Anaesthesia Mccqe Review

Front 1

What is pain?

Back 1

The conscious experience of an unpleasant sensory or emotional experience associated with actual or potential tissue damage.

Front 2

What is nociception?

Back 2

the process of neurotransmission, originating from sensory receptors (nociceptors) which transmits and processes information related to tissue damage.

Front 3

What is hyperalgesia?

Back 3

an exaggerated response to a noxious stimulus.

Front 4

What is allodynia?

Back 4

a pain response to a non-noxious stimulus (such as a gentle touch.)

Front 5

What is peripheral sensitisation?

Back 5

sensitization of C & A nociceptors, predominantly induced by inflammatory mediators released by tissue damage such that their response threshold is lowered and/or they produce a greater response to the same stimulus.

Front 6

What is central sensitisation?

Back 6

The enhanced excitability of spinal nociceptive neurons to result in a hypersensitive and hyperactive nociceptive transmission system. Can be short lived, associated with transient changes in neurotransmitter activity, or long-lived, associated with phenotypic changes in these central neurons.

Front 7

What is analgesia?

Back 7

The absence of pain sensation.

Front 8

What is distress?

Back 8

Physical and emotional / mental strain or stress.

Front 9

What is somatic pain?

Back 9

Somatic pain is easily localized and so often described as acute, aching, stabbing or throbbing. Somatic pain includes cutaneous pain after an operation. Somatic pain can be further classified as superficial (skin) or deep (joints, muscle, or periosteum) in origin.

Front 10

What is peripheral pain?

Back 10

Either visceral (thoracic/abdominal) or somatic (joints, muscles, or periosteum.) Visceral pain is poorly localized and frequently described as cramping or gnawing. May be also reffered pain to cutaneous sites far from site of injury.

Front 11

What is neuropathic pain?

Back 11

The result of trauma, inflammation, or sensitization of peripheral nerves or spinal cord. Neuropathic pain is described as burning, lacerating, and intermittent, and is often poorly responsive to treatment.

Front 12

What is idiopathic pain?

Back 12

Persistent pain in the absence of an identifiable organic substrate. Idiopathic pain is often excessive and associated with emotional stress or behavioral abnormalities.

Front 13

What are the physiological signs of pain?

Back 13

Inc blood pressure, inc heart rate, inc peripheral vasoconstriction - identifiable by pale mucus membranes, inc respiratory rate, possible muscle splinting, inc catabolic processing, dec food / water intake, dec voiding

Front 14

What is multimodal analgesia?

Back 14

The simultaneous administration of a combination of analgesic agents (opiods, NSAIDs, and alpha2-agonists) with different modes of action and different side effects which may act synergistically and achieve optimal analgesia with less risk/side effects than large doses of a single drug.

Front 15

What is pre-emptive analgesia?

Back 15

Administration of an analgesic agent prior to noxious stimulation.

Front 16

How do anaesthetics affect fluid deficits?

Back 16

"Decompensate" - ie, incapacitate compensatory mechanisms, depress cardiac output, derange blood-gases, exacerbate pH changes, impair renal function, increase respiratory water losses (low FiH2O); also, surgery imposed H2O deprivation, 3rd space losses, gross haemorrhage, evaporation from wound, blood sequestration in tissues then removed (ex spay), urinary losses.

Front 17

Define the term: hypotonic.

Back 17

Water lost in excess of electrolytes (pure water).

Front 18

What are the clinical signs of hypotonic /free water loss? How can they be corrected?

Back 18

Skin tenting, tachycardia, hypotension

Front 19

Succinylcholine
1. Type of agent
2. Mechanism of action
3. Indications
4. Speed of onset and clearance
5. Side effects
6. Contraindications

Back 19

1. a depolarizing paralytic anesthetic.
2. Binds to muscarinic (organs) and nicotinic (muscles) receptors, causing depolarization of muscles (fasciculations) and blocks ACh.
3.RSI, Converting from a laryngeal mask to ETT, short procedure, Risk of aspiration, laryngospasm. 4. Onset = 30 sec. Duration 5-10min.
5.Malignant hyperthermia. Plasma Cholinesterase deficiency = paralysis upon waking. Hyperkalemia. Muscarinic = Bradycardia, dysrythmia, sinus arrest. Increased ICP, IOP and Gastric pressure. Fasciculations and post-op myalgia
6. History of MH, PCD. Hyperkalemia, Allergy. myotonia. Caution in eye injury, myasthenia gravis.

Front 20

What type of paralytic is succinylcholine? How does it work?

Back 20

A depolarizing paralytic. It binds to the nicotinic receptor, causes prolonged muscle depolarization and fasciculations then paralyzes the muscle. Then it remains in the receptor and is slowly degraded. Not degraded by acetylcholinesterase.

Front 21

Propofol
1. type of drug
2. Mechanism of action (2)
2. uses (3)
3. Side effects (6)

Back 21

1. A sedative hypnotic and amnesic with muscle relaxant properties. It is not an analgesic and thus fentanyl is also used. It's the white drug.

2. Potentiates GABA and blocks sodium channels.

3. Used for Rapid Sequence Induction RSI, procedural sedation and as a general anaesthetic.

SIDE EFFECTS
1. Increased ICP,
2. increased IOP,
3. decreased RR,
4. decreased BP,
5. decreased HR
6. Apnea

Front 22

Midazolam
1. Mechanism of action
2. Uses
3. Side effects
4. Reversal

Back 22

1. Benzo that potentiates GABA, decreasing CNS neuron activity. Sedative, hypnotic, anxiolytic and amnesic properties.
2. Ultra-short acting benzo - used for procedural sedation, prior to induction
3. Confusion, somnolence, bradycardia, hypotension
4. Overdose reversed by flumazenil.

Front 23

How is benzodiazepine overdose treated?

Back 23

Flumazenil

Front 24

Morphine
1. Mechanism of action
2. Uses
3. Side effects intraoperatively
4. Reversal of overdose

Back 24

1. binding to and activating the μ-opioid receptors in the central nervous system. Endogenous opioids include endorphins, enkephalins, dynorphins also bind to the μ-opioid receptor.
2. Analgesic with long acting properties compared with fentanyl which is quite short.
3. Hypotension & bradycardia. Also causes nausea and constipation.
4. Intraoperatively use phenylephrine (norepinephrine) to increase BP. In overdose use Narcan (Naloxone) but watch for rebound pain.

Front 25

Rocuronium
1. Mechanism of action
2. Uses
3. Length of activity
3. Side effects
4. Reversal

Back 25

1. Non-depolarizing muscle relaxant. Competitively antagonizes acetylcholine nicotinic receptors and prevents muscular contraction. Does not cause fasciculations like succinylcholine.

2. Used as a paralytic and muscle relaxant for intubation and mechanical ventilation and to prevent laryngospasm.

3. Takes effect in 1-2 minutes (2-3 x longer than succ), but can use higher dose for RSI. Lasts longer - 20-30 minutes.

4. No risk of Malignant hyperthermia. Prolonged Apnea and paralysis without reversal.

5. Reversed with a Neostigmine and Glycopyrrolate cocktail.

Front 26

Sevoflurane
1. Mechanism of action
2. Use
3. Side effects
4. Reversal

Back 26

1. An ether which is a sedative, hypnotic and amnesic with mild muscle relaxant properties.
2. Used as an inhaled volatile anesthetic for the induction and maintenance of general anesthesia.
3. Rare cause of malignant hyperthermia. Apnea.
4. Reversed with high flow O2 to wash out lungs.

Front 27

Phenylephrine
1. Mechanism of action
2. Use
3. Side effects

Back 27

1. A vasopressor which is a pure alpha agonist. A weak form of norepinephrine. Causes constriction of blood vessels to increase preload without affecting HR or contractility.
2. Used to increase BP. Increase preload and afterload.
3. Compensatory decrease in heart rate. Due to the increased preload and BP, heart slows down.

Front 28

Ephedrine
1. Mechanism of action
2. Use
3. Side effects

Back 28

1. Ephedrine is a sympathomimetic amine & weak form of epinephrine. Vasopressor and inotrope. Acts on alpha and beta receptors. Causes blood vessel constriction (alpha = preload and afterload) and increased cardiac heart rate and contractility (beta).
2. Used to counteract blood loss and morphine induced hypotension and bradycardia.
3. Hypertension, arrythmias, confusion and agitation, sweating.

Front 29

Neostigmine and Physostigmine
1. Mechanism of action
2. Uses

Back 29

1. a parasympathomimetic, specifically, a reversible cholinesterase inhibitor. By interfering with the breakdown of acetylcholine, neostigmine indirectly stimulates both nicotinic and muscarinic receptors. Unlike physostigmine, neostigmine has a quarternary nitrogen; hence, it is more polar and does not enter the CNS. its effect on skeletal muscle is greater than that of physostigmine, and it can stimulate contractility before it paralyzes.
2. improve muscle tone in people with myasthenia gravis and routinely, in anesthesia at the end of an operation, to reverse the effects of non-depolarizing muscle relaxants such as rocuronium and vecuronium when preparing to extubate. Used in combo with glycopyrrolate.

