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62 Cards in this Set

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TMP-Jul10-016 A patient having a TURP under spinal becomes confused part way through the case. An ABG shows: Na+ 117 / normal gas exchange. What is the likely treatment ?

A. 10 ml 20% Saline as fast push IV
B. 3% NS 100 ml/h
C. Normal saline 200 ml/h
D. Frusemide 40 mg IV
E. Fluid restrict 500 ml/day
ANSWER B

Patient is symptomatic
-3% Saline at 1-2ml/kg/hr (stop as soon as symptoms resolve)


Correction should be no more than 2 mmol/L per hour initially for 3 to 4 hours, then about 1 mmol/L per hour afterwards. In 24 hours, correction should be no more than 12 mmol/L.
-use frusemide
-fluid restriction
41. NEW. 75 year old male with normal renal function for an endoluminal aortic repair. What is the best protection to prevent the development of renal dysfunction?

A: NaCl
B: NAC
C: mannitol
D: dopamine
E: dialysis
ANSWER A

Methods to reduce AKI after contrast (?is this adaptable to EVAR)
-Witholding nephrotoxic drugs: NSAIDs, aminoglycosides, metformin etc

Volume expansion
-well established in AKi
-evidence indicated normal saline or CSL is more effective than half normal saline
-consider bicarbonate solutions
-maintain UO>2ml/kg

Dialysis or hemofiltration
-no evidence for prophylactic dialysis with normal renal function
-evidence in CRI
-may be confounded by hemofiltration ensures adequate intravascular volume

Pharmacological
-no approved agents for prevention of AKI
-Ascorbic acid 3g nocte before and 2g bd
-multicentre RCT, placebo controlled showed reduced incidence
-NAC not consistently shown to be effect, meta analysis showed no effect

Fenoldopam, dopamine, calcium-channel blockers, atrial natriuretic peptide, and L-arginine have not been shown to be effective in the prevention of contrast-induced AKI. Furosemide, mannitol, and an endothelin receptor antagonist are potentially detrimental
AT08c ANZCA version [2001-Apr] Q50, [2001-Aug] Q31, [2003-Apr] Q33, [2003-Aug] Q54, [2005-Apr] Q38, [2005-Sep] Q49, [Mar06][Mar10] [Aug10] (Similar question: [Apr97] [Jul98]) lots of repeats... a marker???

The most appropriate method for improving oxygenation during one lung anaesthesia,
after institution of an FiO2 of 1.0, is application of

A. 5 cm H2O CPAP to the non-dependent lung
B. 10 cm H2O CPAP to the non-dependent lung
C. 5 cm H2O PEEP to the dependent lung
D. 5 cm H2O CPAP to the non-dependent and 5cm H2O PEEP to the dependent lung
E. intermittent re-inflation to the non-dependent lung
CEACCP and a recent previous examiner advocate A

Miller says C.

Group has decided to go with A based mostly on what they think examiners want to hear.
30. NEW. Flow with the O2 flush button pressed and volatile agent turned on will give you:

A: 20-30l/min O2
B: 30-70l/min O2
C: volatile agent + 30l/m O2
D: volatile agent + 40l/m O2
E: volatile agent + 50l/min O2
ANSWER B
Flush does not pass through back-bar of machine.
39. NEW. Fontan patient having an open appendicectomy. What do you want?

A: long I time and PEEP
B: long I time
C: short I time
D: raised ETCO2
E: spontaneous ventilation
ANSWER E

CEACCP 2008
Fontan procedure is to divert all systemic venous blood into the pulmonary arteries, without the interposition of a ventricle. In patient with a single ventricle the pulmonary and systemic circuit runs in parallel. So change the system into a single pump instead of two pumps in series.
Criteria:
1.Sinus rhythm
2.Adequate size pulmonary arteries
3.Good ventricular function
Anaesthetic Goal
1.Maintain ventricular function
2.Minimise V/Q mismatch
3.Optimise pulmonary blood flow
a.Avoid decrease intravascular volume. i.e. Avoid hypovolaemia.
b.Minimise PVR
i.Avoid acidosis
ii.Avoid hypoxia
iii.Avoid hypercarbia
iv.Minimal increase in mean intrathoracic pressure
v.Avoid vasoactive drugs
vi.Adequate analgesia and anaesthesia

