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56 Cards in this Set
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150. Line isolation monitoring protects against microshock |
A
LIM irrelevant to microshock - provides ability to safeguard against macroshock only!! Set to alarm for current leakage>2-5mA (depending on hospital). Our OR's are always reading about 2-3mA. PLUS the fact that the current required for microshock is only 50 - 500 micro amps, well below what the LIM will alarm at. No protection, just a monitor. Reads maximum current that would pass through an earthed patient touching one of the wires of the isolated circuit |
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149. In patients with renal impairment, doses of all the following
drugs may require adjustment EXCEPT A. carbamazepine B. gabapentin C. hydromorphone D. morphine E. oxycodone |
E
Re Cabamazepine. “Kinetics were not altered in the elderly; there are no data on patients with impaired hepatic or renal function.”MIMS ANZCA pain book says no dose adjustment required for oxycodone, is required for gabapentin, morphine, hydromorph, doesn't mention carbamazepine. |
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148. Infra-renal aortic cross-clamping usually results in
A. decreased cardiac contractility B. decreased coronary blood flow C. decreased renal blood flow D. minimal change in cardiac output E. increased heart rate |
C
Miller Regardless of the position of the aortic cross-clamp, RBF is decreased to 50% of normal during surgical preparation of the aorta, presumably because of direct compression or reflex spasm of the renal arteries. After release of the suprarenal cross-clamp, RBF increases above normal (reflex hyperemia), but the GFR remains depressed to a third of control for up to 2 hours |
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147. A patient is scheduled for emergency coronary artery
bypass surgery (CABG) 2 hours after receiving tirofiban (Aggrastat) during coronary angiography and an unsuccessful coronary stenting procedure. The most useful strategy to treat or prevent excessive perioperative bleeding is A. administration of concentrated Factor VIII B. administration of cryoprecipitate C. delaying surgery for a further 2 hours D. haemofiltration during cardiopulmonary bypass E. platelet transfusion |
D
Kelly K. Antiplatelet Drugs. Australasian Anaesthesia 2005 (ANZCA blue book) Tirofiban is a non-peptide, tyrosine based drug, which is administered intravenously and excreted by the kidneys. It has more favourable pharmacokinetics than abciximab, with rapid onset and offset of action. It results in approximately 90% inhibition of platelet function within 30 minutes of infusion and has a short half life of two hours. Following cessation of an intravenous infusion, 50% of platelet function is observed at 1.5 hours and 100% by eight hours. Haemostatsis can be expected within four hours. A & A October 2004 vol. 99 no. 4 989-992 The short-acting platelet glycoprotein IIb/IIIa antagonist tirofiban is beneficial when used in the context of cardiac surgery. Tirofiban has an elimination half-life of 2 h. Renal failure prolongs the half-life and continues inhibition of platelet aggregation refractory to transfusions of platelets. Extracorporeal elimination is necessary to prevent excessive hemorrhage in this condition. MIMS "Aggrastat can be removed by haemodialysis" |
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Regarding placebos
A. for every intervention, a fixed fraction of the population responds to placebo, whatever the outcome B. randomisation of different numbers of patients to active and placebo groups can affect the response to placebo C. the more invasive the method of delivering a treatment, the higher the response to placebo D. the placebo effect can be eliminated by using active treatments in both study groups E. the placebo response is a fixed fraction of the maximum effect of the treatment |
D
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Lumbar epidural analgesia in labour using 0.125%
bupivacaine A. improves FVC (forced vital capacity) if the upper sensory level is kept below T12 B. improves FVC and FEV1 (forced expiratory volume in one second) if the upper sensory level is kept below T12 C. improves FVC, even if the sensory level is above T10 D. improves FVC and FEV1, even if the sensory level is above T10 E. reduces FVC and FEV1 if the sensory level is above T10 |
D
Seems to be based on a study from Anaesthesia Volume 59 Page 350 - April 2004 The effect of epidural analgesia in labour on maternal respiratory function. The respiratory function measurements were taken with mothers completely PAIN FREE, so must have had a block to T10: "As soon as a sensory blockade above T10 was obtained, we started a continuous infusion of 10 ml.h−1 bupivacaine 0.125% with fentanyl 0.0001%...The upper sensory level of epidural analgesia was T8 (T6–T8[T4–T10])" from above article. FVC, FEV1, and PEF all improved |
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Fondaparinux sodium (Arixtra)
A. activates platelet B. cross reacts with sera from patients with heparin induced thrombocytopaenia C. has a mechanism of action that is antithrombin (ATIII) dependent D. is associated with thrombocytopenia E. can be safely used in patients with severe renal impairment |
C
MIMS: "Fondaparinux is a synthetic and specific inhibitor of activated factor X (Xa) with no animal sourced components. The antithrombotic activity of fondaparinux is the result of antithrombin III (ATIII) mediated selective inhibition of factor Xa. By binding selectively to ATIII, fondaparinux potentiates (about 300 times) the innate neutralisation of factor Xa by antithrombin. Neutralisation of factor Xa interrupts the blood coagulation cascade and inhibits both thrombin formation and thrombus development." |