Front 30

Glycopyrrolate
1. Mechanism of action
2. Uses

Back 30

1. Muscarinic anticholinergic with no central effects
2. used as a preoperative medication to reduce salivary, tracheobronchial, and pharyngeal secretions, as well as decreasing the acidity of gastric secretion. It is also used in conjunction with neostigmine, a neuromuscular blocking reversal agent, to prevent neostigmine's muscarinic effects such as bradycardia.

Front 31

Odansatron / Granisetron
1. Mechanism of action
2. Uses
3. Dose

Back 31

Granisetron is a serotonin 5-HT3 receptor antagonist that acts at the nausea and vomiting centre via antagonizing vagus nerve receptors in the medulla oblongata..

2. Antiemetic
a. Chemotherapy
b. Anaesthetic induced Post-op nausea and vomiting prophylaxis.
c. Bowel surgery and radiation releases 5HT3 and it is effective.

3. 1mg IV q8h. Best given intraoperatively 1mg po bid.

Front 32

Metochlopramide (Maxaran)
1. Mechanism of action
2. Uses

Back 32

1. Dopamine antagonist. Powerful antiemetic and gastric motility agent.
2. Used for post op nausea, chemo induced nausea and after bowel surgery to promote gut motility. Also used in combo with Ketorolac (Toradol) for migraine headaches.

Front 33

Ketorolac (Toradol)
1. Mechanism of action
2. Uses
3. Contraindications

Back 33

1. Potent NSAID - can only use for a max of 5 days. Anti-inflammatory, anti-pyretic, analgesic. competitive blocking of the enzyme cyclooxygenase (COX). Like most NSAIDs, ketorolac is a non-selective COX inhibitor.
2. Migraine headaches. Post operative pain.
3. NSAID and ASA allergy. Renal disease (constricts afferent arteriole).

Front 34

Name the structures.

Back 34

Diagram of renal corpuscle structure:

A – Renal corpuscle
B – Proximal tubule
C – Distal convoluted tubule
D – Juxtaglomerular apparatus
1. Basement membrane (Basal lamina)
2. Bowman's capsule – parietal layer
3. Bowman's capsule – visceral layer
3a. Pedicels (podocytes)
3b. Podocyte


4. Bowman's space (urinary space)
5a. Mesangium – Intraglomerular cell
5b. Mesangium – Extraglomerular cell
6. Granular cells (Juxtaglomerular cells)
7. Macula densa
8. Myocytes (smooth muscle)
9. Afferent arteriole
10. Glomerulus Capillaries
11. Efferent arteriole

Front 35

Prochlorperazine (Stemetil)

Back 35

Prochlorperazine (marketed under the names Compazine, Stemzine, Buccastem, Stemetil and Phenotil) is a drug that belongs to the phenothiazine class of antipsychotic agents that are used for the treatment of nausea and vertigo. It is also a highly-potent typical antipsychotic, 10 to 20 times more potent than chlorpromazine.

Front 36

Droperidol
1. Action and use
2. Side effects

Back 36

1. antidopaminergic drug used as an antiemetic and antipsychotic.
2. QT prolongation and torsades de pointes. The evidence for this is disputed, with 9 reported cases of torsades in 30 years and all of those having received doses in excess of 5 mg.[3] QT prolongation is a dose-related effect,[4] and it appears that droperidol is not a significant risk in low doses.

Front 37

Diphenhydramine (Benadryl)
1. Mechanism of action
2. Systemic effects - 2
3. Uses - 3

Back 37

1. A - Blocks histamine at H1 receptor sites.

2 A - increase of vascular smooth muscle contraction, thus reducing the redness, hyperthermia and edema that occurs during an inflammatory reaction. B - Blocking the H1 receptor on peripheral nociceptors also decreases sensitization and reduces itching.

3. A - Antiemetic, nausea and vomiting. B - Antihistamine for allergic reactions. C - extrapyramidal side effects of typical antipsychotics, such as the tremors that haloperidol can cause.

Front 38

Hydromorphone (Dilaudid)
1. Mechanism of action
2. Uses
3. Side effects
4. Reversal

Back 38

1. u-opioid receptor agonist. 5-10 times stronger than morphine. Where morphine is given in doses of 5-10mg post-op, hydromorphone is given in doses of 0.5-2mg.
2. Faster acting than morphine, good for PCA over several days. Also produces fewer active metabolites, thus less side effects.
3. Fewer side effects than morphine. Resp depression, hypotension, Nausea, vomiting, constipation, sedation, dependece, itching, redness.
4. Reversed with naloxone (narcan)

Front 39

Fentanyl
1. Mechanism of action
2. Uses
3. Side effects
4. Dose

Back 39

1. synthetic primary μ-opioid agonist. 100 times more potent than morphine.
2. administered in combination with a benzodiazepine, such as midazolam, for procedural sedation, anesthesia and analgesia.
3. Resp depression, hypotension, nausea, vomiting, itching, redness.
4. Dose - 3-10 ug/kg

Front 40

Define anesthesia.

Back 40

Lack of awareness or sensation. Can be a spectrum from local anaesthesia, conscious sedation with analgesia to general anesthesia.

Front 41

Atropine
1. Mechanism of action
2. Uses
3. Side effects

Back 41

1. Anticholinergic - Competitive antagonist for the muscarinic acetylcholine receptor.
Lowers parasympathetic activity

2 -
a. Cycloplegic / Mydriatic
b. Bradycardia, asystole and pulseless electrical activity (PEA) - usual dosage = 0.5 to 1 mg IV push every three to five minutes
3. Ventricular fibrillation, supraventricular or ventricular tachycardia, dizziness, nausea, blurred vision, loss of balance, dilated pupils, photophobia, and, possibly, notably in the elderly confusion and delerium.

Front 42

1. Signs of atropine overdose.
2. Antidote

Back 42

1. Ventricular fibrillation, supraventricular or ventricular tachycardia, dizziness, nausea, blurred vision, loss of balance, dilated pupils, photophobia, and, possibly, notably in the elderly, extreme confusion, extreme dissociative hallucinations, and excitation
2. The antidote to atropine is physostigmine or pilocarpine.

Front 43

Preload
1. Define
2. Ways that you can increase preload in anaesthesia
3. Ways you can decrease preload

Back 43

1. the pressure stretching the left ventricle after atrial contraction and passive filling. May also be called end-diastolic volume.
2. INcreased with epinephrine- ephedrine (a + B agonist) and norepi - phenylephrine (a agonist). Increased blood volume.
3. Decreased with PEEP (increased intrathoracic pressure) + anaesthetics (relax vessels).

Front 44

Afterload
1. Define
2. Ways that you can increase afterload in anaesthesia
3. Ways you can decrease afterload.

Back 44

1. the tension produced by the left ventricle in order to contract. against systemic resistance.
2. Epinephrine and ephedrine increase preload and afterload (+ rate + contractility). Phenylephrine increase preload and afterload. Trendelenberg position (drop head) increases afterload.
3. Decrease with Nitroglycerine, Nitrates, CCB, Beta-blockers.

Front 45

What drugs can be used to alter heart contractility?

Back 45

1. Increase - ephedrine and epinephrine. Dopamine, dobutamine, calcium, digoxin
2. Decrease - CCB

Front 46

What drugs can be used to alter heart rhythm?

Back 46

1. CCB
2. Digoxin

Front 47

How do calcium channel blockers work?

Back 47

Calcium channel blockers work by blocking voltage-gated calcium channels (VGCCs) in cardiac muscle and blood vessels. This decreases intracellular calcium leading to a reduction in muscle contraction. In the heart, a decrease in calcium available for each beat results in a decrease in cardiac contractility. In blood vessels, a decrease in calcium results in less contraction of the vascular smooth muscle and therefore an increase in arterial diameter (CCB's do not work on venous smooth muscle), a phenomenon called vasodilation. Vasodilation decreases total peripheral resistance, while a decrease in cardiac contractility decreases cardiac output. Since blood pressure is determined by cardiac output and peripheral resistance, blood pressure drops.

Front 48

Digoxin:
Describe the two ways it acts on the heart.

Back 48

1. A decrease of conduction of electrical impulses through the AV node, making it a commonly used antiarrhythmic agent in controlling the heart rate during atrial fibrillation or atrial flutter.
2. An increase of force of contraction via inhibition of the Na+/K+ ATPase pump. This results in increased Ca+ in the sarcoplasmic reticulum. Thus less frequent and more powerful contractions.

Front 49

What factors do you want to consider on an anaesthetic history?

Back 49

1. Difficult intubation + why
2. Neck or Oralaryngeal trauma
3. Medications and drugs
4. Smoking
5. Post-op nausea and vomiting and history of motion sickness
6. Allergies to meds and anaesthetics
7. Personal/Family history of Malignant hyperthermia and Plasma Cholinesteras Deficiency
8. Poor response to codeine - they also won't respond well to Ketorolac (Tramadol)

Front 50

What other drug will not work well for a patient with a history of poor response to codeine?

Back 50

Ketorolac (Tramadol)

Front 51

What are the 2 most common reasons for delayed discharge after surgery?

Back 51

1. Post-op nausea and vomiting
2. Pain

Front 52

How common is post-op nausea and vomiting?

Back 52

About 25% of pts.

Front 53

Which factors predispose to post-op nausea and vomiting?

