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181 Cards in this Set
- Front
- Back
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What are Lee’s criteria for increased CVS risk perioperatively?
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• IHD – defined as history of MI/ angina/ GTN use/ +ve EST/ previous revascularisation
• CCF • Cerebrovascular disease • High risk surgery - 1-2 criteria: 2-7% event rate w’out block • Insulin treatment for DM - 3-4 criteria: 9-20% • Preop creatinine > 180μmol/ L - >=5 criteria: 30% |
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What are the standard monitors required by ANZCA?
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• BP (non invasive), SPO2, FIO2, ETCO2, vol agent, ECG, T, disconnection alarm, NM block
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What are the intermediate risk factors for cardiac morbidity for non-cardiac surgery according to the AHA/ACC guidelines?
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• Mild/ stable angina
• Prior MI • Compensated or prior CCF • DM • Renal insufficiency |
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What is the formula that relates Doppler shift and blood flow velocity?
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• V = c (Fs – Ft)
c= speed of sound in blood (1540m/s) 2 Ft cosT Fs – Ft = Doppler shift T = intercept angle |
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What are the haemodynamic goals for the patient with mitral stenosis?
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• Preload – adequate
• Afterload – no ↑ in RV afterload • Contractility – avoid depression, usually okay • Rate – slow • Rhythm – control AF |
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What are the haemodynamic goals for the pt with cardiac tamponade?
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• Preload – full: therefore ketamine or etomidate
• Afterload – increased • Contractility - ↑ • Rate – fast • Rhythm - sinus |
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What are the factors that worsen LVOT obstruction in HOCM?
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• SAM, systolic anterior motion of mitral valve leaflet- MR and outlet obstrn
• Worse outlet obstruction with ↑ HR, ↓ preload, ↓ afterload, ↑ contractility |
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What factors can we alter to prevent worsening of pulmonary hypertension?
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• Avoid hypoxia/ hypercapnia/ acidosis/ atelectasis/ hyperinflation + PEEP/ drugs/ N2O
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What is the role of jugular bulb oximetry?
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• No preventive role, experimental use in cardiac surgery
• Involves retrograde cannulation IJV – continuous vs intermittent • Imbalance between cerebral O2 supply and demand thought to play a role in development of neurological injury after CPB • Normal SjO2 55-75%, if<50% insufficient to meet metabolic demands • SJ O2 ∝ CMR O2/CBF • Art – Jugular O2 content diff = CMR O2/CBF N 4 – 7 ml/ dL |
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What requirements are necessary before regional anaesthesia is conducted?
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• C consent
• I iv access drugs • M monitoring resuscitation equipment • P position • L landmarks • E evaluate |
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Classify the porphyria’s. What is the defect? List some drugs considered unsafe in porphyria.
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• Hepatic porphyria’s
• Acute intermittent P ] Autosomal Dominant • Variegate P ] • PCT • Hereditary coproporphyria • Erythropoietic porphyrias • Group disorders of porphyrin metabolism due to defects in certain enzymes in the synthesis of haem → overproduction porphyrins due to ↑ aminolaevulinic caid (ALA) synthetase activity 2° +ve ¬¬feedback • Unsafe drugs – STP/ enflurane/ alcuronium/ pentazocine/ phenytoin/etomidate |
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What are the criteria for brain death?
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• Reversible causes coma excluded – eg drugs/ shock/ metabolic
• Not hypothermic • No spontaneous movement or in response to pain • No seizures/ posturing • No brainstem reflexes – pupil/ gag/ corneal/ caloric • Apnoea test PaCO2 > 60 while insufflate O2 |
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What are the indications and CIs for awake fibreoptic intubation?
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Indications
• Known or predicted difficult direct laryngoscopy • Unstable C spine, airway trauma • Mid tracheal lesion – eg retrosternal goitre Contraindication • Gross upper airway abnormalities • Critical upper airway obstruction • Uncooperative patient • Pus or blood in airway (relative) |
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What are the hazards of laser surgery?
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• Atmosphere contamination Eye damage
• Fire/ explosion • Air Embolism – NdYAG coolant gas • Organ or vessel perforation • Those specific to surgery on shared/ compromised airway |
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What is the management of an airway fire?
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• Stop ventilation
• Disconnect O2 • Remove ETT, flood field with saline • Mask ventilate with 100% O2 • Reintubate • Assess damage • Monitor patient/ supportive therapy • May consider continuing with surgery |
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What are the symptoms of the TURP syndrome? How is it treated?
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• Dilutional hyponatraemia, symptoms predominately neurological
• Headaches, dizziness, confusion, nausea, visual changes – coma, seizures • Dyspnoea • Cardiac - ↓ HR, change BP, ↑ QRS → VT/ VF • Make diagnosis, notify surgeon, cease surgery ASAP, ABC, fluid restrict, frusemide, check U & E’s, hypertonic saline for severe cases |
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What are some contraindications for ECT?
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• ↑ ICP – intracranial mass lesion - No consent is only absolute one.
• Recent CVA - NB: Pregnancy isn’t a CI • Recent MI • Not fasted/ aspiration risk |
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What are your indications for an arterial line?
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1. Small BP swings → physiologic problems eg. AS
2. Large BP swings→ want to know when they happen 3. Frequent blood tests 4. Can’t get reliable reading from automated cuff |
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19. What are your criteria for extubation?
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• Adequate LOC
• Airway reflexes intact • ETT not acting as a stent • Stable hemodynamics • T/ pH/ electrolytes/ BSL okay • Adequate analgesia • NMJ/ phrenic n function- sustained head lift 5s • Adequate respiratory function -> pO2 > 60 with FIO2 0.4, PEEP ≤ 5 -ve insp. Force > 25cm H2O |
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What does C.O.V.E.R. stand for?
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• COVER is crisis management algorithm
• C Circulation/ Colour • O Oxygen/ O2 analyser • V Ventilate by hand/ Vaporiser • E ETT/ Eliminate anaesthetic machine • R Review monitors/ Review equipment |
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Checklist prior to going on to CPB.
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• L Labs ACT> 400, heparin 3mg/ kg
• A Anaesthesia adequate, cease iv, alarms off, lungs off • M Monitoring – arterial line, CVP, pull PAC back • P Pressure < 70 for cannulation Pt – cannulation in place, no kinks/ bubbles, heart not distended |
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Checklist for coming off CPB.