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The double stranded hepatitis B virus can survive outside
the body for A. less than 4 hours B. six to twelve hours C. one to two days D. two to seven days E. more than seven days |
E
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A female patient with a history of severe postoperative
nausea and vomiting presents for abdominal surgery. If a volatile agent is used for maintenance of anaesthesia the most effective treatment to reduce her risk of postoperative nausea and vomiting would be A. avoidance of nitrous oxide B. prophylactic dexamethasone (4 mg) C. prophylactic droperidol (1.25 mg) D. prophylactic ondansetron (4 mg) E. a combination of prophylactic dexamethasone and droperidol |
E
A factorial trial of six interventions for the prevention of postoperative nausea and vomiting. NEJM Combinations of antiemetics, including dexamethasone and droperidol, superior to any single agent. The reason "female" is specified in the question is that droperidol was not shown to be effective in reducing PONV in men |
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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 |
A
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Regarding the use of adrenergic drugs to maintain
normotension during regional anaesthesia for elective caesarean section A. alpha-adrenergic agonists are associated with increased fetal acidosis B. alpha-adrenergic agonists are associated with reduced uteroplacental perfusion C. ephedrine increases fetal heart rate and catecholamine levels D. phenylephrine is associated with increased nausea and vomiting compared with ephedrine E. prophylactic ephedrine decreases the incidence of fetal acidosis |
C
Fetal and Maternal Effects of Phenylephrine and Ephedrine during Spinal Anesthesia for Cesarean Delivery' Cooper et al, Anesthesiology Volume 97(6), December 2002, pp 1582-1590 • "In humans, ephedrine given to the mother has fetal effects. It can increase fetal heart rate and fetal catecholamine levels." • "significant differences in nausea and vomiting occurred between groups despite similar systolic arterial pressure control. When phenylephrine was given alone, spinal anesthesia was not associated with a change in nausea and vomiting from baseline, even though hypotension did occur. In contrast, when ephedrine was given alone, or in combination with phenylephrine, spinal anesthesia was associated with a highly significant increase in nausea and vomiting from baseline, and with more nausea and vomiting than with giving phenylephrine alone. The differences in nausea and vomiting between the phenylephrine and combination groups occurred even though there were no differences in systolic arterial pressure control." (3 gps - phenyl, eph, combined phenyl+eph) • "vasopressor infusions with a greater degree of [alpha]-adrenergic receptor activity than ephedrine decreased fetal acidosis at cesarean delivery." |
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Perioperative ulnar neuropathy
A. is more common in diabetics B. is more common in women C. is often associated with contralateral clinical neuropathy D. is usually found to be the result of excess external pressure E. usually presents within 24 hours |
A
Risk factors for ulnar neuropathy (Peripheral nerve injuries associated with anaesthesia, Anaesthesia 2000) Preexisting problems • Pre-existing neuropathy • diabetes • malnutrition • cervical rib • male sex identified in Mayo clinic study • peripheral vascular disease (according to the practice advisory) • alcohol dependency • arthritis Surgical injury • direct including CV • sternal retraction (CABG) • tourniquet Intraoperative conditions • hypothermia – particularly surface cooling • hypotension • anaemia • electrolyte abnormalities Position • internal rotation (pronation) with arm abducted >90 degrees • pronation when by side (should be neutral) • compression or stretch • Elbow flexion greater than 90 degrees increases risk |
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In relation to nausea during obstetric regional anaesthesia
A. atropine is more effective treatment than vasopressors when there is a high spinal block B. nausea is worse with phenylephrine infusion compared to ephedrine infusion C. phenylephrine increases the emetic effect of decreased preload D. metoclopramide is the treatment of choice E. ondansetron is the treatment of choice |
A
Fetal and Maternal Effects of Phenylephrine and Ephedrine during Spinal Anesthesia for Cesarean Delivery. Anesthesiology Volume 97(6), December 2002, pp 1582-1590 “Nausea and vomiting may have been secondary to an absolute, or relative, increase in vagal tone. There is evidence for a vagal mechanism causing nausea during spinal anesthesia. Atropine has been found to be more effective at treating nausea associated with high spinal anesthesia than vasopressors. More recently, glycopyrrolate has been found to reduce nausea during spinal anesthesia for cesarean delivery.” |
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In patients with myasthenia gravis, features which increase
the risk of requiring prolonged postoperative ventilation, include each of the following EXCEPT A. a high dose of pyridostigmine preoperatively B. a long history of the disease C. high sensitivity to neuromuscular blocking agents D. history of a previous respiratory crisis E. presence of a bulbar palsy |
C
Preoperative predictors of postoperative need for ventilation: • duration of disease of greater than 6 years • history of coexisting chronic resp disease • dose requirements of pyridostigmine > 750 mg/day less than 48 H prior to surgery • preoperative VC < 2.9L |
