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63 Cards in this Set
- Front
- Back
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PC Clonidine is |
ANSWER A
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PZ. The active metabolite of ketamine is:
a. Hydroxyketamine b. Hydroxynorketamine c. Ketamine glucuronide d. Ketamine sulphonamide e. Norketamine |
ANSWER E
norketamine Metabolites of ketamine are norketamine and dehydronorketamin |
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PL03 ANZCA version [1986] [1988] [Mar93] [2004-Aug] Q40, [2005-Apr] Q74
The difference in duration of action of lignocaine and bupivacaine is most marked with: A. Infiltration anaesthesia B. Carbonated solutions C. Peripheral nerve block D. Extradural anaesthesia E. Solutions containing adrenaline 1 in 200,000 |
ANSWER A
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PL05 [Aug93] [Mar94]
Placental transfer of bupivacaine: A. Lipid solubility B. Low F/M ratio of bupivacaine C. High F/M ratio of bupivacaine metabolites D. Molecular weight ?? E. Detectable levels of bupivacaine & PPX in the neonate for several days |
ANSWER B
Bupivacaine is 96% protein bound, so less free drug is available for transfer than with lidocaine (67% bound). The mean F/M ratio for bupivacaine is approximately 0.3 and for lignocaine 0.5, confirming lignocaine's greater placental transfer |
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PL06
In 5 mls of 1% lignocaine with 1:200,000 adrenaline, the amount of adrenaline is: A. 10 mcg B. 25 mcg C. 50 mcg D. 100 mcg |
ANSWER B
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PL08
Bupivacaine ('Marcaine'): A. Possesses an ester type chemical formula B. Is unsuitable for paediatric caudal anaesthesia C. Is biotransformed in the liver D. Has poor plasma binding properties E. Has a shelf-life of one year |
ANSWER C
* Aminoamide local anaesthetic (NOT an ester) * Higher toxicity so better to use something else for caudal. Small but significant risk of IV injection with caudal injection. * Metabolised in the liver (as are all the amide LAs) * Lipid soluble -> high plasma protein binding Amides have a shelf life of up to 2 yrs |
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PL11a
Which of the following has the greatest cardiotoxic effect? A. Amethocaine B. Procaine C. Dibucaine D. Etidocaine E. Prilocaine |
ANSWER A
bupivacaine >tetracaine = etidocaine > lignocaine = chloroprocaine > mepivacaine = prilocaine >>>procaine |
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PL11b ANZCA Version [Jul06] Q109, [Apr07]
The local anaesthetic LEAST likely to cause cardiac toxicity after inadvertent intravenous injection is A. bupivacaine B. etidocaine C. levobupivacaine D. lignocaine E. ropivacaine |
ANSWER D
bupivacaine >tetracaine = etidocaine > lignocaine = chloroprocaine > mepivacaine = prilocaine >>>procaine |
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PL24 ANZCA version [2003-Aug] Q133, [2004-Apr] Q4
The MOST correct statement concerning lignocaine toxicity is that A. extremely high concentrations of lignocaine will produce persistent ventricular fibrillation B. hypercarbia increases the convulsive threshold of the drug C. the first sign of lignocaine toxicity is cardiovascular collapse D. the initial treatment of lignocaine induced convulsions is phenytoin E. tonic-clonic convulsions may be preceded by symptoms such as auditory disturbances |
ANSWER E
* A - False. Miller, 6th ed. p 594: "Ventricular arrhythmias were rarely seen with lidocaine, mepivacaine, or tetracaine." and "Ventricular arrhythmias and fatal ventricular fibrillation may occur more often after rapid intravenous administration of a large dose of bupivacaine but far less frequently with lidocaine." * B - False. "Hypercarbia can lower seizure threshold by several mechanisms: (1) Increased CBF with increased drug delivery to the CNS; (2) increased conversion of the drug base to the active cation in the presence of decreased intracellular pH; and (3) decreased plasma protein binding, which increases the amount of free drug available for diffusion into the brain." Goldfrank's toxicologic emergencies (Caffeine: Think hypercarbia ie acidosis actually said to decrease seizure threshold: hyperventilation test as used in the past for dx petit-mal and diamox used as adjunct for Rx of intractable seizures by inducing acidaemia. Agree with increased blood flow delivering more drug to brain with hypercapnoea though. E best answer.) * C - False. "Initial symptoms are subjective and include tinnitus, lightheadedness, circumoral numbness, disorientation, confusion, auditory- and visual disturbances and lethargy." Goldfrank's toxicologic emergencies * D - False. "Treatment: supportive, with oxygenation / cardiovascular support as for CPR. Thiopental or diazepam / midazolam may be used for convulsions, although hypotension may be exacerbated." Yentis, 3rd ed., p 321. * E - True. Sequence of: "Toxicity . . . tingling . . . unconsciousness and or convulsions." Yentis, 3rd ed., p 321. |
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PL25 ANZCA version [2005-Apr] Q114