Back 53

Prototype - young female non-smoker with history of motion sickness who gets opioids intraopertively.
1. Female
2. Non-smoker
3. History of PONV or motion sickness
4. Opioids
5. Prolonged surgery

Front 54

When should you consider prophylaxis for nausea & vomiting (PONV)?

How?

Back 54

When there are 2 or more risk factors.
1. Female
2. Non-smoker
3. History of PONV, motion sickness
4. Opioids during surgery?

Prophylaxis = Odansitron / Granisetron (5HT3 antagonist), dimenhydramine, droperidol

Front 55

What intraopertive drugs can increase the risk of Post-op Nausea Vomiting?

Back 55

Nitrous oxide, inhaled anaesthetics (sevoflurane etc.), opioids, neostigmine

Front 56

What is a 5HT3 antagonist?
Use?
Examples?

Back 56

1. Antagonize a the 5HT3 subtype of serotonin receptor found in terminals of the vagus nerve which stimulates the nausea and vomiting center in medulla oblongata.
2. Used to control chemo induced N+V and PONV.
3. Odansetron and Granisetron

Front 57

List 5 side effects that may occur with the intravenous administration of 1 mg/kg of succinylcholine. (Do not include malignant hyperthermia trigger)

Back 57

Hyperkalemia
Sustained contraction in myotonia
Cholingergic: Sinus bradycardia, increased secretions
Fasciculations, myalgia
Increased IOP, ICP, intragastric pressure

Front 58

What 2 structures obstruct the airway in an unconscious patient who is supine.

Back 58

Tongue, epiglottis

Front 59

With just your hands, how should you open the airway in an unconscious patient who
i) has a suspected C-spine injury

ii) has no suspected C-spine injury.

Back 59

1. Jaw thrust
2. Sniffing position - Head tilt & Chin lift

Front 60

List 2 devices that can be placed blindly that can assist you in opening the airway.

Back 60

Nasopharyngeal airway, oropharangeal airway

Front 61

What concentration of oxygen should be given to all patients who present with apnea?

Back 61

100%

Front 62

What piece of oxygen therapy equipment will you use to deliver this concentration of oxygen to all patients who present with apnea?

Back 62

Ambu bag and mask with 100% O2

Front 63

Where can this piece of equipment be found on most nursing wards?

Back 63

crash cart, on the wall

Front 64

List 5 usual steps taken in examining a patient’s airway to determine the ease of intubating conditions for oral intubation, and note for each what constitutes a normal or abnormal finding:

Back 64

1. TMJ mobility: condyle should be able to move 1 cm anteriorly

2. mouth opening: > 2 fingers

3. thrymental distance: > 6.5 cm

4. cervical spine mobility: flexion and extension without discomfort

5. Mallampati = visability of hypopharyngeal structures: full view of uvula, tonsillar pillars, tonsils, posterior pharyngeal wall, soft palare and tongue

Front 65

A 65-year old man presents to your family practice office for a preoperative assessment before a proposed ventral hernia repair. He is a known hypertensive and has been treated with Metoprolol 50 mg bid and Hydrochlorothiazide 50 mg a day. His blood pressure today is 180/110 mm Hg.

A. What are 4 specific questions you would ask him on history related to his hypertension? (4)

Back 65

Duration

Usual BP

Hx of MI,

Stroke, kidney damage

Front 66

A 65-year old man presents to your family practice office for a preoperative assessment before a proposed ventral hernia repair. He is a known hypertensive and has been treated with Metoprolol 50 mg bid and Hydrochlorothiazide 50 mg a day. His blood pressure today is 180/110 mm Hg.
B. What 3 physical findings are crucial to determine with regards to his cardiovascular "fitness" for elective surgery?

Back 66

S4, retinal changes, renal bruit

Front 67

A 65-year old man presents to your family practice office for a preoperative assessment before a proposed ventral hernia repair. He is a known hypertensive and has been treated with Metoprolol 50 mg bid and Hydrochlorothiazide 50 mg a day. His blood pressure today is 180/110 mm Hg.

What 3 investigations are strongly indicated in this patient related to the information given? (3)

Back 67

Echo, ekg, creatinine

Front 68

You are seeing a 32 year old woman in the holding area outside the operating room immediately prior to her scheduled laparoscopic cholecystectomy. She tells you that she has had a ‘cold’ for 2 days.

What 5 items elucidated on either history, physical examination or laboratory data would cause you to postpone this elective procedure?

Back 68

Increased WBC

Adventitious lung sounds

Absent breath sounds/dullness

Fever

New productive cough

Front 69

A 44 year old morbidly obese (200 kg) man presents for an emergency appendectomy.

List 5 important problems associated with morbid obesity that puts these patients at an increased risk for anaesthesia and surgery. (10)

Back 69

Aspiration

Possible difficult intubation

Decreased FRC – reduced lung space to preoxygenate means less time to intubate before patient desturates

Difficult bag mask ventilation

Increased positive pressures required for ventilation

Front 70

A 75-year-old man presents for a total hip replacement. He is given a general anaesthetic. The drugs used for induction are sodium thiopental 250 mg, fentanyl 250 micrograms and succinylcholine 100 mg. Anaesthesia is maintained with isoflurane 0.2-0.8%, nitrous oxide 60%, rocuronium increments and morphine increments.

His usual blood pressure is 150/85 mm Hg. One and one-half hours after induction, his blood pressure drops to 90/60.

List 5 reasons for intraoperative hypotension in this man: briefly discuss how each of these items actually causes the blood pressure to fall. (10)

Back 70

1. isoflurane = myocardial depression = hypotension

2. nitrous oxide = myocardial depression = hypotension

3. morphine = release histamine = vasodilation hypotension

4. blood loss = hypovolemia hypotension

5. positive pressure ventilation = IVC compression = decreased venous return = decreased preload = hypotension

Front 71

List 5 potential complications from the use of non-steroidal anti-imflammatory drugs i.e NSAIDS. (10)

Back 71

AIN, fluid retention, allergy, gastritis/GI bleed, hypertension, bone marrow suppression (platelet dysfunction), worse CHF

Front 72

What is the aortocaval syndrome?

Back 72

Compression of IVC and/or aorta by gravid uterus.

Front 73

List three ways to decrease the effects associated with aortocaval syndrome.

Back 73

1. Lie patient on left side, 2. Right hip wedge, 3. Avoid supine position

Front 74

List 4 potential complications of single unit blood transfusion and 6 potential complications related to multiple unit blood transfusion. (10)

Back 74

Single: Immune, nonhemolytic: 1. immediate hemolytic reaction, 2. delayed hemolytic reaction 3. infection, 4. allergic reaction

Multiple: 1. hyperkalemia, 2. dilutional coagulopathy, 3. dilutional thrombocytopenia,
4. circulatory overload, 5. citrate toxicity (hypocalcemia), 6. iron overload

Front 75

List 5 ways in which you could distinguish between a neuromuscular block associated with a 1-mg/kg dose of succinylcholine and one associated with a non-depolarizing muscle relaxant (Rocuronium).

Back 75

Succinylcholine = time to block < 1 min, no fade with tetanus, not reversible, TOF ratio > 0.4

Non-depolarizing (Rocuronium) = > 2 mins, fades with tetanus, positive post tetanic facilitation, reversible, TOF ratio < 0.7

Front 76

List 5 ABSOLUTE contraindications to the administration of either succinylcholine or a non-depolarizing relaxant. (Do not give the contraindications to succinylcholine, rather GENERAL absolute contraindications to muscle relaxation with either type of drug. Assume the patient has a functioning intravenous in situ) (5)

Back 76

1. allergy to medication

2. unable to secure airway

3. lack of resuscitative equipment

4. lack of anaethesia medications

5. unable to bag mask ventilate

Front 77

Name 2 situations, 1 in the operating room and 1 outside the operating room setting where a laryngeal mask might be used. (2)

Back 77

Surgery where intubation not required:
1. No risk of aspiration
2. Short procedure
3. Non-obese, not pregnant, no ascites

OUTSIDE OR
Emergent - can't intubate, can't ventilate.
Inadequate seal (e.g. beard) with face mask

Front 78

List 6 contraindications to the elective use of a laryngeal mask in the operating room. (6)

Back 78

need PPV, risk of aspiration, pharyngeal pathology, limited mouth opening, cervical vertebra/laryngeal cartilage #, spontaneous breathing, trendelenberg positioning

Front 79

What size laryngeal mask would be used for an average female (1) and an average male (1)? (2)

Back 79

females 3, males 4

Front 80

35-year old man is having an inguinal hernia repair under general endotracheal anesthesia. He is a previously healthy man with no cardiorespiratory problem. He is intubated with a 8.0mm endotracheal tube and his lungs are being ventilated with a tidal volume of 500 cc at a respiratory rate of 10 breaths/minute. His intraoperative course has been uneventful since the induction of anesthesia, 1 hour ago. Over the course of 15 minutes, his oxygen saturation, which had been stable at 98% has fallen to 90%. BP is 120/80 and heart rate is 110 bpm. List 5 possible causes of this problem and for each problem, list one therapeutic intervention to improve the situation. (10)

Back 80

Endobronchial intubation: pull back tube

Tube disconnected: check tubing

Patient biting down on tube: relaxation, insert oropharyngeal airway

Secretions blocking tube: suction

PE/Atelectasis = increase PEEP to reduce atelectasis

Front 81

Name 5 SPECIFIC preoperative investigations that an anaesthetist would consider important information in the assessment of a patient suffering from severe chronic obstructive lung disease who is scheduled for an elective ventral hernia repair. (5)

Back 81

Hgb, PaO2, PaCO2, HCO3, PFTs, CXR, EKG

Front 82

Name 5 SPECIFIC preoperative investigations that an anaesthetist would consider important information in the assessment of a patient suffering from severe chronic obstructive lung disease who is scheduled for an elective ventral hernia repair and give a BRIEF reason as to the importance for each individual investigation.

