2008 Mar New Mcqs

Front 1

Which of the following statements regarding anaphlactoid and anaphylactoid reactions is FALSE?
A. cross-sensitivity between latex and bananas, chestnuts and avocado has been reported
B. cross-sensitivity of cephalosporins with penicillin is about 8%
C. gelatin solutions used for resuscitation can worsen any reaction
D. reactions to neuromuscular blocking agents are more cornmon in females
E. vecuronium is more likely to cause an anaphylactoid rather than an anaphylactic reaction

Back 1

E

Anaphylaxis is more associated with aminosteroids (eg vec); Anaphylactoid is more associated with benzylisoquinoliniums (eg. atrac)

Front 2

Sepsis resulting from the administration of blood contaminated with Yersinia Enterocolitica typically results in a mortality of:
A. < 5%
B. 20%
C. 40%
D 60%
E. 80%

Back 2

D

Goodnough, Risks of blood transfusion, in Crit Care Med 2003 Vol. 31
"The onset of clinical symptoms typically occurs acutely during transfusion, with a mortality rate of 60% and a median time to death of only 25 hrs."

Front 3

An obese 40-year-old woman is having laparoscopic surgery for endometriosis. She is intubated and
ventilated with a mixture of oxygen and air. The ventilator is set to provide a tidal volume of 600 ml at 12 breath.min-l with 5 cm H2O positive end-expiratory pressure (PEEP). The peak inspiratory airway pressure is 35 cm H2O. She was stable on induction and during preparation for surgery but 10 minutes after introduction of the pneumoperitoneum and being placed in the Trendelenburg position, her arterial oxygen saturation (SaO2) falls to 80%. The SaO2 remains unchanged despite ventilation with 100% oxygen. Her blood pressure is 130i80, pulse 100 min-l and end-tida1 carbon dioxide 44 mmHg. The most likely cause of her desaturation is:
A Aspiration
B. endobronchial intubation
C. gas embolism
D. hlpoventilation
E. pneumothorax

Back 3

B

CEACCP – Laparoscopic surgery 2004
“Pneumoperitoneum and trendelenberg position cause a cephalad Shift of the diaphragm, further decreasing FRC, poss to valued less than closing capacity. This causes airway collapse, atelectasis, VQ mismatch, potential hypoxaemia and hypercarbia.

In TRENDELENBERG position – further reduction in FRC, more VQ mismatch and greater risk of atelectasis. Endobronchial intubation, due to cephalad movement of lungs and carina in relation to fixed ETT, should be prevented.

In REVERSE TRENDELENBERG – few respiratory effects, but more marked effects on CV system – dec. VR results in dec. CO and therefore BP

Front 4

A 65-year-o1d female patient with known chronic renal disease and a normal resting preoperative
electrocardiogram (ECG) has undergone total hip replacement. Three days postoperatively she complains of chest pain and breathlessness. Her pulse rate is 110 min-l and blood pressure 130/90 mmHg. The following ECG is recorded. The diagnosis is most likely to be:
A. Atrial fibrillation
B. hyperkalaemia
C. myocardialinfarction
D. pericarditis
E pulmonary embolus

Back 4

E

Front 5

All of the following tests useful in diagnosing MH except:
A. MRI spectroscopy
B. caffeine stimulated release of calcium from B Lymphocytes
C. resting CK >800
D. muscle contraction on exposure to halothane
E. myofibillary necrosis on histology

Back 5

B & E

Anesthesiology. 2006 Jun;104(6):1191-201
• A. False – useful for investigation of muscle disease
• B. ?True. “Lymphocytes express a functional RYR. Caffeine does not induce RYR-mediated Ca-release in B-lymphocytes.
• C. False – of some use. If a first-degree relative of a patient with known MHS has increased CK, they are highly likely to have MHS as well. While resting elevated CK is non-specific, in relative of known MH patient it is indicative of MH.
• D. False – is useful – main test used.
• E. True – not useful. Histologic examination by itself cannot be used to diagnose MHS specifically—the defect is functional, not structural." Though what about histology post an episode of MH?

Front 6

Antidepressants have benefit in all the following except:
A. Chronic headache
B. Chronic back pain
C. Chronic pain after acute herpes zoster
D. Trigeminal neuralgia
E. Acute herpes zoster

Back 6

B

From APMSE 2010:
• A. False – is benefit – Level 1 evidence for antidepressants in treatment and prophylaxis of chronic headaches.
• B. True – no benefit. Level 1 evidence – no good evidence that antidepressants improve pain relief in pts with chronic back pain (reversed conclusion from prev. addition)
• C. – False - is benefit - Level 3 evidence – amitryptyline given to patients with herpes zoster reduced the incidence of postherpetic neuralgia at 6 months
• D. True – antidepressants not mentioned – treated with Carbamazepine.
• E. ?False – is benefit - Level 3 evidence – amitryptyline given to patients with herpes zoster reduced the incidence of postherpetic neuralgia at 6 months

Front 7

It is MOST important to re-program a patient's implanted cardiac pacemaker prior to:
A. electroconrulsive therapy (ECT)
B. Laser therapy to a laryngeal papilloma
C. Lithotripsy of a renal calculus
D. magnetic resonance imaging of the thorax
E. percutaneous transhepatic cholangiography

Back 7

C

Pacemaker = contraindication for MRI
Lithotripsy = reprograme (at least check) after lithotripsy. The concern is that the ESWL pulse will cause electromagnetic interference leading to oversensing and inappropriate inhibition of pacemaker

Front 8

All the following are predictors of difficult intubation EXCEPT:
A. TMD <6cm
B. Samsoon classification score IV
C. Prominent C1 spinous process
D. Mouth opening <3cm
E. Prominent maxillary canines

