*part Ii 2003A New Mcqs

Front 1

150, The most important pre-operative investigation in a non-anticoagulated patient with chronic atrial fibrillation undergoing direct cardioversion is
A. chest x-ray
B. electrocardiograph (ECG)
C. serum digoxin level
D. serum potassium level
E. transoesophageal echocardiography

Back 1

E

Need to exclude intra-atrial thrombus

Front 2

149. Prior to elective surgery, an increased bleeding risk is most likely to be identified by
A. a platelet count
B. a prothrombin time
C. a skin bleeding time
D. an accurate clinical history
E. an examination for bruising

Back 2

D


Updates in perioperative coagulation: physiology and management of thromboembolism and haemorrhage. BJA 93 (2): 275–87 (2004):
• “The best method to determine haemorrhagic risk with surgery is an adequate history and physical examination. This important message is based on several large trials showing that patients with a definite or suspicious history of bleeding are more likely to bleed during surgery than patients with a negative history.”
• “Even in the 1980s, several studies had clearly demonstrated that no coagulation test, including PT, aPTT and bleeding time, is capable of providing this information. Newer studies have substantiated these findings.”

Front 3

148. The most important potential cause of raised intra-ocular pressure during general anaesthesia for elective anterior segment surgery is
A. endotracheal intubation
B. hypercapnia
C. laryngoscopy
D. nitrous oxide
E. suxamethonium

Back 3

A



Hypercapnia definitely does raise IOP, however there is this quote from Miller:
"Laryngoscopy and endotracheal intubation are the anesthesia-related practices most likely to increase IOP significantly (i.e., at least 10 to 20 mm Hg). The mechanism is not clear but is probably related to sympathetic cardiovascular responses to tracheal intubation."
So both A, B & C all seem correct. Wiki is split between A and B

Front 4

147. The partial pressure of oxygen in the blood of the fetal umbilical vein is
A. 27 mmHg
B. 33 mmHg
C. 40 mmHg
D. 45 mmHg
E. 70 mmHg

Back 4

A


pH PO2 PCO2 SaO2
Umbilical artery 7.21 18 55 45%
Umbilical vein 7.32 28 40 70%

Front 5

145. The first drug to be used in the management of an intra-operative thyrotoxic crisis is
A. esmolol
B. hydrocortisone
C. magnesium
D. potassium iodide
E. propyl thiouracil

Back 5

A


Probably esmolol to control tachycardia/arrhythmia. After this the specific treatments are:
 Propylthiouracil 200-300mg TDS to prevent conversion of T4 to T3
 1 hour after PTU give oral/NG iodide (Lugol's solution 0.5 mL PO TDS) – blocks hormone synthesis
 Hydrocortisone 200mg QID – high dose steroids inhibit conversion of T4 to T3

Front 6

144. The most commonly reported cause of awareness during general anaesthesia for a non-obstetric procedure is
A. equipment failure
B. faulty anaesthetic technique
C. lack of premedication
D. recreational drug use
E. the use of total intravenous anaesthesia

Back 6

B


Similar to previous question
CEACCP 2005: “Awareness is frequently associated with poor
anaesthetic technique”

Front 7

143. Following trauma, aortic arch injury should be suspected in the presence of a
A. cervical spine injury
B. fractured left first rib
C. left-sided pneumothorax
D. splenic rupture
E. thoracic spine injury

Back 7

B


EMST/ATLS Manual:
Signs of Aortic Dissection on CXR
- Widened mediastinum
- Obliteration of the aortic knob
- Deviation of the trachea to the right
- Depression of the left main bronchus
- Deviation of the oesophagus (NG tube) to the right
- Widened paratracheal stripe
- Widened paraspinal interfaces
- Presence of apical/pleural cap
- Left haemothorax
- Fractures of first/second rib or scapula

Front 8

142. A patient presents with headache, morning vomiting and double vision for three weeks. On examination nystagmus is present when the eyes are turned to either side. The most likely diagnosis is
A. acoustic neuroma
B. craniopharyngioma
C. frontal glioma
D pituitary adenoma
E. posterior fossa tumour

Back 8

E

Symptoms and their association:
 early morning vomiting = raised ICP
 double and blurred vision, nystagmus = infratentorial lesion (I,e, posterior fossa)
 problems with equilibrium, gait, and coordination = infratentorial lesion
 focal problems (eg motor or sensory deficit, speech change, seizures) = supratentorial lesion
 strong hand preference = supratentorial lesion
 neuroendocrine problems (DI, hypothyroidism) = suprasellar lesion
 change in visual acuity, visual field defect, Marcus Gunn pupil (afferent papillary defect), nystagmus = visual pathway lesion
 long nerve tract motor and/or sensory deficits, bowel and bladder deficits, and back or radicular pain = spinal cord lesion

Front 9

141. The first priority in managing a witnessed ventricular fibrillation cardiac arrest is
A. defibrillation times 3
B. endotracheal intubation
C. establishment of intravenous access
D. external cardiac massage
E. mask ventilation with 100% oxygen

Back 9

D

Commence CPR until defibrillation can be performed

Front 10

140. The herbal medicine most likely to be associated with cardiovascular instability in the peri-operative period is
A. echinacea purpurea (echinacea)
B. ephedra sinica (ma-huang)
C. ginkgo biloba (ginkgo)
D. hypericum perforatum (St, John's Wort)
E. tanacetum parthenium (feverfew)

Back 10

B


 A: the hepatotoxicity is the only thing, no major periop concerns.
 B: cardiovascular instability: hypertension, angina acutely and catechol depletion chronically.
 C: bleeding, hypoglycaemia
 D: P450 induction. Interaction with tramadol. Increased sensitivity to anaesthesia (along with valerian and kava). Very important is the induction of metabolism of immunosuppressants, antiretrovirals and anticonvulsants. Has caused cardiovascular collapse, but only very rarely.
 E: can increase bleeding

Front 11

139, 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


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.