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Nonsteroidal antiinflammatory drugs given during
pregnancy, have been associated with all of the following EXCEPT A. foetal cardiac complications if given in late pregnancy B. foetal renal complications if given in late pregnancy C. increased production of amniotic fluid D. increased risk of miscarriage E. persistent neonatal pulmonary hypertension |
C
Apparently can cause oligohydramnios |
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Correct statements regarding Hypertrophic Cardiomyopathy
include each of the following EXCEPT that it A. results in a left ventricular wall thickness of greater than 12 mm B. is a condition where the left ventricle is hypertrophied and dilated C. is predominantly a non-obstructive disease D. is most easily and reliably diagnosed with 2-dimensional echocardiography E. the hypertrophy is characteristically asymmetrical |
B
eMedicine Although any region of the left ventricle (LV) can be affected, hypertrophy frequently involves the interventricular septum which can result in outflow tract obstruction. Patients typically have preserved systolic function with impaired LV compliance that results in diastolic dysfunction whether or not outflow tract obstruction is present. The degree of obstruction varies among patients. Some patients have no gradient whereas others develop obstruction only with exertion. The obstruction is also dynamic and depends on the patient's volume status; volume depletion increases the outflow gradient whereas volume repletion increases obstruction. The degree of obstruction does not correlate with risk of sudden cardiac death. Normal LV wall thickness <11mm. Usually not dilated |
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Gabapentin used for acute postoperative pain
A. has it 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 opiates alone E. works by binding at GABA receptors |
C
▪ A: never heard of it and can't reference for. ▪ B: false. It is anxiolytic ▪ C:certainly higher than doses used in epilepsy ▪ D: dizziness and somnolence a common side effect. therefore flase. ▪ E: probably via voltage-gated N-type calcium channel |
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Transient Neurological Syndrome
A. comprises pain localised to the back B. diagnosis is confirmed by typical findings on neurological examination C. is associated with consistent abnormalities on magnetic resonance imaging and electrophysiological studies (EPS) D. is associated with long term deficits in 5% of cases E. may occur with lignocaine, bupivacaine, prilocaine and procaine |
E
▪ A. False: "Follow-up of patients who received uncomplicated spinal anesthesia revealed that some of them developed pain in the lower extremities—transient neurologic symptoms (TNS)" (A & A June 2005 vol. 100 no. 6 1811-1816) ▪ B. False: "In contrast to the lower extremity weakness and bowel and bladder dysfunction observed with cauda equina syndrome (8), neurologic examination, magnetic resonance imaging, and electropathological testing show no abnormalities in patients with TNS" ▪ C. False: See B ▪ D. False: "There was no evidence that this painful condition was associated with any neurologic pathology; in all patients, the symptoms disappeared spontaneously by the 10th postoperative day." ▪ E. True: "The relative risk for developing TNS after spinal anesthesia with lidocaine was higher than with other local anesthetics (bupivacaine, prilocaine, procaine, and mepivacaine)" |
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Ginseng (Panax Ginseng) has been associated with an
increased risk of each of the following EXCEPT A. agitation with concurrent mono amine oxidase inhibitors B. bleeding with concurrent aspirin C. bronchospasm D. hypoglycaemia in fasting patients E. Stevens-Johnson syndrome |
C
All of the following are recorded as S/E in Current Opinion in Anaesthesiology 2007, 20:294–299 editorial: Stevens-Johnson (D), HT, hypoglycaemia , bleeding (and thus advise to avoid with other anticoagulant meds including aspirin), and mania with MAOI |
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The PiCCO monitor (Pulsion Medical Systems) combines
pulse contour analysis and transpulmonary thermodilution to provide a continuous measurement of A. cardiac output B. cardiac output and intermittent assessment of intrathoracic blood volume C. cardiac output and intermittent assessment of extravascular lung water D. cardiac output and intermittent assessment of intrathoracic blood volume and extravascular lung water |
D
PiCCO technology provides clinicians with the following clinical measurements, many of which can be displayed as absolute or indexed values: Continuous Pulse Contour Cardiac Output analysis (PCCO) • Arterial blood pressure (AP) • Heart rate (HR) • Stroke volume (SV) • Stroke volume variation (SVV) • Systemic vascular resistance (SVR) • Index of left ventricular contractility via intermittent transpulmonary thermodilution • Transpulmonary cardiac output (C.O.) • Intrathoracic blood volume (ITBV) • Extravascular lung water (EVLW) • Cardiac function index (CFI) |
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Hepatotoxicity from paracetamol overdose is enhanced in
A. chronic renal failure B. concomitant ingestion of benzodiazepines C. conditions associated with glutathione deficiency D. patients with hepatitis C antibody E. obese patients |
C
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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 |
B
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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 |
C
According to MIMS Apparently sufentanyl has the highest mu affinity of any opioid |
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A 35-yr-old woman with a history of palpitations has the