Back 8

C

C1 does not have a spinous process

Front 9

With regard to surgical antibiotic prophylaxis, which of the following statements is LEAST correct?
A. cephalosporins can usually be safely administered to penicillin allergic patients
B. clindamycin can be indicated in penicillin allergic patients
C. they should be administered at the time of surgical incison
D. ideal timing of administration is less than 30 minutes prior to surgical incision
E. vancomycin should be given routinely in MRSA (methicillin resistant staphylococcus aureus) prevalent area

Back 9

E

Don’t just give vanc because your in MRSA prevalent area – inc. reistance

Front 10

Image of an ultrasound of neck with arrow pointing to carotid artery. Regarding what is arrow pointing to:
A. This will collapse with pressure
B. With doppler will be red if probe directed caudally
C. Is part of the brachial plexus
D. Will get smaller with Valsalva
E. Should centre image over this for CVC insertion

Back 10

B

BART - Blue away, Red towards

Front 11

The systolic blood pressure may be overestimated by the auscultatory method of blood pressure measurement if:
A. the cuff is deflated too slowly
B. the patient has severe arteriosclerosis
C. the patient's arm is very thin
D, there is severe peripheral vasoconstriction
E. too wide a cuff is used

Back 11

D

Interpretation of Haemodynamic Monitoring: http://www.iars.org/2003RCLtest/pdftext/mark2003.pdf

Front 12

The most sensitive monitor for detecting venous gas embolism during neurosurgery is a:
A. capnograph
B. praecordial Doppler transducer
C. praecordial stethoscope
D. pulmonary artery catheter
E. transoesophageal echocardiograph

Back 12

E

Front 13

The capnograph trace shown below was observed in an intubated and ventilated patient. The most likely explanation for this pattern is:
A. endobronchial intubation
B. endotracheal cuff leak
C. gas sample Line leak
D. obstructive airway disease
E. spontaneous respiratory effort

Back 13

C

Front 14

Electrical safety. A device that detects a 10mA difference in active and neutral leads and causes turning off of the circuit within 40 ms. this is a :
A. Class 1 device
B. Equipotential earthing
C. LIM
D. Residual Current Device
E. Fuse

Back 14

D

• A – false – Class 1 = earthed
• B – False – keeps all appliances earthed to the same reference point – will not allow current to flow between
• C – False
o Does NOT disconnect power
o Alarms at 5mA (loss of floating power supply) \ does not protect against microshock
o It does this by intermittently connecting one of the two active wires to ground through a very large resistance. If the other wire is connected to ground a circuit will be formed and current will flow, and this indicates how much current would flow through the circuit if either of the two active wires are connected to ground.
o do not disconnect the power when a fault is detected
o checks that the floating supply is not earth-referenced
• D – True – RCD protects against macroshock only
• E – False – only breaks circuit when it exceeds a certain current.

Front 15

What is the best way to improve resolution on a 2D ultrasound?
A. adjust frame rate
B. increase probe frequency
C. increase 2D gain
D. ?something about waveform scatter?
E. increase TGC

Back 15

B

• A – False – determined by processing power – necessary for moving objects (heart)
• B – True - Increased frequency increases resolution, decreases penetration.
• C – False – Gain = more white screen
• D - ?
• E – False – Time Gain Control = sliders on to adjust gain at varying depth

Front 16

In acute coronary syndromes with ST elevation on ECG:
A. Aspirin should be administered only after reperfusion strategies have commenced
B. patients can wait up to 24 hours from onset of ischaemic syrnptoms before implementation of a
reperfusion strategy
C. patients should have elevated cardiac enzymes before proceeding to reperfusion strategies
D. patients undergoing reperfirsion strategies should have aspirin or clopidogrel but NOT both
E. percutaneous coronary intervention is preferable to fibrinolltic therapy

Back 16

E

Front 17

Hyperparathyroidism and increased Ca+
A. Long QT
B. Polydipsia and polyuria
C. Short PR
D. Increased GFR E.

Back 17

B

• A – false - ↓QT
• B – True
• C – False - prolonged
• D – False – renal failure
• E - ?

• Hyperparathyroid = ↑Ca, PO4
• N&V, Anorexia, constipation, pancreatitis, peptic ulcers, abdo pain, polyuria / polydipsia (stone bones, psychic moans)
• Tx – Saline, lasix , bisphosphonates,
• “Electrocardiographic changes are characterized by slowed conduction, including prolonged P-R interval, widened QRS complex, shortened Q-T interval, shortened or absent S-T segments, and possibly abrupt sloping and early peaking of the proximal limb of T waves” Oxford HM

Front 18

Haemophilia A is commonly associated with;
A. A haemarthrosis in a female infant
B. A haemarthrosis in a male infant
C. Low levels of factor IX
D. normal prothrombin time (PT) and prolonged activated partial thromboplastin time (APTT)
E. prolonged prothrombin time (PT) and prolonged activated partial thromboplastin time (APTT)

Back 18

D

From Stoelting:
As a rule of thumb, clinical severity of hemophilia A is best correlated with the factor VIII activity level. Severe hemophiliacs have factor VIII activity levels less than 1% of normal (<0.01 U/mL) and are usually diagnosed during childhood because of frequent, spontaneous hemorrhages into joints, muscles, and vital organs. They require frequent treatment with factor VIII replacement and even then are at risk of developing a progressive, deforming arthropathy.
Severe hemophilia A patients have a significantly prolonged PTT, whereas with milder disease, the PTT may be only a few seconds longer than normal. Since the tissue factor VII–dependent (extrinsic) pathway of laboratory clotting is intact, the PT is normal.