For relatively short procedures, Fontan patients are probably better off breathing spontaneously, as long as severe hypercarbia is avoided.
For major surgery, or when prolonged anaesthesia is required, control of ventilation and active prevention of atelectasis is usually advisable. Potential disadvantages of mechanical ventilation in Fontan patients relate to the inevitable increase in mean intrathoracic pressure. This causes decreased venous return, decreased pulmonary blood flow, and hence, decreased cardiac output. Low respiratory rates, short inspiratory times, low PEEP, and tidal volumes of 5 – 6 ml kg usually allow adequate pulmonary blood flow, normocarbia, and a low PVR. Hyperventilation tends to impair pulmonary blood flow, despite the induced respiratory alkalosis, because of the increased mean intrathoracic pressure.
43. NEW. What is the most common way to measure end tidal gas concentrations on our anaesthetic machines?

A: mass spectometry
B: Raman scattering
C: ultrasonic
D: infrared
E: piezoelectric
Ans D
CEACCP respiratory gas analysis
Draeger use infrared cheapest

Raman scattering is more expansive so may be in the future might be the standard but not yet.
11. Hypertension- severe- in pregnancy. What should NOT be used?

A: Hydrallazine
B: Nifedipine
C: Labetalol
D: Metoprolol
E: SNP
ANSWER E

Though SNP can and has been used. Stem might be "least desireable drug" or something else with more leeway.
18. NEW. Ageing (adult) causes:

A: Decreased FRC
B: Decreased Cardiac output
C: Diastolic dysfunction
D: Increased creatinine
ANSWER C
MZ82 Ehlers-Danlos syndrome. Most important to specifically do all EXCEPT:

A: Avoid hyperextension of the neck
B: Damage to the teeth
C: Avoid joint hypermobility
D: Gastro oesophageal reflex
E: Strict temperature regulation
ANSWER E

ISSUES
1. GORD and gastritis
2. Early satiety and delayed gastric emptying
3. High, narrow palate and dental crowding
4. Peridontal disease (friability, gingivitis, gum recession)
5. Joint laxity. Subluxations and dislocations are common and represent the major manifestation of the condition. All sites can be involved, including the extremities, vertebral column, costo-vertebral and costo-sternal joints, clavicular articulations, and temporomandibular joints.

Stoelting Anesthesia and Co Existing Disease 5th Edition
ED is associated with skin fragility, easy bruisability and OA. Common presentations are arterial dissection or intestinal rupture.

Anaesthetic consideration:
CVS: Mitral regurgitation, cardiac conduction defect/abnormality.
Resp: Tracheal dilatation, increased incidence of pneumothorax.
Low airway pressures
Careful laryngoscopy to avoid trauma
Haematological: easy bruising, increase risk of bleeding.
Avoid IM injection, instrumentation of nose or oesophagus.
MSK: hyperelasticity, joint hypermobility.
Regional anaesthesia: resistance to LA and increase risk of bleeding.
TMP-Jul10-036 Which is NOT a disadvantage of drawover vaporiser versus plenum vaporiser:

A. Temperature compensation
B. Cannot use sevoflurane
C. Small volume reservoir
D. Flow compensation
E. ?
ANSWER B
14. NEW. Post operative left pneumonectomy. What to do with underwater seal drain?

A: Nurse patient in R lateral decubitus position
B: Expect to see bubbles
C: Suction every hour for 5 minutes
D: Unclamp drain once an hour for 5 minutes, leave clamp on for the rest of the time
E: Leave on free drainage
ANSWER D
TMP-Jul10-024 A 78 year old man with past difficult intubation for arm surgery. Supraclavicular block with 25 mls 0.5% bupivacaine. Shortly after begins convulsing. INITIAL management?