following ECG at rest: She presents for laparoscopic appendicectomy for suspected acute appendicitis. Prior to induction she feels faint and you feel a very rapid irregular brachial pulse. A portion of her 12 lead ECG now is shown below Your treatment of this arrhythmia should be A. carotid sinus massage B. DC (direct current) cardioversion C. intravenous adenosine D. intravenous lignocaine E. intravenous verapamil |
B
This is WPW with AF Note irregular rhythm, slurring of upstroke of broad complexes AV bocking agents (and lignocaine) are specificially contraindicated – will force conduction down the accessory pathway, with 1:1 conduction of atrial impulses VF If stable then amiodarone, flecainide, procainamide (not available in Australia) can be used instead of cardioversion Definitive Mx = EP study and ablation |
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A 26-year-old female with ulcerative colitis has a total
colectomy with J pouch formation. Preoperatively she was on regular oxycodone, fluoxetine and prednisolone orally. She has normal renal function and liver function. Her postoperative pain management consists of PCA (patient controlled analgesia) with morphine, regular intravenous tramadol (100 mg every 6 hrs) and regular intravenous paracetamol (1 gm every 6 hrs). When you assess her 24 hrs postoperatively she is agitated, confused and sweaty with a pulse of 120, BP 150/95 and temp of 38 C°. You should A. administer naloxone B. administer 100 mg of hydrocortisone C. cease her paracetamol D. cease her tramadol E. change her PCA morphine to PCA fentanyl |
D
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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 |
E
Safety and efficacy of patient-controlled analgesia - BJA, 2001, Vol. 87, No. 1 36-46 “Many authors choose to define respiratory depression as a respiratory rate of less than 8 or 10 breaths min–1, even though a decrease in respiratory rate is known to be an unreliable indicator of the presence or absence of respiratory depression. A better clinical indicator of early respiratory depression is sedation, and many centres routinely monitor patient sedation using sedation scores” |
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A 25-year-old 80 kg male with no other health problems is
undergoing ECT (electroconvulsive shock therapy) for severe depression. Anaesthesia for his first 2 treatments consisted of thiopentone 350 mg and suxamethonium 50 mg. The treating psychiatrist is concerned at the limited duration of seizure activity with treatment despite maximal seizure stimulus. An acceptable seizure duration would be best be achieved by A. adjunctive use of remifentanil to reduce the dose of induction agent B. clonidine premedication C. hypoventilating the patient to reduce seizure threshold D. pretreatment with lignocaine to reduce seizure threshold E. using propofol instead of thiopentone for induction of anaesthesia |
A
Remifentanil supplementation of propofol during electroconvulsive therapy: effect on seizure duration and cardiovascular stability. J ECT. 2005 Dec;21(4):235-8: “During anesthesia, the addition of remifentanil to propofol appears to be as effective as propofol alone with regard to anesthesia efficacy and cardiovascular function while significantly increasing seizure duration. Whether this discovery is of relevance to the clinical efficacy of ECT remains to be tested” |
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A 70-yr-old man is to undergo removal of cataract and
intraocular lens implantation. He has long-standing atrial fibrillation and is on warfarin. He has no other health problems. He has never had a stroke. A sub-tenon's block is planned for the procedure. His INR is 2.5. What should be the perioperative management of his warfarin therapy and anticoagulant status? A. Interrupting warfarin therapy is optional for this procedure. If warfarin is interrupted for 5 days to allow normalisation of INR (< 1.5) no other perioperative anticoagulant prophylaxis is necessary B. Warfarin therapy should be ceased 5 days preoperatively and no other perioperative anticoagulant prophylaxis is necessary. Surgery should proceed if INR is < 1.5 C. Warfarin therapy should be ceased 5 days preoperatively. He should commence daily low molecular weight heparin, omitting the dose on the day of surgery. Surgery should proceed if INR is < 1.5 D. Warfarin therapy should be ceased 5 days preoperatively. He should take daily clopidogrel till surgery. Surgery should proceed if INR is < 1.5 E. Warfarin therapy should be ceased 5 days preoperatively. He should take daily low dose aspirin till surgery. Surgery should proceed if INR is < 1.5 |
A |
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Nitrous oxide anaesthesia may cause all of the following
EXCEPT A. an increased incidence of myocardial ischaemia B. decreased leukocyte chemotactic response C. elevation of plasma homocysteine levels D. megaloblastic anaemia E. reversible inhibition of methionine synthetase |
E
Nitrous oxide causes irreversible inhibition of methionine synthetase |
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Regarding a 75-year-old female patient with moderate
aortic stenosis presenting for an elective hip replacement, A. atrial systole has an increased contribution to stroke volume (compared to a patient with no aortic stenosis) B. beta-blockers are poorly tolerated in this degree of aortic stenosis C. hypotension is better tolerated than hypertension D. rheumatic heart disease is the commonest aetiology in this age group in Western Society E. spinal anaesthesia is the preferred method of anaesthesia |
A