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• T Temp > 36.5
• R Rate • A ABG’s/ alarms/ adequate anaesthesia • V Ventilate/ vasoactive drugs ready • E Electrolytes K+ > 4, Ca 2+ normal, Hct > 20 % • L Look at heart- deaired, contractility |
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What are some side effects of cyclosporine?
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• Hypertension
• Nephrotoxicity • Hepatotoxicity • Neurological – epileptogenic, peripheral neuropathy, confusion • Electrolyte changes: ↓ Mg, ↑ K, ↑ BSL |
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What are the anaesthetic implications of a pt on immunosuppressants?
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• Pre – op:
Indication for immunosuppression ? transplant Hypertension ? CAD high prevalence ? Renal dysfunction ? Neurological complications Drug regimen • Perioperatively: Strict attention to asepsis Antibiotic cover Maintenance immunosuppressants |
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How would you make up an adrenaline infusion to begin at 0.2 mcg/kg/min ?
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Patient’s weight in kg
Put 0.3 x wt = x mg in 100mls 1 ml/ hr = 0.05μg/kg/min Therefore for 0.2μg – run at 4 mls/ hour |
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How would you chemically pace someone?
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• Use isoprenaline 2mg in 100mls 5% Dextrose
• Give 1 ml bolus (20μg) then run infusion at 1 – 5 μg/ min = 3 –15mls/ hr • May see hypotension- beta 2 effect |
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What are some causes of delayed awakening?
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• 4 H’s: Hypoxia/ Hypercapnia Hypoglycaemia Hypothermia Hypotension
• Drugs- inc accidental • Metabolic • Neurologic |
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Perioperative Mx of pt with Von Willebrand’s disease.
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• VWD – which type
• I – commonest • II b – DDAVP CI • III – severe, factor VIII concentrate • Treatment – DDAVP 0.3μg/kg as infusion 90 min pre op |
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Perioperative Mx of pt with Haemophilia.
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• Haemophilia A treatment - AHF, factor 8 concentrate(250units/ amp)
Rx bleeding/surgery 40-50u/kg, rpt dose 20u/kg q 12/24. Haemophilia B Rx- factor IX |
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What is the significance of debrisoquine hydroxylase?
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Also known as CYP2D6, fast and slow acetylators depending on enzyme activity- genetically determined (6-10% Caucasians). Substrate drugs include TCAs, codeine, tramadol, ondansetron. Inhibited by SSRIs, quinidine and methadone.
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31. What are the diagnostic criteria for fat embolism syndrome?
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Major criteria are- petechial rash is pathognomonic
- resp Sx CXR- bilateral diffuse infiltrates, ↑A-a gradient - neurological Sx- confusion, drowsiness, coma |
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What are the benefits of epidural analgesia/ anaesthesia?
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• Excellent analgesia
• ↓resp failure (MASTER trial) • ↓blood loss- orthopaedic jt replacement • ↓DVTs • ↓ileus |
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Indications and CI for a DLT.
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• Isolation to prevent contamination of other lung with pus/blood
• Control of distribution of ventilation - CI: lesion in path of DLT, • Bronchopulmonary lavage - small pts, difficult intubation, pt with SLT • Surgical exposure - who can’t tolerate period off ventilator. |
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What is the Apgar Score?
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Named after Virginia Apgar, neonatal assessment score from 0-10 on 5 criteria:
HR, respiratory effort, muscle tone, reflex irritability, colour |
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Classify causes of hypoxia.
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• ↓FIO2
• ↓Ventilation • ↓O2 carrying capacity of blood (CO, CN) • V/Q mismatch • Diffusion block • ↓C.O. |
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Causes of hypotension during anaesthesia.
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• ↓preload- absolute or relative - ALTERNATIVE: HYPOVOLAEMIA
• ↓afterload- ? anaphylaxis - CARDIAC- rate, rhythm, contractility • ↓contractility - RESPIRATORY- PTX, embolism • rate - VASODILATION- drugs/anaphylaxis/sepsis/endo • rhythm - VASOVAGAL • spurious |
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Mx cardiac arrest- rhythm is VF.
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Call for help
Precordial thump Monitors, pulse, 100 % O2 via ETT Defibrillate 200/300/360, CPR 1min. adrenaline 1mg q3/60 Think of cause- ? amiodarone 300mg push, Mg, NaHCO3 |
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How treat a suspected MH reaction?
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Medical emergency, call for help, MH box
Stop trigger agent, clean circuit, 100% O2 , Dantrolene 2.5mg/kg up to 10mg/kg Bicarb 1-2mmol/kg, cool pt, further monitoring/ bloods Treat hyperkalaemia, maintain urine output, ICU Follow up- letter, testing, medic alert |
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How treat air embolism?
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Notify surgeon, Flood field with saline
Pt head down, left lateral position, hyperventilate 100% oxygen, iv fluids, support circulation- adrenaline and CPR if necessary |
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Rules to determine if respiratory compensation has occurred in metabolic acidosis/alkalosis.
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Metabolic acidosis- exp PCO2 = 1.5 (HCO3) + 8
Metabolic alkalosis- exp PCO2 = 0.7 (HCO3) +20 |
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Define mean, mode and median.
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Measures of central tendency in a sample distribution
Mean- average of sample values Mode- most frequently occurring sample value Median- central value if samples arranged from smallest to largest value |
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What is a confounding factor?
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A variable that obscures the true relationship between the study variable and the outcome.
It itself is an independent predictor of outcome. |
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What are some factors that determine the power of a study?
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Power- ability to detect a difference when one is present. - probability of correctly rejecting the null hypothesis
=1-beta factors- sample size, variability in population, magnitude of difference, significance level (p) |
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What are some parametric tests?
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Student’s t test, ANOVA, MANOVA, regression, correlation
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What are CI for cell salvage?
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Tumour in operative field, local sepsis, using cement, use of prothrombotic agents, contamination by gut contents.
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What are some CI for regional anaesthesia in cataract surgery?
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Usual CI for any block- pt refusal, sepsis, coagulopathy, allergy, pt unable to cooperate eg dementia, intellectual impairment
Other- unable to lay still or flat, complex ocular surgery, surgeon refusal, paediatric pts, no vision in non-operative eye, long myopic eye >25mm. |
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What is the capacity of gas cylinders commonly used in anaesthesia?
