose recommendation for phenylephrine is 2-10 mcg/kg as a bolus, which would fit nicely with C (5mcg/kg).
Von Hippel-Lindau disease is associated with:
A. increased risk of malignant hyperthermia
B. meningiomas
C. peripheral neuropathy
D. pheochromocytomas
E. poor dentition
D. Pheo
"Management of anesthesia in patients with von Hippel-Lindau disease must consider the possible presence of pheochromocytomas" (Stoelting)
von Hippel-Lindau disease (VHL) is a rare, genetic multi-system disorder characterized by the abnormal growth of tumors in certain parts of the body (angiomatosis).
The tumors of the central nervous system (CNS) are benign and are comprised of a nest of blood vessels and are called hemangioblastomas (or angiomas in the eye). Hemangioblastomas may develop in the brain, the retina of the eyes, and other areas of the nervous system.
Other types of tumors develop in the adrenal glands, the kidneys, or the pancreas.
Symptoms of VHL vary among patients and depend on the size and location of the tumors. Symptoms may include headaches, problems with balance and walking, dizziness, weakness of the limbs, vision problems, and high blood pressure. Cysts (fluid-filled sacs) and/or tumors (benign or cancerous) may develop around the hemangioblastomas and cause the symptoms listed above. Individuals with VHL are also at a higher risk than normal for certain types of cancer, especially kidney cancer.
Inheritance = Familial Autosomal dominant
Features= Retinal angiomas, Haemangioblastomas, Cerebellar and visceral tumours (usually benign but can cause pressure effects)
Associations = An increased incidence of Phaeochromocytoma - apparently 20%, Renal cysts, Renal cell carcinoma

Anaesthesia= Treat hypertension occurring with phaeochromocytoma, Haemangioblastoma of spinal cord may limit use of spinal although epidural has been used for LSCS, Exagerrated hypertension with surgical stimulation or laryngoscopy = Treat with β blockers and/or SNP

From recollection, Phaeos are associated with the Diseases of Von- Ie. Von Recklinghausen and Von Hippel Lindau.
70 year old post TKJR. On sub-cut heparin. Develops clinical DVT and platelets 40 (sounds like HITS type-II). Management
A. Enoxaparin
B. Fondoparinux
C. Heparin by infusion
D. Lepirudin
E. Warfarin
D - no other direct thrombin inhibitors on list.
Drug eluting stent 6 months old. On aspirin and prasugrel 10mg. Elective lap cholecystectomy for biliary colic.
A. Do case while taking both.
B. Do case while stopping both.
C. Stop Prasugrel for 7 days, keep taking aspirin.
D. Stop Prasugrel for some other different time
E. Post-pone for 6 months
E

ACC/AHA Pre-op:
DRUG ELUTING:
Thrombosis of DES may occur late and has been reported up to 1.5 years after implantation, particularly in the context of discontinuation of antiplatelet agents before noncardiac surgery.

Discontinuation of antiplatelet therapy in the early-surgery group resulted in a 30.7% incidence of MACE (all fatal) versus a 0% incidence in early-surgery patients who continued dual antiplatelet therapy perioperatively. Overall, there was no difference in MACE between patients with bare-metal stents and those with DES. The study reported that all patients with MACE had discontinued antiplatelet therapy before surgery, whereas only 46% without MACE had done so. The study also stated there was no difference in surgical risk between patients in whom antiplatelet agents were discontinued and those in whom they were not. Excessive blood loss occurred in 2 patients, 1 of whom was receiving antiplatelet agents and 1 of whom was not.

** The panel concurred with the AHA/ACC guideline recommendation for 12 months of dual-antiplatelet therapy after DES implantation in patients who are not at high risk for bleeding.
**1. Before implantation of a stent, the physician should discuss the need for dual-antiplatelet therapy. In patients not expected to comply with 12 months of thienopyridine therapy, whether for economic or other reasons, strong consideration should be given to avoiding a DES.