CEACCP: • A - True "The hypertrophied ventricle becomes increasingly stiff, causing diastolic dysfunction with a reduced compliance. Consequently, left ventricular filling becomes dependent on atrial contraction with atrial systole contributing 40%, instead of the usual 20%, of left ventricular end-diastolic volume. The left atrium hypertrophies to maintain left ventricular filling. Preservation of sinus rhythm becomes vital for the maintenance of cardiac output." • B – False. • C - False "Avoidance of systemic hypotension is essential. Hypotension leads to myocardial ischaemia and a downward spiral of reduced contractility causing further falls in blood pressure and coronary perfusion" - hypertension better tolerated due to maintenance of coronary perfusion pressures. • D – False. "Degenerative calcific aortic stenosis: This is now the most common form of aortic stenosis in the UK and tends to occur over the age of 70 yr." • E – False. Regional anaesthesia, particularly the T4 block required for Caesarean section, carries with it a risk of significant hypotension. Traditionally, general anaesthesia was advocated for these patients and remains so in the more severe cases who are at risk of requiring emergency bypass and a combined cardiac procedure. However, it should be borne in mind that most anaesthetic agents cause vasodilatation and that it is the conduct of anaesthesia rather than the specific technique that is important." |
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The commonest cause of visual deficit following anaesthesia
for major surgery is A. central retinal artery occlusion B. central retinal vein occlusion C. cortical blindness D. glycine toxicity E. ischaemic optic neuropathy |
E
Almost Repeat. Miller Ch 63: "Not all postoperative visual loss is a result of direct orbital compression, however. Ischemic optic neuropathy (ION) seems to be a more frequent cause of postoperative visual loss than pressure causing occlusion of central retinal vessels. The cause-and-effect relationships associated with ION are uncertain, but low arterial pressure, low hematocrit, and lengthy surgical procedures are statistically associated with the phenomenon." |
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Regarding endotracheal tubes for paediatric patients
A. a 2.5 mm endotracheal tube is the appropriate size for a term neonate B. armoured (wire spiral) endotracheal tubes have the same outside diameter as non-armoured endotracheal tubes (of the same internal diameter) C. the outside diamter (in mm) of an appropriately sized tube is given by the formula (Age/4) +4 D. the same diameter tube is used for nasal and oral intubation in a child E. uncuffed, paediatric endotracheal tubes do NOT have a Murphy's eye |
D
• A – False. Term neonate – size 3.0-3.5 ETT • B – False. Smaller external diameter for reinforced ETT as walls are thinner. • C – False. (Age/4)+4 = formula for internal diameter. • D – True. • E – False. |
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Regarding ball flowmeters the
A. flow control knob cannot stop gas leakage if the glass chamber is broken B. flowmeter maintains accuracy when tilted C. flowmeter will over estimate gas flow if connected to a high resistance device such as a nebuliser D. gas flow rate is read at the centre of the ball E. gas flow lifts the ball up in a parallel sided tube in the glass chamber |
D
Rosewarne 1st ed. p. 54 "Flow is measured to the middle of the glass ball" |
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An infant is anaesthetised and ventilated using an
endotracheal tube and circle breathing system with CO2 absorber. The item which causes the most resistance to breathing is the A. airway pressure limiting (APL) valve B. circuit hosing C. endotracheal tube D. heat and moisture exchange filter E. inspiratory and expiratory valves |
C
http://www.alfanaes.org “the resistance of the tracheal tube in a young infant is at least 10 times that of the circle system." |
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In elderly patients each of the following statements is true
EXCEPT A. antagonism of neuromuscular blockade with anticholinesterases is less likely to be effective than in the younger patient B. atropine produces a lesser heart rate response than in younger patients C. ephedrine is less likely to be effective (at raising blood pressure) than in the younger patient D. MAC of all inhalational agents is reduced by 20 to 40% E. time of onset of neuromuscular blockade is prolonged due to a reduction in cardiac output |
A
CEACCP 2005 - Perioperative care of the elderly: A. "Antagonism of neuromuscular blockade with anticholinesterase drugs tends to be similar to younger adults." B. "Ageing is associated with reduced b-receptor sensitivity, which results in a reduction in response to exogenous b-agonists. However, the response to alpha-agonists is comparable to that seen in younger patients. This relatively poor response to beta-stimulation also results in the reduced heart rate response to atropine." C. "Ephedrine is likely to be ineffective in the elderly; alpha-agonists such as metaraminol or phenylephrine should be used in preference." D. "The MAC value of all inhalational anaesthetic agents is reduced by 20–40% from young adult values." E. "However, the time of onset and the duration of action are both prolonged because of a reduction in cardiac output and reduced metabolism, respectively" |
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Correct statements regarding tricyclic antidepressant drugs
used in the treatment of chronic pain include each of the following EXCEPT A. are more effective if they have predominantly noradrenergic effects B. block alpha-adrenergic and NMDA receptors C. block neuronal reuptake of serotonin and noradrenaline D. enhance descending inhibitory actions on the spinal cord E. should be used with caution in patients with abnormalities of cardiac conduction |