A. Midazolam 5mg
B. Intralipid 20% 1.5 ml/kg
C. Thiopentone 150mg
D. Suxamethonium 50mg
E. Propofol 50mg
ANSWER A
TMP-Jul10-004 Exponential decline / definition of time constant (with various options)

A. time for exponential process to reach log(e) of its initial value
B. Time until exponential process reaches zero
C. Time to reach 37% of initial value
D. Time to reach half if its initial value
E. 69% of half life
ANSWER C
12. NEW. Post CEA on ward, patient seizes. BP has been hard to control. What to do to prevent further seizures?

A: Add another antihypertensive
B: Start antiplatelet drugs
C: Start anticonvulsants
D: Do angio and stent
E: Nimodipine
ANSWER A
35. New. What percentage of patients with SAH are troponin positive?

A: <5%
B: 15-30%
C: 40-60%
D: 70-90%
E: 100%
ANSWER B
Contin Educ Anaesth Crit Care Pain (2008) 8 (2): 62-66. states 20%"
42 NEW. Very sick patient on CVVHF (continuous veno-veno haemofiltration). On noradrenalin, changed to adrenaline with no improvement in haemodynamic variables. What is your next step?

A: change to another inotrope
B: check their response to a synacthen test
C: give hydrocortisone
ANSWER C
37. New (?). Eisenmengers syndrome:

A: decrease Hb to <180 with venesection
B: Give high FiO2
C: Pulmonary vasodilators will treat the pulmonary hypertension
D: terminal RV failure usually occurs in the 3rd-4th decade
ANSWER D
36. NEW. What is the major cause of death in a patient with perforation of the pharynx, oesophagus or trachea?

A: failure to intubate
B: failure to ventilation
C: sepsis
ANSWER C

Core topics in airway management 2005 chap 23 airway mortality associated with anaesthesia and medico legal aspect pp173-176
Perforation of pharynx/oesophagus or trachea
The cause of death is usually sepsis following the development of mediastinitis or cervical abscess. The mortality rate from mediastinitis is about 20%. Acute airway obstruction or respiratory failure can result from surgical oedema or pneumothorax. Only half of the perforations are recognized (pneumothorax or subcutaneous air) at the time. Perforation can occur during easy intubation, but is strongly associated with difficult intubation.

Emedicine: http://emedicine.medscape.com/article/425410-overview#showall
The esophagus lacks a serosal layer and is, therefore, more vulnerable to rupture or perforation. Once a perforation (ie, full-thickness tear in the wall) occurs, retained gastric contents, saliva, bile, and other substances may enter the mediastinum, resulting in mediastinitis.
Esophageal perforation remains a highly morbid condition. Mortality rates are reported from 25-89% and are based predominantly on time of presentation and etiology of perforation.
If treatment is instituted within 24 hours of symptoms, mortality rates are 25%; rates rose to above 65% after 24 hours and 75-89% after 48 hours.
32. NEW. 75 year old with non-valvular AF usually on warfarin has their warfarin stopped for one week. What is their daily risk of stroke?

A: 1%
B: 0.1%
C: 0.01%
D: 4%
E: 10%
ANSWER C
PZ115 ANZCA version [2005-Sep] Q123

Correct statements regarding fondaparinux include each of the following EXCEPT

A. it has a structure unrelated to heparin
B. it is administered once daily
C. it is a synthetic, selective Factor Xa inhibitor
D. it is recommended for DVT prophylaxis in major orthopaedic surgery
E. the dosage does NOT need to be adjusted for age and sex
ANSWER A

As per Yentis pg 214

* A - derived from the factor Xa-binding moeity of unfractionated heparain (FALSE, hence ANSWER)
* B - single daily dose (TRUE)
* C - "It is a synthetic and specific inhibitor of activated Factor X (Xa)" [1] (TRUE)
* D - only licensed for DVT prophylaxis in orthopaedic surgery (TRUE)
* E - implies standard dose for all (TRUE)
25. NEW. The anterior branch of the femoral nerve supplies everything but:

A: pectinius
B: rectus femoris
C: Medial thigh
D: anterior thigh
E: sartorius
ANSWER B

Femoral nerve
Anterior division
Muscular branches to:
1.Pectineus
2.sartorius.
Cutaneous branches:
1.intermediate cutaneous nerve of thigh
2.medial cutaneous nerve of thigh.
Posterior division
Muscular branches to
1.quadriceps femoris.
Cutaneous branch
1.Saphenous nerve.
Articular branches to:
1.Hip
2.knee.
109.Reverse splitting of the second heart sound occurs with:
A. LBBB
B. Pulmonary hypertension
C. Acute pulmonary embolus
D. ASD
E. Severe MR
ANSWER A
40. NEW. What makes tramadol less effective?