BARE METAL:
A thienopyridine (ticlopidine or clopidogrel) is generally administered with aspirin for 4 weeks after bare-metal stent
placement. The thienopyridines and aspirin inhibit platelet aggregation and reduce stent thrombosis but increase the risk of bleeding. Rapid endothelialization of bare-metal stents makes late thrombosis rare, and thienopyridines are rarely needed for more than 4 weeks after implantation of baremetal stents. For this reason, delaying surgery 4 to 6 weeks after bare-metal stent placement allows proper thienopyridine use to reduce the risk of coronary stent thrombosis; then, after the thienopyridine has been discontinued, the noncardiac surgery can be performed. However, once the thienopyridine is stopped, its effects do not diminish immediately. It is for this reason that some surgical teams request a 1-week delay after thienopyridines are discontinued before the patient proceeds to surgery. In patients with bare-metal stents, daily aspirin antiplatelet therapy should be continued perioperatively. The risk of stopping the aspirin should be weighed against the benefit of reduction in bleeding complications from the planned surgery. In the setting of noncardiac surgery in patients who have recently received a bare-metal stent, the risk of stopping dual-antiplatelet agents prematurely (within 4 weeks of implantation) is significant compared with the risk of major bleeding from most commonly performed surgeries.
Arterial blood gases (ABGs): pH 7.12, PO2 100, PCO2 65, HCO3 20.3, BE -10. Consistent with?
A. Chronic renal failure
B. Malignant hyperthermia
C. Diabetic ketoacidosis
D. End-stage respiratory failure
E. Ethylene glycol toxicity
Combined metabolic and respiratory acidosis = MH!
a. CRF wouldn't have high CO2
c. DKA = low CO2 to breathe off
d. Would be metabolic compensation i.e. high bicarb
e. Would try to breathe off CO2 to compensate for non-anion gap metabolic acidosis
Compared to lignocaine, bupivacaine is
A. Twice as potent
B. Three times as potent
C. Four times as potent
D. Five times as potent
E. Same potency
c. Just is
Aneurysm sugery. Propofol/remifentanil/NMDR. DOA monitoring (Entropy). MAP 70 , HR 70/min, State entropy 50, Response entropy 70. What do you do?
A. ?
B. Metaraminol
C. Check TOF
D. Nothing
E. Increase TCI.
Not sure what they're asking.
RE of 70 compared to SE of 50 means paralysis is wearing off --> C (check TOF)
If SE/RE numbers climbing or about to climb --> increase RCI
MAP of 70 isn't very high for aneurysm surgery so would you give aramine?!?!
Interscalene block, patient hiccups...where do you redirect your needle?
A. Anterior
B. Posterior
C. Caudal
D. Cranial
E. Superficial
You are hitting the phrenic nerve which is ANTERIOR to the interscalene plexus therefore B
What is the SVR in a patient with MAP 100mmHg, CVP 5, PCWP 15, CO 5L/min?
A. ?0.8
B. ?3
C. 520
D. 1280
E. 1520 dynes.sec/cm-5
E. 1520 dynes.sec/cm3
Resistance = Change in Pressure / flow
= (100-5) / 5 = 19mmHg/L/min

Need to change to dynes.sec/cm cubed --> multiplied by 80 = 1520
Stellate ganglion
A. Anterior to scalenius anterior
B. ?
C. ?
D. ?
E. ?
Yup, it is
The median nerve
A. can be blocked at the elbow immediately medial to the brachial artery
B. can be blocked at the wrist between palmaris longus and flexor carpi ulnaris
C. can be blocked at the wrist medial to flexor carpi ulnaris
D. is formed from the lateral, medial, and posterior cords of the brachial plexus
E. provides sensation to the ulnar half of the palm
See my beautiful-about to be constructed anatomy pictures in full pen colour ;)
A. is correct
B = too medial (lateral to palmaris longus, in between FCR)
C = too medial again
D = lateral and medial I think
E = nope, that's Ulnar!

http://www.nysora.com/ultrasound-anatomy/3321-ultrasound-anatomy-median-nerve-elbow.html
A 75yo male with moderate aortic stenosis (valve area 1.1cm2).. Gets mild dyspnoea on exertion but otherwise asymptomatic. Needs hip replacement.
A. Continue with surgery
B. Beta block then continue
C. Get myocardial perfusion scan
D. Postpone surgery awaiting AVR
E. Postpone surgery awaiting balloon valvotomy
Is the dyspnoea from the AS? B/E wrong - maybe C as this would see if any LVF from the AS...
No clear indication for D as below. E nope as too old.
If brave - A?

Indications for Aortic Valve Replacement (ACC/AHA)
Recommendations for Aortic Valve Replacement in Aortic Stenosis
Indication / Evidence class
1. Symptomatic patients with severe AS. = I
2. Patients with severe AS undergoing coronary artery bypass surgery. = I
3. Patients with severe AS undergoing surgery on the aorta
or other heart valves. = I
4. Patients with moderate AS undergoing coronary artery bypass surgery or surgery on the aorta or other heart valves. = IIa
5. Asymptomatic patients with severe AS and
c LV systolic dysfunction IIa
c Abnormal response to exercise (eg, hypotension) IIa
c Ventricular tachycardia IIb
c Marked or excessive LV hypertrophy (>15 mm) IIb
c Valve area <0.6 cm2 IIb
6. Prevention of sudden death in asymptomatic patients
with none of the findings listed under indication = III

Special Considerations in the Elderly
Because there is no effective medical therapy and balloon valvotomy is not an acceptable alternative to surgery, AVR must be considered in all elderly patients who have symptoms caused by AS. AVR is technically possible at any age, but the decision to proceed with such surgery depends on many factors, including the patient’s wishes and expectations.

Active Cardiac Conditions for Which the Patient Should Undergo Evaluation and Treatment Before Noncardiac Surgery (Class I, Level of Evidence: B)
Severe valvular disease
Severe aortic stenosis (mean pressure gradient greater than 40 mm Hg, aortic valve area less than 1.0 cm2, or symptomatic)
Symptomatic mitral stenosis (progressive dyspnea on exertion,
exertional presyncope, or HF)
Baby with Tracheo-oesophageal fistula found by bubbling saliva and nasogastric tube coiling on Xray. Best immediate management?
A. Bag and mask ventilate
B. Intubate and ventilate
C. position head up, insert suction catheter in oesophagus (or to stomach?)
D. Place prone, head down to allow contents to drain
E. Insert gastrostomy
C
Neonates with TOF should have a "nasogastric" tube inserted into the oesophageal stump to drain secretions and prevent accumulation in the blind-end pouch. The NGT should be connected to continuous suction. The infant should be nursed prone or in the lateral position with 30 degrees head up tilt to decrease the risk of aspiration. See A Practice of Anesthesia for Infants and Children - 4th edition by Cote, Lerman, Todres; p.755. Saunders (2009)
A 60yo man with anterior mediastinal mass, during induction for mediastinoscopy....lose cardiac output, decreased saturations, drop in ETCO2. Management:
A. Adrenaline
B. CPR
C. CPB
D. Place prone
E.
D
Slinger article says needs urgent sternotomy if lightening GA doesn't work. Change in position is an early manouevre though.