Front 12

138, Management of an overdose of paracetamol could include all of the following EXCEPT
A. activated charcoal
B. alkalinisation of the urine
C. gastric lavage
D. hepatic transplantation
E. N-acetylcysteine

Back 12

B

Alkalinisation is for salicylate overdose

Front 13

137. During elective major vascular surgery the best way to reduce the risk of acute renal failure is to maintain a normal
A. cardiac output
B. central venous pressure
C. mean arterial blood pressure
D. pulmonary capillary wedge pressure
E. renal blood flow

Back 13

E


Main cause of renal failure post-vascular surgery will be an ischaemic (i.e. pre-renal cause)
MAP and RBF both seem kind of right – but RBF is surely more correct
The question was repeated the following year but with only CO, MAP and RBF present as same options.

Front 14

136. In a patient with myasthenia gravis undergoing a laparotomy for large bowel obstruction, the need for post-operative ventilation is significantly increased by a
A. daily dose of pyridostigmine > 180 mg
B. known history of resistance to suxamethonium
C. known history of sensitivity to non-depolarising muscle relaxants
D. past history of prednisolone treatment > 10 mg.day-1
E. recent history of dysphagia

Back 14

E


Similar to previous question
" Any degree of bulbar palsy is predictive of the need for both intra- and post-operative ventilation"
Miller:
Post-op ventilation is especially important in cases involving:
• myasthenia gravis of more than 6 years duration
• chronic obstructive lung disease
• daily pyridostigmine requirement of 750 mg in association with significant bulbar weakness
• vital capacity of less than 40 mL/kg

Front 15

135. 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

Back 15

C

Non-specific Plasma, Red Cell & Tissue Esterases

Front 16

133. The age at which separation anxiety begins in most infants is approximately
A. 1 month
B. 3 months
C. 6 months
D. 9 months
E. 12 months

Back 16

C


A&A 2001:
“In the first weeks of life, infants are able to discriminate among people, but will accept care and comfort from adults other than their parents (14). By 3 mo of age, however, infants begin to respond differently to familiar and unfamiliar people. Older infants smile more at familiar people and may even try to engage their attention (14). Separation anxiety usually begins at 7–8 mo of age and peaks around 1 yr of age”

Front 17

132. In patients with hypokalaemic periodic paralysis one should avoid
An anxiolytic drugs
B. beta-adrenergic antagonists
C. intravenous dextrose
D. regional anaesthesia
E. suxamethonium

Back 17

C



Miller:
Preoperative stress should be adequately alleviated by the administration of anxiolytic drugs such as benzodiazepines...A normal response to succinylcholine is noted in these patients... Spinal anesthesia and epidural anesthesia are safe alternatives to general anesthesia in these patients. It should be noted, however, that epidural, axillary, and intercostal nerve blocks lower serum potassium 0.3 to 0.7 mmol/L on average. Administration of epinephrine with the local anesthetic accounts for a proportion of this decline
Dextrose  insulin release  decreased K

Front 18

131, The LEAST likely complication of a peribulbar regional block for cataract surgery is
A. bradycardia
B. damage to the optic nerve
C. globe perforation
D. ocular muscle palsy
E. peribulbar haemorrhage

Back 18

B


Rubin BJA 1995 75;93
 Ocular muscle palsy - temporary "common" - prolonged (6 weeks) 1%
 Retro or peribulbar haemorrhage 0.1 - 1.7%
 Vasovagal response 0.5 - 0.85 %
 Optic nerve penetration - 0.2%
 Globe perforation 0 - 0.2%
 Oculocardiac reflex 0%

Front 19

130, In a child with NO history of epilepsy the commonest cause of post-operative convulsions is
A. hyperthermia
B. hyponatraemia
C. hypoxia
D. local anaesthetic toxicity
E. pethidine toxicity

Back 19

C

Front 20

129. In the management of exposure to toxic nerve agents (highly potent anticholinesterases)
A. early treatment with glycopyrrolate is more effective than
atropine
ketamine is contra-indicated for endotracheal intubation
C. oximes (e.g. pralidoxime) in normal doses have no endogenous anticholinergic effects
D. oximes reactivate acetylcholinesterase by cleavage of phosphorylated active sites
E. pre-treatment with pyridostigmine prevents the effects of these agents

Back 20

D


BJA.White 89 (2): 306 (2002). Implications of chemical and biological weapons for anaesthesia and intensive care:
A: False. "Atropine and oximes are effective antidotes if administered early after exposure. Atropine antagonizes muscarinic side-effects and is more beneficial than glycopyrrolate, which has a shorter half-life and does not cross the blood-brain barrier."
B: False. "Ketamine may be beneficial for intubation."
C: False. "They (oximes) in normal doses have an endogenous anticholinergic effect."
D: True. "Administered early, oximes reactivate AChE by cleavage of phosphorylated active sites."
E: False

Front 21

128. When a new diagnostic test is evaluated in a group of subjects in whom the diagnosis is known, the following results are obtained
Disease known Disease known
to be present to be absent
New test result positive 2 4
New test result negative 6 8
The specificity of the new test is closest to
A. 25%
B. 33%
C. 57%
D. 67%
E. 75%

Back 21

D

Specificity = TN / (TN + FP) = 8 / (8+4) = 0.67

Front 22

127. Haemodynamic responses to pneumoperitoneum include all the following EXCEPT
A. decreased cardiac output
B. decreased venous vascular resistance
C. increased pulmonary artery occlusion pressure
D. increased systemic vascular resistance
E. increased systemic blood pressure

Back 22

B

Venous resistance is increased

Front 23

126. The most appropriate intravenous fluid volume to administer to a one-year-old 10 kilogram infant, fasted for five hours having minor peripheral surgery of two hours duration (with minimal blood loss) is
A. 200 ml
B. 260 ml
C. 320 ml
D. 410 ml
E. 490 ml

Back 23

C


Fluid requirements per hour:
4ml/kg/hr first 10 kg
2ml/kg/hr next 10 kg
1ml/kg/hr each further kg