A: ondansetron
B: prochlorperazine
C: metoclopramide
ANSWER A

http://www.anesthesia-analgesia.org/content/94/6/1553.full.p

ondansetron reduced the overall analgesic effect of tramadol, probably blocking spinal 5-HT3 receptors.
TMP-Jul10-062 In pregnancy the dural sac ends at:

A. T12
B. L2
C. L4
D. S2
E. S4
ANSWER D
22. NEW. Anaesthetising an obese patient. Acelerometer on TOF 0.9. Could dose suxamethonium on ideal body weight or total body weight. With respect to 1mg/kg IBW vs. TBW you will see:

A: shorter onset and faster twitch recovery
B: shorter onset and similar twitch recovery
C: shorter onset and slower twitch recovery
D: similar speed of onset with similar speed of twitch recovery
E: similar onset and longer recovery
ANSWER E

A & A February 2006 vol. 102 no. 2 438-442

The appropriate dose of succinylcholine (SCH) in morbidly obese patients is unknown. We studied 45 morbidly obese (body mass index >40 kg/m2) adults scheduled for gastric bypass surgery. The response to ulnar nerve stimulation of the adductor pollicis muscle at the wrist was recorded using the TOF-Watch SX® acceleromyograph. In a randomized double-blind fashion, patients were assigned to one of three study groups. In Group I, patients received SCH 1 mg/kg ideal body weight, in Group II 1 mg/kg lean body weight, and in Group III 1 mg/kg total body weight. After SCH administration, endotracheal intubating conditions were scored. The recovery from neuromuscular block was recorded for 20 min. There was no difference in the onset time of maximum neuromuscular blockade among groups, but maximum block was significantly less in Group I. The recovery intervals were significantly shorter in Groups I and II. In one third of the patients in Group I, intubating conditions were rated poor, whereas no patient in Group III had poor intubating conditions. Our study demonstrates that for complete neuromuscular paralysis and predictable laryngoscopy conditions, SCH 1 mg/kg total body weight is recommended.
26. NEW: During interscalene block placement get medial movement of the scapula. This is secondary to stimulation of:

A: long thoracic nerve
B: dorsal scapula nerve
C: suprascapular nerve
D: supraclavicular nerve
E: accessory nerve
Answer B. From Google: the dorsal scapula nerve arises from C5. It innervates the rhomboids which medialise the scapula and levator scapulae which elevates the scapula (Nathan)

TROUBLE SHOOTING

Needle contacts bone at 102cm depth, no twitches
-needle stopped by transverse process
-insertion point is too posterior
-reinsert needle more anteriorly

Twitches the diahragm
-stimulation of phrenic nerve
-needle inserted anteriorly
-reinsert more posteriorly

Arterial blood
-carotid artery puncture
-angled too anterior
-withdraw and apply pressure
-redirect posteriorly

Twitch of scapula
-direct stim of serratus anterior muscle
-direct stim of thoracodorsal nerve (supplied lat dorsi)
-direct stim of dorsal scapular nerve (supplies rhomboid muscles and levator scapulae)
-re-direct needle anteriorly
23. NEW: The half life of the active metabolite of levosimendan (OR-1896) is:

A: 1hr
B: 8hr
C: 24hr
D: 3 days
E: 7 days
ANSWER D

Clin Pharmacokinet. 2007;46(7):535-52.