From notes on computer:
Local anaesthesia if at all possible.
• Keep in position of comfort.
• Ensure ability to quickly change to lateral or prone position is maintained.
• Avoid distress – judicious anxiolysis. Minimal sedation as tolerable.
• If able, perform fibreoptic bronchoscopic examination of tracheobronchial tree
o Intubate following examination
• Otherwise, Inhalational induction
o PA/Heart compression: Maintain VR (fluid load, keep BP up)
o SVC: LL IV access. Beware airway oedema for difficult intubation. Maintain Head / UL venous drainage
• If in strife,
o Rigid bronchoscopy with jet ventilation (ensure this is available pre‐op, set up and ready to go)
o Cardiopulmonary bypass
The MAIN indication for biventricular pacing is
A. complete heart block
B. congestive cardiac failure
C. VF
D.
E.
B
BJA 2004 Anaesthetics and PPM

Current indications for this atrio-BV pacing include moderate or severe chronic heart failure. Therefore, unlike most patients with conventional single- and dual-chamber pacemakers, patients with these devices will already have signicant morbidity and an increased anaesthetic risk. In patients with chronic heart failure, optimizing medical therapy before surgery with, for example, vasodilators, diuretics or beta-blockers is vital.

It is equally important, however, to ensure that pacemakers are programmed optimally. This is particularly important for BV pacemakers because, unlike most pacemakers, for which it is acceptable that the device paces only when required, BV pacemakers deliver a therapy (electrical ventricular resynchronization) with each ventricular paced beat.

COMPANION and CARE studies
What's the most appropriate mode for neuromuscular monitoring during aneurysm clipping?
A. TOF count
B. TOF ratio
C. Post tetanic count
D. ?
E. ?
PTC = C
What's the area burnt in the following man? Half of left upper arm, all of left leg and anterior abdomen.
A. 27%
B. 32%
C. 42%
D.
E.
Rule of 9's = 2-3% + 18% + 9% = 29% (A)
Torsades, what's not useful?
A. Amiodarone
B. Isoprenaline
C. ?
D.
E.
A. Amiodarone - can cause it
(Need shock + magnesium)

Amiodarone prolongs the QT interval and is widely reported as a precipitant of torsades de points. "We present two patients who had life-threatening arrhythmias, which are highly likely to be secondary to amiodarone. This class III anti-arrhythmic is commonly prescribed for the acute presentation of supra-ventricular and ventricular arrhythmias. However, occasionally its use can transform arrhythmias from benign to dangerous. These cases highlight the need for careful attention to the indications, cautions and contra-indications of amiodarone as well as the need for vigilance following initiation of anti-arrhythmic therapy." (Resuscitation, Volume 76, Issue 1, Pages 137-141 (January 2008)
The intercostobrachial nerve:
A. Arises from T2 trunk
B. Is usually blocked in brachial plexus block
C. Supplies antecubital fossa
D. can be damaged by torniquet
E. Arises from inferior trunk
D.
Intercostobrachial nerve NOT supplied by brachial plexus (wiki) = the lateral cutanoeous branch of the 2nd intercostal nerve.
Supplies skin of upper half of medial and posterior part of the arm, communicating with posterior brachial cutaneous branch of the radial nerve. Often the source of referred cardiac pain.
Labour epidurals increase maternal and foetal temperature. This results in neonatal
A. Increased sepsis
B. Increased investigations for sepsis
C. increased non shivering thermogenesis
D. Increased need for resuscitation
E. Cerebral palsy
B. Increased Ix for sepsis but NOT increased sepsis

Labour epidural analgesia is associated with an increase in maternal core body temperature, but also with an increased neonatal temperature and fetal heart rate. Several studies have shown that labour epidural analgesia is associated with increased neonatal neonatal sepsis evaluations, but no increase in neonatal sepsis.
Chestnut's Obstetric Anesthesia: Principles and Practice (4th Edn), Chestnut et al. 2009; p457.
Maternal cardiac arrest. In making the diagnosis of amniotic fluid embolism, large amount of PMNs surrounding foetal squamous cells are
A. Pathognomonic
B. Supportive
C. Only found at postmortem
D. Irrelevant
E. Incidental
B. Supportive

CEACCP:
There is still no pathognomic marker of AFE. The diagnosis is one of the exclusion criteria. The presence of fetal squamous cells in pulmonary vasculature was once considered diagnostic, but it is now considered to be neither sensitive nor specific. The presence of fetal squamous cells in the broncho-alveolar lavage may support the diagnosis.