10kg child 7hr x 40ml/hr = 280ml
Third space losses = 0-2ml/kg/hr for relatively atraumatic surgery or 6-8ml/kg/hr for traumatic procedures, so 2ml/kg/hr x 10kg x 2hr = 40ml
Total = 320ml
See Morgan and Mikhails Clinical Anesthesiology 4th ed P. 937

Front 24

125. In the management of torsades de pointes (a type of ventricular
tachycardia), all the following drugs may be useful EXCEPT
A. amiodarone
B. isoprenaline
C. lignocaine
D. magnesium
E. phenytoin

Back 24

A

Amiodarone prolongs the QT

Front 25

124. The bibliographic database of LEAST relevance to anaesthetists is
A. CINAHL
B. Cochrane Library
C. Embase
D. Medline
E. PsycINFO

Back 25

E

Front 26

123, The dose of phenylephrine in one drop (assume one drop = 0.05 ml) of 10% phenylephrine solution is
A. 5 microgram
B. 20 microgram
C. 200 microgram
D. I milligram
E. 5 milligram

Back 26

E


10% solution = 100mg/ml
So one drop = 0.05 ml = 0.05 x 100 = 5mg

Front 27

122 In patients suffering from multiple sclerosis it is better to avoid the use of
A. epidural lignocaine
B. neostigmine
C. pancuronium
D. spinal anaesthesia
E. suxamethonium

Back 27

E


Depends how severe the disease is – if mild disease then D may be true, if severe disease E more likely:
Current Opinion in Anaesthesiology 2002, 15:365-370
Succinylcholine poses the risk of hyperkalemia due to the release of intracellular potassium. Hyperkalemia after depolarizing neuromuscular block represents a risk to all patients with muscle
denervation pathology, and may lead to cardiac arrest. Only patients with lesions involving motor nuclei, as evidenced by flaccidity, spasticity or hyperreflexia, are at risk for hyperkalemia. Upregulation ofacetylcholine receptors even by the fourth day after the onset of symptoms
leads to sensitivity to succinylcholine in multiple sclerosis patients. Patients remain at risk for hyperkalemia for months or years and succinylcholine is best avoided

Front 28

121. The American Society of Anaesthetists (ASA) Physical Status Classification rating system was designed for categorising
A. intra-operative adverse anaesthetic event risk based on
physical status
B. intra-operative adverse surgical event risk based on physical
status
C. physical status in a standardised manner
D. peri-operative adverse anaesthetic event risk based on
physical status
E. peri-operative adverse surgical event risk based on physical status

Back 28

C

Consensus on wiki seems to be C

Front 29

120. Which of the following sequences best indicates the order of
structures in the path of a needle inserted in the midline for placement of a spinal anaesthetic?
A. interspinous ligament, supraspinous ligament, ligamentum
flavum, epidural space, dura mater, arachnoid mater
B. supraspinous ligament, interspinous ligament, ligamentum
flavum, epidural space, dura mater, arachnoid mater
C. supraspinous ligament, interspinous ligament, ligamentum flavum, epidural space, dura mater, pia mater
D. supraspinous ligament, ligamentum flavum, interspinous ligament, epidural space, dura mater, arachnoid mater
E. supraspinous ligament, ligamentum flavum, interspinous ligament, epidural space, dura mater, pia mater

Back 29

B


1. Supraspinous ligament
2. Interspinous ligament
3. Ligamentum flavum
4. Epidural space
5. Dura mater
6. Arachnoid mater
7. Pia mater

Front 30

119. The risk of seroconversion of a non-immunised anaesthetist, after a needlestick injury with a hollow needle contaminated with blood containing Hepatitis B virus, is approximately
A. 10%
B. 20%
C. 30%
D. 40%
E. 45%

Back 30

C


"The risk of HBV seroconversion after a percutaneous injury ranges from 23% to 62% in unvaccinated persons and is dependent on the hepatitis B e antigen status of the source."
Clinics in Liver Disease - Volume 14, Issue 1, February 2010

Front 31

118. Peri-operative cardiac morbidity and mortality in patients with
coronary artery disease undergoing non-cardiac surgery is significantly reduced by
A. ceasing smoking one month pre-operatively
B. controlling moderate systemic hypertension pre-operatively
C. delaying surgery for one month following percutaneous transluminal coronary stent insertion
D. delaying surgery for three months following an uncomplicated myocardial infarction
E. tight peri-operative control of blood sugar level in diabetic patients

Back 31

C

AHA guidelines: Looks like there is very high risk with surgery within 1 month of stent placement. Rare to have events after 1 month. This may have changed from prior guidelines that suggested waiting 3 months post MI

Front 32

117. Neurological outcome following traumatic brain injury is best predicted by
A. blood pressure immediately following injury
B, initial Glasgow Coma Scale score
C. intracranial pressure
D. jugular bulb oximetry
E. progress in the first 24 hours

Back 32

B


IMPACT trial – prognosis after TBI. Journal of Neurotrauma;Feb 2007;Vol. 24 (2):
• “The most powerful independent prognostic variables were age, Glasgow Coma Scale (GCS) motor score, pupil response, and computerized tomography (CT) characteristics, including the Marshall CT classification and traumatic subarachnoid hemorrhage”

Front 33

116. The commonest cause of maternal convulsions in the immediate post-partum period is
A. amniotic fluid embolism
B. eclampsia
C. epilepsy
D. local anaesthetic toxicity
E. water intoxication due to syntocinon infusion

Back 33

B

CEACCP – whilst epilepsy is most common cause in pregnancy, eclampsia is most common in the per-partum period

Front 34

115. The most important characteristic of non-particulate antacids in obstetrics is their
A. inability to cross the placenta
B. low cost
C. pleasant taste
D. reduced incidence of nausea
E. speed of onset of action

Back 34

E

Sodium citrate is an antacid used as prophylaxis against aspiration pneumonitis before a rapid sequence induction. 30 ml of a .3 molar solution should be given less than 10 minutes before the start of surgery due to its limited duration of action