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A 85L B 200L C 400L water cap 2.8L, 13700 kPa, 440L O2
D 1400 water cap 9.3L 1500L O2 3200L N2O E 3500 G 7000 pressure around 16000 kPa |
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Anaesthetic implications of Down’s syndrome.
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Airway- big tongue, tonsils, subglottic stenosis, URTIs, poor muscle tone. OSA
Atlantoaxial instability in 15% CVS- endocardial cushion defects, VSD, PDA, TOF CNS- intellectual impairment, unpredictable response to CNS depressants Other- hypothyroid, obese, GOR, difficult iv access. |
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Clinical signs of severe aortic stenosis and mitral stenosis.
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1. plateau pulse 1. small pulse pressure
2 aortic thrill 2. diastolic thrill 3 length and lateness of the peak of the systolic murmur 4 S4 3. length of mid-diastoloic murmur 5 splitting of S2 4. early opening snap 6 LVF 5. pulmonary hypertension |
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Clinical signs of severe mitral regurgitation.
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• Small volume pulse soft S1
• LVH pulmonary HTN • S3 early diastolic rumble |
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What are your criteria for readiness to operate for infantile pyloric stenosis?
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Not a surgical emergency
NGT, iv fluids, adequately resuscitated HCO3<30 Cl>90 K>3 UO>1ml/kg/hr Urinary Cl- guide to volume resuscn |
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What are some risk factors for PONV?
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Apfel- female, non-smoker, Hx PONV/ motion sickness, use of opioids post-op.
Incidence PONV depending on no. factors from 0-4: 10, 20, 40, 60, 80%. |
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Draw the axes for the unipolar and bipolar limb leads
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N axis –30 to +120 LAD up I, down II,III RAD up II,III down I
EAD down in all 3 |
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What is the pethick test?
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Test used to assess the integrity of the inner tubing (7mm) of a BAIN circuit. Describe it
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Draw the Mapleson circuits and compare their efficiency for spontaneous vs controlled ventilation.
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Spontaneous A>D>F>E>C>B all dogs for ever cause bites
Controlled D>F>E>B>C>A don’t for ever bother cats again |
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What are the features of a Howison alarm.
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O2 pressure alarm- spring loaded valve
1 whistle alarm when p< 40psi 2 cuts off N2O 3 supplies O2 at a reduced rate 800ml reservoir |
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Draw a circle circuit.
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need to draw
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What is the max recommended dose of epidural bupivacaine in a child?
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0.4mg/kg/hr (0.2mg for neonates) If use 0.125% solution= 0.3mls/kg/hr
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Define quality assurance.
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QA is the process which assesses and evaluates overall performances in the delivery of health care.
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What are the CVS effects of aortic X-clamping?
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↑ SVR/ MAP/ PAWP/ CVP/LVEDP
↑LV wall tension and myocardial O2 demand ↓CO and EF ↑preload- may not be significant if infrarenal clamp and splanchnic shunting. |
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What are the surface markings for the pleural margins? The lungs?
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Superiorly 1 “ above medial 1/3 clavicle, meet at sternal angle and continue to the 4th costal cartilage where the left arches laterally , both are lateral at the 6th cartilage.
8th MCL 10th MAL 12th lat erector spinae lungs- 2 ribs higher than pleura |
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How do volatile agents act as myocardial preconditioning agents?
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Definition. Mechanism not fully elucidated but opening of ATP dependent K channels imp.- K efflux and ↓Ca influx. Less free radicals generated. Adenosine A1 receptor activation.
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What are some adverse consequences of mild hypothermia?
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CVS- ↑SVR/CVP/ myocardial O2 demand/ adverse cardiac events
Haem- coagulopathy, ↑viscosity Resp- ↑V/Q mismatch, ↓HPVasoconstriction= hypoxaemia Immune/ Metabolic/ CNS/ NMJ/ drug metabolism |
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What are some limitations of the laryngeal mask airway?
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• Doesn’t protect airway against aspiration
• Ventilation may be inadequate • Incorrect insertion can precipitate laryngospasm • Misplacement possible • Minimum mouth opening required- 11mm classic, 20mm ILMA |
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What are your criteria for discharge from a day surgery unit?
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General- awake/alert/orientated
Specific- complicns of Sx looked for Vital signs stable Ambulant Nausea/ vomiting controlled Responsible carer and means of transport Written instructions re contact details/ follow-up |
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What are some complications of intubation?
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F.T.A.B.E. failure to secure airway/ trauma/ autonomic response/ bronchospasm/ endobronchial intubation
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What are the contents of the pterygopalatine fossa?
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Terminal br.’s maxillary a., V2, pterygopalatine ganglion
Small pyramidal space inferior to apex of orbit, communicates via inf orbital fissure. |
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How would you do a sciatic nerve block?
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CIMPLE Posterior approach of Labat- lateral position, heel on knee of dependent leg.
Line 1 from PSIS to greater trochanter, line 2 perpendicular to line 1 bisects it, line 3 from sacral hiatus to greater trochanter. Junction line 2 & 3= puncture site. Alternatives- anterior and high popliteal approach. |
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Describe the anatomy of the intercostal space.
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3 Intercostal mm. Neurovascular bundle VAN sup to inf, inferior groove. Anterior rami 1st 11 thoracic nn, branches- rami c.,collateral, lateral, ant cut., muscular
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What are the clinical features of pre-eclampsia?
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Hypertension, proteinuria, headache, nausea, epigastric pain, hyperreflexia, visual disturbances, oedema.
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What nerves are blocked for an ankle block?
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5- tibial, saphenous (br. Femoral), sural, superficial and deep peroneal
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What are the margins of the paravertebral space?
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• Wedge shaped area between head and necks of the ribs • Post- sup costotransverse lig., posterior intercostal membrane
• Ant.- parietal pleura • Medial- post. Lat aspect of vertebra/ disc/ intervertebral foramen |
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73. Landmarks for deep cervical plexus block.
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Position- supine, neck extended, turned to contralateral side.
• Line from mastoid p. to Chassaignac’s tubercle, another line 1cm posterior • C4 at level inferior border mandible • Direct needle medially and slightly caudad until hit transverse process. |
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74. How would you perform a cricothyroidotomy?
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Pray. Surgical vs needle in kids. Neck extended, prep, equipment ready
• Transverse stab incision through cricothyroid membrane, scalpel handle or haemostat twisted and holding incision open. Cuffed 6.0 ETT. Confirm in correct place clinically and with capnography. Lots of complications. |
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75. Complications of an interscalene block.