Front 19

You are reviewing a 55-year-old man with carcinoid sl.ndrome prior to anaesthesia. You suspect he has carcinoid heart disease. The most likely clinical finding on auscultation would be:
A. an "opening snap" at the apex ofthe heart
B. a pericardial rub
C. a systolic mufinur loudest at the apex of the heart
D. a systolic munnur loudest at the left stemal edge
E. inspiratory crackles at the iung bases

Back 19

D

Carcinoid syndrome - associated with lesions in (R) side of heart - stenotic or regurgitant. Left side of heart relatively spared due to inactivation of humoral agents by lung (except in ASD or primary bronchial carcinoid).

Carcinoid Syndrome:
- Triad of "diarrhea + flushing + R-heart vavular disease"
- TR > PR >> other valve disease
- due to vasoactive substances (histamine, 5HT, Sub P, PGs)
- Other manifestations: bronchospasm (bradykinin), hyperglycemia (glucagon), hepatomegaly (mets), SVT

Front 20

You are anaesthetising a patient who suffers from acute intermittent porphyria (AIP) for abdominal surgery. You wish to administer an anti-emetic. The drug which is MOST likely to precipitate an acute attack of this disorder is:
A. droperidol
B. metoclopramide
C. ondansetron
D. prochlorperazine
E. tropisetron

Back 20

B

Front 21

Central anticholinergic syndrome, which is NOT true:
A. Will improve with neostigmine
B. Peripheral anticholinergic symptoms
C. Caused by Anti-Parkinson drugs
D. CNS depression
E. Associated with agitation, delirium, and ???

Back 21

A

CEACCP:
Central anticholinergic syndrome

Historically, anticholinergic syndrome was a commonly encountered sequel to anaesthesia. Nowadays, less anticholinergic medications are used. Symptoms range from cerebral irritation with delirium and agitation to CNS depression with stupor and coma. These accompany peripheral anticholinergic effects that is tachycardia, blurred vision, dry mouth and urinary retention. The symptoms are rapidly reversed by physostigmine (an acetylcholinesterase inhibitor), but may recur when its effect terminates. Anti-Parkinsonian, antidepressant and antihistamine drugs can cause central anticholinergic syndrome.

Syndrome may consist of either agitation, including seizures, restlessness, hallucinations, and disorientation, or of signs of depression, such as stupor, coma, and respiratory depression. The syndrome may be induced by anticholinergic drugs such as atropine or scopolamine but has also been observed after administration of opiates, benzodiazepines, phenothiazines, butyrophenones, ketamine, cimetidine, etomidate, propofol, nitrous oxide, and volatile inhaled anesthetics (2). After general anesthesia, the incidence of CAS has been reported to be 1%–9%

A – false – doesn’t cross BBB
“The diagnosis is confirmed by the administration of physostigmine, an acetylcholine esterase inhibitor that, in contrast to other acetylcholine esterase inhibitors like pyridostigmine, is able to cross the blood-brain barrier where it transiently increases the acetylcholine concentrations at cholinergic neurons.”
B – True
“Central anticholinergic syndrome (CAS) is a clinical entity which shows central and peripheral effects produced by over dosage or abnormal reaction to clinical dosage of anticholinergic drugs. Anxiety, delirium, disorientation, hallucinations, seizures, tachycardia, hyperpyrexia, mydriasis, vasodilatation, gastric and urinary retention can be observed during CAS. In this syndrome, it is common decreased salivary, sweating, bronchial, and nasopharyngeal secretions.”(1)
C- True
“Anti-cholinergics (eg orphenadrine) - act by antagonising the excitatory effects of cholinergic pathways. Anaesthetic cautions- risk of central anticholinergic syndrome.” http://www.frca.co.uk/article.aspx?articleid=100807
D - True
E – True

Front 22

Old man with small cell lung ca, post lobectomy, in PACU, SOB, desaturating. Shoulder abduction and hip flexion weakness, weak but sustained handgrip. 8mg cisatrac given 90 minutes earlier, reversed with 2.5mg neostigmine and 1.2mg atropine. Most likely cause:
A. Eaton-Lambert syndrome
B. Myasthenia gravis
C. Steroid myopathy
D.
E.

Back 22

A

A – True
Eaton Lambert syndrome
• Proximal muscle weakness
• Autonomic dysfunction
• Frequently associated with SCLC
B – False – Myasthenia is fatiguing
C – False – proximal myopathy, not sudden onset

Front 23

Hyponatraemia and dehydration are associated with each of the following EXCEPT:
A. hypoadrenalism
B. nephritis
C. pancreatitis
D. renal tubular acidosis
E. Syndrome of inappropriate anti-diuretic hormone (SIADH)

Back 23

E

Front 24

The use of large amounts of normal saline for patient resuscitation is associated with:
A. hyperchloraemic acidosis
B. hyperchloraemic alkalosis
C. hypernatraemic acidosis
D. hypernatraemic alkalosis
E. serum hyperosmolarity

Back 24

A

Front 25

Serotonin syndrome
A. delays clinical treatment
B. has the specific antidote promethazine
C. has signs and symptoms which are difficult to distinguish from neuroleptic malignant syndrome, but the distinction between the two syndromes is unnecessary for clinical management
D. is self-limiting
E. may be contributed to by pethidine

Back 25

E

Front 26

You are performing epidural anaesthesia on an adult patient. To minimize the chance of inserting the
epidural catheter into a blood vessel you could:
A. avoid using a combined spinal-epidural technique
B. establish loss-of-resistance with saline rather than air
C. inject saline prior to threading the catheter
D. perform the procedure in the sitting rather than the lateral position
E. use a midline rather than a paraspinous (paramedian) approach