Front 35

114. The effect of a drop in patient core temperature from 37°C to 34°C is to
A. decrease arterial blood pressure
B. decrease blood glucose concentration
C. decrease blood viscosity
D. impair platelet adhesion
E. increase blood potassium concentration

Back 35

D


A fall from 37 to 34 will cause tachycardia, hypertension and increased SVR because of sympathetic stimulation. As the temperature falls more, bradycardia and hypotension will occur.
Mild/moderate hypothermia is associated with hypoK, hypoPO4, hypoMg. At 34C platelets appear activated but aggregation and adhesion is decreased.
Viscosity is increased

Front 36

113. To normalise platelet function prior to surgery, chronic diclofenac therapy should be ceased for at least
A. 12 hours
B. 1-2 days
C. 4 days
D. 7 days
E. 10 days

Back 36

B


Half-life if diclofenac is 1.1-1.8hrs. After 5 half lives (5-10hrs) plasma concentration of diclofenac should be down to 5% of steady state.
But how long does it take platelet function to return to normal? - thinking it would be more than 12hrs

Front 37

112. The strongest indication for the use of transoesophageal echocardiography during major non-cardiac surgery is
A. recent myocardial infarction (less than six weeks old)
B. acute significant intra-operative ST segment depression on the ECG
C. massive intra-operative blood loss
D. a history of severe valvular heart disease
E. unexplained significant intra-operative hypotension

Back 37

E

Table in Miller has a table evaluating use of TOE and this is one of its most appropriate uses. It can differentiate causes and thereby probably is most effectively used as it will more impact on treatment

Front 38

111. Which of the following parameters occurring during cardio-
pulmonary bypass (at 28°C) is most likely to contribute to an adverse neurological event post-operatively?
A. arterial carbon dioxide partial pressure (PaCO2) below 30 mmHg
B. arterial oxygen partial pressure (Pa02) over 400 mmHg
C. blood sugar level (BSL) over 15 mmo1,1-1
D. mean arterial blood pressure below 60 mmHg
E. pump flow less than 2.4 1.m-2.min-1

Back 38

C



Neuroprotection during cardiac surgery.Expert Rev Cardiovasc Ther. 2008 Apr;6(4):503-20
"Although a recent retrospective analysis [15] failed to demonstrate an association between maximum intraoperative glucose concentration and adverse neurological ourtcome, an earlier prospective study revealed worse neuropsychological outcome in patients exposed to hyperglycaemia."

"Despite considerable research, the characteristics of ‘optimal’ CPB perfusion remain to be defined. Profound hypotension combined with prolonged cerebral hypoperfusion is clearly injurious to the brain – particularly the watershed zones. However, within the bounds of usual CPB conduct, pressure, flow rate and flow character appear to have little influence on neurological outcome. A recent retrospective study suggests, perhaps paradoxically, that higher perfusion pressure is associated with worse neurological outcome."

Front 39

110. A reflex hypertensive response to bladder dilation is common in patients with a spinal cord lesion at or above
A. seventh cervical vertebra (C7)
B. fifth thoracic vertebra (T5)
C. ninth thoracic vertebra (T9)
D. twelth thoracic vertebra (T12)
E. fourth lumbar vertebra (L4)

Back 39

B



Clinical Anesthesiology Ch 27
"Overactivity of the sympathetic nervous system is common with transections at T5 or above but is unusual with injuries below T10. Interruption of normal descending inhibitory impulses in the cord results in autonomic hyperreflexia. Cutaneous or visceral stimulation below the level of injury can induce intense autonomic reflexes: sympathetic discharge produces hypertension and vasoconstricltion below the transection and a baroreceptor-mediated reflex bradycardia and vasodilation above the transection. Cardiac arrhythmias are not unusual."

Front 40

109, In a Jehovah's Witness patient undergoing a revision of a total hip replacement, the most effective technique to minimise post¬operative anaemia would be
A. epidural anaesthesia
B. induced hypotension
C. intra-operative cell saving
D. intra-operative intentional normovolaemic haemodilution
E. pre-operative administration of recombinant erythropoietin

Back 40

E


Difficult to choose which is most effective:
A - epidural anaesthesia, does reduce blood loss by up to 50%. Due to relative hypotension and possibly negative intrathoracic pressure
B - induced hypotension, does reduce blood loss by a relatively minor degree
C - cell saver, is effective and acceptable to most JW
D - normovolaemic haemodiltion is unacceptable to many JW
E - EPO will raise the pre-op hb. In "Surgery Without Blood" Crit Care Med 2003 Vol31, "Increased preop red cell mass" ranks higher than cell salvage

Front 41

108. In infants with congenital pyloric stenosis
A. dehydration is associated with early hyponatremia
B. plasma chloride levels seldom fall below 85 mmo1,1-1
C. renal conservation of hydrogen and potassium ions occurs
D. the urine is initially alkaline, then may become acidic
E. vomiting causes a loss of potassium ions

Back 41

D


Anaesthesia & Intensive Care Medicine Volume 9, Issue 4, April 2008:
"Vomiting normally results in equal loss of gastric acid and alkaline duodenal fluid. However, with gastric outlet obstruction, gastric acid along with a variable amount of Na+ and K+ is lost in vomitus without loss of HCO3− from the duodenum. The resultant systemic alkalosis overwhelms the capacity of the proximal convoluted tubule to reabsorb HCO3−, producing an alkaline urine. As extracellular fluid volume depletion increases, aldosterone is secreted, leading to renal conservation of Na+ in exchange for K+. Eventually hypokalaemia forces Na+ exchange preferentially with H+ instead of K+ in the renal tubules. This produces the characteristic ‘paradoxical acid urine’ in the face of systemic alkalosis."