Back 82

1. ABG: hypoxemia, acidosis and appropriate compensation

2. CXR: hyperflation and evidence of any cardiac failure or pulmonary infection

3. CBC: any additional pulmonary infection

4. PFT: extent of obstruction

5. ECG: cardiac failure

Front 83

List 5 classes of drugs that a patient may be asked to discontinue prior to elective surgery. (10)

Back 83

1. oral hypoglycemics

2. anticoagulants

3. antiplatelets

4. insulin

5. antidepressants

Front 84

A 75-year-old man undergoing a laparotomy for a bowel obstruction has received a general anaesthetic. He is intubated and ventilated and has been paralyzed with rocuronium. Anesthesia is maintained with 70% nitrous oxide, 30% oxygen and 1% isoflurane. He has a history of hypertension for which he takes Vasotec. One hour after the surgery began, his blood pressure, which had been stable, drops to 80/40 mm Hg.

A. List 5 actions you would take at this point.

Back 84

1. verify monitors connected properly

2. crystalloid infusion - Ringer's Lactate

3. decrease nitrous oxide = will increase BP

4. decrease isoflurane = will increase peripheral resistance

5. consider phenylephrine - will increase peripheral resistance without increasing heart rate and contractility.

Front 85

List 5 common causes of intraoperative hypotension. (5)

Back 85

1. inhalational anesthesia

2. opiods

3. hemorrhage

4. loss of fluids

5. positive airway ventilation causing IVC compression

Front 86

A previously healthy 32-year-old man has undergone an open reduction and internal fixation of a tibial fracture following an injury incurred in a football game. He weighs 90 kg and has no history of abnormal bleeding or bruising. He is currently taking ranitidine 150 mg once daily for a duodenal ulcer and is asymptomatic. He has no known allergies. In the Post Anaesthetic Care Unit (PACU), he is complaining of severe pain.

A. In the PACU, what medication and dose would you use to start treating his pain? (3)

Back 86

Morphine 1-3 mg IV

Front 87

What THREE specific methods of anaesthesia can be used for a Caesarean section. (3)

Back 87

Epidural, spinal, GA

Front 88

List 4 common side effects of opioid medications.

Back 88

1. histamine release leading to hypotension

2. constipation

3. respiratory depression

4. nausea/vomitting

Front 89

A previously healthy 32-year-old man has undergone an open reduction and internal fixation of a tibial fracture following an injury incurred in a football game. He weighs 90 kg and has no history of abnormal bleeding or bruising. He is currently taking ranitidine 150 mg once daily for a duodenal ulcer and is asymptomatic. He has no known allergies. In the Post Anaesthetic Care Unit (PACU), he is complaining of severe pain.

After 1 hour and a large dose of morphine he is still in pain. What alternate therapy could you offer him?

Back 89

(3) PCA Using hydromorphone

Front 90

What THREE specific methods of anaesthesia can be used for a Caesarean section. List two significant disadvantages of each technique. (6)

Back 90

1. epidural: block sympathetic nerves and worsen hypotension, slower onset

2. spinal: block sympathetic nerves and worsen hypotension, one dose only, motor block, dural puncture headache

3. general: technique difficult due to upper airway edema, maternal drugs transfer to neonate causing neonatal depression and requiring resuscitation

Front 91

What type of anaesthesia would most likely be given to a patient requiring EMERGENCY Caesarean section for an acute haemorrhage secondary to an abruptio placenta? (1)

Back 91

insufficient time to establish regional anaesthesia. Thus rapid sequence general anesthesia.

Front 92

List 2 common uses for propofol. (2)

Back 92

1. induction, 2. maintenance anesthesia

Front 93

List 5 important physiological effects of an intravenous induction dose of propofol. (5)

Back 93

1. decreased ICP, 2. increased IOP, 3. decreased RR, 4. decreased BP, 5. decreased CO

Front 94

Pain on injection may occur with propofol. List 3 ways you might avoid or decrease the incidence of this side effect? (3)

Back 94

1. mix in small dose of lidocaine, 2. administer through a fast flowing iv catheter,

3. adminster through a more proximal iv catheter

Front 95

What are the five minimum pieces of equipment required to intubate? (5)

Back 95

1. suction, 2. O2, 3. laryngoscopy, 4. ETT, 5. stylet

Front 96

A 24 year old previously healthy male is brought by ambulance to the emergency department. He has taken an unknown quantity of an unknown drug. He is unconscious and breathing at a rate of 5 per minute. His saturation on room air is 88%. He has no gag reflex and the casualty officer would like you to intubate him. He has not sustained a cervical spine injury. Assuming that all the equipment you need is ready, describe the five steps you would follow to perform the intubation. (5)

Back 96

1. position patient
2. open mouth
3. laryngoscopy
4. insert ETT though vocal cords, remove laryngoscope
5. confirm ETT placement

Front 97

Name 3 ways to confirm placement of an ETT.

Back 97

1. Chest wall rising with ventillation
2. Air entry heard by stethoscope at bilaterally at the mid-axillary line
3. End tidal CO2 30-40mmHg

Front 98

List 5 GENERAL causes of hypoxaemia. (10) (Do not give specific examples i.e. pulmonary embolus).

Back 98

1. decreased FIO2
2. decreased alveolar ventilation
3. increased shunting
4. increased dead space ventilation
5. decreased diffusion
6. poor placement of ETT

Front 99

A 60 year old woman with insulin-dependent diabetes presents to the preoperative consultation clinic having been scheduled for a total knee arthroplasty in 2 week’s time.
A. What 6 specific questions related to her diabetes would be important to ask to assess her fitness for anaesthesia and surgery? (6)

B. What 4 specific tests would you order preoperatively? (4)

Back 99

1. how long?
2. end organ damage?
3. monitor blood glucose regularly?
4. adequate control?
5. admissions to hospital for hypo or hyperglycemia?
6. other CAD risk factors?

1. blood glucose, 2. ECG, 3. lytes and creatinine, 4. urinalysis

Front 100

A 50 year old man takes beta blockers and Ca2+ channel blockers for stable angina. He is coming for elective surgery in one week. What should you tell him about his medications and eating and drinking before his operation? (3)

B) What are 2 reasons that we have patients fast before elective surgery? (2)

C) What immediate outcome may occur under general anaesthesia in a patient who has a full stomach?

D - What is a potential consequence of this outcome?

E - What 3 reasons contribute to these outcomes? (3)

Back 100

A- 1. take B-blockers and CCB at usual time with sips of water
2. no solids at least 8 hrs prior
3. no fluids at least 4 hrs prior

B - 1. decrease gastric volume, 2. decrease gastric acidity

C - (1) aspiration

D - (1) pneumonitis, atelectasis, ARDS, abscess

E - volume, acidity, particulate matter

Front 101

Many unnecessary blood tests are ordered prior to surgery. List 5 pieces of information learned from the patient’s history that would cause you to order preoperative coagulation studies. (10)

Back 101

1. on anticoagulants, 2. liver disease, 3. known factor deficiency, 4. family history of factor deficiency
5. surgery involving lots of blood loss

Front 102

A. You are called to the postanaesthetic care unit to see a patient who has a saturation of 80%. She has been in the PACU for 20 minutes after having had a total abdominal hysterectomy. She is otherwise healthy. Her blood pressure is 120/80 mm Hg and her heart rate is 120 bpm. Describe in point form EXACTLY what your management of this situation would be. (5)

B. What are five GENERAL potential causes of her tachycardia? (5)

Back 102

A - 1. assess airway, secure airway
2. assess need for ventilation
3. increase O2
4. look for acute blood loss, stop
5. fluid resuscitation
6. Control pain
7. Empty bladder

B - Hypovolemia, pain, arrhythmia, full bladder, anxiety, anemia, drugs (e.g. atropine, pancuronium)

Front 103

You are called to the floor to see a patient who the nurse believes has had a narcotic overdose. He has been on the ward for 2 hours having just had an open reduction and internal fixation of a femoral fracture. He is on PCA which his wife has been using regularly on his behalf.
A. What would be your management of the situation at this point? (2)

B. If the patient is rousable and maintains his airway, what would you do in this case? (5)

C. If the patient is difficult to rouse, snores and has a respiratory rate of 8 per minute, and a saturation of 80% on room air with a stable BP and Heart rate, what would you do? (3)

Back 103

A - Assess responsiveness, resp rate, heart rate, pupils, educate patient and wife

B - reduce PCA infusion rate, hold bolus doses for now, reassess frequently

C - 1. assess and secure airway
2. give O2
3. give small incremental doses of 40 mcg naloxone

Front 104

List 5 options for pain relief during labour. (5)
Lamaze, epidural, NO, pudendal block, opioids
B. For each of the options for pain relief during labour listed above; give 1 advantage and 1 disadvantage for each. (5)

Back 104

Lamaze: gives woman control, not great analgesia
Epidural: good analgesia, hypotension
NO: easy, does not relieve pain completely
Spinal: good analgesia, motor blockade
Opioids: easy, maternal/neonatal depression

Front 105

You are called to the recovery room (PACU) to see a patient who has just arrived after having had a laparoscopic cholecystectomy. The patient was awake, alert, extubated and breathing spontaneously. The nurse has just given a gram of Ancef intravenously at the surgeon’s request. The nurse tells you that the patient is having an “allergic reaction”.