Back 26

C

Anesth Analg 2009;108:1232–42
“Injecting fluid through the epidural needle before catheter insertion decreases risk (OR 0.49)”

Remembered version would suggest E, however with the official version:
“The risk of epidural vein cannulation was significantly higher in the sitting group (16 of 102 = 15.7%) compared with the lateral position group (4 of 107 = 3.7%)”

“Adoption of the lateral recumbent head-down position for the performance of lumbar epidural blockade, in labour at term, reduces the incidence of lumbar epidural venous puncture in these obese parturients.” Canadian Journal of Anesthesia

Front 27

You are asked to review a patient on the day after an uneventful Caesarean section under spinal anaesthesia.
She is complaining ofpain and numbness on the upper, outer aspect ofher right thigh which she first noticed
on the night ofthe delivery. On further questioning you establish that she has not been incontinent. Review
ofthe medical record reveals that the spinal anaesthesia was administered through a27 galge pencil-point
needle at the L3l4 intervertebral space and was atraumatic. On examination she is moderately obese. You
note some oedema of her hands and feet. The power and reflexes in her lower limbs are normal. She has an
area of numbness to pin prick on the outer upper right thigh as shown in the illustration below. The most
likely diagnosis is:
A. A conus medullaris lesion
B. a first lumbar (L1) nerve root lesion
C. a second lumbar (L2) nerve root lesion
D. a third lumbar (L3) nerve root lesjon
E. meralgia paraesthetica

Back 27

E

Due to focal entrapment of Lateral Femoral Cutaneous Nerve as it passes through the inguinal ligament

Front 28

Each of the following statements regarding the haemodymamic changes during pneumoperitoneum for laparoscopy is true EXCEPT:
A. in patients with severe cardiac disease changes are qualitatively similar to those in normal patients
B. right atrial pressure is NOT a reliable indicator of cardiac filling
C. they are well tolerated by morbidly obese patients
D. they are well tolerated in cardiac transplant patients with good ventricular function
E. they are well tolerated in patients with low cardiac output secondary to 1ow preload

Back 28

E

Note ANZCA version doesn’t mention anything about head down position. Therefore answer should be E for the ANZCA version = D of the remembered version

Front 29

During laparoscopic surgery, pneumoperitoneum usually results in a fall in cardiac output when intraabdominal pressure exceeds:
A. l0mmHg
B. 20mmHg
C. 30mmHg
D. 40mmHg
E. 50mmHg

Back 29

A

Front 30

In the head down position with pneumoperitoneum:
A. cardiac work is increased
B. pulmonary compliance is increased
C. ICP unchanged
D. IOP unchanged
E. pulm venous pressure unchanged

Back 30

D

"The increasing SVR, systolic and diastolic blood pressures and tachycardia, result in a large increase in myocardial workload" - CEACCP Vol 4(4) 2004. pp. 107-110

Front 31

You are anaesthetizing a patient who is undergoing a posterior fossa craniotomy in'the sitting position. The praecordial Doppler monitor sounds harshly and the end-tidal carbon dioxide falls. The mean arterial pressure falls from 90 mmHg to 60 mmHg and the central venous pressure rises from 5 mmHg to 20 mmHg. Your immediate management should include all of the following EXCEPT:
A. Asking the surgeon to flood the wound with saline
B. aspirating the celrtral venous catheter
C. compressing the neck veins
D. infusins intravenous fluid
E. instituting a Valsalva manoeuwe

Back 31

E

Miller's 7th Edition
"As noted previously, PEEP has been advocated in the past as a means of reducing the incidence of VAE or of responding to an acute VAE event to prevent further air entry. Perkins and Bedford suggest that PEEP increases the risk of PAE, however, and argue against the use of PEEP in seated neurosurgical procedures. As these authors point out, even 10 cm of PEEP would be unlikely to result in positive venous pressures in cerebral venous structures, which may be 25 cm above the heart. The ineffectiveness of PEEP and the relative superiority of jugular venous compression in increasing cerebral venous pressures have been confirmed by several investigations. An inflatable neck tourniquet available for rapid inflation in the event of VAE has been studied in animals and used in humans by Pfitzner and McLean.There are additional arguments against the acute use of increased positive airway pressure in the event of VAE. The release of a Valsalva maneuver promotes paradoxical embolism. In addition, the impairment of systemic venous return caused by the sudden application of substantial PEEP may be undesirable in the face of the cardiovascular dysfunction already caused by the VAE event."

Front 32

A toumiquet is being used on the arm of an adult patient to reduce haemorrhage during surgery on the hand. The maximum recommended time to leave the tourniquet continuously inflated is:
A. 60 minutes
B. 90 minutes
C. 120 minutes
D. 150 minutes
E. 180 minutes

Back 32

C

OHA p.451
"2hr should be regarded as maximum, although this will not be safe for all patients"

Miller's 7th Edition
"Nerve injury after extended tourniquet inflation (>120 minutes) has been attributed to the combined effects of ischemia and mechanical trauma. Peroneal nerve palsy, which is a recognized complication of TKA (incidence of 0.3% to 10%), may be caused by the combination of tourniquet ischemia and surgical traction. Horlocker and colleagues reported a combined tibial and peroneal nerve dysfunction of 7% of TKA patients associated with younger age, the presence of preoperative flexion deformities, and longer total tourniquet time. When prolonged tourniquet inflations are required, deflating the tourniquet for 30 minutes of reperfusion may reduce neural ischemia."