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Epidural/ subarachnoid injection, vertebral artery puncture/ injection, Horner’s syndrome, phrenic nerve block >90%, RLN block- hoarseness.
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76. How do you perform a coeliac plexus block?
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• Pt prone- pillow under abdomen, I-I recommended. CIMPLE- fluid load Indications
• Line through inferior aspect spinous process L!, extend 7cm laterally, join to inferior aspect SP T12. 2x 10-15cm needles at 45o, aim to hit lateral aspect L1. Test dose, confirm with radio-opaque injection. Then use L.A. or alcohol. |
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77. In what order are the sensory modalities blocked by a SAB?
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1 autonomic
2 pain 3 touch 4 proprioception 5 motor |
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78. How do you assess blood loss in a patient?
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• ATLS Class I 15% II 15-30% III 30-40% ↓BP IV >40%
• Assess- skin perfusion, capillary refill I vasoconstriction, tachycardia • PR/BP/pulse pressure II tachy, reduced pulse p., anxious • Respiratory rate III tachycardic/pnoeic, hypotension, oliguric • Organ perfusion- LOC, oliguria IV v tachy, hypotensive, oliguric, ↓GCS |
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79. You stick the PAC introducer in to the carotid artery in a pt for a MVR. Mx?
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Leave it in. Tell surgeon. Cancel case. Vascular consult- may need surgical repair.
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80. What are the components of the primary survey?
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• Performed with simultaneous resuscitation
• Airway maintenance and C spine protection •Breathing and ventilation • Circulation and haemorrhage control • Disability- AVPU • Exposure and environmental control- T |
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81. List some life threatening chest injuries.
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Upper airway obstruction, tension PTX, open PTX, flail chest, massive haemothorax, cardiac tamponade, tracheobronchial tree injuries, aortic disruption, diaphragmatic injury, mediastinal traversing wounds.
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82. You’ve placed an LMA in a pt and can’t ventilate- what is your Mx?
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• Simultaneously diagnose and treat problem
• Remove LMA, hand ventilate with 100% O2, ? deepen anaesthesia • Reinsert LMA. Still no good?- mask ventilate OK?, ? laryngospasm, ? lung compliance, change to ETT. |
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83. How do you treat a ‘Tet’ spell?
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• Present with cyanosis, problem is worsening of R to L shunt due to ↑PVR or ↓SVR or both.
• Mx- correct factors that cause pulm HTN esp hypoxia • - raise SVR eg squatting, phenylephrine. |
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84. Describe the anatomy of the epidural space.
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• Epidural space is within spinal canal and outside the dural sac. Widest L2 5mm
• Contents- traversing nerve roots, fat, lymphatics and internal vertebral venous plexus (lateral, has no valves- allowing transmission of raised venous pressure, provides a venous bypass of the diaphragm.) • Sup- f magnum Inf- sacral hiatus S4 • Ant- vertebral body/ discs/ posterior longitudinal ligament • Post- vertebral laminae, lig flavum • Lat- pedicles, intervertebral foramina |
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85. You induce a pt with STP/Sux and initial BP is 50/. Mx?
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Check BP, 100% O2, volume, volatile off, legs raised, metaraminol/ phenylephrine- adrenaline if poor response. Looks for signs of anaphylaxis.
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86. Line Isolation Monitor goes off- what do you do?
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Check pt is OK, then systematically unplug equipment until it goes off, contact engineering department. Don’t do next case until problem sorted. Alarm when >5mA leakage current if circuit was earthed.
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87. After a prolonged labour with an epidural, pt c/o a numb leg. Approach to Mx?
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See pt and examine them, if signs suggesting epidural haematoma (neurology) organize urgent CT/MRI and neurosurgical consult. Document findings. Otherwise continued r/v and neurology consult- neuropraxia from birth trauma most likely cause.
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88. What are the anaesthetic implications of scleroderma?
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Airway (contractures) / reflux/ lungs (fibrosis, pulmonary HTN)/ CVS (heart block, pericardial effusion)/ renal disease/ difficult iv and arterial access.
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89. What are some causes of bigeminy?
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Light anaesthesia, excess volatile, hypercarbia and acidosis, ischaemia, electrolyte disturbance- ↓K
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90. What are the indications for dialysis?
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• Hyperkalaemia/ acidosis/ fluid overload- not manageable by other means
• Uraemia and uraemic complications eg pericarditis • Detoxification • ESRD on regular dialysis • Deteriorating renal function in a critically ill pt which is expected to progress. |
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91. What do the letters denoting a pacemaker type mean?
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NBG code I chamber paced II chamber sensed III mode of response (O/T/I/D) IV programmability, rate response V antitachycardia function
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92. What agents may be used for regional intravenous anaesthesia (IVRA)?
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• Prilocaine agent of choice 0.5ml/kg, lignocaine 3mg/kg OK, bupivacaine CI
• Additives: alkalinization, NSAIDS/ clonidine 1mcg/kg- improved post-op analgesia, opioids- little benefit, muscle relaxants- better motor block and easier # reduction. |
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93. What are the landmarks for the infraclavicular approach for a brachial plexus block?
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• Block at the level of the cords (lat/post/medial) • Supine, arms by side
• Injection site- 2cm medial and 2cm inferior to tip of coracoid process, plumb bob (parasagittal) , average depth 4-5cm. Need distal n stimulation at 0.4mA for success. |
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94. What is in cophenylcaine?
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Topical anaesthetic and vasoconstrictor. Lignocaine 5% (50mg/ml), phenylephrine 0.5%, benzalkonium HCl. Dose- 5 puffs/nostril
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95. What is an EXIT procedure?
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Ex-utero intrapartum treatment or Airway Management on Placental Support. • For foetal upper airway obstruction/ tumours (teratoma, cystic hygroma)
GA- profound tocolysis (sevoflurane, GTN), maintain placental perfusion (phenylephrine), foetal anaesthesia (direct, transplacental). Deliver to mid-thorax (cord not exposed), foetal monitoring- foetal oximetry (keep >30%). Haemostasis. Extensive planning. |
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96. What do you understand by the term informed consent?