Prilocaine is superior to lignocaine for intravenous regional anaesthesia because prilocaine A. exhibits no cardiotoxicity B. has a higher pKa C. has a larger volume of distribution D. is an ester, metabolised in the bloodstream E. is more highly protein bound |
ANSWER C
* A. exhibits no cardiotoxicity - false * B. has a higher pKa * C. has a larger volume of distribution - true o Prilocaine: "Distribution: Vd: 0.7-4.4 L/kg; crosses blood-brain barrier" o Lignocaine: "Distribution: Vd: 1.1-2.1 L/kg" * D. is an ester, metabolised in the bloodstream - false: Prilocaine is an amide anaesthetic. o "Prilocaine is a membrane stabilising agent and a local anaesthetic of the amide type" (Mims online) * E. is more highly protein bound - false o Prilocaine: "Protein binding: 55%" (uptodate) o Lignocaine: "Protein binding: 60% to 80% to alpha1 acid glycoprotein" (Uptodate) |
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PL27 ANZCA version [2004-Apr] Q141
All of the following may be useful in the treatment of ventricular fibrillation due to bupivacaine cardiotoxicity EXCEPT A. adrenaline B. diazepam C. intralipid D. propofol E. vasopressin |
ANSWER C
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PL31 Aug10
Time to reach peak plasma concentration after injection of 2% lignocaine with adrenaline into epidural space A. 20 min B. 30 min C. 40 min D. 50 min E. 60 min |
ANSWER A
CJA. Between 20-30mins. Only took 2 samples though. Could have missed peak. Highest 4.4mcg/ml. http://www.springerlink.com/content/12727258463u7q30/ Look at Fig 1 in Anaes & Anal: 1979 58(5); 360-363 |
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PN42b ANZCA Version [2006-Mar] Q125, [Jul06] Q69
When instructing ward staff on monitoring for respiratory depression in a patient using PCA (patient controlled analgesia) you would advise that early respiratory depression is best detected by monitoring A. frequency of boluses on PCA machine B. pulse oximetry C. pupil size D. respiratory rate E. sedation scores |
ANSWER E
These studies confirm that assessment of sedation is a more reliable way of detecting opioid induced respiratory depression, although monitoring respiratory rate is still important" |
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PN46 ANZCA version [2006-Mar] Q128, [Jul06] Q83 (NB. PN43b = the same question)
Concerning opioids, A. fentanyl is the agent of choice for patient controlled analgesia (PCA) in the opioid addicted patient presenting for surgery B. morphine in therapeutic dosage is a common cause of postoperative confusion C. pethidine is suitable for subcutaneous injection D. sufentanil has a higher affinity for the mu receptor than morphine E. the patient’s age is the best clinical indicator of opioid requirement in the perioperative period |
ANSWER ?C
A. FALSE B. FALSE: Morphine causes confusion in 14% of patients C. TRUE: MIMs states pethidine can be given SC, most correct answer D. TRUE: Sufentanil has a high affinity for the mu receptor, higher than any other opioid E. TRUE: from latest pain book. But it is also dependent on the type of surgery |
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PN47 ANZCA version [2006-Mar] Q129, [Jul06] Q48
Correct statements concerning naloxone include each of the following EXCEPT A. appropriate titration of naloxone will allow reversal of opioid induced respiratory depression B. naloxone is a partial agonist C. naloxone is most effective at blocking mu receptors D. serious side effects such as arrhythmias and pulmonary oedema are rare E. the elimination half-life of naloxone is approximately 60 minutes |
ANSWER B
* A True, respiratory depression is mu effect * B False (so correct answer) naloxone is competitive antagonist * C True but also some action at delta and kappa * D True rare, but reported * E True 1.2 hours |
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PZ120 [Mar06] Q134
Gabapentin used for acute postoperative pain A. has its analgesic effect reduced by concurrent use of COX-2 inhibitors B. increases anxiety if administered preoperatively C. may require high doses to be effective D. reduces the incidence of dizziness when compared with opioids alone E. works by binding at GABA receptors |
ANSWER C
A - sounds like nonsense B - incorrect, it is an anxiolytic. C - Doses of 300mg reduced morphine consumption post-op in this study Acta Anesthesiogica Scandanavica Volume 48 Issue 3, Pages 322 - 327. However the same (and clearly the ref for this Q) BJA editorial states "Unfortunately, it may be that smaller doses are ineffective." D - When used with PCEA in the BJA study (ref below) "There was a significant increase in the incidence of dizziness (35% vs 5%) and a non-significant increase in somnolence (25% vs 10%)". But no mention of PCA. Could it be the examiners did not read the article poperly? E - BJA ref below says this is not its bag, "despite its name gabapentin does not bind at the GABAA or GABAB receptor." |
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PZ78b ANZCA version [2001-Apr] Q34, [2004-Aug] Q53, [2005-Apr] Q40, [Mar06]
