General Surgery

Front 1

SG12 ANZCA version [2001-Apr] Q12, [2002-Aug] Q4

In patients with portal hypertension undergoing surgery, laboratory results associated with an increase in postoperative mortality include

A. an elevated aPTT (activated partial thromboplastin time)

B. a total bilirubin over 25 micromol.l-1 (normal range 3 - 17)

C. a serum albumin less than 30 g.l-1 (normal range 35 - 50)

D. an ALT (alanine transaminase) of 80 (normal range < 55)

E. a serum albumin greater than 55 g.l-1 (normal range 35 - 50)

Back 1

C. a serum albumin less than 30 g.l-1 (normal range 35 - 50)
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Front 2

SG13 ANZCA version [1985] [1986] [1987] [Aug91] [Mar95] [2003-Aug] Q59, [Jul05][Jul07][Apr08]

A 46 year old brewery worker has cirrhosis of the liver with oesophageal varices and has bled from these varices on one occasion. A portacaval shunt is being considered as definitive treatment for his portal hypertension. The operation would be contraindicated if he had

A. a serum bilirubin greater than 50 micromol.litre-1

B. a serum albumin less than 30 gram.litre-1

C. ascites

D. all of the above are true

E. none of the above are true

Back 2

E. none of the above are true


no individual test result will give a Class C for Child Pugh

Child-Pugh (All alcoholics Bleed Puke and Exsanguinate)

- albumin
- ascites
- bilirubin
- prothrombin time (PT)
- encephalopathy

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Front 3

SG16 [Apr98] [Jul98] [Mar00] (type A)

The first biochemical sign of liver metastases are best indicated by:

A. Increased bilirubin

B. Decreased serum albumin

C. Increased alkaline phosphatase

D. Increased gamma globulins

E. Increased AST (?ALT)

F. Increased INR

April 98 version: "The first biochemical sign of liver metastases:"

Back 3

C. Increased alkaline phosphatase
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Front 4

SG30 ANZCA version [1985] [1987] [Mar93] [Aug96] [Apr97] [Jul00] [2001-Apr][Mar12][Aug12]

A patient has suffered flash burns of the upper half of the left upper limb, all of the left lower limb and the anterior surface of the abdomen. The approximate percentage of the body surface which has been burned is:

A. 18%

B. 23%

C. 32%

D. 41%

E. 48%

Back 4

C. 32%


Upper half of the left upper limb = 0.5 × 9 = 4.5%
All of the left lower limb = 18%
Anterior surface of the abdomen = 0.5 × 18 = 9%
TOTAL ≈ 32%
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Front 5

SG33d ANZCA version [2002-Mar] Q47, [2005-Apr] Q95, [Jul07]

The LEAST effective means of preventing post-operative deep venous thrombosis (DVT) in elderly patients undergoing surgery for a fractured neck of femur is the use of

A. intermittent pneumatic compression devices
B. low molecular weight heparin (LMWH) with no haematologic monitoring
C. spinal anaesthesia
D. unfractionated heparin adjusted to upper range normal aPTT
E. warfarin adjusted to an INR of 1.5 times normal

Back 5

C. spinal anaesthesia
vs. E. warfarin adjusted to an INR of 1.5 (previous grp answer)

Spinal anaesthesia reduces DVT risk, but is not in any guideline/recommendation.

"The incidence of postoperative deep-vein thrombosis and pulmonary embolism in patients who have undergone total hip replacement or knee replacement is decreased by more than 50% in patients receiving epidural or spinal anesthesia compared with those undergoing the same surgery but with GA. DVT does still occur, and long term outcome is not affected by the choice of anesthesia. Beneficial effects presumably due to vasodilation, analgesia leading to ambulation, increased fluid loading, platelet aggregation inhibitory effect of local anaesthetic agents."

Regarding E. From http://bestpractice.bmj.com/best-practice/monograph/1087/treatment/step-by-step.html
The American Society for Clinical Oncology and the European Society of Medical Oncology recommend prophylactic LMWH, or low-dose warfarin (target INR 1.5), or fondaparinux in hospitalised cancer patients.

2008 Cochrane review authors' conclusions:

U and LMW heparins protect against lower limb DVT. There is insufficient evidence to confirm either protection against pulmonary embolism or an overall benefit, or to distinguish between various applications of heparin.