A) What 5 signs and/or symptoms might the patient be experiencing to support this diagnosis? (5)

B) What 5 steps MUST be taken to treat this patient? (Be specific) (5)

Back 105

A - rash, stridor, tachycardia, hypotension, bronchospasm, urticaria

B - 1. Stop Ancef, 2. 100% O2, 3. 50 mcg epinephrine iv, 4. N/S, 5. benadryl 50 mg iv 6. Ranitidine

Front 106

A. What two genetic disorders related to anaesthesia might be elicited by asking a patient about their family history of anaesthetics? What investigations can be done to determine if the disorder has been transmitted to the patient? (4)

B. What would be the symptoms that might occur, related to each disorder, if a patient received a general anaesthetic without any precautions against the above problems? (6) (Separate the symptoms according to the disorder.)

Back 106

A - Cholinesterase deficiency: genotyping
MH: muscle biopsy

B - Cholinesterase deficiency: prolonged paralysis
MH: - hypermetabolic state (increased temp, increased O2 consumption, resp acidosis, tachypnea, tachycardia)
- muscle rigidity
- rhabdomyolysis
- renal failure

Front 107

With respect to the following drugs:
A. What is the usual initial dose of epinephrine used in a cardiac arrest situation? (1)

B. What is the optimal route of administration of epinephrine in the above situation? (1)

C. What is the dose of lidocaine used for ventricular dysrhythmias?

D. What is the weight of a patient to whom the administration of 20 ml of 2% lidocaine with epinephrine would be a maximum?

E. What dose of epinephrine is contained in 1 cc of a 1:200,000 solution? (1)

F. List 3 advantages of mixing epinephrine in local anaesthetic solutions (3)

G. What dosage of atropine should be given to a patient with a bradyarrhythmia who is hypotensive? (1)

H. 20ml of 1.5% lidocaine is equivalent to how many milligrams?

Back 107

A - 1mg IV push q3-5 min
B - IV push q3-5 min
C - 1-1.5 mg/kg push
D - 400mg/7=57
E - 5 mcg
F - Decrease systemic absorption, higher threshold for anesthetic, longer duration of epidural
G - 0.5-1.0mg
H - 300mg - IV lidocaine 1% = 10mg/ml. 1.5% lidocaine = 15mg/ml

Front 108

List 5 maneuvers that can be used to open the airway and permit ventilation in an unconscious patient that you are unable to ventilate with a bag and mask alone. (10)

Back 108

1. chin lift, 2. jaw thrust, 3. insert nasal airway, 4. insert oral airway, 5. remove any foreign object

Front 109

. List 4 methods to absolutely confirm that an endotracheal tube is situated in the trachea. (10)

Back 109

See it go through cords, bronchoscope, capnograph, CXR

Front 110

You are seeing a 30 year old woman in your family practice office as part of a work-up for infertility. She has had asthma for the past ten years and uses a Ventolin inhaler on a prn basis. Over the past three weeks, she has been using the Ventolin more than usual and has been waking up at night coughing. On physical examination she has bilateral wheezes that do not clear with cough. She is scheduled to have a diagnostic laparoscopy in one week’s time.
A. What are four therapeutic modalities that may be used to improve her condition? (8)

B. When you see her again on the day prior to surgery, her condition is unchanged. What would you do at this point? (2)

Back 110

A - 1. addition of inhaled steroid, 2. addition of inhaled LABA, 3. addition of oral steroid, 4. smoking cessation

B - Cancel and optimize?

Front 111

A 65 year old man with untreated hypertension presents to the emergency department, complaining of severe abdominal pain. He has been seen by general surgery and has an incarcerated inguinal hernia that required EMERGENCY surgery. His blood pressure is now 200/120 mm Hg. List five IMPORTANT and specific anaesthetic considerations of this patient undergoing this procedure.

A. Give 5 indications for performing a rapid sequence induction. (5)

B. Besides performing a rapid sequence induction, how can we minimize the risk of aspiration? (5)

Back 111

A - GERD/hiatus hernia, not NPO, pregnant, overdose/LOC, delayed emptying

B - 1. NPO (8 hrs for food, 4 hrs for clear fluids)
2. H2-antagonists to decrease acidity (eg. Na citrate)
3. increase gastric emptying (eg. metoclorpropamide)
4. NG tube to empty stomach
5. extubate awake on side

Front 112

A - Describe the ACLS protocol for symptomatic Bradycardia.

B - What should be done if the above measures fail?

Back 112

Pacing Always Ends Danger

Pacing **TCP Immediately prepare for transcutaneous pacing (TCP) with serious circulatory compromise due to bradycardia (especially high-degree blocks) or if atopine failed to increase rate.

Consider medications while pacing is readied.
Always - Atropine = 1st-line drug, 0.5 mg IV/IO q3-5 min. (max. 3mg)

Ends - Epinephrine 2-10 µg/min 2nd-line drugs to consider if atropine and/or TCP are ineffective. Use with extreme caution.
Danger - Dopamine - 2-10 µg/kg/min

B - Search for other causes -

Front 113

What are the ACLS DDx for a problem search when interventions fail to correct cardiac abnormalities.

Back 113

6H's and 5T's

Hypoxia
Hypoglycemia
Hypo/Hyperkalemia
Hypocalcemia
Hypovolemia
Hypothermia
Hyperacidemia

Thrombus - MI/PE
Tension Pneumo
Tamponade

Front 114

How should you treat symptomatic hyperkalemia?

Back 114

Sodium bicarbonate, calcium chloride, albuterol nebulizer, insulin/glucose, dialysis, diuresis, Kayexalate

Front 115

What features would you see with a patient who is crashing and has cardiac tamponade?

What is the treatment?

Back 115

No pulse w/ CPR, JVD, narrow pulse pressure prior to arrest.

Tx - Pericardiocentesis.

Front 116

Why do you give Fentanyl intraoperatively despite the patient being unconscious?

What about when harvesting organs from a brain dead patient?

Back 116

Despite unconsciousness, incision and intubation will result in a pronounced sympathetic drive at level of spinal cord.

You must control pain and hemodynamics even on a brain dead patient.

Front 117

What are contraindications to inhaled anaesthetics?

What are your options?

Back 117

Hx of Malignant Hyperthermia
Cardiopulmonary procedures that bypass heart and lungs
Neck Surgery preventing access

Options are to use local, regional or TIVA GA (propofol, thiopental or Ketamine )

Front 118

How are exhaled anaesthetics such as sevoflurane and isoflurane cleared from the body?

Back 118

By inhalation - thus you need to increase the O2 when preparing for extubation.

Front 119

An 82 year old male is scheduled for elective repair of a AAA. What factors will affect his perioperative plan and outcome?

Back 119

Elderly - Requires lower MAC, less opioids, increased risk of delirium, more pronounced hemodynamic changes, less pulmonary reserve for intubation.

Vascular surgery = >5% mortality.

Front 120

Describe the primary and secondary ABCDs.

Back 120

Primary = BLS protocol, Airway with head tilt, Breathing with bag, Chest compressions, Defibrillation.

Secondary = ETT, Breathing monitors, Circulatory IV and Meds, Differential Dx = PATCH4 MDS

Front 121

How should you manage an unstable VT or VF tachycardia without pulses?

ACLS Pulseless arrest algorythm

Back 121

1. 5 cycles of CPR followed by Synchronized cardioversion for all unstable VT and VF tachycardias. Followed by 5 cycles of CPR. Give Epinephrine. 5 cycles CPR. Check rhythm.

2. Do secondary survey - PATCH4 MDS if no response to measures.

Front 122

How should you manage an unstable PEA and Asystole tachycardia without pulses?

ACLS Pulseless Arrest Algorythm

Back 122

5 cycles of CPR. IV epinephrine 1 mg every 3-5 min. 5 cycles of CPR. Atropine 1mg IV. 5 cycles of CPR. Check rhythm.

Do secondary survey - PATCH4 MDS if no response to measures.

Front 123

How should tachycardia with pulses be managed.

ACLS Tachycardia Algorythm

Back 123

1. Unstable? Immediate synchronized cardioversion.

2. Stable?
Narrow QRS = Vagal manoevre, Adenosine,
Converts = SVT Tx recurrence with Beta blocker (metoprolol) or diltiazem

Does not convert = A Fib or Flutter - Diltiazem oe Beta-blocker (metoprolol).

Wide QRS = Amiodarone and Cardioversion

Front 124

How should Bradycardia be approached within the ACLS algorythm?