A
CEACCP 2005 - Treatment of chronic pain: antidepressant, antiepileptic and antiarrhythmic drugs: A: false, "It is thought by many that mixed reuptake inhibitors such as amitriptyline are more effective than selective agents, emphasizing the importance of both serotonergic and noradrenergic pathways in pain perception." B: true " The drugs also, to varying degrees, block a number of other receptor types involved in pain processing including a-adrenergic, H1-histaminergic and N-methyl-D-aspartate (NMDA) receptors." C: true "However, their efficacy is generally thought to be related to central blockade of central nervous system (CNS) monoamine uptake, specifically serotonin and/or norepinephrine, in addition to other neurotransmitters” D: true “They may alter nociceptive processing by prolonging synaptic activity of these monoamines, thereby enhancing descending inhibitory action in the spinal cord in addition to monoaminergic effects elsewhere in the CNS” E: true "Side-effects (which commonly limit their use) include sedation and anticholinergic effects, particularly dry mouth. Constipation and urinary retention are less common but well documented. The drugs have a number of effects on the heart including slowing of atrioventricular and intraventricular conduction. Cardiac side-effects are important as they may preclude the use of these drugs in patients with cardiac conduction disturbances or recent infarction." |
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When a new diagnostic test is evaluated in a population 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 80 40 New test result negative 20 180 In this population the POSITIVE predictive value of this test is closest to A. 10% B. 33% C. 67% D. 80% E. 90% |
C
PPV = TP / (TP + FP) = 80 / (80 + 40) = 67% |
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Post partum foot drop is most frequently caused by
A. compression of the lumbosacral trunk by the foetal head or forceps B. damage to the common peroneal nerve from lithotomy position C. damage to the conus medullaris by misplaced spinal anaesthesia D. L4 Nerve root damage from epidural analgesia E. the excessive lumbar lordosis of pregnancy stretching nerve roots |
A
CEACCP (2003) Neurological complications following regional anaesthesia in obstetrics. “Postpartum foot drop is caused by damage to the lumbosacral nerve trunk or, less frequently, the common peroneal nerve. The lumbosacral trunk (L4 and L5) is compressed between the ala of the sacrum and the descending fetal head. It may also occur during a forceps delivery.” |
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When an anaphylactoid reaction occurs during anaesthesia, the percentage of cases presenting with bronchospasm as the ONLY feature is approximately
A. 30% B. 15% C. 5% D. 0.5% |
C
Association of Anaesthetists Great Brittain & Ireland – Anaphylaxsis Guidelines: • % bronchospasm as SOLE feature ~ 5% |
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Epidural blood patch for severe post-dural puncture
headache A. is contraindicated in patients with Acquired Immunodeficiency Syndrome (AIDS) B. has NOT been shown to be associated with a higher success rate if performed more than 24 hours after dural puncture C. is associated with a higher success rate if more than 20 ml of blood is used D. is rarely associated with back pain during injection E. is most effective when given immediately following accidental dural puncture |
C
A. ?true. ANZCA pain book: "The use of autologous blood patch may be contraindicated in patients with leukaemia, coagulopathy or infection including HIV”. However BJA 2003: “Limited experience with HIV‐positive patients suggest that it is acceptable providing no other bacterial or viral illnesses are active” B. false. "The technique has a success rate of 70–98% if carried out more than 24 h after the dural puncture." C. trueish.ANZCA pain book p273: "There is no consensus as to the precise volume of blood required”. “20ml recommended as the ‘optimal’ target volume”. “EBP volumes in the range of 10 to 20 ml were effective in relieving PDPH in 98% of patients, following spinal or epidural anaesthesia" D. false. “beyond [20ml] there was a higher incidence of lumbar discomfort on injection” E. false. Greater success if you wait at least 24hrs |
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Complications of an intra-orbital local anaesthetic block are
minimised if A. the eye is oriented in a supero-medial direction for an infero-lateral injection B. the anaesthetic solution is placed posteriorly where the nerves are close together C. a shallow bevel (Atkinson-type) rather than a sharp intravenous-type needle is used D. the injection site is medial rather than supero-medial E. retro-bulbar needle placement is used for all myopic patients |
D |
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Complications, which usually present early 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 |
A
Similar to previous question Still think bronchopleural-fistula is not an early complication |
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In elderly patients
A. opioid requirements are decreased, primarily due to age-related changes in physiology B. pain thresholds are decreased C. self-rated pain scores are lower than in younger patients D. there is a decrease in the density of unmyelinated but not myelinated nerve fibres E. there is impairment of pain inhibitory systems |
C