Front 33

A 20-year-old, 80 kg, previously well male is awaiting surgery for a fractured femur. He was admitted 12 hours earlier following a motor-bike accident. His admission chest X-ray was normal. Since admission, analgesia has been provided with a femoral nerve block and 40 mg of intravenous morphine. He has been placed in leg traction. He is now drowsy and confused. His blood pressure is 120/70 mmHg, pulse 120 min-I and respiratory rate 25 min-1. On auscultation of the chest, inspiratory crepitations can be heard. Despite supplemental oxygen of 6L min- 1 via Hudson mask his arterial oxygen saturation (SaO2) is 85%. The most likely cause of the 1ow SaO2 is:
A. Aspiration
B. fat embolism syndrome
C. hypoventilation
D. pneumothorax
E. pulmonary contusions

Back 33

B

GURD’s CRITERIA for Diagnosis of Fat Embolism
Major criteria
 Axillary or subconjunctival petechiae
 Hypoxaemia PaO2 <60 mm Hg; FIO2 = 0.4)
 Central nervous system depression disproportionate to hypoxaemia
 Pulmonary oedema
Minor criteria
 Tachycardia <110 bpm
 Pyrexia <38.5°C
 Emboli present in the retina on fundoscopy
 Fat present in urine
 A sudden inexplicable drop in haematocrit or platelet values
 Increasing ESR
 Fat globules present in the sputum

Front 34

You are performing an awake fibreoptic intubation, through the nose, on an adult patient. In order, the
fibrescope will encounter structures with sensory innervation from the following nerves:
A. facial, trigeminal, glossopharyngeal
B. facial, trigeminal, vagus
C. glossopharyngeal,trigeminal,vagus
D. trigeminal, glossopharymgeal, vagus
E. trigeminal, vagus, glossopharyngeal

Back 34

C

NYSORA
http://www.nysora.com/peripheral_nerve_blocks/head_and_neck_block/3049-regional-topical-anesthesia-endotracheal-intubation.html
• Three major neural pathways supply sensation to airway structures (see Figure 1).
• Terminal branches of the ophthalmic and maxillary divisions of the trigeminal nerve supply the nasal cavity and turbinates.
• The oropharynx and posterior third of the tongue are supplied by the glossopharyngeal nerve.
• Branches of the vagus nerve innervate the epiglottis and more distal airway structures.

Front 35

Regarding thoracic epidural analgesia for acute post-operative pain:
A. it has NO role in improving preservation of total body protein after upper abdominal surgery
B. opioids alone via the thoracic epidural provide significantly better analgesia than systemic opioids alone
C. there is NO effect on the incidence of postoperative myocardial infarction
D. the addition of adrenalin (epinephrine) to a local anaesthetic mixture has NO measurable benefit
E. rising local anaesthetics improves bowel recovery after abdominal surgery

Back 35

E

From ANZCA pain management book:
• Thoracic epidural analgesia improves bowel recovery after abdominal surgery (including colorectal surgery). (Level 1) - making A definitely correct
• Thoracic epidural analgesia in combination with NSAIDs and IV nutritional support after major abdominal surgery has been shown to prevent protein loss compared with epidural analgesia alone, or PCA with or without nutritional support (Barratt et al, 2002 Level II). - making B tru-ish depends on exact wording.
• Thoracic epidural analgesia extended for more than 24 hours reduces the incidence of postoperative myocardial infarction (U) (Level I). - making C definitely incorrect
• Opioids alone via the epidural route seem to be of limited benefit. In particular, when administered via a thoracic approach, opioids failed to demonstrate any advantage over parenteral opioids except for a slight reduction in the rate of atelectasis (Ballantyne et al, 1998 (Level I). - making D false too

Front 36

An 50-year-old male with peripheral vascular disease undergoes unilateral chemical lumbar sympathectomy. The most likely complication he will experience is:
A. Genitor femoral neuralgia
B. haematuria
C. lumbar radiculopathy
D. postural hypotension
E. psoas haematoma

Back 36

A

Complications
• Genitofemoral Neuralgia occurs in 5% of all blocks. This causes pain in the L1 groin area and is thought to be due to bruising of the L1 nerve root by the needle passing by it. More than 90% of cases recover spontaneously after 6 weeks. Treatment with amitriptyline and gabapentin / pregabalin can help greatly.
• Bleeding due to aorta and inferior vena cava injury by the needle.
• Intravascular injection Upper abdominal organ puncture with abscess / cyst formation.
• Paraplegia from injecting phenol into the arteries that supply the spinal cord (should be prevented by checking the needle position with radio-opaque dye).

Front 37

A 75-year-old male presents for a cataract extraction and insertion of intra-ocular lens' He has a history of stable angina, non-insulin dependent diabetes mellitus and hypertension. The surgeon says the operation cannot be done under topical anaesthesia alone. You perform an uneventful block - on the wrong eye. Following explanation and apology, the most appropriate course of action is to:
A. convince the surgeon to perform the surgery on the correct side, under topical anaesthesia' on the same list
B. perform an eye block on the correct side and proceed with surgery on the same list
C. postpone surgery to another day which is convenient for the patient
D. provide general anaesthesia for correct side cataract surgery to be performed on the same list
E write an incident report and postpone surgery until the outcome of the subsequent enquiry is known

Back 37

C

No specific reference to base this on

Front 38

Globe perforation with eye blocks is most likely with:
A. Axial length <25mm
B. Medial canthus peribulbar injection
C. Inferotemperal peripulbar injection
D. Age < 40 years
E. Sub-Tenon's block

Back 38

C

A - false. Axial length >26mm is associated with globe perforation.
B &C - Not sure about these, however this article (http://www.ijo.in/article.asp?issn=0301-4738;year=2006;volume=54;issue=2;spage=77;epage=84;aulast=Kumar) suggests that for patients with posterior staphyloma “A single medial peribulbar injection technique is advocated” to reduce chance of perforation. Another reference claims: "The continued risk of ocular perforation (up to 0.1%) by the inferotemporal route, and of general complications, have resulted in a search for safer alternatives”
D - Can't find any reference for Age<40. An unusual age group for eye blocks
E - false. Sub-Tenons is considered to have less risk for globe perforation

Front 39

Retrobulbar block is least likely to block which muscle?
A. Lateral rectus
B. Superior oblique
C. Levator palpebrae superioris
D. Inferior rectus
E. Medial rectus

Back 39

B

Ripart,J. Regional anesthesia for eye surgery. Regional anesthesia and pain medicine, 2005; vol 30(1):pp72-82
"Because of its extraconal motor control, the oblique superior muscle may frequently remain functional and thus elude total akinesia."