Front 42

106. Side-effects of protamine include all of the following EXCEPT
A. anaphylaxis
B. platelet dysfunction
C. pulmonary hypertension
D. pulmonary oedema
E. systemic hypertension

Back 42

E


UptoDate:
"Hypotension, cardiovascular collapse, noncardiogenic pulmonary edema, pulmonary vasoconstriction, and pulmonary hypertension may occur."

Front 43

105. Early complications following pneumonectomy include all of the following EXCEPT
A. broncho-pleural fistula
B. respiratory failure
C. right heart failure
D. right to left shunt
E. supraventricular arrhythmias

Back 43

A



Note: wording in 2006 Mar was "Complications, which usually present early following pneumonectomy, include all of the following EXCEPT"

The point of contention is whether or not a broncho-pleural fistula represents an early or late complication
• if it is early, then "right to left shunt" is the answer
• right to left shunting is theoretically likely as the PVR is doubled and PFOs occur in 20% of the population
• it is described intra-operatively, early, and late, but the magnitude of the problem seems to be small
• you would require a very high PVR to get clinically important shunting however
If it is late, then "broncho-pleural fistula" may be the answer

Front 44

104. The average expected depth of insertion of an oral endotracheal tube, from the lip, in a normal newborn infant is
A. 7.5 cm
B. 8.5 cm
C. 9.5 cm
D. 10.5 cm
E. 11.5 cm

Back 44

C


Paediatric advanced life support: Australian Resuscitation Council Guidelines 2006)
 in a newborn is 9.5 cm,
 11.5 cm for a 6 months old infant
 12 cm for a 1 year old.
 Thereafter, the approximate depth of oral insertion is given by the formula: age (years)/2 + 12 cm.

Neonates: Weight in Kg + 6. So 3.5Kg = 9.5cm at lips

Front 45

103. 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 45

E

BJA article and stoelting report it decreases vascularity

Front 46

102. Acute cannabis use just prior to surgery is most likely to
A. cause intra-operative bradycardia
B. decrease anaesthetic requirements
C. increase the incidence of peri-operative nausea
D, increase the risk of intra-operative awareness
D. reduce the reliability of a BIS (bispectral index) monitor

Back 46

B


Reduced anaesthetic requirement with recent administration, however will result in higher anaesthetic requirement during withdrawal in chronic users .
BJA CEPD "Abusers and anaesthesia"

Front 47

101. The use of Xenon in anaesthesia is limited because it
A. has a blood/gas solubility coefficient similar to that of ether
B. is a myocardial depressant
C. is less potent than nitrous oxide
D. is expensive to extract
E. lacks analgesic properties

Back 47

D

Front 48

100. The first step in developing a clinical audit should be to
A. define the question to be asked
B. develop the relevant clinical protocol
C. draw up the audit form
D. find the relevant standards
E. obtain ethics committee approval

Back 48

A


The clinical audit process seeks to identify areas for service improvement, develop & carry out action plans to rectify or improve service provision and then to re-audit to ensure that these changes have an effect.-->Clinical audit can be described as a cycle or a spiral, see figure. Within the cycle there are stages that follow the systematic process of: establishing best practice; measuring against criteria; taking action to improve care; and monitoring to sustain improvement. As the process continues, each cycle aspires to a higher level of quality.

Stage 1: Identify the problem or issue
Stage 2: Define criteria & standards
Stage 3: Data collection
Stage 4: Compare performance with criteria and standards
Stage 5: Implementing change

Front 49

99. The most common reason for patients complaining about their medical treatment is
A. charging of excessive fees
B. patient's predisposition to complain
C. poor communication with medical staff
D. poor outcome of medical treatment
E. poor physical environment

Back 49

C

Front 50

98. In a patient undergoing a femoro-popliteal bypass, the most predictive independent risk factor for the development of post-operative myocardial infarction would be
A. an acute myocardial infarct 3 months ago
B. an episode of intra-operative myocardial ischaemia
C. an episode of post-operative myocardial ischaemia
D. 50% blood volume blood loss intra-operatively
E. poorly controlled diabetes mellitus

Back 50

C

Similar to previous question

Front 51

97. Twenty-four hours following a vaginal hysterectomy, a 48-year-old obese female complains of severe pain that radiates down both buttocks and thighs. She had received a spinal anaesthetic with hyperbaric lignocaine. A likely explanation for these complaints includes all of the following EXCEPT
A. a spinal abscess
B. a spinal haematoma
C. lumbar disc herniation
D. transient neurological symptoms syndrome
E. trauma due to improper positioning

Back 51

A

Too early for abscess surely

Front 52

96. Aortic valve stenosis is more likely to be severe if
A. a loud second heart sound is present
B. an ejection click is heard
C. a third heart sound is present
D. the murmur is long in duration and peaks late in systole
E. the systolic murmur is transmitted to the carotid arteries

Back 52

D


• 2nd heart sound is soft with AS. UptoDate : “S2 is soft and single since A2, which is due to aortic valve closure, is delayed and tends to occur simultaneously with P2”
• Click goes away as gets severe. "In the young patient with valvular AS, a systolic ejection sound (systolic ejection click) initiates the systolic murmur but later tends to disappear as AS becomes severe”
• 3rd heart sound is sign of heart failure. Could have heart failure with severe AS – but a direct marker of severity
• The three most important signs indicating AS is severe in the older patients are late peaking of ejection systolic murmur, S2 that is single or A2 that is paradoxical, and the ejection systolic murmur is a seagull sound that is not frequently heard but is very specific."
• Is transmitted to carotids but its presence doesn't indicate severity

Front 53

92. A 52 year old asthmatic female has a difficult intubation for
laparoscopy. After four attempts at intubation over three minutes, the saturation has decreased from 98% to 73%. The physiological change most likely to have occurred as a consequence of the above is a
A. decrease in sytemic blood pressure
B. decrease in cardiac output
C. displacement of the Haemoglobin-oxygen dissociation curve to the left
D. decrease in pulse rate
E. increase in pulmonary artery pressure