In AFE, amniotic fluid enters maternal circulation via ruptured membranes or ruptured uterine or cervical vessels down a pressure gradient from the uterus to veins. Although the site of placental implantation is one portal of entry, small tears in the lower uterine segment and endocervix are thought to be the most common site of entry. The pathophysiology of AFE syndrome is unclear. In the past, it was thought to be due to fetal tissue/amniotic fluid forcibly entering maternal circulation causing transient pulmonary vasospasm, cardiac failure, hypoxaemia, and death. However, in 1995, Clark suggested that the syndrome arose from an immune rather than embolic process. According to Clark, AFE is caused by fetal antigens in the amniotic fluid stimulating a cascade of endogenous immunemediators,
producing a reaction similar to anaphylaxis.
Half life of tirofiban:
A. 2hrs
B. 8hrs
C. 12hrs
D. 24hrs
E. 15 minutes
A. 2 hours
Why is codeine not used in paediatrics?
A. Poor taste
B. High inter-individual pharmacokinetic variability
C. Not licensed for <10 year old
D. not as effective as adult when given in ?weight adjusted dose?
E. ?
It is, but for argument's sake = B, high interindividual PK variability
Best agent to decrease gastric volume AND increase gastric pH before semi-urgent procedure
A. Omeprazole
B. Cimetidine
C. Ranitidine
D. Sodium citrate
E.
Hrmm - either A or C
Probably C for semi urgent as ranitidine is most potent agent for reducing volume and increasing pH within 1-1.5 hours (Stoelting)
Myaesthenia gravis - features predicting need for post op ventilation EXCEPT
A. Prolonged disease
B. High dose Rx
C. Previous respiratory crisis
D. Increased sensitivity to NMB's
E. bulbar dysfunction
D. Be careful instead
(If asked which increases rate of post op ventilation need - especially recent bulbar pulsy or dysphagia)

According to Oxford Handbook:
Preoperative predictors of postoperative need for ventilation:
duration of disease of greater than 6 years
history of coexisting chronic resp disease
dose requirements of pyridostigmine > 750 mg/day less than 48 H prior to surgery
preoperative VC < 2.9L
Miller (p1098-9):
"postop ventilation ....... is especially important in cases involving myasthenia gravis of more than 6 years duration, chronic obstructive lung disease, daily pyridostigmine requirement of 750 mg in association with significant bulbar weakness, and vital capacity of less than 40 mL/kg"
Innervation of larynx
A. The internal branch of the superior laryngeal nerve ...
B. ?
C.
D.
E. Cuff compression of recurrent laryngeal nerve against thryoid can cause palsy
E. The larynx is innervated by branches of the vagus nerve on each side. Sensory innervation to the glottis and laryngeal vestibule is by the internal branch of the superior laryngeal nerve. The external branch of the superior laryngeal nerve innervates the cricothyroid muscle. Motor innervation to all other muscles of the larynx and sensory innervation to the subglottis is by the recurrent laryngeal nerve. While the sensory input described above is (general) visceral sensation (diffuse, poorly localized), the vocal fold also receives general somatic sensory innervation (proprioceptive and touch) by the superior laryngeal nerve.
Injury to the external laryngeal nerve causes weakened phonation because the vocal folds cannot be tightened. Injury to one of the recurrent laryngeal nerves produces hoarseness, if both are damaged the voice may or may not be preserved, but breathing becomes difficult.
The nerve supplying area of skin between greater trochanter and iliac crest:
A. subcostal nerve
B. ilioinguinal nerve
C. genitofemoral nerve
D. femoral nerve
E. lat cutaneous femoral nerve.
A. Subcostal nerve

Wiki: It communicates with the iliohypogastric nerve of the lumbar plexus, and gives a branch to the Pyramidalis. It also gives off a lateral cutaneous branch that supplies sensory innervation to the skin over the hip.
"The 12th thoracic (subcostal) nerve runs along the lower border of the 12th rib below the subcostal vessels, passes behind the lateral arcuate ligament to run in front of quadratus lumborum behind the kidney and colon. The nerve then passes between transversus abdominis and internal oblique and then has a course and distribution which are similar to the lower intercostal nerves. However, there is one point of difference: the lateral cutaneous branch of the 12th nerve descends without branching to supply the skin over the lateral aspect of the buttock" (Ellis)
IV paracetamol:
A. late plasma levels around the same as oral
B. highly protein bound
C. ?30%? renally excreted
D. VD 10L/kg
E.
A
Low PB%
VD 1L/kg
90% renal excretion as glucuronide (60-80%) and sulfate (20-30%) conjugates
Patient with diastolic dysfunction. Is it caused by:
A. Restrictive cardiomyopathy
B. Dilated cardiomyopathy
C.
D.
E.
A
Most likely to result in myocardial infarction:
A. intraop myocardial ischaemia
B. post op myocardial ischaemia.
C.
D.
E.
B
Indication for percutaneous closure of ASD
A. Primun < 3cm
B. Primun > 3cm
C. Secundum < 3 cm
D. Secundum > 3cm
E. sinus venosus ASD
C