When paracetamol is used in infants and children, A. a dose of 10 mg.kg-I is more effective than placebo for relief of symptoms of tonsillitis B. the bioavailability of rectal suppositories is less than 50% of that from an equivalent oral dose C. a rectal loading dose of 45 mg.kg-I will reliably produce therapeutic plasma levels with a peak concentration after 1 hour D. the elimination half life is 2 - 2.3 hours E. a far greater proportion of unmetabolised paracetamol is excreted by the kidney, compared to adults |
ANSWER D
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PZ86d ANZCA Version [Mar06]Q96 | [Jul06]Q20 | Aug10
Each of the following herbal treatments is associated with an increased risk of perioperative bleeding EXCEPT A. garlic B. ginger C. ginko D. ginseng E. St John's Wort |
ANSWER E
St John's wart NOT assoc with coagulopathy. Ginseng DOES increase risk of bleeding, so actually 4 G's do this - ginseng, gingko, ginger, garlic. |
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PZ86b ANZCA version [2004-Apr] Q129, [2004-Aug] Q13
The herbal medicine associated with enhanced bleeding is A. echinacae B. ginko C. golden seal D. kava-kava E. St. John's wort |
ANSWER B
* A. echinacae - false: "Echinacea appears to have a favourable adverse effects profile [9, 23]. Although echinacea preparations contains pyrrozolidine alkaloids [24], hepatotoxicity is unlikely because these alkaloids are structurally different from the pyrrozolidine alkaloids known to be hepatotoxic [12, 25]. Adverse effects include unpleasant taste, gastro-intestinal upset, headache and dizziness." * B. ginko - true: "Danshen, dong quai, jui, ginkgo biloba and garlic have anticoagulant effects and therefore increase the risk of bleeding during surgery." * C. golden seal - false: "Effects on Bleeding: None reported" (Uptodate: Golden seal (Hydrastis canadensis): Natural drug information) * D. kava-kava - maybe: "The herb may also affect platelets in an antithrombotic manner by inhibiting cyclo-oxygenase" (Curr Opin Anaesthesiol. 2007 Aug;20(4):294-9.) * E. St. John's wort - false: "In vitro studies have demonstrated that St John's Wort decreases the efficacy of warfarin by this mechanism [106]. A decreased anticoagulant effect of warfarin associated with concomitant use of St John's Wort has been recorded [103]. Therefore, INR should be closely monitored when starting or stopping St John's Wort" (Anaesthesia Volume 57, Issue 9, 2002. Pages: 889–899) |
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PZ86c ANZCA version [2005-Apr] Q109
Correct statements regarding complementary and alternative medications include A. ginger is a superior antiemetic to metoclopramide B. ginseng and ephedra may produce cardiovascular complications during general anaesthesia C. ginseng and ephedra may potentiate the analgesic properties, but not the bleeding side-effects, of the non-steroidal anti-inflammatory drugs (NSAIDS) D. it is generally recommended that patients can continue these medications perioperatively E. St. John's Wort is associated with acute tubular necrosis perioperatively |
ANSWER B
* A. ginger is a superior antiemetic to metoclopramide - false: o "Ernst and Pittler performed a systematic review of the evidence from six double-blind, randomised, placebocontrolled studies of the efficacy of ginger in preventing nausea and vomiting [87]. Of the three studies on PONV, two studies suggested that ginger is equally effective as metoclopramide, and is superior to placebo. However, the pooled absolute risk decrease for the incidence of PONV indicated that there was no significant difference between ginger and the placebo groups. A recent doubleblind, randomised, placebo-controlled trial, which was not included in Ernst’s systematic review, concluded that ginger was not effective in decreasing the incidence of PONV after day-case gynaecological laparoscopy" (Anaesthesia, 2002, 57, pages 889–899) * B. ginseng and ephedra may produce cardiovascular complications during general anaesthesia - true: o "Furthermore, because of ginseng’s association with hypertension and the deleterious outcomes linked to chronic hypertension, the anesthesiologist should be aware of whether and for how long patients may have been taking this herbal product. Many anesthetic agents can cause generalized vasodilation, and so hemodynamic lability may be observed." (Current Opinion in Anaesthesiology 2007, 20:294–299) o "Ephedra contains alkaloids such as ephedrine, pseudoephedrine, methylephedrine and norpseudo-ephedrine, obtained from the roots and branches of a shrub native to central Asia [79]. Ephedrine is the predominant active component and is a non-catecholamine sympathomimetic agent that acts directly and indirectly at alpha- and betaadrenergic receptors, causing increased blood pressure and heart rate, relaxation of bronchial and gastrointestinal smooth muscle, central nervous system stimulation and mydriasis." (Anaesthesia, 2002, 57, pages 889–899) * C. ginseng and ephedra may potentiate the analgesic properties, but not the bleeding side-effects, of the non-steroidal anti-inflammatory drugs (NSAIDS) - false * D. it is generally recommended that patients can continue these medications perioperatively - false: o "Currently, the American Society of Anaesthesiologists recommends that patients cease herbal medicines at least 2 weeks before surgery" (Anaesthesia, 2002, 57, pages 889–899) * E. St. John's Wort is associated with acute tubular necrosis perioperatively - false |