Front 40

Each of the following statements regarding cardiac tamponade as a complication of central venous lines is true, EXCEPT:
A. catheters with multiple lumens carry greater risk
B. for a left sided catheter, placement of the tip at the mid-point of the brachiocephalic vein is safe
C. it usually occurs within the first week following insertion
D. placement of the catheter tip above the junction of the right atrium and superior vena cava will avoid this complication
E. visceral chest pain with drug infusion is an early symptom

Back 40

D

Safe placement of central venous catheters: where should the tip of the catheter lie? BJA 2000, 85(2): 188
A: TRUE..."Stiffer catheters are more likely to perforate. Stiffness is a function of the composition of the catheter (Silastic probably being safest) and the number of the lumen (a function of the greater diameter and presence of ‘septa’ within the catheter)."
B: TRUE..."Zone C (mid‐point, left innominate vein). This is a suitable site for the tip when the catheter is introduced from the left internal jugular or subclavian vein, and reduces the risk of SVC perforation." (In reference to a diagram of the heart and great vessels showing various "zones" for the CVC tip)
C: TRUE..."Most cases occur in the first week after insertion"
D: FALSE (and answer to choose)..."the pericardium may ascend alongside the medial wall of the SVC by up to 5 cm (mean 3 cm). Thus, placement just proximal to the atrium does not obviate the risk of tamponade".
E: TRUE..."This results in two warning signs: visceral‐type chest pain on infusion of drugs or parenteral nutrition solutions and a curved appearance of the distal catheter seen on chest x‐ray"

Front 41

When using osmotic agents to reduce intracranial pressure (ICP), the patient's serum osmolality should not be allowed to exceed:
A. 280 mosmol.l-l
B. 300 mosmol.l-l
C. 320 mosmol.l-l
D. 340 mosmol.l-1
E. 360 mosmol.l-1

Back 41

C

Managing elevated intracranial pressure. Nicole Forster and Kristin Engelhard. Curr Opin Anaesthesiol 17:371–376. 2005
"As mannitol is entirely excreted in the urine there is a risk of acute tubular necrosis, particularly if serum osmolarity exceeds 320 mOsmol/l [41]. Therefore, plasma osmolarity has to be monitored during therapy with hyperosmotic agents"

Front 42

A patient is ventilated and invasively monitored in intensive care following a traumatic brain injury. Systemic arterial blood pressure is 140/80 mmHg with a mean pressure of 100 mmHg. Central venous pressure is 8 mmHg and intracranial pressure is l5 mmHg. The cerebral perfusion pressure (CPP) for this patient is:
A. 72mmHg
B. 85 mmHg
C. 92 mmHg
D. 125 mmHg
E. 132 mmHg

Back 42

B

CPP = MAP – (ICP or CVP whichever is higher) = 100-15 = 85

Front 43

You are performing a post-anaesthesia visit on the ward. A member of the nursing staff asks you to urgently assist with the management of a patient in the next room. She has found the patient cyanosed and unresponsive. After you have opened the airway and confirmed that there are no signs of life, the most appropriate management is to:
A. give a single direct current (DC) shock from a defibrillator
B. give three stacked direct current (DC) shocks from a def,rbrillator
C. intubate the trachea
D. perform a precordial thump
E. commence cardio-pulmonary resuscitation (CPR)

Back 43

E

Front 44

Induced hypothermia of proven benefit in:
A. asystolic arrest
B. CVA
C. SAH
D. traumatic brain injury
E. perinatal ischemic encephalopathy

Back 44

E

Clinical applications of induced hypothermia CEACCP 6 (1): 23. (2006):
A. False. On the basis of the published evidence to date, the Advanced Life Support (ALS) Task Force of the International Liaison Committee on Resuscitation (ILCOR) made the following recommendations in October 2002: Unconscious adult patients with spontaneous circulation after out-of-hospital cardiac arrest should be cooled to 32°C to 34°C for 12 to 24 hours when the initial rhythm was ventricular fibrillation (VF). Nolan et al. Circ 108 (1): 118. (2003)
B. False. “in their study of 396 patients, Kammersgaard and colleagues were able to show that the admission body temperature seems to be a major determinant for long-term mortality after stroke.10 They concluded that ‘hypothermic therapy in the early stage, in which body temperature is kept low for a longer period after stroke onset, could be a long-lasting neuroprotective measure’. Since then, there have been numerous animal models and some preliminary studies but no conclusive results.”
C. False. “A recent multicentre trial (IHAST2) showed no benefit of cooling patients to 33 C intraoperatively for clipping of intracranial aneurysms after sub-arachnoid haemorrhage.” IHAST investigators. Mild intraoperative hypothermia during surgery for intracranial aneurysm. N Engl J Med 2005; 352: 135–45
D. False. “mortality and morbidity after severe head injury remains high. The use of hypothermia for head trauma remains controversial despite its continued use in many centres. A large multicentre study in 2001 showed no benefit from hypothermia in traumatic brain injury. There were, however, more complications in the hypothermic group” Clifton et al. Lack of effect of induction of hypothermia after acute brain injury. N Engl J Med 2001; 344: 556–6
E. True. “The concept of brain protection by hypothermia has been extended to the treatment of the newborn. In a randomized, multi- centre, controlled trial of delayed cerebral hypothermia for neonatal encephalopathy, 234 infants were randomized to hypothermia or normothermia.8 The infants had clinically defined moderate to severe neonatal encephalopathy plus abnormal amplitude integrated electroencephalography (aEEG). The results suggested a protective effect of the hypothermia; although there was no effect on those with the most abnormal aEEG. In those with an intermediate aEEG, a significant reduction in adverse outcome was observed with no increase in complications.” Gluckman et al. Selective head cooling with mild systemic hypothermia after neonatal encephalopathy: multicentre randomised trial. Lancet 2005; 365: 663–70