Back 124

1. HR <60 and adequate perfusion = monitor with ECG, IV access, O2, oximetry, ABG, Lytes.

2. HR <60 and poor perfusion = Prepare transcutaneous pacing, consider atropine 1mg IV, epinephrine 1mg IV if no response, continue pacing. Search for causes - PATCH4 MDS

Front 125

A 50 year old man takes beta blockers and Ca2+ channel blockers for stable angina. He is coming for elective surgery in one week. What should you tell him about his medications and eating and drinking before his operation? (3)

Back 125

1. take B-blockers and CCB at usual time with sips of water
2. no solids at least 8 hrs prior
3. no fluids at least 4 hrs prior

Front 126

B) What are 2 reasons that we have patients fast before elective surgery? (2)

Back 126

1. decrease gastric volume, 2. decrease gastric acidity

Front 127

What immediate outcome may occur under general anaesthesia in a patient who has a full stomach?

What is a potential consequence of this outcome?

What 3 reasons contribute to these outcomes? (3)

Back 127

(1) aspiration

(1) pneumonitis, atelectasis, ARDS, abscess

volume, acidity, particulate matter

Front 128

Many unnecessary blood tests are ordered prior to surgery. List 5 pieces of information learned from the patient’s history that would cause you to order preoperative coagulation studies. (10)

Back 128

1. on anticoagulants, 2. liver disease, 3. known factor deficiency, 4. family history of factor deficiency
5. surgery involving lots of blood loss

Front 129

A 60 year old woman with insulin-dependent diabetes presents to the preoperative consultation clinic having been scheduled for a total knee arthroplasty in 2 week’s time.

A. What 6 specific questions related to her diabetes would be important to ask to assess her fitness for anaesthesia and surgery? (6)

B. What 4 specific tests would you order preoperatively? (4)

Back 129

1. how long?
2. end organ damage?
3. monitor blood glucose regularly?
4. adequate control?
5. admissions to hospital for hypo or hyperglycemia?
6. other CAD risk factors?

1. blood glucose, 2. ECG, 3. lytes and creatinine, 4. urinalysis

Front 130

List 5 GENERAL causes of hypoxaemia. (10) (Do not give specific examples i.e. pulmonary embolus)

Back 130

1. decreased FIO2
2. decreased alveolar ventilation
3. increased shunting
4. increased dead space ventilation
5. decreased diffusion

Front 131

A. You are called to the postanaesthetic care unit to see a patient who has a saturation of 80%. She has been in the PACU for 20 minutes after having had a total abdominal hysterectomy. She is otherwise healthy. Her blood pressure is 120/80 mm Hg and her heart rate is 120 bpm. Describe in point form EXACTLY what your management of this situation would be. (5)

B. What are five GENERAL potential causes of her tachycardia? (5)

Back 131

A. 1. assess airway, secure airway
2. assess need for ventilation
3. increase O2
4. look for acute blood loss, stop
5. fluid resuscitation

B. Hypovolemia, pain, arrhythmia, full bladder, anxiety, anemia, drugs (e.g. atropine, pancuronium)

Front 132

You are called to the floor to see a patient who the nurse believes has had a narcotic overdose. He has been on the ward for 2 hours having just had an open reduction and internal fixation of a femoral fracture. He is on PCA which his wife has been using regularly on his behalf.
A. What would be your management of the situation at this point? (2)

B. If the patient is rousable and maintains his airway, what would you do in this case? (5)

C. If the patient is difficult to rouse, snores and has a respiratory rate of 8 per minute, and a saturation of 80% on room air with a stable BP and Heart rate, what would you do? (3)

Back 132

A. Assess responsiveness, resp rate, heart rate, pupils, educate patient and wife

B. reduce PCA infusion rate, hold bolus doses for now, reassess frequently

C. 1. assess and secure airway
2. give O2
3. give small incremental doses of 40 mcg naloxone

Front 133

List 5 options for pain relief during labour and give 1 advantage and 1 disadvantage for each. (5)

Back 133

Lamaze: gives woman control, not great analgesia
Epidural: good analgesia, hypotension
NO: easy, does not relieve pain completely
Spinal: good analgesia, motor blockade
Opioids: easy, maternal/neonatal depression

Front 134

You are called to the recovery room (PACU) to see a patient who has just arrived after having had a laparoscopic cholecystectomy. The patient was awake, alert, extubated and breathing spontaneously. The nurse has just given a gram of Ancef intravenously at the surgeon’s request. The nurse tells you that the patient is having an “allergic reaction”.
A) What 5 signs and/or symptoms might the patient be experiencing to support this diagnosis? (5)

B) What 5 steps MUST be taken to treat this patient? (Be specific) (5)

Back 134

A. rash, stridor, tachycardia, hypotension, bronchospasm, urticaria

B. 1. Stop Ancef, 2. 100% O2, 3. 50 mcg epinephrine iv, 4. N/S, 5. benadryl 50 mg iv

Front 135

What two genetic disorders related to anaesthesia might be elicited by asking a patient about their family history of anaesthetics? What investigations can be done to determine if the disorder has bee transmitted to the patient? (4)

B. What would be the symptoms that might occur, related to each disorder, if a patient received a general anaesthetic without any precautions against the above problems? (6) (Separate the symptoms according to the disorder.)

Back 135

A. Cholinesterase deficiency: genotyping
MH: muscle biopsy

B. Cholinesterase deficiency: prolonged paralysis
MH: - hypermetabolic state (increased temp, increased O2 consumption, resp acidosis, tachypnea, tachycardia)
- muscle rigidity
- rhabdomyolysis

Front 136

A. What is the usual initial dose of epinephrine used in a cardiac arrest situation? (1)
1mg
B. What is the optimal route of administration of epinephrine in the above situation? (1)
IV push
C. What is the dose of lidocaine used for ventricular dysrhythmias? (1)
1-1.5 mg/kg push
D. What is the weight of a patient to whom the administration of 20 ml of 2% lidocaine with epinephrine would be a maximum? (1)
400mg/7=57
E. What dose of epinephrine is contained in 1 cc of a 1:200,000 solution? (1)
5 mcg
F. List 3 advantages of mixing epinephrine in local anaesthetic solutions (3)
Decrease systemic absorption, higher threshold for anesthetic, longer duration of epidural
G. What dosage of atropine should be given to a patient with a bradyarrhythmia who is hypotensive? (1)
0.5-1.0mg
H. 20ml of 1.5% lidocaine is equivalent to how many milligrams? (1)
300mg

Back 136

A. 1mg
B. IV push
C. 1-1.5 mg/kg push
D. 400mg/7=57
E. 5 mcg
F. Decrease systemic absorption, higher threshold for anesthetic, longer duration of epidural
G. 0.5-1.0mg
H. 300mg

Front 137

List 5 maneuvers that can be used to open the airway and permit ventilation in an unconscious patient that you are unable to ventilate with a bag and mask alone. (10)

Back 137

1. chin lift, 2. jaw thrust, 3. insert nasal airway, 4. insert oral airway, 5. remove any foreign object

Front 138

List 4 methods to absolutely confirm that an endotracheal tube is situated in the trachea. (10)

Back 138

See it go through cords, bronchoscope, capnograph, CXR

Front 139

You are seeing a 30 year old woman in your family practice office as part of a work-up for infertility. She has had asthma for the past ten years and uses a Ventolin inhaler on a prn basis. Over the past three weeks, she has been using the Ventolin more than usual and has been waking up at night coughing. On physical examination she has bilateral wheezes that do not clear with cough. She is scheduled to have a diagnostic laparoscopy in one week’s time.
A. What are four therapeutic modalities that may be used to improve her condition? (8)

B. When you see her again on the day prior to surgery, her condition is unchanged. What would you do at this point? (2)

Back 139

A. 1. addition of inhaled steroid, 2. addition of inhaled LABA, 3. addition of oral steroid, 4. smoking cessation

B. Cancel and optimize

Front 140

Give 5 indications for performing a rapid sequence induction. (5)

B. Besides performing a rapid sequence induction, how can we minimize the risk of aspiration? (5)

Back 140

A. GERD/hiatus hernia, not NPO, pregnant, overdose/LOC, delayed emptying,

B. 1. NPO (8 hrs for food, 4 hrs for clear fluids)
2. H2-antagonists to decrease acidity (eg. Na citrate)
3. increase gastric emptying (eg. metoclorpropamide)
4. NG tube to empty stomach
5. extubate awake on side

Front 141

You are attending a breech delivery (in a peripheral hospital) with the staff obstetrician. It is a very difficult delivery complicated by trapping of the after-coming head. When the baby is finally delivered, it is limp and blue. The obstetrician is attending to the mother who is having a brisk postpartum haemorrhage.
A. The baby’s heart rate is 50 bpm. What resuscitative efforts should be done now? List 8 steps/actions in the management of this situation (8)

B. At 6 minutes of life, the heart rate is 120 bpm, respirations are slow and irregular. The baby is limp, does not respond to stimulation but is centrally pink with blue hands and feet. What Apgar score corresponds with these findings? (2)

Back 141

A.
1. open airway (infant supine or on side)
2. suction mouth then nose
3. 100% O2
4. keep neonate warm and dry
5. physical stimulation (slapping soles of feet, rubbing back)
6. PPV if apnea, HR <100, or central cyanosis despite 100% O2
7. chest compressions (if HR < 80 despiate PPV)
8. iv fluids (pallor despite 100% O2, weak pulse, BP < 55.30)
9. epinephrine (0.01 mg/kg) if HR still < 80 despiate 100% O2 and chest compressions

B. HR: 2, Respiration: 1, Irritability: 0, Tone: 0, Colour: 1, TOTAL: 4

Front 142

What are the five minimum pieces of equipment required to intubate? (5)

Back 142

1. suction, 2. O2, 3. laryngoscopy, 4. ETT, 5. stylet

Front 143

A 24 year old previously healthy male is brought by ambulance to the emergency department. He has taken an unknown quantity of an unknown drug. He is unconscious and breathing at a rate of 5 per minute. His saturation on room air is 88%. He has no gag reflex and the casualty officer would like you to intubate him. He has not sustained a cervical spine injury. Assuming that all the equipment you need is ready, describe the five steps you would follow to perform the intubation. (5)

Back 143

1. position patient in sniffing position
2. open mouth and check for obstructions, dentition
3. laryngoscopy, exposing the vocal cords
4. insert ETT though vocal cords, remove laryngoscope
5. confirm ETT placement with stethoscope, end-tidal CO2, condensation or bronchoscope confirmation.