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Information provided so that the patient can make a decision to proceed with an agreed anaesthetic plan. Person should be able to understand discussion i.e. culturally appropriate, and have an opportunity to ask questions. Discussion may include risks of procedure esp. if detriment is severe or adverse outcome is common as well as alternatives and anaesthetist’s preference. There should be documentation of such discussion.
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97. What is the difference between Mobitz type I and II? Indications for perioperative pacing.
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• Mobitz I= Wenkebach, PR interval progressively increases until dropped beat.
• Mobitz II –intermittent failure AV conduction, see 2 to3-1 block. • Consider pre-op pacing for- Mobitz II, 1oHB with bifascicular block (LAD/RAD+RBBB), 3o HB, any symptomatic bradyarrhythmia. |
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98. What is the difference between a meta-analysis and a systematic review?
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• Meta-analysis is the statistical analysis of pooled data, increases power to detect a difference due to the study intervention.
• Systematic review is a comprehensive structured review of all the available relevant data in the literature, eg. Cochrane database. |
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99. What precautions should you take prior to prescribing tramadol?
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Dose? Features of serotonin syndrome.
• Tramadol not licensed <12 yrs • CI in pts on MAOIs- risk of serotonin syndrome : ↑T, delirium, ↑↓BP, ↑HR, myoclonus, profuse sweating, coma. • Avoid in pts with epilepsy, taking TCAs and SSRIs. • Potential for drug interactions via CYP2D6 eg. 5HT antagonists |
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100. How would you treat a thyroid storm?
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Rare life threatening syndrome usually occurs 6-24 hrs post-op- ↑T/HR, ↓BP, altered LOC • Rx- active cooling, iv fluids, paracetamol, esmolol/ propranolol, antithyroid drugs- PTU, iodide eg iv contrast, dexamethasone. Pressors may be necessary.
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101. Give a formula to calculate maximum acceptable blood loss and to calculate blood volume replacement.
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If maintain isovolaemia, for up to 1.5 blood volume lost the following formula is useful:
• MABL = EBV. [(Hbinitial-Hblowest accept)/Hbaverage] • How much blood is required to raise the haematocrit by a certain amount • Volume PRBC (mls) = Wt (kg) . change Hct desired. |
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102. What are the anaesthetic implications of myotonic dystrophy?
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Airway- reflux/ aspiration risk
• Drugs- avoid Sux, sensitivity to CNS depressants and relaxants • Precipitation of myotonia by host of factors. • Resp- respiratory m weakness, restrictive deficit, OSA • CVS- conduction defects, MVP, CMP • Endocrine- diabetes, hypothyroidism • HDU, temp maintenance. |
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103. What are evoked potentials? What are their applications in anaesthesia?
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EPs are a measurement of the electrical potentials produced in response to stimulating the nervous system. Applications include- monitoring integrity nervous system.during Sx where preventable injury can occur, diagnostic in pain syndromes, depth of anaesthesia/ sedation monitoring (MLAEP), confirmatory in brain death.
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104. Quote the maximum flow rates for iv cannulas.
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20g 65ml/min, 18- 100, 16- 200, 14- 330.
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105. What are some causes of stridor post-thyroidectomy? Describe your approach to Mx.
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Laryngospasm, glottic oedema, bilateral RLN palsy, wound haematoma, tracheal collapse due to tracheomalacia, PTX. Hypocalcaemia takes hrs to develop.
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106. What are Guedel’s stages of anaesthesia?
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Described in 1937 re spontaneous respiration with ether. • Stage 1 analgesia
• Stage 2 excitement • Stage 3 surgical anaesthesia- 4 planes • Stage 4 coma- apnoea and hypotension. |
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107. What are the ECG changes of a posterior infarct?
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Dominant R in V1 without signs of RVH. Confirm with posterior chest V lead.
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108. What do you understand about hepatorenal syndrome? How is it differentiated from ATN?
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A form of acute renal failure with raised creatinine and oliguria seen in cirrhotic pts with portal HTN- it has s slow onset and is associated with a poor prognosis and poorly responds to drug therapy. It results from intense afferent arteriolar vasoconstriction.
cf ATN there is low urinary Na, urine/plasma Cr >10 and Urine specific gravity >1.01 |
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109. What are some effects of liver disease on drug kinetics?
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Absorption usually normal, increased Vd for water soluble drugs, reduced for lipid soluble
• Decreased drug clearance from ↓hepatic Q/liver mass/metabolic capacity. If high ER then reduce dose same interval, if low ER then same dose and increase interval. • May be increased in alcoholics from enzyme induction. ↓plasma protein binding→↑free fraction • Portasystemic shunting→↓first pass effect→↑oral bioavailability. |
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110. What are some high risk groups for venous thrombosis?
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Obese pts- jt replacement and abdominal surgery.
• Pts with cancer • Pts with mechanical valves esp mitral, 1st 3/12 post tissue valve • AF with CVA or embolism in last 12/12 • recurrent arterial or venous embolism, venous thrombosis last 3/12 |
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111. What are some risk factors for PONV?
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Patient- PHx, female, young age, obese, anxious, pain, full stomach, co morbid states
• Anaesthetic- opioid premed, N2O, gas distension stomach, anticholinesterases, high block • Surgical- site (gynae/GIT/eyes/ENT), emergency, long case |
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112. What are some side effects of B2 agonists?
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Tachycardia, tremor, hyperglycaemia, hypokalaemia, arrhythmias, lactic acidosis.
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113. What are the indications to ventilate an asthmatic patient and what ventilation stategy would you employ?
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• Respiratory arrest, ↓LOC, exhaustion, increasing hypoxaemia or acidosis despite maximal medical therapy.
• Strategy- low RR, I:E ratio with prolonged expiration, low tidal volumes vs barotrauma, permissive hypercapnia, ?extrinsic PEEP. |
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114. What are the symptoms of raised ICP? The signs?
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• Headache, vomiting, confusion, neck stiffness, drowsiness, seizures
• Decreased LOC, papilledema, Cushing reflex, irregular respirations, III and VI palsies, posturing. |
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115. What are the main determinants of myocardial O2 supply and demand?
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• Demand- HR, wall tension (Pr/2thickness) and contractility.
• Supply- CPP (mean aortic diastolic p.-LVEDP), length diastole, coronary vascular resistance and blood oxygen content. Latter depends on [Hb], SO2 and PaO2. |
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116. What is the ACT? How is it measured?