Back 53

E


From NUNN:
 Hyperventilation once PaO2 52.5mmHg
 Increased pulmonary artery pressure
 Increased cardiac output improves regional blood flow
 Sympathetic activation
 Vasodilation in every organ except pulmonary vasculature
 Right shift of O2 curve by increased 2,3 DPG and acidosis if present
 Anaerobic metabolism

Front 54

91. The sciatic nerve
A. can be readily identified during neural blockade by the production of paraesthesia on contact with a needle
B. has no sympathetic fibres
C. is formed from the dorsal branches of the anterior rami of L5 and S1 to S4
D. provides motor innervation to the psoas muscle
E. provides sensory innervation from the knee joint

Back 54

E

Front 55

90. The primary duty of an expert witness called by the defence is to the
A. Court
B. Defence Counsel
C. defendent doctor
D. medical profession
E. patient taking legal action

Back 55

A

Front 56

89. The most appropriate investigation to diagnose Type A aortic dissections in potentially unstable patients is
A. angiography
B. CAT scan
C. magnetic resonance imaging (MRI)
D. transoesophageal echocardiography
E. transthoracic echocardiography

Back 56

D

In the unstable patient this is most appropriate. TTE is not sensitive enough

Front 57

88. A dock-worker is extricated from beneath a fallen lift platform and has signs of respiratory distress. He has a jagged wound of the chest wall with blood-stained froth alternately oozing from, and sucking back into the wound. Initial treatment at the scene should be to
A. start mouth-to-mouth resuscitation
B. apply large sterile packs to the wound and instruct the patient to hold these in place until he reaches hospital
C. apply large sterile packs and seal the dressing with adhesive tape
D. insert an intercostal drainage tube connected to an underwater seal
E. pass an endotracheal tube

Back 57

D


Trauma.org:
“The definitive management of the open pneumothorax is to place an occlusive dressing over the 'wound and immediately place an intercostal chest drain”

Front 58

87. Hyperosmolar non-ketotic coma is associated with
A. a normal coagulation profile
B. a normal serum sodium concentration
C. a normal urinary potassium concentration
D. intracellular dehydration
E. known diabetic patients

Back 58

D or E

Similar to some previous questions - ?which is best out of D and E though

Front 59

84. Beta-blockade has been shown to decrease the incidence of post-operative myocardial ischaemia. This is most likely due to a reduction in
A. heart rate in the post-operative period
B. post-operative blood glucose level
C. post-operative hypercoagulability
D. systemic blood pressure in the post-operative period
E. the incidence of post-operative cardiac arrhythmias

Back 59

A

Similar to 2001-2 Q79

Front 60

82, Adverse effects of a remifentanil infusion for surgery under general anaesthesia include
A. a 10% incidence of post-operative nausea and vomiting
B. delayed respiratory depression after prolonged infusions
C. increased sensitivity to morphine post-operatively
D. muscle rigidity with an infusion rate of 0.5 mcg.kg-1,mirr1
E. pain on bolus injection

Back 60

D


MIMS Online:
"Skeletal muscle rigidity can be caused by remifentanil and is related to the dose and speed of administration. Remifentanil may cause chest wall rigidity (inability to ventilate) after single doses of > 1 microgram/kg administered over 30 to 60 seconds or infusion rates > 0.1 microgram/kg/minute. Administration of doses < 1 microgram/kg may cause chest wall rigidity when given concurrently with a continuous infusion of remifentanil."

Front 61

81. Following superficial and deep cervical plexus blockade for carotid endarterectomy, the incidence of ipsilateral phrenic nerve block is
A. less than 10%
B. 20-30%
C. 50-60%
D. 80-90%
E. nearly 100%

Back 61

C


Anaesth Intensive Care. 1998 Aug;26(4)
"This study detected a 55% incidence of phrenic nerve block which is similar to the 61% incidence reported by Castresana et al for deep and superficial cervical plexus block. This incidence is lower than that reported for interscalene plexus block which was 100%, and similar to reports for supraclavicular brachial plexus block where a rate of 67% was reported."

Front 62

80. Pain continuing well after the rash of Herpes Zoster has disappeared (Post Herpetic Neuralgia)
A. has an incidence of approximately 25%
B. is more common after ophthalmic than after spinal segment involvement
C. is more common in the immunocompromised but is independent of age and gender
D. is best treated with high dose opioids
E. has been shown to occur less commonly after acyclovir (Zovirax)

Back 62

E


However now E is probably false - Most recent ANZCA pain book has reversal of recommendations:
"However contrary to the previous literature the use of the antiviral agent aciclovir did not significantly reduce the incidence of post-herpetic neuralgia"

Front 63

76. Asbestos exposure is typically associated with each of the following EXCEPT
A, pleural effusions
B. mesothelioma of the pleura
C. laryngeal cancer
D. hilar lymphadenopathy
E. gastrointestinal cancer

Back 63

D


UptoDate:
 A - "As an example, benign asbestos pleural effusions (BAPEs) usually occur within 15 years of first exposure to asbestos (range less than 1 year to up to 50 years)"
 C. laryngeal cancer - true: "A weak linkage between laryngeal carcinoma and exposure to the dry cleaning agent perchloroethylene has been described. Other occupations or occupational hazards have been linked to HNC. These include asbestos"
 D. hilar lymphadenopathy - "Hilar and mediastinal lymphadenopathy are not seen with asbestosis and should suggest the presence of another process."