Front 144

Name 5 ways that you can confirm placement of an ETT tube.

Back 144

1. Visualize placement with naked eye or glidescope.
2. Bronchoscopy down tube
3. Auscultate lungs for breath sounds
4. End Tidal CO2
5. Condensation on ETT
6. Compliance of manual bag with ventillation and chest expansion
7. CXR

Front 145

Describe the sniffing position for placement of an ETT. Why important?

Back 145

Flexion of C6-C7 and Extension of C1-C2.

Aligns Oral, pharyngeal and laryngeal axis.

Front 146

List 5 problems associated with the use of intramuscular narcotics ordered on a prn basis for postoperative pain. (10)

Back 146

Inadequate analgesia, increased side-effects, delays to relief, large variability in different patients in maximum levels, wide fluctuations, painful injections

Front 147

A 20 year old male is scheduled for removal of impacted wisdom teeth under general anaesthesia. During a pre-op assessment, he states that his first cousin had an unusual reaction under anaesthesia and subsequently had a positive biopsy for malignant hyperthermia. Neither of his parents has had a general anaesthetic.
A. What 2 anaesthetic agents should be avoided in this patient? (4)


B. List five signs of a malignant hyperthermia reaction. (5)

C. What is the drug of choice and dose for treating malignant hyperthermia? (1)

Back 147

A. succinylcholine, inhalational agents

B. Hyperthermia, muscle rigidity, hypertension, tachycardia, tachypnea, cyanosis

C. dantrolene (2 mg/kg)

Front 148

List four GENERAL indications for endotracheal intubation (NOT restricted to the operating room setting). (10)

Back 148

Five P's
1. Protect airway - aspiration
2. Pharm - administer medications NAVEL (naloxone, atropine, ventolin, epinephrine, lidocaine)
3. Pulmonary toilet - to remove tracheobronchial secretions and prevent ARDS and Atelectasis
4. Positive pressure ventilation - hypoventilation, apnea, hypoxia, status asthmaticus
5. Patency - decreased LOC, facial fractures, edema

Front 149

A 65-year old man is referred to your internal medicine office with the following story: He has had stable class I angina for four years, for which he is taking Vasotec and sublingual nitroglycerine prn. Recently, he has experienced some angina at rest and at night and an episode a week ago lasted half an hour and did not respond to nitroglycerine. He has benign prostatic hypertrophy and is scheduled for surgery (transurethral resection of the prostate) in two weeks time.
A. What are three specific concerns regarding this man’s story? (6)

B. List 4 items in your plan of action at this time. (4)

Back 149

A. 1. night symptoms, 2. angina at rest, 3. not responsive to NTG

B. Go to ER, ECG, troponins, stress test, Echo, cath

Front 150

At the end of a 2-hour laparoscopic cholecystectomy, all inhalation anaesthetics are turned off and the patient is ventilated through the endotracheal tube with 100% oxygen. After 10 minutes, the patient, who is still intubated, has not begun to breathe spontaneously. Blood pressure is 120/80 mm Hg, heart rate 98 bpm. Anaesthesia was induced with propofol and fentanyl. Intubation was facilitated by 100 mg of intravenous succinylcholine. Maintenance of anaesthesia involved the use of incremental doses of rocuronium, morphine, nitrous oxide and isoflurane. List 5 common and important potential causes of this patient’s postoperative apnea. (10)

Back 150

1. rocuronium, 2. morphine, 3. nitrous oxide, 4. isoflurane, 5. succinylcholine

Front 151

A 83 year old man with a history of hypertension is undergoing emergency surgery for an incarcerated inguinal hernia. Shortly after induction of the general anesthesia with fentanyl 50 micrograms, propofol 160 mg and rocuronium 50 mg, Nitrous oxide 70% and oxygen 30% and Isoflurane 1%, his blood pressure which had been 150/90 mm Hg on admission to the OR is now 80/60 with a heart rate of 120 bpm.
A. What might be the cause of this fall in blood pressure? (5)

B. What would you do? (5)

Back 151

A. 1. fentanyl, 2. propofol, 3. nitrous oxide, 4. isoflurane, 5. decreased sympathetics after removal of painful stimulus

B. 1. crystalloids, 2. phenylephrine (increases BP without increasing HR), 3. decrease nitrous oxide
4. decrease isoflurane, 5. monitor

Front 152

Name 5 conditions that are associated with difficult VENTILATION.

Back 152

BONES.
Beard, Obeses, No teeth, Elderly, Snoring (Sleep apnea).

Front 153

Name 6 conditions associated with a difficult INTUBATION and 1 reason why for each.

Back 153

1. Obesity - extra tissue collapses airway
2. Pregnancy - edematous tissues
3. Scleroderma - connective tissue leads to low compliance in pharynx.
4. Arthritis - Osteo and Rheum - c-spine instability, TMJ stiffness, atlanto-axial instability
5. Acromegaly - big tongue, thick throat
6. Congenital anomolies.

Front 154

List 4 MAJOR side effects related to the use of NSAIDS. (8)

B. What is the mechanism of action that leads to the adverse effects? (2)

Back 154

A. 1. bleeding, 2. renal failure, 3. worsens CHF, 4. PUD

B. 1. platelet inhibition, 2. prostaglandin synthesis inhibition

Front 155

List 5 advantages of the use of patient-controlled analgesia over intramuscular injections of narcotics. (10)

Back 155

Quicker onset
No painful injections
Able to adjust to patient variability
Able to adjust as pain needs change overtime
Reduce side-effects
More effective analgesia

Front 156

You have just positioned a patient supine after administering a spinal anesthetic with hyperbaric bupivacaine for an elective repeat cesarean section. The patient’s blood pressure was 110/65 preoperatively and is now 88/45.
A. List 2 reasons why her blood pressure has dropped. (2)

B. What is your immediate management? (3)

C. List three signs or symptoms that she might experience while her blood pressure is 88/45. (2.5)

D. List three other signs or symptoms that she might experience while her blood pressure is 88/45. (2.5)

E. List the 5 components of the Apgar score. (2.5)

Back 156

A. Aortocaval, sympathetic nerve block from spinal anesthesia

B. 1. position patient on left side, 2. O2, 3. IV crystalloids

C. lightheadedness, palpitations, visual changes,

D. 1. tachycardia, 2. tachypnea, 3. presyncope

E. Activity, Pulse, Grimmace, Appearance, Respirations 1-3.

Front 157

A previously healthy 18 year old male was stabbed in the back at an after hours club. He comes to the ER with a single wound 2 cm in length, 5 cm below the left scapula and 15 cm left of the midline. He is awake and alert, BP 110/50 mm Hg, SpO2 97%.
A. What immediate steps should be taken in the management of this patient? (3)

10 minutes later he is pale, diaphoretic: BP 70/40 mm Hg, HR 130 bpm. SpO2 88%
B. What are 3 LIKELY possibilities for the above changes. (3)

C. What treatment measures would you institute at this point? (2)


He stabilises for 1 hour, then again gets hypotensive. His repeat Hb is 45. You now decide to give him a blood transfusion immediately. Unfortunately the blood bank says it will be 30 min. before fully cross matched blood is available.

D. What are your transfusion options at this time? (2)

Back 157

A. ABCs, IV, O2 monitor, Cardiac monitor

B. Tension pneumo, tamponade, hemothorax

C. Ventilate with 100% O2, fluids wide open

D. O positive, type specific

Front 158

Succinylcholine is often given to patients undergoing anaesthesia and surgery. In otherwise healthy patients with no history of neuromuscular diseases, allergy, personal or family history of pseudocholinesterase deficiency, list 5 side effects that may occur with the intravenous administration of 1 mg/kg of succinylcholine. (Do not include malignant hyperthermia trigger) (10)

Back 158

Myalgias, hyperkalemia, bradycardia, increased secretions, increased ICP/IOP

Front 159

A 50 year old female has undergone a total abdominal hysterectomy. She has been fasting since midnight. Her surgery began at 08:00 and took 2 hours. The total estimated blood loss was 500 cc. Considering all sources of perioperative fluid loss, answer the following question.
How much fluid (i.e. Normal saline) should she be given by the end of the case? Show how you derived the total amount, including formulas. She weighs 50 kg. (10)

Back 159

maintenance requirement per hour: 4 ml x 10 kg + 2 ml x 10 kg + 1 ml x 30 ml = 90 ml/h
fluid deficit: 90 ml/h x 10 h = 900 ml
third space losses: 6 ml/kg/h x 50 kg x 2 hr = 600 ml
blood loss replacement: 500 ml x 3 = 1500 ml
TOTAL: 3090 ml

Front 160

What is more important, Ventilation or Intubation?