Foot and calf pumping devices appear to prevent DVT, may protect against pulmonary embolism, and reduce mortality, but compliance remains a problem.

Good quality trials of mechanical methods as well as direct comparisons with heparin and low dose aspirin should be considered.
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Front 6

SG33e ANZCA version [2003-Aug] Q109, [2004-Aug] Q33, [Jul05] [Apr07]

The most effective method of deep venous thrombosis (DVT) prophylaxis for a fifty-year-old woman presenting for anterior resection for cancer of the colon would be

A. electrical calf stimulation

B. Dextran 70 infusion

C. graduated compression stockings

D. intermittent pneumatic leg compression

E. low dose heparin (5000 units bd)

Back 6

E. low dose heparin (5000 units bd)
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Front 7

SG43 [Jul97] [Apr98] [Jul98] [Apr99] [Aug99] [2001-Aug] Q33, [2002-Mar] Q37, [2003-Apr] Q7, [2004-Aug] Q37, [2005-Apr] Q12, [Jul05]

Bowel preparation for colonoscopy:

A. may cause hypophosphaturia, hypercalcaemia and dehydration

B. can be omitted in high risk patients

C. does not cause significant fluid loss with modern formulations

D. may cause Trousseau's sign to be positive

E. may result in arrhythmias and a shortened QT interval

Back 7

D. may cause Trousseau's sign to be positive
-
From http://www.australianprescriber.com/upload/pdf/articles/45.pdf
A – false
Sodium Phosphate is Fleet - it causes hyperphosphataemia and hypocalcaemia and can be fatal in CCF or renal failure. ie use Glycoprep in frail patients
B – false – I think this negates the purpose. should use alternate preparations
C – false – depends on the formulation. Fleet can cause large fluid shifts
D – True
Trousseau’s sign is a sign of hypocalcaemia - Carpal spasm may be elicited by occluding the brachial artery. To perform the maneuver, a blood pressure cuff is placed around the arm and inflated to a pressure greater than the systolic blood pressure and held in place for 3 minutes. If carpal spasm occurs, manifested as flexion at the wrist and metacarpophalangeal joints, extension of the distal interphalangeal and proximal interphalangeal joints, and adduction of the thumb and fingers, the sign is said to be positive and the patient likely has hypocalcemia.
E - ?False – Some preparations are magnesium which does not affect the QT interval and hypocalcaemia prolongs QT

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Front 8

SG46 ANZCA version [2002-Mar] Q75, [2002-Aug] Q77, [2003-Aug] Q89, [2004-Apr] Q76, [Jul05]

The most correct statement regarding a 70 kg male who has sustained third degree burns to all of his right arm and second degree burns to the anterior aspect of his trunk is that

A. he has burns to 21% of his body

B. he will require 2 to 4 ml of Hartmann's solution per kilogram per percent burn in the first 8 hours after admission

C. a normal blood gas and chest X-ray on admission will be useful in excluding inhalational injury

D. prophylactic antibiotics and steroids are of proven benefit if he has suffered an inhalational injury

E. alkalinizing the urine will prevent renal damage if the burns were electrical

Back 8

A. he has burns to 21% of his body
(previous grp said B)
-
B. false - fluids need to be calculated from time of BURN INJURY not admission.
C. false -
D. false
E. no evidence
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Front 9

SG47 ANZCA version [2003-Aug] Q149, [2004-Aug] Q90, [2005-Apr][Aug12]

A 20 kilogram child suffered 15% full thickness burns 6 hours ago. Optimum crystalloid resuscitation for the first hour is

A. 160ml

B. 260ml

C. 360ml

D. 460ml

E. 660ml

Back 9

C. 360ml


• Parkland formula (Fluid in first 24 hours) = % burn x kgs x 4

∴ Fluid required in first 24 hours is 15 x 20 x 4 = 1200mls.

Plan to give half of this (600mls) in first 8 hours after the burn then the 2nd half (600mls) in the next 16 hours.

As 6 hours has already passed, then the 600mls needs to be given in the 2 hours remaining in the first 8 hour period (This is what the detail about the Parkland formula says to do to catch-up).

So give 300 mls/hr in "the next hour" (& same in the hour after that)

• "Maintenance fluids" should also be added to this value.