Front 45

A 12-year-old boy presents at 11pm having fallen and dislocated his hip at 4 pm. One hour after the injury he ate a meal. He will require closed reduction of the dislocation. The BEST anaesthesia option is to:
A. defer the case until the next morning and keep him fasted
B. perform a femoral nerve block
C. perform an inhalational induction and then maintain spontaneous ventilation using a face mask
D. perform a rapid sequence induction with cricoid pressure and intubate the trachea
E. provide intravenous sedation

Back 45

D

Front 46

A 4-year-old girl with recurrent otitis media is scheduled for insertion of grommets. Prior to the commencement of the operating list you assess her and you notice that she has a clear runny nose. Her mother says that she has had a dry cough for a few days but has been otherwise well. She is afebrile and her chest is clear on auscultation. You should:
A. arrange a full blood count and chest X-ray
B. post pone the case for 1 week
C. post pone the case for 2 weeks
D. proceed with the case using an anaesthesia facemask
E. proceed with the case using endotracheal intubation

Back 46

D

Rate of respiratory complications: ETT > LMA > Facemask

Front 47

You are about to anaesthetise a 20 kg infant. For this patient, advantages of a T-piece breathing system include each of the following EXCEPT:
A. ability to assess lung compliance
B. abilitv to assess tidal volume
C. ability to use low gas flows
D. ability to vary CPAP (continuous positive airway pressure)
E. low resistance

Back 47

C

Anaesthesia UK
Advantages of T-piece systems
Compact
Inexpensive
No valves
Minimal dead space
Minimal resistance to breathing
Economical for controlled ventilation

Disadvantages
The bag may get twisted and impede breathing
High gas flow requirement

Uses
Children under 20 kg weight

Front 48

Regarding the normal term infant:
A. Foetal haemoglobin (HbF) comprises approximately one-third the total haemoglobin at birth and falls to negligible levels by 3 months of age
B. foetal haemoglobin (HbF) comprises approximately 70o/o of the total haemoglobin at birth and falls to negligible levels by 6 months of age
C. foetal haemoglobin (HbF) comprises approximately 70oh of the total haemoglobin at birth and falls to negligible levels by 6 months of age
D. normal haemoglobin at birth should be greater than 200 g.1-1, unless there has been delay in umbilical cord clamping
E. total blood volume is approximately 70 ml.kg-l body weight

Back 48

B

• HbF important in the last 7 months of pregnancy (before this, relies on embryonic haemoglobin Gower1, Gower2, Portland, requiring zeta and epsilom chains, which appear to be syntehsised almost entirely in the yolk sac!!)
• HbF at 50-95% at birth (80% according to Brandis)
• HbF at ~0% at 6 months (5% according to Brandis)
o (Wikipedia said minimal at 12 weeks i.e. 3 months)
• HbF <1% in adults Brandis.

Front 49

Clonidine
A. inhibits postslmaptic alpha-2-receptors
B. inhibits presynaptic alpha-2-receptors peripherally
C. is an alpha-l-adrenergic agonist
D. is an alpha-2-adrenergic antagonist
E. stimulates presynaptic alpha-2-receptors centrally

Back 49

E

Front 50

Levosemendin:
A. Increases contractility and myocardial oxygen consumption
B. Increases SVR
C. Binds to troponin C and induces a conformational change
D. Increases contractility by increasing calcium influx
E. Causes coronary vasodilation but NOT peripheral vasodilation

Back 50

C

Anesthesiology 2006; 104:556 – 69. Levosimendan, a New Inotropic and Vasodilator Agent
A. False.
B. False. Systemic vasodilatation.
C. True. “Levosimendan enhances myocardial contractility by binding to the N-terminal lobe of cardiac TnC with a high affinity and stabilizing the Ca2

Front 51

In Duke's activity status index, one metabolic equivalent (MET) in a 40-year-old would represent an oxygen consumption of:
A. 1-2ml.kg-1.min-1
B. 2-3ml.kg-1.min-1
C. 3-4ml-.kg-1.min-1
D. 4-5ml.kg-1.min-1
E. 5-6ml.kg-1.min-1

Back 51

C

1 MET = 3.5 ml O2/Kg/min

Front 52

Number needed to treat (NNT) is the number of patients who need to be treated to prevent one additional bad outcome. The NNT (of a treatment) is the reciprocal of the:
A. absolute odds of the bad outcome
B. absolute risk of the bad outcome
C. absolute risk reduction in the bad outcome (due to the treatment)
D. odds ratio of the bad outcome (due to the treatment)
E, relative risk of the bad outcome (due to the treatment)