Back 160

Ventilation - if you can't ventilate they die. If you can't intubate you can still ventilate until you wake or get a surgical airway.

Front 161

A. List four devices for delivering supplemental oxygen to spontaneously-breathing (not intubated) patients. For each, give the approximate FiO2 or range of FiO2 that can be delivered by each: (8)

B. What device and corresponding FIO2 would you select for a 60 year old obese patient with severe COPD, a known CO2 retainer, who has presented to the Emergency Department with acute bronchitis, and whose PaO2 is 48 (normally 55) and PaCO2 is 65 (previously 50)? His lips and nail beds are blue-tinged. (2 marks):

Back 161

A. Nasal Prongs =24-44%, face mask=40-60%, mask with reservoir=60-80%, Venturi 24, 28, 31, 35, 40%

B. Venturi 24%

Front 162

What is the standard medication to use in wide QRS (>0.12sec) tachycardia with pulses?

Back 162

Amiodarone 150mg IV over 10 minutes. If Torsades de Pointes give 1-2 mg magnesium over 30 min.

Front 163

A 50 kg male has been NPO for 12 hours prior to a 3 hour laparatomy. He lost 300cc of blood. Calculate fluid requirements.

Back 163

12h NPO = 4:2:1 = 90cc/h x 12 = 1080
3h Surgery Maint. = 90cc/h x 3 = 270
Losses @ 3:1 = 900cc
Third space loss (Medium surgery) = 6cc/kg/h = 6 x 50 x 3 = 900cc
Total = 3150 of Ringers (or NS).

Note: Third space loss calculation
Small surg (nose, foot, hand) = 4cc/kg/h
Med. Surg (laparotomy, bowel resec, c-sec) = 6cc/kg/h
BIG = 8cc/kg/h (AAA, cardiac, thoracic, transplant).

Front 164

How do you calculate third space losses for surgical procedures?

Back 164

Note: Third space loss calculation
Small surg (nose, foot, hand) = 4cc/kg/h
Med. Surg (laparotomy, bowel resec, c-sec) = 6cc/kg/h
BIG = 8cc/kg/h (AAA, cardiac, thoracic, transplant).

Front 165

Laryngospasm
1. Etiology
2. When does it most commonly occur?
3. Complications
4. . Tx

Back 165

1. induced by secretions, inadequate anestheisa, anaphylaxis and airway manipulation.

2. Most commonly occurs in a patient who is going into or out of paralysis during intubation or extubation.

3. Results in inability to ventilate a patient = EMERGENCY.

4. Succinylcholine to stop spasm, then ETT.

Front 166

Laryngeal Mask (LMA)
1. When to use
2. Sizing
3. Contraindications

Back 166

1. a. Great for can't intubate/ventillate.
b. When not using a paralytic.
c. Short procedure.
d. Breathing spontaneously.

2. Women = Size 3, Men = Size 4.

3. Succinylcholine, Sevoflurane. Full stomach, preganant, ascites, reflux.

Front 167

DDx of Hypertension Intraoperatively. Give 10.

Back 167

Pain, hypoxia, drugs (epi, phenyl, atropine, dopamine), fluid overload, electrolytes (Ca+) Pheochromo, Thyroid storm, Malignant Hyper, Machine not working (art line too low, wrong size BP cuff).

Front 168

DDx of High Airway pressure with ventilation. Give 10.

Back 168

Kink/Fluid in tubes, Kink in ETT, secretion/tissue in ETT, ETT placed down Left bronchus, PTX, trendelenberg, obesity, ascites, surgeon leaning on patient, bronchospasm.

Front 169

Bronchospasm
1. Etiology
2. Clinical signs
3. Complications
4. Management

Back 169

Bronchospasm or a bronchial spasm is a sudden constriction of the muscles in the walls of the bronchioles. Often occurs at the induction stage before patient is fully anesthetized. It is caused by the release (degranulation) of substances from mast cells or basophils under the influence of anaphylatoxins. Asthma, chronic bronchitis, anaphylaxis, pilocarpine (which is used to treat illness resulting from the ingestion of deadly nightshade as well as other things) and beta blockers
2. Prolonged expiratory phase, wheeze, hypoxia, increased airway pressures, silent chest, upslopping CO2 tracing with ventilation.
3. Hypoxia, unable to venilate, hypercarbia, resp acidosis, CV collapse.
4. Atropine, increase inhalation anesthetic (bronchodilator), Induction (propofol) for Status athmaticus, salbutamol & Ipratoprium bromide by MDI, Prednisone,

Front 170

1. An elderly male with pain in his left hip is scheduled for a hip arthroplasty. He requests to have a spinal anesthetic. All are potential complications of a spinal anesthetic EXCEPT:
Hypotension
Infection at site
Hematoma at site
Local anesthetic toxicity
Nausea & Vomiting

Back 170

Nausea & Vomiting

Front 171

2. All of the following are contraindications to spinal anesthesia EXCEPT:
Raised intracranial pressure
Hypovolemia
Coagulopathy
Infection at site of needle insertion
Kyphosis

Back 171

Kyphosis

Front 172

3. A 24 week pregnant woman is in need of an emergency appendectomy. All are physiologic changes in pregnancy EXCEPT:
Decreased gastroesophageal sphincter tone
Decreased haemoglobin
Decreased coagulation factors
Decreased functional residual capacity
Decreased systemic vascular resistance

Back 172

Decreased coagulation factors

Front 173

What is the name of the curved laryngoscope blade? Straight?

Back 173

Macintosh is curved, Miller is straight

Front 174

Name important measurements and classification systems in the assessment of an airway?

Back 174

Mallampati Score, weight, head and neck movements, mouth opening, thyromental distance, jaw subluxation

Front 175

How long prior to surgery is a patient able to consume clear fluids?

Back 175

2 hours

Front 176

A patient who is a smoker, is obese or has controlled Type 2 diabetes is considered which ASA class?

Back 176

2

Front 177

What length of time must a patient wait post MI before undergoing elective surgery?

Back 177

4-6 weeks

Front 178

When is an ECG indicated prior to surgery?

Back 178

Heart disease, hypertension, diabetes, other risk factors for cardiac disease (may include age), subarachnoid hemorrhage, CVA, head trauma

Front 179

Define MAC

Back 179

The minimum alveolar concentration of an inhalational anesthetic agent is the concentration that prevents movement in response to standard surgical stimulus (incision) in 50% of patients

Front 180

What is the proper positioning of patients during intubation?

Back 180

The sniffing position: head bowed forward, nose in the air

Front 181

What is the proper depth of endotracheal tube placement?

Back 181

The tip 2 cm above the carina, the cuff 2 cm below the vocal cords

Front 182

What medications can be given through the ET tube?

Back 182

Naloxone, atropine, ventolin, epinephrine, lidocaine

Front 183

What are some signs of an esophageal intubation?

Back 183

ETCO2 zero or near zero, poor breath sounds on auscultation, impaired chest excursion, hypoxia

Front 184

At what SaO2 can cyanosis be detected?

Back 184

SaO2 = 80%

Front 185

How do you calculate the fluid maintenance requirements in an adult?

Back 185

4 mL/kg/hour for the first 10 kg, 2 ml/kg/hour for the second 10 kg, 1 ml/kg/hour for the remaining weight

Front 186

What replacement ratio must be used when using crystalloid to replace blood loss? Colloid?

Back 186

3 mL crystalloid / 1 ml blood loss, 1 ml colloid / 1 mL blood loss

Front 187

Which anesthetic drugs can trigger Malignant Hyperthermia crisis?

Back 187

Enflurane, halothane, isoflurane, desflurane, sevoflurane (end in –ane), succinylcholine, decamethonium

Front 188

All of the following are contraindications to
spinal anesthesia EXCEPT:
a) Raised intracranial pressure
b) Hypovolemia
c) Coagulopathy
d) Infection at site of needle insertion
e) Kyphosis

Back 188

e) Kyphosis

Front 189

An elderly male with pain in his left hip is scheduled for a hip arthroplasty. He requests to have a spinal anesthetic. All are potential complications of a spinal anesthetic EXCEPT:
a) Hypotension
b) Infection at site
c) Hematoma at site
d) Local anesthetic toxicity
e) Nausea & Vomiting

Back 189

e) Nausea & Vomiting

Front 190

A 24 week pregnant woman is in need of an emergency appendectomy. All are physiologic changes in pregnancy EXCEPT:
a) Decreased gastroesophageal sphincter tone
b) Decreased haemoglobin
c) Decreased coagulation factors
d) Decreased Functional Residual Capacity
e) Decreased Systemic Vascular
Resistance

Back 190

c) Decreased coagulation factors