Maintenance fluids for 20kg child = (4 x 10) + (2 x 10) = 60 mls/hr

Fluids in 1st hour = replacement fluids + maintenance fluids

CORRECT ANSWER: Fluids in first hour = 300 + 60 = 360 mls/hr.

Then give the remaining 600mls over the next 16 hours - ie 37.5 mls/hour for 16 hours. BUT remember this is just an estimate and actual fluids given have to be adjusted based on urine output (aim for 1-1.5 mls/kg/hr in a child this age). (Est age for 20kg child is 6 yrs) and overall clinical assessment.
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My comments:
from 'Burns in Children' CEACCP 2007 article, Table 1:
Parkland formula
For the first 24 h after the burn, give 4ml/kg per % BSA burn Hartmann's solution, half of this volume in the first 8 hour post-burn, the other half in the next 16 hours.
Maintenance - 4-2-1
Urine output - monitor and aim for 1mL/kg/hr

For this patient:
First 24 hours = 4x15x20 = 1200 mLs
Give 600 mLs in first 8 hours
PLUS maintenance of 60ml/hr - so in first 8 hours will need 480mLs of maintenance

So if this patient has had NO fluid resus - needs 600+(60x8) = 1080mLs in first 8 hours.

Can divide this volume over two hours - 540ml/hr??

Front 10

SG48 [Jul03] [Jul04] [Apr05] Q47.

All of the following may be associated with ulcerative colitis EXCEPT

A. cirrhosis

B. iritis

C. psoriasis

D. arthritis

E. sclerosing cholangitis

Back 10

C. psoriasis
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Front 11

SG49 ANZCA version [2003-Apr] Q139, [2003-Aug] Q52, [2004-Aug] Q56, [2005-Apr] Q56

Hoarseness following a total thyroidectomy may be due to damage to the

A. deep cervical plexus

B. external branch of the superior laryngeal nerve

C. hypoglossal nerve

D. internal branch of the superior laryngeal nerve

E. superficial cervical plexus

Back 11

B. external branch of the superior laryngeal nerve


The superior laryngeal nerve (SLN) has 2 divisions: internal and external.

• The internal branch provides sensory innervation to the larynx. It enters the larynx through the thyrohyoid membrane and therefore should not be at risk during thyroidectomy.

• The external branch provides motor function to the cricothyroid muscle and is at risk during thyroidectomy. This muscle is involved with elongation of the vocal folds. Trauma to the nerve results in an inability to lengthen a vocal fold and thus to create a higher-pitched sound. The external branch of the SLN is probably the most commonly injured nerve in thyroid surgery. The rate of injury to the external branch of the SLN has been estimated at 0-25%. This rate is probably underestimated, because the diagnosis is frequently missed.
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Front 12

SG50 ANZCA version [2003-Apr] Q103, [Jul06]

The most important effect of Lugol's iodine administration prior to thyroid surgery is

A. a reduced incidence of thyroid storm

B. a reduced incidence of vocal cord palsy

C. an increased chance of preservation of the parathyroid glands

D. increased pigmentation to assist in gland identification

E. reduced vascularity of the gland

Back 12

A. a reduced incidence of thyroid storm


Lugol's iodine, also known as Lugol's solution, first made in 1829, is a solution of iodine named after the French physician J.G.A. Lugol. It consists of 5% iodine (I2) and 10% potassium iodide (KI) in distilled water with a total iodine content of 130 mg/mL. Potassium iodide is added to render the iodine water-soluble.

This is the Wolf-Chaikoff effect: "In cases of thyroid storm, severe hyperthyroidism, or preoperative preparation for emergent surgery, more rapid control of the hyperthyroid state can be achieved with beta blockers, thionamides, and additional medications, including iodine, cholestyramine, glucocorticoids, and lithium.
Iodine immediately inhibits both new hormone synthesis (by blocking organification, known as the Wolf-Chaikoff effect) and the release of thyroid hormone. It also decreases gland size and vascularity. This effect is transient, however, lasting approximately one to three weeks. One to five drops of a supersaturated solution of potassium iodine or Lugol’s solution can be given three to four times a day. Iodine usually is given 7 to 14 days prior to surgery. In thyroid storm, sodium iodine may be given intravenously at 0.5 to 1 gm every 8 to 12 hours. It is important to give the iodine at least one hour after administration of a thionamide to prevent possible worsening of hyperthyroidism."
from Emerg Med 38(3):24-38, 2006.
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Front 13