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Activated coagulation time, a measure of whole blood clotting but little effect from platelet disorders. Normal is 107=/-13s. Hemochron consists of heated detector containing a glass tube with a magnet (proximity detection switch) and diatomaceous earth (celite) as a contact activator of coagulation. Aprotinin falsely elevates celite ACT and so kaolin, which binds it, should be used.
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117. How would you assess BSA burn in a child? Adult?
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Lund-Browder chart. A=1/2 head, B=1/2 thigh, C=1/2 leg. A=9.5 in neonate. Rule of 9’s
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118. Fluid replacement formula for burn in adult and child in 1st 24hrs.
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• Parkland formula- Hartmann’s 4ml/kg/%BSA burnt, ½ in 1st 8hrs + maintenance fluids.
• Kids- 3ml/kg/% burn + maintenance fluids as 1/2N.S. in 5%dextrose. Give resuscitation fluids as 50:50 of 5% albumin and Hartmann’s. • Formulae are guides only, monitor response esp. UO- 0.75mls/kg/hr child |
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119. What is in Painstop? Liquigesic?
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• 120mg paracetamol+ 5mg codeine+ 6.5mg promethazine, alcohol and sugar/ 5mls.
• Dose- 0.5mls/kg tds • Liquigesic same except no antihistamine. Dose- 0.75mls/kg qid. |
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120. Draw flow-volume loops for assorted airways obstruction
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Draw here
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121. What factors would make you suspect an inhalation injury in a burns patient? Mx.
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• Hx- fire in enclosed space, explosion, inhalation of toxic fumes
• O/E- burnt face, singed eyebrows, soot in sputum, stridor, respiratory distress • Ix- ↑COHb levels, flow volume loop. Mx- early intubation. |
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122. What is the t½ of COHb in air, 100% O2 and hyperbaric oxygen?
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4-5hrs, 1 hr and 20 mins respectively
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123. Describe the components of the Glasgow Coma Scale.
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• E4- spontaneous, speech, pain, none.
• V5- orientated, confused, inappropriate words, grunts, none. • M6- obeys, localizes, withdraws, abnormal flexion, abnormal extension. |
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124. What is the effect of adding dead space to the circuit of a ventilated patient on PaCO2, ETCO2 and their difference?
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PaCO2 and ETCO2 are both elevated but difference is the same, alveolar dead space (physiological-anatomical) is the same.
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125. What are some adverse effects of DDAVP?
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Nausea, headache, mental status changes and seizures.
• Hyponatraemia due to antidiuretic action • HTN due to smooth m. contraction and hypotension with rapid iv administration. |
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126. What is banked blood tested for?
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Compatibility testing- blood typing (ABO &Rh), Antibody screen, Xmatch
• Infectious- HBSAg, HCV Ab, HIV-1,2, HTLV-1, CMV, RPR, ALT (Qld). |
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127. What are some contraindications for autologous blood donation?
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Planned procedure not likely to require transfusion, pt refusal, [Hb]<110, severe cardiac disease, infective illness, poor nutritional state.
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128. A pt with a known or suspected difficult airway has an ETT in situ which requires exchange, how would you perform this?
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Assess airway- expect difficulty? Can pt tolerate it? Screening direct laryngoscopy
• Use a Cook exchange catheter (features- markings, connector, hollow, single use), preoxygenate pt with 100% O2, ensure adequate relaxation, equipment including tubes of various sizes/ bougie/bronchoscope available. Put bronchoscope adaptor on ETT and introduce well lubricated Cook catheter through it, railroad procedure, anticlockwise twist. |
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129. Discuss the difference between Myaesthenia gravis and Myaesthenic syndrome. How would you distinguish a cholinergic crisis from a myasthenic one?
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• MG- Ab vs ACh receptor, gradual onset pharyngeal/ ocular weakness, worse with exercise, Tensilon test, EMG- decreased amplitude and rate of rise of EPP. Sens NDMRs, res Sux
• MS- assocn with malignancy, Ab vs prejunctional voltage-gated Ca channels, increase in action potential at high rates stimulation, peripheral weakness better with exercise (cranial n spared), diminished reflexes, myalgias, sens to NDMRs and Sux , poor response to anticholinesterases. • Cholinergic crisis- excess cholinesterases ,miosis and muscarinic effects, if myasthenic crisis edrophonium helps. |
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130. How would you jet ventilate via an emergency cricothyroidotomy?
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Interlink iv tubing cut with standard green oxygen tubing, needle thru bung-finger.
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131. Respiratory physiological changes in the morbidly obese.
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↑VO2 and VA, VC, closing capacity and RV normal. ↓FRC and ERV and chest + lung compliance= restrictive deficit, V/Q mismatch with anaesthesia as FRC less than closing volume.
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132. What are some types of errors that may lead to a critical incident?
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Active; Latent; Violations; Human- knowledge based, skill based, rule based, ‘slips and lapses’.
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133. What ECG changes are seen with significant pulmonary embolism?
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S1Q3T3, RBBB, TWI V1-3, sinus tachycardia. May be none.
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134. How would you manage an IDDM scheduled for major surgery?
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• 1st on list, 4 hrly BSLs pre-op, check urine for ketones, aiming for BSL 6-10. Omit normal insulin, check BSL 2hrly from commencement infusion and 1 hrly intraoperatively.
• Separate infusions of actrapid (50 in 50) and 5% dextrose 100mls/hr with 20mmol KCl/1L. |
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135. What are the anaesthetic considerations for a pt with Parkinson’s disease?
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Dysautonomia with orthostatic hypotension and urinary retention, pharyngeal m. dysfunction, respiratory impairment esp. upper airway dysfunction, reflux, muscle rigidity, poor nutrition, high incidence confusion post-op. May be on anticholinseterases • Mx- usual drug regime, preferably induce close to last dose, can give L dopa by NGT, avoid dopamine antagonists and pethidine with selegiline (MAOI-B inhibitor). Avoid halothane as sensitises myocardium to catecholamines, avoid ketamine because of exaggerated SNS response. Muscle rigidity with fentanyl. Muscle relaxants safe.
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136. Describe the popliteal approach to a sciatic nerve block.
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Pt supine, lower leg on pillow. Stimuplex. Needle inserted in horizontal plane with 45o cephalad angulation immediately anterior to the biceps femoris tendon at a point 5cm proximal to where it meets the popliteal fossa skin crease. Av. Depth 4.5cm, looking for inversion/ plantarflexion. Alternative: prone, apex of triangle superiorly.