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PZ101 ANZCA version Mar06 Q146 |
ANSWER D |
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PZ103 ANZCA version [2005-Sep] Q140, [Mar06] Q70 [Aug10]
Intravenous paracetamol A. has a volume of distribution of 10 l.kg-1 B. is excreted 20% unchanged C. is highly protein bound D. is mainly excreted in the gut E. results in similar late plasma concentrations as oral paracetamol |
ANSWER E
Distribution 1L/kg Metabolism liver via 2 major pathways glucuronic acid and sulfuric acid conjugation -4% by cytochrome P450 -rapidly detoxified by reduced glutathione Elimination mainly excreted in the urine -60% as glucuronide -20% sulfate conjugates -<5% unchanged -Plasma 1/2 life 2.7 hour -Clearance 18L/hour |
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PZ107 [Mar06] Q149, [Jul06] Q96
In patients with renal impairment, doses of all of the following may require adjustment EXCEPT A. carbamazepine B. gabapentin C. hydromorphone D. morphine E. oxycodone |
ANSWER B
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PZ112 ANZCA version [2004-Apr] Q105, [Mar06] Q131, [Jul06] Q2
Hepatotoxicity from paracetamol overdose is enhanced in A. chronic renal failure B. concomitant ingestion of benzopdiazepines C. conditions associated with glutathione deficiency D. obese patients E. patients with hepatitis C antibody |
ANSWER C
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PL26 ANZCA Version Jul06 Q111
In severe bupivacaine toxicity, drugs likely to improve the cardiac conduction abnormalities include A. clonidine B. lignocaine C. ketamine D. metoprolol E. propofol |
ANSWER ?A
Outdated question Management * Oxygenation/ventilation and good CPR to prevent acidosis. * Defibrillation, adrenaline or vasopressin (vasopressin better). * Best option would be 1ml/kg intralipid 20% x 3 doses q3min + infusion of 0.25ml/kg/hr as per A&IC. * Cardiopulmonary bypass or intraaortic ballon pump. * Amiodarone forms part of the current ACLS guidelines and has a non-significant trend to improved survival in piggies. * Lignocaine has been reported but I can't find a reference and Miller says not to. * Propofol is useful in early toxicity as may prevent seizures, but should not be used for treatment of arrhythmia or in severe cv collapse because the amount of lipid in propofol is low and the total propofol dose required would cause severe CVS impairment. Better to give Intralipid as that is the therapeutically effective agent. |
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PZ79b ANZCA version [2003-Aug] Q105, [2004-Apr] Q69, [Jul06] Q54, [Apr07] Q105
Features of paracetamol administration in children include A. limitation of the daily dose to a maximum of 150 mg.kg-1 because of the risk of hepatotoxicity B. reliable absorption when administered rectally with most patients achieving a therapeutic concentration with a loading dose of 20 mg.kg-1 C. peak blood levels being reached approximately 1 hour following rectal administration D. a one hour delay between peak plasma concentration and maximum analgesia E. a faster absorption of high dose rectal paracetamol compared to oral |
ANSWER D
Rectal administration may be erratic and prolonged. Therapeutic plasma concentrations (>10mcg/mL) are rarely achieved with a rectal loading dose of 20mg/kg but more commonly achieved with a rectal loading dose of 40-60mg/kg. Peak plasma levels following rectal administration are at 2.6hrs and following oral administration at 1.6-1.9 hrs. Rectal absorption is thus slower than oral absorption. Toxicity occurs with plasma levels greater than 120mg/ml. The maximum daily dose of oral paracetamol is 90-100mg/kg because at 150mg/kg hepatotoxicity has occurred. The maximum daily dose for rectal paracetamol has not been elucidated in children |
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PZ109 ANZCA Version [Jul06] Q134 |
ANSWER E |
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PN22 [Apr99] [Aug99] [Apr07] Q34, [Jul07]
Norpethidine toxicity A. Is only seen if renal function is abnormal B. Develops because the half life of norpethidine is twice that of pethidine C. Is not seen unless treatment is prolonged D. only seen if dose of pethidine in excess of 1.2g/day E. May manifest early as anxiety and mood changes |
ANSWER E
* A. Is only seen if renal function is abnormal - false * B. Develops because the half life of norpethidine is twice that of pethidine - maybe: "Although the elimination half-life of pethidine varies from 3 to 6 h, that of norpethidine is around 17 h in healthy patients, but it may be much longer if renal function is compromised." * C. Is not seen unless treatment is prolonged - false: "Numerous cases of seizures have been reported in patients receiving pethidine over a period of days or in some cases only hours." * D. only seen if dose of pethidine in excess of 1.2g/day - false * E. May manifest early as anxiety and mood changes - true: "toxic side effects such as seizures, agitation, irritability, tremors, twitches and myoclonus" |