SG51 [Apr07]

Laparotomy and hemicolectomy, the least effective way to minimize post op surgical infection

A. Aggressive peri operative fluid management

B. Timely administration of prophylactic antibiotics

C. Perioperative hyperoxia

D. Avoidance of hypothermia

E. Avoidance of blood transfusion

Back 13

A. Aggressive peri operative fluid management
-
Anaesthesiology 105(2)413-21 Aug 2006 "The Anesthesiologist's role in reducing surgical site infections"

And also:
Anesthesiology 2008; 109:723– 40 "A Rational Approach to Perioperative Fluid Management" -- Wound infection and Tissue Oxygenation section.
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Front 14

SG52 [Apr07][Oct09][Mar10]

Post liver resection, the time when prothrombin time derangement is maximal is:
(or "Timing of worst coagulopathy after liver transplant is"

A. day 1-2

B. day 3-4

C. day 4-5

D. day 6-7

E. unpredictable time after surgery

Back 14

A. day 1-2


Major liver resection results in measurable decreases in levels of various clotting factors. This factor depletion is thought to be a result of consumption and halflife-dependent decay, as well as a transient synthetic insufficiency of the remnant liver. Studies in humans after liver resections have shown diminished levels of hepatically synthesized factors II, V, VII, IX, X, although the level of factor VIII, which is produced and stored in significant amounts outside the liver, remains unchanged. As a result, prolongation of the PT is a common finding after major hepatic resection. It has generally been accepted that massive transfusion, underlying liver disease, and extent of resection (7,9,16,17) contribute to the development of this coagulopathy. Other studies suggest that the postoperative synthetic dysfunction may also be related to the duration of vascular occlusion (used to limit blood loss during parenchymal dissection).
Figure 1 shows the PT after surgery in the first five DRLs performed at our institution, including the above case. It has been common for the PT to increase on POD 1 and to normalize in subsequent days.
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Front 15

SG53a [Jul05] [Mar06] [Jul06]

During laparoscopic surgery, pneumoperitoneum usually results in a fall in systemic blood pressure when intra-abdominal pressure exceeds

A. 5 mmHg

B. 10 mmHg

C. 20 mmHg

D. 30 mmHg

E. 40 mmHg

Back 15

C. 20 mmHg
-
FROM CEACCP ARTCLE Laparoscopic abdominal surgery 04:
* IAP < 10 mm Hg: increases VR, increases CO
* IAP 10–20 mm Hg decreases VR, decreases CO BUT increases SVR and therefore
BP unchanged or increased
* IAP > 20 mm Hg greater decrease VR, greater decrease CO, so
decreases BP
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Front 16

SG53b [Apr08][Oct08][Oct09]
During laparoscopic surgery, pneumoperitoneum usually results in a fall in cardiac output when intra-abdominal pressure exceeds

A. 10 mmHg….

B. 20 mmHg

C. 30 mmHg

D. 40 mmHg

E. 50 mmHg

Back 16

A. 10mmHg
-
FROM CEACCP ARTCLE Laparoscopic abdominal surgery 04:
* IAP < 10 mm Hg: increases VR, increases CO
* IAP 10–20 mm Hg decreases VR, decreases CO BUT increases SVR and therefore
BP unchanged or increased
* IAP > 20 mm Hg greater decrease VR, greater decrease CO, so
decreases BP
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Front 17

SG54 [Jul05]

Pneumoperitoneum to pressure greater than 10 mmHg for laparoscopic surgery usually results in

A. a decreased arterial to end-tidal CO2 difference

B. a decrease in airway resistance

C. an increase in pulmonary compliance

D. an increase in physiological dead space

E. an increase in functional residual capacity (FRC)

Back 17

D. an increase in physiological dead space
-
see wiki. Much debated.
From Miller Ch68
A. a decreased arterial to end-tidal CO2 difference - false. Increases - see wiki… though much debated.
B. a decrease in airway resistance - false - see CEACCP Laparscopic abdominal surgery 2004.
C. increase in plum compliance - false. 'Pneumoperitoneum decreases thoracopulmonary compliance by 30-50% in healthy and obese patients'
D. ? true… though contested on wiki. Miller states no increase in healthy individuals however this is probably the better answer over A.
E. an increase in FRC - false. 'Reduction in FRC and development of atelectasis due to elevation of the diaphragm and changes in the distribution of pulmonary ventilation and perfusion from increased airway pressure can be expected.'
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Front 18