Front 64

72. The TEC 6 desflurane vaporiser provides a constant vapour pressure of
A. 1100 mmHg at 32°C
B. 1380 mmHg at 38°C
C. 1460 mmHg at 39°C
D. 1520 mmHg at 40°C
E. 1520 mmHg at 42°C

Back 64

C


"A parallel flow issues from a heated (39°C) enclosure (sump) containing liquid and gaseous desflurane, the latter at a total pressure of about 1500 mmHg (approx 2 atm)”
Pharmacology of Inhaled Anaesthetics, p211

Front 65

67. The following capnograph tracing is most likely to represent
A. partial obstruction of sampling tube
B. sticking ventilator bellows
C. incomplete neuromuscular blockade
D. air entrainment into sampling tube
E. partial obstruction of endotracheal tube

Back 65

D


Entrainment of air into sample line → normal flat plateau with terminal peak just before inspiration

End-tidal CO2 excretion waveform and error with gas sampling line leak. Anesth Analg 1988;67:
 "In summary, when there is a loose connection between an end-tidal CO, sampling line and the CO, analyzer (Saracap), the CO, excretion waveform is very unusual and consists of a long plateau followed by a brief peak, rather than the usual square CO, excretion waveform. The long CO, plateau is caused by entrainment of room air through the leaky connection by the continuous CO, analyzer suction, and the brief CO, peak is caused by the next PIP, which transiently pushes undiluted end-tidal gas through the sampling line into the CO, analyzer. Because the 0, and N,O values digitally displayed by the Saracap are mean exhalation values, the 0, and N20 concentrations are a function of both the size of the leak and the PIP."

Front 66

66, The patient most likely to desaturate significantly during one lung anaesthesia is one who is having
A. a left sided thoracotomy, has reasonable Pa02 values during two-lung ventilation, but poor pre-operative spirometry
B. a right-sided thoracotomy, has relatively poor Pa02 values during two-lung ventilation but good pre-operative spirometry
C. a left-sided thoracotomy and has diminished perfusion but not ventilation to the operative lung on a V/Q scan
D. a right-sided thoracotomy, has relatively poor Pa02 values during two-lung ventilation and poor pre-operative spirometry

Back 66

B


Singer, The Patient Intolerant of One-Lung Ventilation:
The predictors of hypoxaemia with OLV:
 Right sided surgery
 Good preoperative spirometry (FEV1 or FVC)
 Poor PaO2 during two lung ventilation, particularly in the lateral position
 High percentage of ventilation or perfusion to operative lung with V/Q scan

Front 67

64. A morbidly obese patient is to have an open cholecystectomy. Compared with a patient of normal weight the
A. risk of thromboembolism is increased by 20%
B. dose of patient controlled intravenous analgesia is increased
and is related more closely to body surface area than weight
C. recovery time from atracurium is unchanged
D. Increased volume of distribution of some drugs may prolong
the elimination half-life even though clearance may be unchanged or increased
E. volume of the central compartment is significantly changed

Back 67

D


­ A : obesity is associated with increased thromboembolism - CEACCP 2008(5):
 "Obese patients are at increased risk of venous thromboembolism; appropriately sized compression stockings, low molecular weight heparin, and dynamic flow boots should be used from arrival in theatre until full postoperative mobilization."
­ B: same article as above:
 “when using total i.v. anaesthesia, the infusion rate should be calculated on total body weight, not ideal body weight."
­ C: Clinical Pharmacology and Therapeutics (1990) 48
 "Although atracurium concentrations were consistently higher in obese patients than in nonobese patients, there was no difference in the time of recovery from neuromuscular blockade between the two groups. Consequently, the median effective concentration was higher in obese than in nonobese patients"
­ D: above CEACCP article:
 "An increase in Vd prolongs the elimination half-life, despite increased clearance “
­ E: same article:
 "The volume of the central compartment is largely unchanged, but dosages of lipophilic and polar drugs need to be adjusted due to changes in volume of distribution (Vd)."
So not clear – both C and D appear correct

Front 68

54, In a mechanically ventilated patient the haemodynamic parameter that correlates most closely with hypovolaemia is
A. systolic pressure variation
B. central venous pressure
C. pulmonary artery occlusion pressure
D. pulse pressure
E. cardiac output

Back 68

A


British Journal of Anaesthesia 83 (4): 550–1 (1999):
"Systolic pressure variation has not become popular in the UK, despite the fact that it correlates with hypovolaemia more closely than any other measured variable, including central venous pressure, pulmonary artery occlusion or diastolic pressure, pulse pressure, cardiac output or systolic arterial pressure."

Front 69

53, A sympathetic block could be effective in treating all of the following conditions EXCEPT
A. chronic tinnitus
B. quinine poisoning
C. post-cardiac-surgery pain syndrome
D. phantom limb pain
E. compartment syndrome

Back 69

E


Stellate ganglion/lower cervical sympathetic block has been advocated for diagnostic, therapeutic and prognostic purposes for a variety of conditions, including:
 CRPS I & II to the upper extremities
 Vascular insufficiency/occlusive vascular disorders of the upper extremities
 Poor lymphatic drainage and edema of the upper extremity following mastectomy
 Postherpetic neuralgia
 Phantom pain
 CRPS of the breast & pain following mastectomy
 Quinine poisoning
 Sudden hearing loss & tinnitus
 Hyperhidrosis of the upper extremity
 Ischemic cardiac pain
 Bell's palsy & a variety of orofacial pain syndromes, including neuropathic orofacial pain & trigeminal neuralgia
 Vascular headache, including cluster and migraine headaches & sympathetically maintained headaches.
 Neuropathic pain syndromes in cancer pain

Front 70

48. The pain of the first stage of labour is transmitted via
A. grey rami communicantes
B. T1O-L1 anterior roots
C. the hypogastric plexus
D. inhibitory nerves to the internal vesical sphincter
E. parasympathetic nerves

Back 70

C


Update in Anaesthesia - PAIN RELIEF IN LABOUR
The uterus and cervix are supplied by afferents accompanying sympathetic nerves in the uterine and cervical plexuses, the inferior, middle and superior hypogastric plexuses and the aortic plexus. The small unmyelinated 'C' visceral fibres3 transmit nociception through lumbar and lower thoracic sympathetic chains to the posterior nerve roots of the 10th, 11th and 12th thoracic and also to 1st lumbar nerves to synapse in the dorsal horn4. The chemical mediators involved are bradykinin, leukotrienes, prostaglandins, serotonin, substance P and lactic acid5. As the labour progresses severe pain is referred to the dermatomes supplied by T10 and L1.