Levosimendan has been developed for the treatment of decompensated heart failure and is used intravenously when patients with heart failure require immediate initiation of drug therapy. It increases cardiac contractility and induces vasodilatation. The pharmacokinetics of levosimendan are linear at the therapeutic dose range of 0.05-0.2 microg/kg/minute. The short half-life (about 1 hour) of the parent drug, levosimendan, enables fast onset of drug action, although the effects are long-lasting due to the active metabolite OR-1896, which has an elimination half-life of 70-80 hours in patients with heart failure (New York Heart Association functional class III-IV). Although levosimendan is administered intravenously, it is excreted into the small intestine and reduced by intestinal bacteria to an amino phenolpyridazinone metabolite (OR-1855). This metabolite is further metabolised by acetylation to N-acetylated conjugate (OR-1896). The circulating metabolites OR-1855 and OR-1896 are formed slowly, and their maximum concentrations are seen on average 2 days after stopping a 24-hour infusion. The haemodynamic effects after levosimendan seem to be similar between fast and slow acetylators despite the fact that the enzyme N-acetyltransferase-2, which is responsible for the metabolism of OR-1855 to OR-1896, is polymorphically distributed in the population. Levosimendan reduces peripheral vascular resistance and has direct contractility-enhancing effects on the failing left ventricle. It also improves indices of diastolic function and seems to improve the function of stunned myocardium. Despite an improvement in ventricular function, levosimendan does not increase myocardial oxygen uptake significantly. An increase in coronary blood flow and a reduction in coronary vascular resistance have been observed. Levosimendan reduces plasma brain natriuretic peptide (BNP) and N-terminal pro-BNP (NT-proBNP) levels substantially, and a decrease in plasma endothelin-1 has been observed. Levosimendan also exerts beneficial effects on proinflammatory cytokines and apoptosis mediators. The effects of a 24-hour levosimendan infusion on filling pressure, ventricular function and BNP, as well as NT-proBNP, last for at least 7 days.
AB50 ANZCA version [2005-Sep] Q120

Transfusion related acute lung injury (TRALI)

A. can be caused by all homologous blood components, but particularly FFP (fresh frozen plasma)
B. is associated with significantly elevated pulmonary artery pressure
C. is the commonest cause of morbidity associated with blood transfusion
D. should be treated with high dose steroids
E. typically presents 24 hours following transfusion
ANSWER C

TRALI not caused by Albumin. Is most common with FFP, and female donors. Is the biggest cause of major morbidity.
TMP-Jul10-042 Patient post anterior cervical fusion. Patient in recovery. Confused and combative. Nurse concerned about haematoma. Taken to theatre: Most appropriate way of securing airway:

A. Gas induction / laryngoscopy / intubate
B. Awake tracheostomy
C. Awake fibreoptic intubation using minimal sedation
D. Thiopentone, suxamethonium, direct laryngoscopy and intubation
E. Retrograde intubation
Ans: A
CEACCP V7 No3 2007
Re-intubation may be difficult. The patients must be managed in a semi-sitting posture. Awake fibreoptic intubation is sometimes a good option, but direct laryngoscopy after sevoflurane and oxygen induction (with judicious doses of propofol) may be easier. The gum-elastic bougie is often vital and an LMA (+fibrescope,+gum elastic bougie or Aintree catheter) or an ILMA-guided technique may save the day. The use of succinylcholine in myelopathic patients is hazardous because of abnormal potassium shifts.
MH61 A 35yr old African-American with sickle cell and fractured ankle for ORIF. Hb 90, Haematocrit 0.3.

A: Transfuse 2 units packed cells (?pre-op)
B: Let him cool passively to low/normal temperature
C: Spinal is safe
D: Avoid thiopentone
E: Tourniquet is absolutely contra-indicated
ANSWER C

A - WRONG: "Although widely practiced, prophylactic erythrocyte transfusion remains a treatment with appreciable complications whose potential benefits have not been clearly demonstrated by a prospective, randomized clinical trial". Also a study in orthopaedic patients "did not detect a prophylactic effect from preoperative transfusion" (Sickle Cell Disease and Anesthesia. Anesthesiology 2004; 101:766-85)

B - WRONG: "Although hypothermia would tend to retard sickling because of a left shift of the oxygen dissociation curve, hypothermia is often identified as a precipitant of perioperative SCD complications". "avoidance of patient hypothermia is a basic objective for most anesthetics" (Same reference)

C - CORRECT: "The use of regional anesthesia therefore does not appear to be contraindicated in SCD" (Same reference) and OHA p202 agrees

D - ??? but seems unlikely

E - WRONG according to OHA p202 -JC
TMP-Jul10-051 Visual loss with pupillary reflexes retained. What is the likely cause ?