SG55 [Jul05] [Jul06] [Apr07]

Phosphate-containing bowel preparations for colonoscopy are contra-indicated in frail, elderly patients because of the

A. frequent nausea, bloating and abdominal pain

B. risk of hypercalcaemia

C. risk of hypokalaemia

D. risk of hypomagnesaemia

E. risk of large fluid shifts

Back 18

E. risk of large fluid shifts
-
"Phosphate preparations have the potential to cause electrolyte disturbances including serious hyperphosphataemia and hypocalcaemia; deaths have been reported. Sodium phosphate must therefore be avoided in patients with impaired renal function and used with great care in the presence of congestive cardiac failure because of the potential large fluid shifts. The frail, elderly and the very young are particularly at risk of fluid and electrolyte complications and alternative preparations should be used." Australian Prescriber
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Front 19

SG56 [Jul05][Mar10] [??Aug12]

During surgery there is increased secretion of each of the following hormones EXCEPT

A. aldosterone

B. glucagon

C. growth hormone

D. thyroid stimulating hormone

E. vasopressin

Back 19

D. thyroid stimulating hormone

Insulin and Thyroxine goes down
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Front 20

SG57 [Mar06]

Rise in CO2 secondary to CO2 pneumoperitoneum results in

A. Increase in cardiac output

B. Increase in cerebral blood flow

C. ?

D. ?

E. ?

Back 20

B. Increase in cerebral blood flow


DIRECT EFFECT OF HYPERCARBIA - Decreased CO, SVR, Increased PVR. Decreased responsiveness to catecholamines.

INDIRECT EFFECT OF HYPERCARBIA (prevailing effect in patients with intact SNS)- Sympathoadrenal stimulation, Increased HR, CO, PVR and BP, but with decreased SVR.

The rise in CO of up to 50% exceeds the rise in BP, because of the drop in peripheral resistance and increase in blood flow primarily in cerebral and coronary circulations.(Yao)
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Front 21

SG58 [Jul06]

To control massive haemorrhage from liver laceration a surgeon may perform the Pringle manouvre. This involves clamping of the

A. aorta above the coeliac axis

B. hepatic artery only

C. hepatic vein

D. portal pedicle

E. splenic artery

Back 21

D. portal pedicle


Pringle manoeuvre: occlude inflow to liver to minimise bleeding - ie. clamp hepatic artery and portal vein.

The Portal pedicle contains hepatic artery, portal vein and common hepatic duct (also known as portal triad).
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Front 22

SG59 [Apr07][May09][Oct09][Mar10][Sep11][Aug12]

Blunt liver trauma can be treated non surgically if

A. No peritoneal signs

B. Low Grade injury on CT scan

C. Severe COPD

D. Haemodynamically stable

E. US confirms <500mls peritoneal fluid collection (i thought this was a paracentesis result)

Back 22

D. Haemodynamically stable

It was concluded that non-operative management should be the initial approach to all patients with blunt liver injury if haemodynamic stability can be ensured. When continued bleeding can be safely ruled out, a period of intensive monitoring is warranted.

Non-operative management of blunt hepatic injury in multiply injured adult patients. Al-Mulhim A S. Mohammad H A H. Surg J R Coll Surg Edinb Irel 2003; 1: 81-85.
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Front 23

SG61 [Jul07][Apr08]

45 y.o for elective laproscopic cholecystectomy. No recent hx cholelithiasis. Drinks 40g of alcohol per week and smokes 40/day. URTI 1/52 ago. Finishing course of augmentin. No respiratory symptoms now. LFTS done – ALP 300, GGT 300, ALT normal, AST normal, albumin normal. What is next step?