Though E also seems true • A – True, ANZCA pain book “a large interpatient variability still exists and doses must be titrated to effect in all patients. The decrease is much greater than would be predicted by age related alterations in physiology and seems to have a significant pharmacodynamic component” • B – False, ANZCA pain book “Examples of differences in reports of acute pain are commonly related to abdominal pain (eg associated with infection, peptic ulcer, cholecystitis, or intestinal obstruction) or chest pain (eg myocardial ischaemia or infarction; pneumonia) and are in general agreement with the experimental finding of increased pain thresholds in the older person.” • C- True, ANZCA pain book “In a study of pain following placement of an IV cannula (a relatively standardised pain stimulus), older patients reported significantly less pain than younger patients (Li et al, 2001 Level IV)” • D – False, ANZCA pain book "The peripheral nerves show a decrease in the density of both myelinated and, particularly, unmyelinated peripheral nerve fibres, an increase in the number of fibres with signs of damage or degeneration and a slowing of the conduction velocity" • E – True, ANZCA pain book “In general, in the nervous system of the older person, there are extensive alterations in structure, neurochemistry and function of both peripheral and central nervous systems, including neurochemical deterioration of the opioid and serotonergic systems. Therefore there may be changes in nociceptive processing, including impairment of the pain inhibitory system” |
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The most common site of injury to the airway during
anaesthesia is A. larynx B. oesophagus C. pharynx D. temporomandibular joint E. tongue |
A
Anesthesiology 1999; 91: 1703-1711 Closed claims analysis from the ASA (American Society of Anesthesiologists): • Approximately 6% (266) of 4,460 claims in the database were for airway injury. The most frequent sites of injury were the larynx (33%), pharynx (19%), and esophagus (18%). Injuries to the esophagus and trachea were more frequently associated with difficult intubation. Injuries to temporomandibular joint and the larynx were more frequently associated with nondifficult intubation |
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In patients with chronic renal failure there is
A. increased calcium absorption B. increased phosphate excretion C. increased vitamin D3 production D. increased osteoclastic activity E. decreased osteoblastic activity |
D
• A - wrong = failure of VitD production/conversion results in reduced Ca absorbtion • B - wrong = CRF results in failure of PO4 excretion (thus treated with phosphate binders in diet) • C - wrong = failure of VitD production/conversion • D - correct = due to increased PTH • E - wrong = increased both osteclast and osteoblast activity by increased PTH |
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Regarding decontamination of anaesthetic equipment
A. alcohol is an effective sporicidal agent B. disinfection is sporicidal C. phenol is an effective sporicidal agent D. sterilisation with ethylene oxide requires 5 to 12 hours to be effective E. sterilisation with glutaraldehyde requires 5 to 8 hours to be effective |
D
CEACCP - Decontamination of anaesthetic equipment 2004 • A, B, C - Alcohol, disinfection, phenol are not sporicidal • D – ethylene oxide requires 5-12 hours to work. Closest answer • E – glutaraldehyde requires > 10 h |
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Regarding perioperative use of processed salvaged red blood
cells, A. malignant cells are removed by the washing process B. storage of salvaged cells should be limited to six hours C. the high free haemoglobin levels are associated with renal failure D. the salvaged cells have lower oxygen carrying capacity than banked blood E. the survival of the salvaged red blood cells is significantly impaired |
C
• A - False, CEACCP 2010: "Cell salvage is not recommended by the manufacturers in patients undergoing surgery for malignancy because of the possibility of reinfusion of tumour cells, potentially giving rise to distant metastasis... It is recommended that leucodepletion filters should be used before reinfusion to filter malignant cells and further elimination of malignant cells can be achieved by irradiation." • B – True – Cell salvage as part of a blood conservation strategy in anaesthesia. BJA 2010 105 (4):401-416 – “The current accepted storage time of cell salvaged blood is 6 h, but a recent well-conducted prospective study of 101 paediatric patients undergoing cardiac surgery demonstrated that extension to 18 h resulted in minimal microbiological contamination or chemical deterioration “ • D and E: Miller - "The oxygen-transport properties of recovered RBCs are equivalent to those of stored allogeneic RBCs. The survival of recovered RBCs appears to be at least comparable to that of transfused allogeneic RBCs." |
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The following measures have been shown to reduce
intraoperative blood loss in some surgical situations, EXCEPT A. arterial hypotension (MAP = 50 mmHg) B. controlled ventilation C. hypothermia (less than 34°C) D. maintenance of a low central venous pressure E. regional anaesthesia |
C
Cold=coagulopathic |
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When anaesthetising a patient with a ventricular assist
device (VAD) for noncardiac surgery A. anticoagulation should be temporarily discontinued during surgery B. electrocautery is well tolerated by these devices C. malignant arrhythmias should be treated with defibrillation if indicated D. the most important causes of decreased pump output are hypovolaemia and increased afterload E. volatile anaesthetic agents should be avoided |
D