"Of these, only an ostium secundum ASD is suitable for percutaneous closure..." "If the defect is very large (>3 cm) or complicated (associated with other abnormalities),
or an incomplete rim is detected, referral for surgical closure is indicated."CEACCP 2008
Respiratory function in quadriplegics is improved by
A. abdominal distension
B. an increase in chest wall spasticity
C. interscalene nerve block
D. the upright position
E. unilateral compliance reduction
B.
From JCA
"Lesions below the C5 level (T1–T12) affect intercostal and abdominal muscles. In this situation, respiratory impairment results predominately from inspiratory and expiratory muscle weakness; intercostal muscle function is altered and there is a resulting paradoxic inward rib cage movement on inspiration. These patients most often do not require mechanical ventilatory support unless there are also associated injuries, such as cerebral involvement, cardiac or pulmonary contusions, pulmonary edema, or respiratory insufficiency from pneumonia. In this type of injury, improvement in ventilatory mechanics begins as early as 3 to 5 days after the initial insult, because muscle function improves as a result of the transition from flaccid paralysis to muscle spasticity. During this transition, there is an increase in muscular tone that promotes rib cage stability and decreases paradoxical chest wall movement during the inspiratory phase, improving vital capacity, and overall inspiratory function for up to 6 months. This gradual improvement is more prominently noted for inspiratory than expiratory muscles."
Carbon dioxide is the most common gas used for insufflation for laparoscopy because it
A. is cheap and readily available
B. is slow to be absorbed from the peritoneum and thus safer
C. is not as dangerous as some other gases if inadvertently given intravenously
D. provides the best surgical conditions for vision and diathermy
E. will not produce any problems with gas emboli as it dissolves rapidly in blood
C
Histamine release in anaphylaxis does NOT cause:
A. Tachycardia
B. Myocardial depression
C. Coronary artery vasodilatation
D. Prolonged PR interval
E. Decreased impulse conduction
B
A device that detects a 10mA difference in active and neutral leads and causes turning off of the circuit within 40 ms. This is a:
A. Class 1 device
B. Equipotential earthing
C. Line isolation monitor
D. Residual Current Device
E. Fuse
D
Which of the following is NOT an absolute contra-indication for MRI?
A. cochlear implant
B. heart valve prosthesis
C. ICD
D. pacemaker
E. intracranial clips
B
One lung ventilation and hypoxaemia. After 100% O2 and FOB next step is:
A. CPAP 5cm top lung
B. CPAP 10cm top lung
C. PEEP 5cm bottom lung
D. CPAP 5cm top + PEEP 5cm bottom
E. ?
Controversial!
I like CPAP 5cm top + PEEP 5cm bottom
Long duration of surgery, arms stretched out, head turned 30 degrees to right. On waking patient has a neurological deficit. Sensory loss over ventral lateral palm and 3 fingers, some weakness of the hand, weakness of the wrist, some paraesthesia of the forearm and weak elbow flexions. Most likely injury is
A. Median nerve
B. Ulnar nerve
C. C5 nerve root
D. Upper cervical trunk
E. Musculocutaneous
D. again
Plasma glucose level compared to blood glucose level
A. 32% higher
B. 14% higher
C. Same
D. 14%lower
E. 32% lower
B? 14% higher
"Whole-blood values are about 10 to 15 per cent lower than those of plasma" - OTM p 1449
With regards to obstructive sleep apnoea (OSA), which of the following statements is INCORRECT?
A. hypoxaemia is the main stimulus to arousal
B. the main method of treating this syndrome is with Continuous Positive Airway Pressure (CPAP)
C. this syndrome is the most likely diagnosis in patients presenting with excessive daytime sleepiness
D. this syndrome occurs in up to 5% of adults
E. this syndrome rarely has an obstructive component
E. Seriously?!
Management of rhabdomyolysis – best option?
A. Haemodialysis
B. Bicarbonate
C. Frusemide
D. IV fluids
E.
Fluids fluids and more fluids!! D
Residual current devices:
A. Compare current between active and neutral lines
B.
C.
D. Must be fitted in cardiac protected areas
E. Must be fitted in operating theatres
A

CEACCP Electrical Safety in OT + Steve Threlfo's notes
Serotonin syndrome has been reported following SSRI coadministration with:
A. Gingko
B. Garlic
C. Ginger
D. St John’s wort
E. Vallerian
D. St John's Wort --> Increases serotonin

(Gingko increases bleeding; Garlic increases bleeding; st john's wort has procoagulant effect (decreases warfarin efficacy))
Child with ?pyloric stenosis and 3 days of vomiting. Which bloods would you expect? [Not given pH]
A. Na 130 K 4.5 Cl 90 Bic 17
B. Na 130 K 2.5 Cl 87 Bic 24
C.
D.
E.
B. Hypochloraemic hypokalaemic metabolic alkalosis
Which LMA has highest seal pressure?
A. Classic
B. Disposable supreme
C. Flexible
D. Intubating
E. Proseal
Depends what we're referring to again - ILMA has highest oesophageal pressure seal / Proseal has highest laryngeal
Why is tachycardia bad in mitral stenosis?
A.
B. Increases transvalvular pressure gradient
C.
D.
E.
B

Patients with mitral stenosis usually have symptoms typical of left-sided heart failure: dyspnea on exertion, orthopnea, and paroxysmal nocturnal dyspnea. Less frequently, they have hemoptysis, hoarseness, and symptoms of right-sided heart failure; these symptoms are somewhat more specific for mitral stenosis. Often the patient remains asymptomatic until she becomes pregnant or has atrial fibrillation, when dyspnea and orthopnea are noted. The symptoms of mitral stenosis stem from increased left atrial pressure and reduced cardiac output, primarily caused by mechanical obstruction of filling of the left ventricle. Although the symptoms are those of left ventricular failure, contractility of the left ventricle is usually normal in mitral stenosis.

However, in some cases, the left ventricular ejection fraction is reduced because of excessive afterload secondary to a reflexive increase in systemic vascular resistance. Since it is the right ventricle that ultimately bears the burden of propelling blood through the mitral valve, right ventricular function is compromised first by the afterload imposed on it by high left atrial pressure and then by the development of secondary pulmonary vasoconstriction.
If atrial fibrillation develops, rate control with digoxin, a beta-blocker,or a calcium-channel blocker is crucial, since a rapid heart rate further impairs left ventricular filling, simultaneously reducing cardiac output and increasing left atrial pressure.