A. LFTS changes likely due to recent illness. Proceed with case

B. Defer case until liver USS done

C. Cancel case as patient has early cirrhosis

D. Perform hepatitis screen pre-operation

E. likely secondary to drugs, so just continue

Back 23

B. Defer case until liver USS done

~~

Markers of Cholestasis
Cholestasis (lack of bile flow) results from the blockage of bile ducts or from a disease that impairs bile formation in the liver itself. ALP and gamma-glutamyltransferase (GGT) levels typically rise to several times the normal level after several days of bile duct obstruction or intrahepatic cholestasis. AST and ALT can rise immediately, but drop quickly, so a very early presentation can have a hepatitic picture on LFTs - http://www.aafp.org/afp/990415ap/2223.html

E. likely secondary to drugs, so just continue - TRUEish -
Cholestatic liver injury is an uncommonly recognized, probably immunologically based adverse reaction to
therapy with penicillin and its derivatives.

A. is also possible


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Alcoholic hepatitis - Laboratory values can appear cholestatic, and symptoms can mimic cholecystitis.
Minimal elevations of AST and ALT often occur.
AST level greater than 500 U per L The AST elevation is unlikely to result from alcohol intake alone.

In a heavy drinker, consider acetaminophen toxicity.

Common bile duct stone Condition can simulate acute hepatitis.
AST and ALT become elevated immediately, but elevation of ALP and GGT is delayed.

Isolated elevation of GGT level This situation may be induced by alcohol and aromatic medications, usually with no actual liver disease.

Isolated elevation of ALP level (asymptomatic patient with normal GGT level) Consider bone growth or injury, or primary biliary cirrhosis.
ALP level rises in late pregnancy.

Isolated elevation of unconjugated bilirubin level - Consider Gilbert syndrome or hemolysis.

Low albumin level Low albumin is most often caused by acute or chronic inflammation, urinary loss, severe malnutrition or liver disease; it is sometimes caused by gastrointestinal loss (e.g., colitis or some uncommon small bowel disease).

Normal values are lower in pregnancy.

Blood ammonia level Blood ammonia values are not necessarily elevated in patients with hepatic encephalopathy.

Determination of blood ammonia levels is most useful in patients with altered mental status of new onset or unknown origin.

Front 24

SG62 [Jul07][Sep11][Mar12]

Patient presents with carcinoid syndrome and develops hypotension intraoperatively. Best drug to treat it is:

A. Noradrenaline

B. Adrenaline

C. Metaraminol

D. Octreotide

E. Ephedrine

Back 24

D. Octreotide


Octreotide, which is a long acting somatostatin analogue which suppresses 5-HT and other hormone secretion.


Carcinoid syndrome
-----------------
Carcinoid syndrome occurs as a result of enterochromaffin tumours which secrete not only 5-HT but other neuropeptides such as substance P and vasoactive intestinal polypeptide (VIP), as well as prostaglandins, histamine and bradykinin

More than 80% of these tumours originate in the gut and so symptoms do not appear until they metastasise to the liver. Prior to metastasis these substances are degraded to inactive metabolites. Once they gain direct access to the circulation, either from primary sites in the lung or from metastases, then the problems of flushing, hypotension, tachycardia, wheeze, abdominal cramps and diarrhoea may supervene. Endocardial and valvular fibrosis (which affects the right-side of the heart more frequently than the left) may also complicate the condition, as may pellagra. This is due to nicotinamide (vitamin B2) deficiency, which is caused by the excessive consumption of dietary tryptophan by the tumour. The symptoms of carcinoid are due not solely to serotonin secretion, but those which are mediated via 5-HT can be treated with the 5-HT2 antagonist cyproheptadine. Octreotide, which is a long acting somatostatin analogue which suppresses 5-HT and other hormone secretion, can also be used.

The Anaesthesia Science Viva Book

In the severe crisis of carcinoid syndrome the flush is usually accompanied by hypotension and occasionally shock.
Injection of octreotide, the long-acting analog of somatostatin, usually prevents or aborts this vasomotor reaction.


As per Stoelting pg 334
the occurrence of intraoperative carcinoid crisis manifesting as bronchospasm or hypotension is treated with IV octreotide 100-200 mcg

"Carcinoid crisis can occur spontaneously or as a response to stress, such as anesthesia or chemotherapy. Symptoms may include intense flushing, diarrhea, abdominal pain, tachycardia, hypertension or hypotension, altered mental status, and coma. This condition can be life threatening, but treatment with somatostatin analog SMS-201-995 has improved the outcome of patients with carcinoid crisis."