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PZ81a ANZCA version [2001-Apr] Q48, [2004-Aug] Q71, [2005-Apr] Q32, [Jul07]
Expected adverse drug effects in a geriatric population receiving a high dose of a selective serotonin reuptake inhibitor for depression would include all of the following EXCEPT A. hyponatraemia caused by inappropriate secretion of ADH B. impairment of platelet aggregation caused by depletion of 5HT (serotonin) stores C. withdrawal symptoms characterised by anxiety, agitation and increased sweating D. sedation, dry mouth, orthostatic hypotension and cardiac conduction defects E. gastro-intestinal effects (nausea, vomiting, diarrhoea) |
ANSWER D
The SSRIs do NOT cause sedation, dry mouth, orthostatic hypotension and cardiac conduction defects, all of which are seen with the tricyclics." (Selective serotonin reuptake inhibitors Pharmacology and clinical implications in anaesthesia and critical care medicine in Anaesthesia Volume 52, Issue 10, Date: October 1997, Pages: 982-988) |
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PN44 [Jul07] Naltrexone
A. given as a single usual dose antagonises the effects of opioids for approximately 8 hours B. mainly renally metabolised C. no hepatic side effects even at high doses D. is mixed opioid agonist-antagonist E. used for alcohol abuse |
ANSWER E
A. FALSE: duration of oral naltrexone is 72-108 hours B. FALSE: hepatic metabolism C. FALSE hepatocellular injury when given in excessive doses D. FALSE: opioid anatgonist E. TRUE: used for alcohol and opiate dependence |
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PZ116 ANZCA version [2005-Sep] Q147
Serotonin syndrome may be appropriately managed with each of the following EXCEPT A. bromocryptine B. chlorpromazine C. cyproheptadine D. diazepam E. non-depolarizing neuromuscular blockers |
ANSWER A
As per A&IC article "Serotonin Syndrome and the Anaesthetist" April 2005 (local rag with perfect timing for Jul05 exam), drugs useful inclde: * cryproheptidine (5HT2 antagonist) * chlorpromazine (70% as potent as cryproheptidine)- antipsychotic. * diazepine (to treat neuromuscular abnormalities) * neuromuscular paralysis ie NDMR (aims to counter myoclonus to prevent rhavdomyolysis) Bromocriptine is a dopamine receptor agonist, so should not have a role in serotonin syndrome |
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PZ124 [Jul07]
Which of the following is NOT associated with serotonin syndrome A. phenelzine B. pethidine C. ondansetron D. chlorpromazine E. sumatriptan |
ANSWER D
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MM21 ANZCA version [Apr08] Q122
Serotonin syndrome A. delays clinical treatment (sic) B. has the specific antidote promethazine C. has signs and symptoms which are difficult to distinguish from neuroleptic malignant syndrome, but the distinction between the two syndromes is unnecessary for clinical management D. is self-limiting E. may be contributed to by pethidine |
ANSWER E
* No direct antidote * Cyproheptadine and chlorpromazine potentially antagonize serotonin in the CNS, but there are no controlled trials of these agents...chlorpromazine may be contraindicated in neuroleptic malignant syndrome because of its antidopaminergic properties (important as they are hard to distinguish)...Current Critical Care, 2008 * Benzodiazepines generally are considered useful for the serotonin syndrome. They are anticonvulsants, are not associated with serotonin release, and are anxiolytic and sedating. Dantrolene uncouples excitation-contract in skeletal muscles and has been used in malignant hyperthermia, neuroleptic malignant syndrome, and serotonin syndrome. There are case reports of benefit from dantrolene in serotonin syndrome but no controlled trials. * Meperidine-induced serotonin syndrome in a susceptible patient, Br. J. Anaesth., September 2009; 103: 369 - 370. * Tramadol, pethidine, fentani(y)l (and congeners), methadone, dextromethorphan, dextropropoxyphene, pentazocine...all possible |
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PN45 ANZCA Version [Jul07] Q126
Which one of the following statements concerning Tramadol is FALSE? A. It has an active metabolite B. It inhibits serotonin and noradrenaline reuptake C. It is LESS likely (at normal doses) to cause respiratory depression than other opioid agonists D. It is metabolised in the liver and excreted in the kidneys E. It structurally resembles codeine |
ANSWER E
* A. It has an active metabolite TRUE, THEREFORE NOT THE ANSWER = O desmethyltramadol * B. It inhibits serotonin and noradrenaline reuptake TRUE AND THEREFORE NOT THE ANSWER [2] * C. It is less likely to (at normal doses) to cause respiratory depression than other opioid agonists TRUE AND THEREFORE NOT THE ANSWER. APMS third edition 2010 page 63. * D. It is metabolised in the liver and excreted in the kidneys TRUE AND THEREFORE NOT THE ANSWER [3] * E. It structurally resembles codeine FALSE AND THEREFORE THE ANSWER. |