With mitral stenosis, a diastolic gradient develops between the left atrium and ventricle. As the degree of mitral stenosis worsens, a progressively higher transvalvular pressure gradient becomes necessary to maintain adequate cardiac output. The mean left atrial pressure in patients with severe mitral stenosis may be in the range of 15 to 20 mmHg at rest, with a mean transvalvular gradient of 10 to 15 mmHg. The high left atrial pressure and gradient rise substantially with exercise. LV end-diastolic pressure is usually in the normal range.
You intubate a young male patient for a left thoracotomy with a 39FG Robertshaw tube. When you inflate both cuffs and ventilate the bronchial lumen you get left sided ventilation. When you attempt to ventilate the tracheal lumen the pressures are very high and you get no air entry. Yet when you deflate BRONCHIAL cuff you can ventilate BOTH left and right lungs through the tracheal lumen. The most appropriate step to take next is:
A. Change to a 41FG tube
B. Change to a 37FG tube
C. Deflate both cuffs and insert further cm and recheck
D. Deflate both cuffs and withdraw a few cm and recheck
E. Pull ETT out and start again.
C. Cuff herniating into other bronchus?
** Review
If you can ventilate BOTH lungs when cuffs are down (assume that is what they mean when they say you can ventilate the patient) then, when the bronchial cuff is inflated, it must be blocking the passage of air via the tracheal lumen, ie bronchial cuff is at the carina and tube needs to go in further.
The average expected depth of insertion of an oral endotracheal tube, from the lip, in a normal newborn infant is
A. 7.5 cm
B. 8.5 cm
C. 9.5 cm
D. 10.5 cm
E. 11.5 cmC
C.

Miller:
Premature 6-7
Term 8-10
Infants Age/2 + 12
In neonates of various weights (ie to include prems) the formula to remember is weight plus 6. Thus average newborn weight is 3.5 kg so average length is 9.5 cm.
The approximate depth of insertion measured from the centre of the lips for an oral tube:
in a newborn is 9.5 cm,
11.5 cm for a 6 months old infant
12 cm for a 1 year old.
Thereafter, the approximate depth of oral insertion is given by the formula: age (years)/2 + 12 cm. (Paediatric advanced life support: Australian Resuscitation Council Guidelines 2006)
What is NOT a feature of high spinal block?
A. Hypotension
B.
C. Hard to speak
D. Numb hands
E. Tachycardia
E. Bradycardia from blockage of sympathetic thoraco-lumbar fibres (PNS = cervical and sacral)
Positive predictive value is:
A. The proportion of people without disease who are correctly identified as not having the disease.
B. The proportion of people with disease who are correctly identified as having the disease.
C. The proportion of people with disease who have a positive test result
D. The proportion of people without disease who have a positive test result
E. etc
C
PPV = TP/(TP+FP)
the proportion of positive test results that are true positives (such as correct diagnoses). It is a critical measure of the performance of a diagnostic method, as it reflects the probability that a positive test reflects the underlying condition being tested for. Its value does however depend on the prevalence of the outcome of interest, which may be unknown for a particular target population.
Stellate ganglion block is associated with all EXCEPT:
A. Ptosis
B. Miosis
C. Sweating
D. Facial flushing
E. Nasal stuffiness
C.
Causes a Horner's syndrome - miosis, ptosis and anhydrosis
Recognised clinical associations with dystrophia myotonica include
A. development of diabetes mellitus
B. abnormal intestinal motility
C. cardiomyopathy
D. ovarian dysfunction
E. all of the above
E.
Myotonia dystrophica usually manifests as facial weakness, wasting and weakness of SCM, ptosis, dysarthria, dysphagia, inability to relax handgrip. Triad of mental retardation, frontal baldness and cataracts. Endocrine involvement = gonadal atrophy, DM, hypothyroidism, adrenal insufficiency. Delayed gastric emptying and intestinal pseudo-obstruction may be present.
Death from pneumonia or heart failure often occurs by 6th decade, reflecting involvement of skeletal muscles, cardiac muscle and smooth muscle.
Periop M & M high due to cardiopulmonary complications.

Wiki
Acta Anaesthesiol Scand 2003; 47: 630—6
Patients with MC are at high risk of developing a severe myotonic response with generalised muscle spasms whenever depolarising muscle relaxants are used.
Left bundle branch block (LBBB) on the ECG is
A. commonly a normal variant
B. associated with a delay in atrio-ventricular conduction
C. demonstrated by a notched R wave in chest lead V1
D. associated with right axis deviation
E. a relative contra-indication to flotation of a pulmonary artery catheter
A. No - RBBB can be normal. LBBB is pathological from LVH or IHD (Stoelting)
B. Anatomically are in left BUNDLE of His
C. This is a RBBB (moRroW)
D. RBBB again - LBBB are LAD
E. 5% of patients can get RBBB with PAC therefore leading to complete heart block...uh oh

Shah et al reviewed 6245 patients undergoing pulmonary artery catheterization, and reported an incidence of complications of 72%. Transient dysrhythmias resolving with advancement or withdrawal of the catheter included PVCs, which occurred in 68% of patients and PACs, which occurred in 1.3%. 3.1% of the patients had PVCs which persisted despite catheter advancement or withdrawal, and required treatment with lidocaine. Transient right bundle branch block (RBBB) was reported in 0.048%. 113 patients developed left bundle branch block (LBBB), one of whom developed complete heart block and required pacing.
Sprung et al reported a 3% incidence of RBBB with no higher risk in patients with pre-existing conduction defects. (e.g., LBBB)