~~
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Carcinoid tumors are derived from primitive stem cells in the gut wall but can be seen in other organs (Broaddus, 2003), including the lungs (Moraes, 2003), mediastinum, thymus (Soga, 1999), liver, pancreas, bronchus, and ovaries (Piura, 1995). In children, most tumors occur in the appendix and are benign and asymptomatic.

Carcinoid tumors are of neuroendocrine origin and are derived from primitive stem cells, which can give rise to multiple cell lineages

Front 25

SG63 ANZCA version [Apr08] Q118

Each of the following statements regarding the haemodynamic changes during pneumoperitoneum for laparoscopy is true EXCEPT:

A. in patients with severe cardiac disease changes are qualitatively similar to those in normal patients
B. right atrial pressure is NOT a reliable indicator of cardiac filling
C. they are well tolerated by morbidly obese patients
D. they are well tolerated in cardiac transplant patients with good ventricular function
E. they are well tolerated in patients with low cardiac output secondary to low preload

Back 25

E. they are well tolerated in patients with low cardiac output secondary to low preload
- false thus the answer.
-
A. true - Miller Ch 68 - The demonstration of significant hemodynamic changes during pneumoperitoneum raises the question of tolerance of these changes in cardiac patients (see Chapters 35 and 60 [Chapter 35] [Chapter 60] ). In patients with mild to severe cardiac disease, the pattern of change in mean arterial pressure, cardiac output, and systemic vascular resistance is qualitatively similar to that in healthy patients. [87] [88] [123] [124] [125] [126] QUANTITATIVELY, these changes appear to be more marked.
B. true - Miller Ch 68 - The mechanism of the decrease of cardiac output is multifactorial ( Fig. 68-4 ). A decrease in venous return is observed after a transient increase in venous return at low IAPs (<10 mm Hg). [77] [78] Increased IAP results in caval compression,[79] pooling of blood in the legs,[80] and an increase in venous resistance. [77] [78] The decline in venous return, which parallels the decrease in cardiac output,[63] is confirmed by a reduction in left ventricular end-diastolic volume measured using transesophageal echocardiography.[74] Cardiac filling pressures, however, rise during peritoneal insufflation. [69] [71] The paradoxical increase of these pressures can be explained by the increased intrathoracic pressure associated with pneumoperitoneum. [70] [81] [82] RIGHT ATRIAL PRESSURE AND PULMONARY ARTERY OCCLUSION PRESSURE CAN NO LONGER BE CONSIDERED RELIABLE INDICES OF CARDIAC FILLING PRESSURES DURING PNEUMOPERITONEUM. The fact that atrial natriuretic peptide concentrations remain low despite increased pulmonary capillary occlusion pressure during pneumoperitoneum further suggests that abdominal insufflation interferes with venous return.[83] The reduction in venous return and cardiac output can be attenuated by increasing circulating volume before the pneumoperitoneum is produced ( Fig. 68-5 ). [77] [84] Increased filling pressures can be achieved by fluid loading or tilting the patient to a slight head-down position before peritoneal insufflation, by preventing the pooling of blood with intermittent sequential pneumatic compression device,[85] or by wrapping the legs with elastic bandages.
C - true - Miller Ch 68 - Several studies suggest that hemodynamic changes during pneumoperitoneum ARE WELL TOLERATED BY MORBIDLY OBESE patients.
D - true - Miller Ch 68 - The hemodynamic consequences of pneumoperitoneum are MINOR IN HEART TRANSPLANT RECIPIENTS WHO HAVE GOOD VENTRICULAR FUNCTION.
E - false - Miller Ch 68 - Patients who experienced the most severe hemodynamic changes with inadequate oxygen delivery were patients with low preoperative cardiac outputs and central venous pressures and high mean arterial pressures and systemic vascular resistances—a profile suggesting depleted intravascular volume.
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Front 26

SG65 [Apr 08]

In the head down position with pneumoperitoneum:

A. cardiac work is increased

B. pulmonary compliance is increased

C. ICP unchanged

D. IOP unchanged

E. pulm venous pressure unchanged

Back 26

A. cardiac work is increased


Cardiac Work = Systolic Pressure x Ejection Fraction

Pneumoperitoneum causes increases in central venous pressure, systemic vascular resistance, capillary wedge pressure, and mean arterial pressure which lead to an increase in cardiac work.