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PZ. The active metabolite of ketamine is:
a. Hydroxyketamine b. Hydroxynorketamine c. Ketamine glucuronide d. Ketamine sulphonamide e. Norketamine |
ANSWER E
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PZ19. Antidepressants are not effective/recommended for
a. Chronic headache b. Chronic back pain c. Chronic pain post mastectomy d. Chronic pain post acute herpes zoster e. Trigeminal neuralgia |
ANSWER B
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PN40 ANZCA version [2004-Apr] Q106, [2004-Aug] Q86
Codeine phosphate A. is converted by the liver to its active metabolite, oxycodone B. is not associated with tolerance on chronic use C. is not effective as an analgesic in approximately 20% of Causcasians D. is poorly absorbed from the gastrointestinal tract E. when given orally has approximately 5% of the analgesic potency of intramuscular morphine |
ANSWER E
# A - False, most to codeine-6-glucuronide, some to norcodeine, morphine, normorphine and hydrocodone. # B - False, tolerance does occur therefore oxycodone a better choice. # C - False,CYP2D6 exhibits genetic polymorphism in 9% UK and 30% Hong Kong population. # D - False, oral bioavailability of at least 50%. # E - True, see above or consider 60mg codeine oral goes to 30mg with first pass and then 10% metabolised to morphine is 3mg - 5% if you put oral codeine vs IM morphine. |
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PN: A man on PCA controlled with 2 mg morphine bolus is having a lot of pruritus. You decide to switch him to fentanyl. Which dose is the most appropriate bolus to be equi-analgesic with morphine 2mg:
A. 10mcg B. 20mcg C. 40mcg D. 60mcg E. 80mcg |
ANSWER C
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A patient with chronic pain using morphine PCA after lower limb orthopaedic surgery. Daily usage of IV morphine works out at about 400mg/day. What dose of oral methadone would you start him on to replace the morphine?
A. 60mg/day B. 120mg/day C. 400mg/day D. 600mg/day E: 1200mg/day |
ANSWER A
Methadone replacement depends on dose of oral morphine Daily Dose : Conversion Ratio <100mg 3:1 100 - 300mg 5:1 300 - 600mg 10:1 600mg - 800mg 12:1 800mg - 1000mg 15:1 >1000mg 20:1 400mg IV = 1200mg oral. 20:1 conversion so 60mg of methadone per day = A |
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27. (NEW) As per ANZCA Acute Pain Guidelines (2nd ed update), after a prophylactic subcutaneous dose of heparin, minimum time before you can remove epidural catheter is
a. 2 hours b. 4 hours c. 6 hours d. 8 hours e. 10 hours |
ANSWER C
From update guidelines "Thromboprophylaxis with SC heparin is not a contraindication to neuraxial blockade. To identify heparin-induced thrombocytopenia, a platelet count should be done prior to removal of an epidural catheter in patients who have had more than 4 days of heparin therapy. Epidural catheters should be removed a minimum of 6 hours after the last heparin dose and not less than 2 hours before the next dose." |
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47. Mechanism of action of antiepileptics in chronic pain, which is false?
a. Phenytoin workes at Na channels b. Gabapentin increases gaba in cns c. Carbamazepine works at Na channels d. Valproate increases GABA in the CNS e. lamotrogine acts at Ca channel |
ANSWER B and E
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88. Central anticholinergic syndrome, which is NOT true:
A. Will improve with neostigmine B. Peripheral anticholinergic symptoms C. Caused by Anti-Parkinson drugs D. CNS depression E. Associated with agitation, delirium, and ??? |
ANSWER A
Central anticholinergic syndrome Historically, anticholinergic syndrome was a commonly encountered sequel to anaesthesia. Nowadays, less anticholinergic medications are used. Symptoms range from cerebral irritation with delirium and agitation to CNS depression with stupor and coma. These accompany peripheral anticholinergic effects that is tachycardia, blurred vision, dry mouth and urinary retention. The symptoms are rapidly reversed by physostigmine (an acetylcholinesterase inhibitor), but may recur when its effect terminates. Anti-Parkinsonian, antidepressant and antihistamine drugs can cause central anticholinergic syndrome. Emedicine Physostigmine is the only reversible acetylcholinesterase inhibitor capable of directly antagonizing the CNS manifestations of anticholinergic toxicity; it is an uncharged tertiary amine that efficiently crosses the blood brain barrier |
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TMP-100 [Mar10] [Aug10]
Compared to lignocaine, bupivacaine is: A. Twice as potent B. Three times as potent C. Four times as potent D. Five times as potent E. Same potency |
ANSWER C
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TMP-Jul10-013 Timing of peak respiratory depression post intrathecal 300 mcg morphine:
A. < 3.5 hours (think it was one hour) B. 3.5 – 7.5 hours (then three hours) C. 7 - 12.5 hours (then 7.5 - 12.5 hrs) D. 12.5 -18 hours E. > 18 hours |