Back 52

C

NNT = 1/Absolute Risk Reduction

Front 53

An elderly patient with chronic lung disease on home oxygen therapy is to have a submandibular lymph node biopsy under local anaesthesia. An appropriate measure to reduce the risk of fire occurring during this procedure is:
A. Separating the surgical site from the patient oxygen supplementation with an adhesive tape
B. titrating the supplemental oxygen so the patient's SaO2 is greater than 97% but less than l00%
C. using aqueous chlorhexidine instead of aqueous iodine as the surgical skin preparation
D. using bipolar diathermy instead of monopolar for the procedure
E. using nitrous oxide in oxygen to provide sedation and reduce oxygen concentration

Back 53

D

Front 54

Fit and healthy young female for lap. gyne operation, which of the following doesn't require continuous monitoring
A. ECG
B. Saturation probe
C. Disconnect alarm
D. Oxygen analyzer
E. Capnography

Back 54

A

PS18 ANZCA document:
­ O2 analyser - Continuous
­ SpO2 for “every” patient
­ Disconnect / vent failure alarm – continuous
­ ECG – available
­ Temp – available
­ CO2 monitor “every” patient
­ Nerve Stim “every” relaxed patient
­ Volatile monitor “every”
­ NIBP cycling – available
­ Brain monitor – available when needed

Front 55

Application of cricoid pressure with a force of 40 newtons will resist reflux with an intra-oesophageal pressure of
A. 30 mmHg
B. 40 mmHg
C. 50 mmHg
D. 60 mmHg
E. 70 mmHg

Back 55

E

Cricoid pressure of 40N will be effective against a lower oesophageal pressure of at least 100 cm H2O (Miller IV p1456)

100 cmH20 roughly equals 73 mmHg

Front 56

T4 paraplegic. Develops hypertension during bladder operation under GA. What is true about autonomic hypereflexia:
A. T4 injury will not casue RSD
B. Spinal anaesthesia could have prevented this situation
C. RSD will stop once surgical stimulation stops
D. treat with beta blockers
E. treat with opioids

Back 56

B

Front 57

45 y.o for elective laproscoptic choecystectomy. No recent symptoms from his cholelithiasis. Drinks 40g of alcohol per week and smokes 40/day. URTI 1/52 ago. Finishing course of augmentin. No respiratory symptoms now. LFTS done – ALP 300, GGT 300, ALT normal, AST normal, albumin normal. What is next step?
A. Proceed with case with perioperative thiamine
B. Defer case until liver USS done
C. Cancel case as patient has early cirrhosis
D. Perform hepatitis screen pre-operation
E. likely secondary to drugs, so just continue

Back 57

B

Front 58

You are asked to see a 60-year-old male 2 days following a cervical laminectomy because he has new neurological symptoms in his right arm. The surgical team think these may be due to poor patient positioning. The sign that would most help differentiate a C8-T1 nerve root injury from an ulnar nerve injury is
A. loss of sensation in the index finger
B. loss of sensation in the little finger
C. weakness of the abductor digiti minimi muscle
D. weakness of the abductor pollicis brevis muscle
E. weakness of the first dorsal interosseous muscle

Back 58

D

A - False (supplied by ulnar (C7, C8, T1)).
B - False (C6/C7 dermatome à not useful).
C - False (not useful - all interosseous muscles innervated by ulnar).
D - True (this muscle is innervated by the MEDIAN Nerve (C5,C6,C7,C8,T1) - if ulnar nerve injury was the cause this muscle would be preserved, if C8/T1 root was injured this muscle will be affected).
E=False (innervated by ulnar).

Mnemonic:
A good way to remember what muscles are in the thenar eminence is "OAF"; oafs have big thenar eminences. 'O' = opponens, 'A' = abductor, 'F' = flexor. There is only one opponens. The other two muscles each have a long partner and thus are called "brevis."

Meat-LOAF: the "M" in the word "Meat" helps you remember that the LOAF muscles of the hand are innervated by the Median Nerve

ABOF (pronounced "above") the Law muscles. The law states muscles of the hand are supplied by ulnar nerve. However, ABOF the Law muscles are supplied by MEDIAN nerve. 'AB' = abductor, 'O' = Opponens, 'F' = Flexor, Law 'L' = Lateral Lumbricals

Front 59

Each of the following findings is consistent with brain death EXCEPT
A. absence of diabetes insipidus i.e. continued vasopressin secretion
B. Babinski's reflex
C. focal EEG (electroencephalogram) activity
D. limb movement in response to touch
E. nystagmus on injection of cold water into the ear canal

Back 59

E

Front 60

The commonest initial presenting feature in anaphylaxis is
A. coughing
B. desaturation
C. hypotension
D. rash
E. wheeze

Back 60

C

Anaphylaxis During the Perioperative Period. Anaesthesia & Analgesia, 2003 vol. 97 no. 5 1381-1395:
• “Because patients are under drapes and mostly unconscious or sedated, the early cutaneous signs of anaphylaxis are often unrecognized, leaving bronchospasm and cardiovascular collapse as the first recognized signs of anaphylaxis. A survey of anaphylaxis during anesthesia demonstrated that cardiovascular symptoms (73.6%), cutaneous symptoms (69.6%), and bronchospasm (44.2%) were the most common clinical features”

Front 61

Investigation of a suspected anaphylactic reaction requires measurement oftryptase levels. Correct
statements regarding tryptase include each of the following EXCEPT:
A. 99% of body tryptase is in mast cells
B. a concentration of greater than 20 ng.ml-l suggests an anaphylactic reaction
C. blood samples should be repeated 24 to 48 hours after the reaction
D. maximum blood concentrations occur within I hour of the reaction
E. tryptase concentrations rise afterboth anaphylactic and anaphylactoid reactions

Back 61

C