Stone, Soong et al The Anesthetic Considerations in Patients with Ventricular Assist Devices Presenting for Noncardiac Surgery: A Review of Eight Cases • A. false. 'With the exception of the Heartmate, maintenance of therapeutic levels of anticoagulation is imperative for extracorporeal circulation through these devices (because of the risk of thromboembolism), and both the surgeon and anesthesiologist must be prepared for increased intraoperative bleeding. Heparin infusions or warfarin maintenance should not routinely be discontinued before surgery ' • B. false. 'Extracorporeal devices (the Abiomed and the Thoratec) and the well shielded Novacor will not be affected by defibrillation or the electrocautery. Unfortunately, the Heartmate is not well shielded and may be reset to a fixed-rate mode by the electrocautery and potentially damaged by external defibrillation. When feasible, the use of bipolar electrocautery is recommended. ' • C. falsish. 'Standard Advanced Cardiac Life Support (ACLS) protocols (with the exception of chest compressions that could cause potential dislodgement of intracardiac cannulae) should be used when needed, and malignant arrhythmias should be electrically or pharmacologically terminated. ' • D. true. 'The two most important factors leading to decreased pump output are hypovolemia and increased afterload. ' E. false. 'As long as there is adequate intravascular volume, VAD function will not be depressed, regardless of what drug is used for the induction or maintenance of anesthesia' |
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In anaesthetised patients undergoing controlled ventilation,
release of a lower-limb arterial tourniquet after sixty minutes will A. cause no change in end-tidal CO2 tension B. decrease central venous pressure for more than 30 minutes before returning to baseline C. decrease oxygen consumption D. increase cerebral blood flow E. increase core body temperature transiently |
D
Peter Kam article: Anaesthesia, 2001, 56, pages 534-545 • A: False - increase EtCO2 by 0.1-2.4 kPa; peak increase at 1 minute post tourniquet release, return to baseline by 10-13 mins • B: False - decreased CVP for 15 minutes before return to baseline • C: False - increased O2 consumption by up to 55%, increased CO2 production by up to 80%. Peak effect at 2 minutes, return to baseline by 8 minutes • D: True - increased EtCO2 corresponds with increased PaCO, resulting in transient increase in middle cerebral artery blood flow by up to 50%. Peak increased blood flow at 2-4 mins, return to baseline at 8-10 mins. The resulting increased cerebral blood flow may increase sedondary brain injury in patients with raised ICP. • E: False - transient decrease in core body temperature on arterial tourniquet release (redistribution of body heat and return of hypothermic limb venous blood to the systemic circulation) |
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The duration of action of suxamethonium may be increased
by A. betamethasone B. bleomycin C. carvedilol D. neostigmine E. all of the above |
D
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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 |
E
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The differential diagnosis of asymmetric consolidation on a
chest X-ray includes each of the following EXCEPT A. pleural effusion B. pneumonia C. pulmonary haemorrhage D. pulmonary infarction E. pulmonary oedema |
E
Discussion on wiki leans towards E |
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The sural nerve
A. is a branch of the posterior tibial nerve B. supplies the skin of the anterior two thirds of the sole of the foot C. lies anterior to the lateral malleolus at the ankle D. reaches the foot in contact with the short saphenous vein E. supplies the small muscles of the foot |
D
• A – False. Branch of the tibial nerve. • B – False. Supplies posterolateral lower 1/3 of calf and lateral aspect of foot. • C – False. Crosses lateral malleolus posteriorly. • D – True. Pierces deep fascia halfway down posterior aspect of leg. • E – False. It is a cutaneous nerve. |
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The most useful finding to confirm the diagnosis of aortic
stenosis in an adult with a systolic murmur is A. increasing murmur intensity with inspiration B. decreasing murmur intensity with passive leg elevation C. increased second heart sound D. effort syncope E. a slow rate of rise of the carotid pulse |
E
ACC/AHA Guidelines for the Management of Patients With Valvular Heart Disease. JACC Vol. 32, No. 5 November 1, 1998:1486–588: • midsystolic (systolic ejection) murmurs, often crescendo decrescendo in configuration, occur when blood is ejected across the aortic or pulmonic outflow tracts. The murmurs start shortly after S1, when the ventricular pressure rises sufficiently to open the semilunar valve. As ejection increases, the murmur is augmented, and as ejection declines, it diminishes. • Left-sided murmurs usually are louder during expiration. • With prompt squatting, most murmurs become louder, (but those of HCM and MVP usually soften and may disappear). Passive leg raising usually produces the same results as prompt squatting. • A soft or absent A2 or reversed splitting of S2 may denote severe AS. • A slow-rising, diminished arterial pulse suggests severe AS in a patient with a grade 2/6 midsystolic murmur at the upper intercostal spaces |
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Recognised clinical associations with dystrophia myotonica
include A. development of diabetes mellitus B. abnormal intestinal motility C. cardiomyopathy D. ovarian dysfunction E. all of the above |
E
Dystrophia Myotonica Most common muscular defect, dominant inheritance. Persistent contractions results in progressive myopathy. Muscles Affected: Skeletal, cardiac and smooth muscle. Clinical associations: 1. Insulin resistance 2. Gonadal atrophy 3. Cardiac conduction defects 4. Pseudo-obstruction Anaesthetic Implications: 1. Avoid Sux – inc. contractions 2. Keep spont ventilation if possible 3. Consider regiona |