ANSWER B
ANZCA Acute Pain: Scientific Evidence 3rd ed p195: "Respiratory depression occurs in up to 1.2% to 7.6% of patients (Meylan et al, 2009 Level I) given intrathecal morphine. When measured in opioid-naive volunteers, respiratory depression peaked at 3.5 to 7.5 hours following intrathecal morphine at 200 to 600 mcg doses (Bailey et al, 1993 Level IV). Volunteers given 600 mcg had significant depression of the ventilatory response to carbon dioxide up to 19.5 hours later. |
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TMP-Jul10-004 Exponential decline / definition of time constant (with various options)
A. time for exponential process to reach log(e) of its initial value B. Time until exponential process reaches zero C. Time to reach 37% of initial value D. Time to reach half if its initial value E. 69% of half life |
ANSWER C
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PZ86d Serotonin syndrome has been reported following SSRI coadministration with:
A. Gingko B. Garlic C. Ginger D. St John’s wort E. Vallerian |
ANSWER E
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PL31 Aug10
Time to reach peak plasma concentration after injection of 2% lignocaine with adrenaline into epidural space A. 20 min B. 30 min C. 40 min D. 50 min E. 60 min |
ANSWER A
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PL24 ANZCA version [2003-Aug] Q133, [2004-Apr] Q4
The MOST correct statement concerning lignocaine toxicity is that A. extremely high concentrations of lignocaine will produce persistent ventricular fibrillation B. hypercarbia increases the convulsive threshold of the drug C. the first sign of lignocaine toxicity is cardiovascular collapse D. the initial treatment of lignocaine induced convulsions is phenytoin E. tonic-clonic convulsions may be preceded by symptoms such as auditory disturbances |
ANSWER E
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PL25 ANZCA version [2005-Apr] Q114
Prilocaine is superior to lignocaine for intravenous regional anaesthesia because prilocaine A. exhibits no cardiotoxicity B. has a higher pKa C. has a larger volume of distribution D. is an ester, metabolised in the bloodstream E. is more highly protein bound |
ANSWER C
* A. exhibits no cardiotoxicity - false * B. has a higher pKa * C. has a larger volume of distribution - true o Prilocaine: "Distribution: Vd: 0.7-4.4 L/kg; crosses blood-brain barrier" o Lignocaine: "Distribution: Vd: 1.1-2.1 L/kg" * D. is an ester, metabolised in the bloodstream - false: Prilocaine is an amide anaesthetic. o "Prilocaine is a membrane stabilising agent and a local anaesthetic of the amide type" (Mims online) * E. is more highly protein bound - false o Prilocaine: "Protein binding: 55%" (uptodate) o Lignocaine: "Protein binding: 60% to 80% to alpha1 acid glycoprotein" (Uptodate) |
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PL18 [Aug92]
Which local anaesthetic vasoconstricts skin blood vessels: A. Mepivacaine B. Bupivacaine C. Lignocaine D. Ropivacaine E. Prilocaine |
ANSWER D
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PL02
The toxic level of lignocaine is: A. 1 mcg/ml B. 2 mcg percent C. 5 mcg/ml D. 3 mcg percent E. 10 mcg/ml F. 10 mcg percent |
ANSWER C
Local Anaesthetic Toxic plasma concentration (mcg/ml) Lignocaine >5 Prilocaine >5 Bupivacaine >1.5 Ropivacaine >4 Lignocaine: 5-10: excitatory 10-15: seizures, 15-25 coma >25 cvs collapse. |
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PN48 [Mar10] [Aug10]
Why is codeine not used in paediatrics? A. Poor taste B. High inter-individual pharmacokinetic variability C. Not licensed for children < 10 years old D. Not as effective as adult when given in ?weight adjusted dose? E. ? |
ANSWER B
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PN39 ANZCA version [2004-Apr] Q118
A patient is requiring 70 mg per day of morphine by continuous subcutaneous infusion, for the treatment of cancer pain. You are asked to change the patient to oral morphine. An appropriate initial order for slow release oral morphine would be A. 35 mg twice a day B. 70 mg twice a day C. 100 mg twice a day D. 200 mg twice a day E. 300 mg once a day |
ANSWER C
Parental or oral morphine conversion is 3:1 |
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PN38 ANZCA version [2003-Aug] Q141, [2004-Apr] Q35
Which drug is contra-indicated in a patient with chronic renal failure presenting with a fractured femur? A. fentanyl B. morphine C. paracetamol D. pethidine E. oxycodone |
ANSWER D
Acute Pain Scientific Evidence * Fentanyl - no dose adjustment required * Oxycodone - no dose adjustment required * Morphine - reduced dose, alternative agent if high doses anticipated * Pethidine - dose reduction, altenative agent recoomended as norpethidine accumulation None contra-indicated but Pethidine best avoided |
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PN37 ANZCA version [2003-Apr] Q135
Characteristics of remifentanil include all of the following EXCEPT A. a weakly active metabolite B. high potency C. metabolism by pseudocholinesterase D. muscle rigidity following rapid bolusing E. very short context-sensitive half-life |