Morris et al evaluated 82 PA catheterizations in 47 patients with LBBB. No complete heart block was associated with PA catheter placement.
When hearing loss occurs following spinal anaesthesia it is usually in which of the following frequency ranges:
A. 125 - 1000 Hz
B. 1500 - 3000 Hz
C. 3500 - 5500 Hz
D. 6000 - 10000Hz
E. > 11000Hz
A.
Hearing loss after spinal anesthesia: The effect of different infusion solutions . Otolaryngology - Head and Neck Surgery , Volume 137 , Issue 1 , Pages 79 - 82, 2007 Quotes the range in A (125-1000Hz

Anaesth Analg 2002; 94: 1318-20
Anaemia in chronic renal failure is characteristically
A. due to haemolysis in the renal vascular bed
B. normochromic and microcytic
C. due to defective haemoglobin synthesis
D. responsive to ion and folate therapy
E. associated with increased 2,3-DPG levels in blood cells
E.
Normochromic normocytic from decreased eythropoietin.
A 12 year old child with hip dislocation at 4pm. Ate something 1 hour after injury. Now 11 pm. Best anaesthetic:
A. RSI with ETT
B. delay until next day then treat elective
C. inhalational induction and continue with face mask
D. Reduce immediately with iv sedation
E. inhalational induction and continue with face mask
A or C
Central anticholinergic syndrome, which is NOT true:
A. Will improve with neostigmine
B. Peripheral anticholinergic symptoms
C. Caused by anti-Parkinson drugs
D. CNS depression
E. Associated with agitation, delirium, and ???
A. Physostigmine is the only treatment as cross BBB

B true / C true / D yes / E yes

Possible effects of anticholinergics include:
Ataxis, xerostomia/dry mouth, anhydrosis, hyperthermia, mydriasis, photophobia, blurred vision, diplopia, tachycardia, urinary retention, ileus, increased IOP, shaking, confusion, disorientation, agitation/dysphoria, resp depression, myoclonic jerking, orthostatic hypotension


CEACCP article on anticholinergics:
Reversal of intoxication caused by central
anticholinergic drugs
Anticholinergics that cross the blood–brain barrier (e.g. atropine, hyoscine) can give rise to central excitation or depression. This is known as the central anticholinergic syndrome. Patients may suffer thought impairment, hallucinations, ataxia, recent memory loss, and behavioural abnormalities. It can be reversed by intravenous physostigmine 2 mg followed by additional doses as required.
Carcinoid syndrome - finding on examining heart:
A. Fine inspiratory crepitations
B. Systolic murmur at apex
C. Systolic murmur at left sternal edge
D. Murmur at apex with opening snap
E. Pericardial rub
C

Wiki: About 50% of patients have cardiac abnormalities, caused by serotonin-induced fibrosis of the tricuspid and pulmonary valves, called cardiac fibrosis. Elevated levels of circulating serotonin have been associated with cardiac failure, due to fibrous deposits on the endocardium. These deposits are thought to be responsible for the fibrous degeneration of the valve apparatus. "TIPS" is an acronym for Tricuspid Insufficiency, Pulmonary Stenosis (fibrosis of tricuspid and pulmonary valves).
Lowering intra-ocular pressure by applying pressure to the globe (e.g. Honan balloon) is typically contraindicated in a patient having
A. a revision corneal graft
B. a revision trabeculectomy
C. an extra-capsular lens extraction
D. a redo vitrectomy
E. repeat retinal cryotherapy
B. As per the consensus on wiki.

The question refers to which condition is the honan ballon contraindicated in? A: cloudy cornea – false B: glaucoma – relative contraindication, high IOP C: cataract – false D: variety of conditions: haemorrhages, retinal detachments most commonly. E: retinal detachments, tumours, angiomas....

When using peribulbar and retrobulbar injections in patients with advanced glaucoma, reduced anesthetic volumes and avoiding the use of orbital Honan balloons is advisable because these can increase intraocular pressure. (Current Opinion in Ophthalmology Issue: Volume 16(2), April 2005, pp 107-113)

A trabeculectomy involves formation of a bleb under the upper eyelid, as part of the mechanism by which IOP is relieved. Excess fluid drains into the bleb and is slowly absorbed into the episcleral (or conjunctival, can't remember) blood vessels.
Troponin is elevated post-infarct
A. 1-2 days
B. 2-5 days
C. 5-14 days
D. 7-21 days
E.
C

CEACCP article on troponins:
After myocardial cell damage, unbound cytoplasmic troponin is released from cardiac myocytes. Both troponin I and T exhibit biphasic release kinetics. Release from the cytosolic pool gives increase to blood concentrations rising 4–6 h after the onset of damage and peaking at 12–24 h after myocardial
injury. Structural protein release leads to a second peak 2–4 days after injury.
Continuing breakdown of myofibrillary-bound complex explains the prolonged elevation of both troponins for up to 10 days after infarction.
Myotome of C6-7
A. Shoulder flexion
B. Shoulder extension
C. Elbow flexion
D. Wrist flexion and extension
E. Finger flexion and extension
D. Wrist flexion and extension
C6 - wrist extensors, carpi radialis longus and brevis (radial extension), biceps brachii; C7 - triceps, wrist flexors, finger extensors
Head Trauma patient with unilateral dilated pupil, whats the diagnosis ?
A.Global injury
B.Optic nerve injury
C.Horners syndrome
D.Transtentorial herniation
E.
D. Concerning!
Horner's = mioisis
Global = why unilateral
Optic nerve = not unilateral?
The PREDOMINANT pathophysiological effect of restrictive cardiomyopathy is:
A.
B. Diastolic dysfunction
C.
D.
E.
B