In the second stage, the direct pressure by the presenting part on the lumbosacral plexus causes neuropathic pain. Stretching of the vagina and perineum results in stimulation of the pudendal nerve (S2,3,4) via fine, myelinated, rapidly transmitting 'A delta' fibres3. From these areas, the impulses pass to dorsal horn cells and finally to the brain via the spino-thalamic tract

Front 71

41. Patients with ankylosing spondylitis usually exhibit
A. skin rash
B. raised Erythrocyte Sedimentation Rate (ESR)
C, positive test for Rheumatoid Factor
D. HLA B27 antigen
E. urethritis

Back 71

D


Stoelting:
"The strong familial incidence is supported by the finding that 90% of patients with ankylosing spondylitis are HLA-B27 positive compared to only 6% of the general population."

Front 72

35. In patients with Eisenmenger's Syndrome,
A. compensation for poor oxygenation at rest is achieved by an increase in cardiac output
B. the high pulmonary vascular resistance is usually able to be treated with a specific vasodilator
C. an Fi02 of 1.0 will produce a substantial improvement in Sa02
D, the usual clinical course includes right ventricular failure
during the 3rd or 4th decade, and subsequent death
E. venesection should be used to treat a haemoglobin greater
than 180 04to prevent the problems of hyperviscosity

Back 72

D



• False, I presume this would increase the shunt
• "No treatment has proved effective in producing sustained decreases in pulmonary vascular resistance, although intravenous epoprostenol may be beneficial." (Stoelting)
• Increasing FiO2 won’t improve oxygenation with shunt
• Usually die 2nd-4th decade
• "Phlebotomy with isovolemic replacement should be undertaken in patients with moderate or severe symptoms of hyperviscosity" (Stoelting), however looks like it should be done when HCT > 65% ie Hb > 210

Front 73

32. Post-intubation croup in paediatric anaesthesia
A. rarely occurs if uncuffed endotracheal tubes are used
B. is reduced if prophylactic steroids are administered intra-operatively
C. occurs predominantly in children under the age of five years
D. can be treated with one millilitre of aerosolysed 4% racemic adrenaline
E. is less frequent if local anaesthetic lubricants are used

Back 73

C

Front 74

30. In the hand the median nerve supplies
A. abductor pollicis brevis
B. adductor pollicis
C. the first dorsal interosseous
D. abductor pollicis longus
E. extensor indicis

Back 74

A


Median nerve supplies the LOAF muscles in the hand (for Lumbricals 1 & 2, Opponens pollicis, Abductor pollicis brevis and Flexor pollicis brevis).
Anatomy for Anaesthetist:
"The lateral terminal branch of the median nerve sends off a short, stout and important branch immediately distal to the flexor retinaculum and 3 cm distal to the distal wrist skin crease, which plunges into the thenar eminence, there to supply the abductor brevis, opponens and flexor brevis of the thumb."

Front 75

28. Anatomical features of the spinal cord do NOT include
A. an anterior median fissure and a posterior median septum
B. thirty-two pairs of spinal nerves
C. a filum terminale ending at the coccyx
D. four to six spinal arteries arising from the posterior inferior cerebellar arteries
E. the anterior spinal artery arising from the vertebral arteries

Back 75

B


A. "The spinal cord presents an anterior median fissure and a shallow posterior median sulcus from which a glial posterior median septum extends about halfway into the substance of the cord."
B. false: "There are 31 pairs of spinal nervesaeight cervical, 12 thoracic, five lumbar, five sacral and one coccygeal. Each is formed by the fusion of an anterior and posterior spinal root."
C. "Below, the spinal cord tapers into the conus medullaris, from which a glistening thread, the filum terminale, continues down to become attached to the coccyx."
D. unsure, ?probably false "The posterior spinal arteries comprise one or two vessels on either side derived from the posterior inferior cerebellar arteries. They supply the posterior grey and white columns on either side. These arteries are reinforced serially by spinal branches of the vertebral, deep cervical, intercostal, lumbar, ilio-lumbar and lateral sacral arteries; the lower branches being responsible for the blood supply of the cauda equina."
E. "The anterior spinal artery is a midline vessel lying on the anterior median fissure and is formed at the foramen magnum by the union of a branch from each vertebral artery."

Front 76

26. The fall in body temperature seen intra-operatively is
A minimised by thermoregulatory vasoconstriction
B. greater in the elderly because basal metabolic rate increases with age
C. less well controlled by forced air warming than by a circulating water mattress
D. decreased by high spinal blockade
E. beneficial for patients with ischaemic heart disease

Back 76

A


• A is true, though anaesthesia interferes with this effect
• BMR decreases with age
• C is false, forced air warmers quite effective
o "One of the most effective methods is forced-air warming." (Current Anaesthesia & Critical Care (2001) 12, 79-86)
• D doesn’t sound true
• E certainly false

Front 77

16, The second lumbar nerve root (L2) normally contributes to the each of the following nerves EXCEPT
A. femoral nerve
B. obturator nerve
C. genito-femoral nerve
D. lateral cutaneous nerve of the thigh
E. ilio-inguinal nerve

Back 77

E


Summary of branches of the lumbar plexus
 Iliohypogastric L1
 Ilio-inguinal L1
 Genitofemoral L1, 2
Dorsal divisions
 8lateral cutaneous nerve of thigh L2, 3
 femoral nerve L2–4
Ventral divisions
 obturator nerve L2–4
 accessory obturator nerve L3, 4

Front 78

8. Thiazide diuretics may cause
A. hypernatraemia
B. precipitation of acute gout
C. hypoglycaemia
D. hyperkalaemia
E. hepatic failure

Back 78

B


Yentis:
"Side effects include hypokalaemia, hyponatraemia, hyperuricaemia, hypomagnesaemia, hypochloraemic alkalosis, hyperglycaemia, hypercholesterolaemia, exacerbation of renal and hepatic impairment, impotence, and rarely rashes and thrombocytopaenia."