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137. How do you treat Reflex Sympathetic Dystrophy?
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Multidisciplinary approach. Confirm Dx. Priority is restoration of mobility (physio esp.) in conjunction with desensitisation. Sympathetic blockade may be helpful. If unresponsive- pharmacological agents: anticonvulsants, antidepressants, MSAs. Psychosocial support.
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138. Define Eisenmenger’s Syndrome. Anaesthetic considerations.
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A rare cardiac condition where an abnormal connection between the systemic and pulmonary circulations (VSD/ASD/PDA) gives rise to severe pulmonary hypertension resulting in a bi-directional/ R→L shunt. • Mx- managing the balance between SVR and PVR. Avoid factors that worsen PVR and maintain BP- ketamine, phenylephrine. Precautions vs air emboli, SBE prophylaxis, maintain preload. Gas induction is slow and iv induction is faster.
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139. What muscles does the median nerve supply in the hand?
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LOAF- lateral 2 lumbricals, opponens pollicis, abductor pollicis brevis and flexor pollicis
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140. How would you manage anticoagulation therapy for pt with a mechanical mitral valve in AF booked for a bowel resection?
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High risk for an embolic event 8-15%/ yr. 3% risk of major bleeding with perioperative heparin therapy. Would cease warfarin 5/7 prior, check INR day before, FFP or vitamin K if >1.8. Then commence UFH or LMWH, cease 6 or 12hrs preop and recommence 6hrs postop or earlier if surgeon happy, cease when INR>2. No preop heparin indicated if AVR.
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141. Draw the Mapleson rebreathing circuits.
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Draw here
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142. What are some indications for premedication?
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Seven A’s- anxiolysis, analgesia, antiemesis, antacid, antisialogogue, amnesia, additional- oxygen, steroids, heparin.
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143. Discuss the use of mannitol and frusemide in treating intracranial hypertension.
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Used together have a synergistic action. Act to decrease CSF production by decreasing production and decrease brain volume through differing mechanisms. Dose mannitol 0.25g/kg give over 20 mins 1st then furosemide 0.5mg/kg. Mannitol can transiently increase ICP and relies on an intact BBB.
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144. What airway problems can rheumatoid arthritis present?
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Cervical instability from weakening of transverse lig. Atlas, limited C-spine movement esp. fixed flexion deformity, TMJ involvement restricts mouth opening and cricoarytenoid can cause hoarseness.
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145. What are some causes of coma?
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• Trauma
• Tumour • Drugs • Infection • Metabolic • Vascular- ischaemia, haemorrhage, vasculitis |
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146. You are using an oxylog to transfer a pt to another hospital . How much oxygen do you need?
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Oxylog uses 0.8 L/min + minute ventilation, should take double estimated amount required.
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147. Discuss the anaesthetic management of massive haemoptysis.
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• Definition. Unstable (haemodynamics +/-gas exchange) vs stable. Fluid resuscitation/ blood products/ large bore iv access.
• Medical Rx if stable- most due to chronic infection. Emergency bronchoscopy for Dx and Rx- DLT preferable but SLT in emergent situation. May proceed to lung resection or local therapy (laser, vasoconstrictors) or bronchial a. embolisation. |
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148. A man becomes confused during the course of a TURP. What are some possible causes?
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• TURP syndrome- dilutional hyponatraemia
• Hypoxia Preexisting neurological impairment • Hypotension/ haemorrhage • Hypothermia • Pain- bladder perforation • TIA/ MI • Sepsis |
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149. List some analgesic options for a patient having an open cholecystectomy.
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Thoracic epidural, PCA- opioid +/- NSAIDs, paravertebral block, interpleural catheter, intercostal nerve block
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150. Classify causes of hyponatraemia. How are they differentiated?
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• Factitious, pseudohyponatraemia- hyperlipidaemia, proteinaemia
• Hyperosmolar dilutional- eg. HONK (osmolar gap) • Hypoosmolar- assess volume status and urinary Na to define categories: 1. Hypovolaemia- U Na low in GI losses, high if renal losses eg. Diuretics, Addison 2. Normovolaemia- inappropriately high U Na in SIADH 3. Oedema- low U Na if CCF/ cirrhosis/ nephrotic syndrome, • High if renal failure |
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151. How would you treat a serum potassium of 7 mmol/L?
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Calcium chloride 5-10 mls (6.8mmol Ca) iv, 50mls 50% dextrose (25g) with 10 units actrapid , NaHCO3 50-100mmol or hyperventilate if GA. Other options are resonium 15g qid po and salbutamol Nebs. May need dialysis to ultimately remove K+
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152. What is your prescription for a 5yr old weighing 20kg for a morphine PCA? What about a 5 month old child?
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Put 20mg morphine in total volume of 100mls with saline. Background of 1ml/hr (=10mcg/kg/hr) up to maximum 4mls/hr , bolus of 1ml 10min lockout. Order antiemetics and cease infusion if RR<14/min. • For 5/12- half dose, NCA, larger interval for boluses, cease if RR<16, naloxone 10mcg/kg.
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153. What are some signs of right heart failure?
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Raised JVP- large v waves, RV heave, may have signs of functional TI, dependent pitting oedema, enlarged smooth liver.
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154. What is QTc? How is it calculated?
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QTc= QT/√R-R, normal<= 0.44s
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155. What are some causes of perioperative dysrhythmias?
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1. general anaesthetic agents- volatiles and iv agents
2. sympathetic block of neuraxial blockade 3. abnormal ABGs and electrolytes 4. intubation 5. reflexes, surgical stimulation mediastinum 6. pre-existing cardiac disease 7. central venous cannulation |
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156. How would you assess a pt for autonomic neuropathy at the bedside?
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Postural hypotension >30mmHg drop, lack of heart rate variability with deep respirations or Valsalva manoeuvre. Hx nocturnal diarrhoea, impotence, heat intolerance.
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157.What are some contraindications for ESWL ?
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absolute CI are pregnancy, untreated coagulopathy and abdominal pacemakers.
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158. Discuss hypothesis testing.
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Decision made Ho true Ho false
Accept Ho correct type II error, FN Reject Ho type I error,FP correct=power |
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159. Draw the areas of myocardium supplied by the coronary arteries.