CEACCP on Cardiomyopathy - see also Diastolic dysfunction article
Diastolic dysfunction can be caused by either impairment of active relaxation or a reduction in left ventricular compliance or a combination of both. Active relaxation is most commonly affected by ischaemia, while a reduction in ventricular compliance may be due to intrinsic myocardial changes including fibrosis or external restriction due to pericardial disease
When does effect of diclofenac on platelets wear off?
A.
B. 12 hours
C.
D.
E.
B
??

Half life 2 hours
Depends on whether SR or IR


What Should We Do With
Aspirin, NSAIDs, and
Glycoprotein-Receptor Inhibitors?
Michael W. Russell, MD
David Jobes, MD
What does C6/7 do?
A.
B.
C.
D.
E. wrist flexion/extension
E

Kam 2002 Notes ("Essential Anatomy for Anaesthetists" file)
C5-7 - Musculocutanous; supplies
- Motor - coracobrachialis / biceps / brachialis (therefore elbow flexion)
- Sensory - elbow joint and lateral aspect of forearm

C5-T1 = Median nerve
Motor to pronator teres, FCR, palmaris longus, FDS, thenar eminence, lateral 2 lumbricals, half FDP, FPL, pronator gradratus
Sensory to elbow, wrist, anterior aspect of lateral 3.5 digits and dorsal aspect of distal phalanges of same digits

C8-T1 = medial cutaneous nerve of arm + medial cutaneous nerve of forearm
First supplies (sensory) distal half of medial side of arm
Latter supplies anterormedial aspect of forearm + posteromedial aspect of forearm

Ulnar C7-T1 = continuation of medial cord
Motor to FCU, FDP (with median), intrinsic muscles of hand except lateral lumbricals
Sensory to elbow, wrist, medial 1.5 fingers

Circumflex C5-6 supplies shoulder, deltoid, teres minor and sensory skin on posterolateral upper arm

Radial = C5-T1, branches are:
- Posterior interosseous = supinator, extensors of wrist and fingers and APL
- Muscular branches = triceps, anconeus, brachialis, brachioradialis and ECR longus
- Posterior cutaneous = proximal 1/3 of posterior arm
Muscle NOT supplied by sciatic nerve:
A.
B. gluteus maximus
C.
D.
E.
B

Sciatic nerve supplies:
Long head of biceps femoris
Semitendinosus
Semimembranosus
Ischial fibres of adductor magnus (Kam notes)

(Gluteus maximus supplied by: inferior gluteal nerve)

Anatomy:

The sciatic nerve is the largest nerve in the body. It originates from the anterior divisions of L4 + 5 + S1 - 3. The roots fuse + leave the pelvis through the greater sciatic notch below the piriform muscle. It is lateral to the inferior gluteal + pudendal nerves + vessels. It lies on the ischium over the posterior part of the acetabulum. The sciatic nerve lies ≈ midway between the ischial tuberosity + the greater trochanter of the femur, below the lower part of the gluteus maximus muscle. It passes vertically downwards over obturator internus + quadratus femoris + then descends into the upper thigh midway between the ischial tuberosity + the greater trochanter, where it becomes deep to biceps femoris. In the thigh the nerve gives off branches to the hamstring muscles + the abductor magnus muscle. About half to two-thirds of the way down the thigh the nerve splits into its two major components, the tibial + common peroneal nerves.
The tibial component of the sciatic nerve provides motor branches to the long head of biceps femoris, semitendinosus, semimembranouus + the ischial fibres of adductor magnus. The common peroneal components supplies the short head of biceps.
Negative predictive value is best described as
A.
B. Chance of a negative test in people without a disease.
C.
D.
E.
B

The whole point of a diagnostic test is to use it to make a diagnosis, so we need to know the probability that the test will give the correct diagnosis. The sensitivity and specificity do not give us this information. Instead we must approach the data from the direction of the test results, using predictive values.
Positive predictive value is the proportion of patients with positive test results who are correctly diagnosed.
Negative predictive value is the proportion of patients with negative test results who are correctly diagnosed.

BMJ Stats article 1994; 309:102 (9 July)
Time to reach peak plasma concentration after injection of 2% lignocaine with adrenaline into epidural space
A. 20 min
B. 30 min
C. 40 min
D. 50 min
E. 60 min
B
Anesth Analg. 1997 Mar;84(3):527-32.
J W Downing, H V Johnson, H F Gonzalez, T L Arney, N L Herman, and R F Johnson
The pharmacokinetics of epidural lidocaine and bupivacaine during cesarean section
= around 30 mins

Also: http://www.nysora.com/test2/regional_anesthesia/neuraxial_techniques/3026-epidural-blockade.html
Onset 10-15 mins; duration increased 40-60% with adrenaline

Decreased peak plasma concentration by 30-50% with addition of adrenaline - Neural Blockade book on google (Michael Cousins)