- Pulmonary compliance is DECREASED

- ICP: UNCHANGED or INCREASED by pneumoperitoneum and INCREASED in head down

- IOP UNCHANGED or INCREASED by pneumoperitoneum and INCREASED in head down

- Pulmonary venous pressure will be initially INCREASED, then DECREASED with increasing IAP. Head down position will INCREASE pulmonary pressures. Unlikely to remain unchanged.

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Front 27

SG65 ANZCA version [Apr08][Mar12][Aug12]

During prolonged trendelenburg positioning there is:

a. No change in ICP
b. No change in IOP
c. Increased pulmonary compliance
d. Increased myocardial work
e. No increased pulmonary venous pressures

Back 27

d. Increased myocardial work
--
a. false - increases ICP (Miller)
b. false - increases IOP (Miller)
c. false - decreases pulmonary compliance (Miller)
d. ?true - presumably increased preload and venous return results in increased cardiac output and therefore myocardial work.
e. ?false - presumably increased preload and venous return translates to increased pulmonary venous flow and pressure if resistance is unchanged
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Front 28

SG66 [Jul07]

To improve oxygenation in a patient intubated and ventilated for a laparotomy you adjust the ventilator settings to apply 10 cm H2O of PEEP (positive end-expiratory pressure). The patient's blood pressure falls from 130/80 to 90/50 mmHg. The addition of PEEP may result in a fall in blood pressure because PEEP causes
A. decreased myocardial contractility
B. decreased venous return
C. increased left ventricular afterload
D. increased left ventricular compliance
E. increased right ventricular afterload

Back 28

B. decreased venous return
-

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Front 29

TMP-Mar12-001

A patient undergoing liver surgery has a venous air embolism, what is the most appropriate position to place them in:

a. Reverse trendelenburg, right side up

b. Reverse trendelenburg left side up

c. Reverse trendelenburg, neutral

d. Trendelenburg right side up

e. Trendeleburg left side up

Back 29

B. Reverse trendelenburg left side up
--
Management of venous air embolism
- flood the field
- increase venous pressure at operative site to prevent further embolism

?or A. right side up to trap air in RV so it doesn't go in lungs?
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Front 30

SG60 ANZCA version [Jul07]

Pneumoperitoneum for laparoscopy is commonly associated with an INCREASE in each of the following EXCEPT

A. arterial pressure
B. inotropic state
C. secretion of vasopressin
D. systemic vascular resistance
E. venous resistance

Back 30

B. inotropic state
-
A. arterial pressure - If pneumoperitoneum <20 mmHg - BP increases or stays the same. If above 20 mmHg then BP decreases due to decrease in venous return and CO
B. - answer by exclusion.
C. secretion of vasopressin - increases - From Miller Ch68: "Catecholamines, the renin-angiotensin system, and especially vasopressin are all released during the presence of the pneumoperitoneum and may contribute to the increasing after load. However, only the time course of vasopressin release parallels that of the increase in SVR."
D. SVR - increases
E. venous resistance - increases.
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Front 31

SG28 [Mar93] [Sep11]
TMP-Jul10-049

The earliest indication of hypocalcaemia following thyroidectomy is usually:
A. Tingling of face, nose & hands
B. Positive Chvostek's sign
C. Carpopedal spasm
D. Hyperthermia
E. Tachycardia

Back 31

A. Tingling of hands and feet

?earliest sign or earliest symptom?
Wikipedia state A. as early symptom

Chvostek's sign present in 10% of normal individuals and is elicited by tapping over CNVII under the ear -> ipsilateral contraction of facial muscles

Trousseau's sign - BP cuff on arm and increase pressure above systolic -> leave for 3-5 minutes. Carpal spasm presents as flexion of wrist, thumb abduction, finger extension except at MCP joints
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Front 32

SG29

Which of the following is most likely to be the first sign of
hypoparathyroidism following total thyroidectomy?
A. Carpopedal spasm
B. Positive Chvostek's sign
C. Circumoral tingling
D. ?Tachycardia ?Tetany
E. All of the above

Back 32

C. Circumoral tingling
-
See SG28.
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