ANSWER C
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PN36 ANZCA version [2002-Mar] Q94, [2002-Aug] Q36
Tramadol A. may be used with caution in patients receiving monoamine oxidase inhibitors (MAOI) B. is useful in the treatment of narcotic withdrawal C. has no clinically significant effect on heart rate, left ventricular function or cardiac index at usual therapeutic doses D. use in patients on selective serotonin reuptake inhibitors has NOT been associated with signs of serotonin syndrome E. needs to be given in reduced doses to patients with severe hepatic disease, but not to patients with impaired renal function |
ANSWER C
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PN32 ANZCA version [2001-Aug] Q81
Remifentanil is A. metabolised by non-specific esterases in the liver B. metabolised by plasma cholinesterase C. rapidly metabolised with a context sensitive half life of around 3 minutes regardless of infusion duration D. rapidly metabolised with a context sensitive half life of around 3 minutes after a one hour infusion and around 7 minutes after a 6 hour infusion E. metabolised by non-specific esterases in the kidney and liver |
ANSWER C
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PN24 [Mar00] (type A)
Known adverse effects of intrathecal pethidine include: A. Hypertension B. Hypotension C. Tachycardia D. Sedation E. Increased sweating |
ANSWER B and D
* A. False. * B. True. "Following a dose of 0.5 mg/kg, the reported incidence of hypotension ranged from 0 - 17% . . ." * C. False. "Bradycardia after intrathecal pethidine has been observed in a number of other reports." * D. True. "Other adverse effects that are associated with intrathecal pethidine include nausea and vomiting, pruritus, sedation and respiratory depression." * E. False. |
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PN13b ANZCA version [2002-Mar] Q7, [2002-Aug] Q20, [2005-Apr] Q39, [2005-Sep] Q6 |
ANSWER D
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PV18 ANZCA version [2001-Apr] Q88
When ketamine is used for management of acute post-operative pain A. analgesia is usually accompanied by hallucinations B. a starting dose of 0.05 to 0.1 mg.kg-1.hour-1 is appropriate C. benzodiazepines are ineffective in decreasing dysphoric reactions D. morphine is contraindicated as respiratory depressant effects are additive E. the intravenous route is recommended because absorption is more reliable than via the subcutaneous route |
ANSWER B
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PZ97 ANZCA version [2004-Aug] Q133
In its pure form, arnica (a herbal medicine), can cause postoperative A. angina B. bleeding C. prolonged sedation D. oculogyric crises E. vomiting |
ANSWER B
# "Two sesquiterpene lactones of Arnica montana, helenalin and 11, 13-dihydrohelenal have been shown to inhibit collagen-induced platelet aggregation, thromboxane formation, and 5-hydroxytryptamine secretion." (Uptodate) # "Use with caution in individuals with a history of bleeding, hemostatic disorders, or drug-related hemostatic problems. Use with caution in individuals taking anticoagulant medications, including warfarin, aspirin, aspirin-containing products, NSAIDs, or antiplatelet agents (eg, ticlopidine, clopidogrel, dipyridamole). Discontinue use prior to dental or surgical procedures (generally at least 14 days before)." ( |
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PZ99 ANZCA version [2005-Apr] Q124
Intravenous paracetamol has A. a duration of antipyretic effect of 4 hours B. an antipyretic effect within 10 minutes C. an onset of analgesic effect at 30 minutes D. a peak analgesic effect at 30 minutes E. a peak analgesic effect at 60 minutes |
ANSWER E
* A - False - lasts at least 6 hours * B - False - ↓ fever within 30 minutes * C - False - Onset within 5-10 minutes * D - False - peak effect in one hour * E - True |
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PZ89 ANZCA version [2002-Mar] Q73, [2002-Aug] Q21
Patients taking a selective serotonin reuptake inhibitor (SSRI e.g. fluoxetine): A. should NOT be given high doses of tramadol B. can have their SSRI medication ceased without risk of withdrawal symptoms C. will have potentiation of the effect of direct acting adrenergic agonists D. are less sensitive to benzodiazepines than the general population E. will have the majority of active drug cleared from the body within 36 hours following discontinuation |
ANSWER A
* A : True : Seizures and serotonin syndrome have been reported in patients using tramadol. Some medications, including fluoxetine, are known to reduce the seizure threshold. The risk of seizures and serotonin syndrome may be enhanced when fluoxetine and tramadol therapy are combined (Prod Info Ultram(R), 2001). * B : False : Numerous case reports and several controlled studies document a withdrawal syndrome following discontinuation of selective serotonin reuptake inhibitors (SSRIs). * C : False: MAOI's potentiate effect of direct acting adrenergic agonsists * D : False * E : False : Elimination Half-Life (Fluoxetine) : 4 to 6 days, chronic administration |