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Draw here
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160. How does pH affect the lipid solubility of a basic drug.
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Becomes more ionised as pH < pKa, alkaline urine will retard its excretion as more unionised and will be resorbed across tubule. Less lipid soluble in acidic environment.
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161. What do you know about Xenon`?
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Noble gas with anaesthetic properties. MAC 70%, blood/gas 0.14, analgesic, cardiostable, nonflammable, doesn’t support combustion, rare and expensive. May have neuroprotective qualities due to suppression of glutamate release.
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162. Define criteria for diagnosis of preeclampsia.
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• PIH BP> 140/90 or rise 30/15 cf 1st trimester, proteinuria 500mg day = preeclampsia
• Severe- BP>160/110, 5g protein/ day, organ dysfunction. |
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163. What is the role of albumin in the critically ill ?
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T ½ albumin 19 days. Controversial. Low serum albumin associated with poor outcome, but correcting hypoalbuminaemia doesn’t improve outcome. • Albumin no better than artificial colloids. Cochrane meta-analysis found increased mortality (6%) assoc with its use in the critically ill. Study has been criticized- need further RCT, one is under way SAFE trial, also albumin is expensive (mostly from intragam production).
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164. What are the recommendations re epidurals in the presence of anticoagulants ?
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• Warfarin- avoid if INR > 1.3 • Aspirin- alone OK
• Clopidogrel- wait 7-10 days • Other platelet agents- wait 2 times half life • IV heparin- wait 4-6 hrs and check APTT, wait at least 1 hour after siting epidural before giving iv bolus heparin • Sc heparin- wait 6 hrs post injection, 1 hr post placement • LMWH- wait at least 12 hrs, 24 hrs if therapeutic dose, remove catheter 12 hrs post dose and wait 2 hrs before next dose is given. Recommend waiting 24 hrs from placement of epidural before giving next dose. |
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165. What are the base SI units ?
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metre, Kelvin, second, candela, kilogram, ampere, mole.
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166. What is the risk of death of anaesthesia ?
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Risk of death partially or wholly due to anaesthesia in Australia overall is 1 in 80,000 as per 97-99 triennium report.
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167. Causes of large anion gap metabolic acidosis ?
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• M methanol
• U uraemia • D DKA • P paraldehyde • L lactic acidosis • A aspirin • N nitroprusside • E ethylene glycol |
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168. Causes of peripheral neuropathy.
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• D drugs, toxins
• A alcohol • M metabolic- diabetes, porphyria, renal failure • I infections • T tumour • B B1, B12 deficiency • I idiopathic, eg CIDP • C connective tissue diseases and vasculitis • H hereditary eg CMTooth |
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169. What is 4 METS equivalent ?
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Climb a flight of stairs, walk up a hill, run a short distance, walk on level ground 6km/ hr (100 metres a minute).
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170. Causes of jaundice post-op.
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• increased bilirubin production- haemolysis, haematoma resorption
• hepatocellular damage- drugs, hypotension, halothane • biliary tract obstruction- mechanical • cholestasis- drugs • cholecystitis |
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171. Problems of massive transfusion.
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• Definition- 1 blood volume in 24hrs, >1unit/5mins. Problems common to all transfusions
• Coagulation- dec platelets, factor V/VIII/Ca, DIC, BM suppression • Metabolic- raised K, dec 2,3 DPG and left shift ODC, citrate toxicity • Physical- hypothermia, fluid overload, micro aggregates, infection risk. |
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172. Discuss the sphenopalatine ganglion.
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• 1 of 4 parasympathetic ganglia in the head and neck
• “Hayfever ganglion” • CN III- ciliary, CN IX- otic, CN VII- submandibular and sphenopalatine, CN X • Only synapsing fibres are the PNS, i.e. greater petrosal nerve from CN VII. • SNS- nerve of pterygoid canal from superior cervical ganglion via ICA plexus • Sensory fibres, branches V2. |
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173. Nomenclature for stereoisomers
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d (+) dextro – rotate light to the right
• l (-) laevo - rotate light to the left • If molecular configuration known: • R, rectus right • S, sinister, left • These may be + or -, eg. dexmedotomidine, S + |
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174. What are the 4 H’s and T’s of CPR ?
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Hypoxia, hypovolaemia, hypothermia, hyper/hypokalaemia • Tension pneumothorax, tamponade, toxins, thromboembolism
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175. What are the diagnostic criteria for SIADH ?
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• hypoosmolar hyponatraemia
• U Na >20, U osmolality > serum- at least more than maximally dilute (50mmol) • No oedema • Normal renal and adrenal function • Responds to fluid restriction alone |
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176. Mx of scoline apnoea?
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• Support respiration until return of function- take several hrs, ICU appropriate with sedation
• Initially ↓TOF with no fade then phase II block with return to function. • Take blood for cholinesterase level, dibucaine and fluoride no.’s |
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177. Causes of pleural effusion
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transudate- cardiac failure, hepatic failure, nephrotic syndrome • exudate- infection, neoplasm, connective tissue d., infarct, drugs, sympathetic.
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178. Discuss components of blood crossmatch testing.
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• 3 components: blood typing- both donor and recipient tested for presence of IgM anti A and B and A/B antigens as well as Rh D Ag.
• Antibody screen- test serum for unusual antibodies eg. Kell, Duffy • Xmatch- saline test is ABO test + detect some non ABO eg Lewis • - indirect Coombs test for IgG Ab.’s |
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179. Discuss the use of fire extinguishers
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• Fires are classified A-F on basis of components that are involved.
• Water for wood/plastic/paper, wet chemical for cooking oils, foam for same as water, powder can be used for most, CO2 for electrical fires. |
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180. Discuss the use of gabapentin in neuropathic pain.
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MOA unsure but is NMDA antagonist and acts on voltage gated Ca channels. Orally active, excreted unchanged renally, few drug interactions and SE. Commonest adverse effects are GI, somnolence and dizziness, 1% incidence seizures despite its use as anticonvulsant. Proven effectiveness in neuropathic pain states, dose 300 tds up to 1200 tds.
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181. What are some indications for use of a rigid bronchoscope ?
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• To obtain an airway in crisis situation eg. Bleeding tonsil
• To facilitate surgical procedure eg. Removal FB, bronchoscopy, laser surgery to airway • To enable ventilation eg. Airway trauma, bronchopleural fistula, airway compression by mediastinal mass. |