A. Retinal detachment
B. Occipital mass
C. Frontal mass
D. Chiasmal mass
E. Optic neuritis
ANSWER B

Cortical blindess = visual loss but with retained pupillary reflexes and normal fundoscopy. Caused by pathology in the occipital lobes.
19. NEW. TEG tracing given, post cardiac surgery. Had quite slim tail but broader 'shoulders'.

A: Fibrinolysis
B: Hypofibrinogenaemia
C: Platelet dysfunction
D: Heparin effect
E: Surgical bleeding
ANSWER A
ANSWER A
8. NEW. TMP-Jul10-010?? Long stem about an old #NOF patient with aortic stenosis. What is a sign/ investigation/ symptom that shows the most severity? (ie Which one of these would indicate that the lesion was severe?)

A: Thrill in Aortic area
B: Murmur in lower left sternal edge
C: Murmur radiating to carotids
D: History of ischaemic heart disease or coronary artery disease
E: history of angina/ syncope
ANSWER A

A - True - "A precordial thrill may be felt, especially on leaning forward in expiration. Its presence is reasonably specific for severe aortic stenosis"
29. NEW. During lumbar plexus block placement, which of the following indicates inappropriate needle placement?

A: hip flexion
B: hip adduction
C: knee extension
D: knee flexion
E: lumbar extension
ANSWER E

Method
1. Mark out midline over spinus processes
2. Mark out perpendicular line, line connect iliac spines
3. Needle insertion 4cm from midline along interiliac spine, aim perpendicular, parallel to spine
4. 6-8 cm depth
5. aim is for twitch of quadraceps (femoral nn), but twitch of any of the lumbar nerves possible
6. Nerve stimulation from 1mA to 0.5mA
7. aspirate and inject 20-25ml of solution (0.5-0.75% ropivacaine)
ME46 Acromegaly due to excess of growth hormone. Why is it difficult to do a direct laryngoscopy?

A: Distorted facial anatomy
B: Macroglossia
C: Glottic stenosis
D: Prognathe mandible
E: Arthritis of the neck
ANSWER B

Acromegaly : either pituitary tumour or extra-pit (breast, ovary, lung and and pancreas)
•usually characteristic facies with marked prognathism, frontal bossing and prominent supra-orbital ridges
•clinical features develop slowly, and usually present in the 4th decade, with
a.local effects : pituitary tumour → visual field defects and increasing ICP
b.GH effects (i) overgrowth of bones : big limbs, skull, kyphoscoliosis
(ii) overgrowth of CT – coarse skin with skin tags, macroglossia and carpal tunnel syndrome and hyperhidrosis
c.CVS effects – ATS, HT, cardiomegaly with cardiomyopathy → CCF
d.Other Endocrine disturbances : DM, hypothyroid, impotence, amenorrhea, galactorhhea
•Difficult airways : both ventilation and intubation, for a number of reasons
oBig jaw, tongue and soft tissues → facemask ventilation difficult
oNose may be obstructed because of hypertrophy of turbinates
oLonger distance between incisors and glottis
oGlottis may ne narrowed by CT overgrowth involving vocal cords, crico-arytenoid joints and recurrent larungeal nerve (sub-glottic diameter may also be reduced → use smaller ETT)
•Dx : GH levels – fasting elevated AND doesn’t suppress with glucose load plus MRI
•Rx : to reduce GH levels to normal, minimise local effects and replace other hormones
oSurgery, irradiation
odrugs (bromocriptine or octreotide (long acting somatostatin analogue inhibits GH secretion))
38. NEW. Your registrar gives a Duchenne patient 1mg/kg of suxamethonium. What are you most worried about?

A: hyperkalaemia
B: rhabomyolysis
C: MH
ANSWER A
16. Magnesium for treatment of pre-eclampsia. What is the therapeutic level?

A: 1 - 3 mmol/L
B: 3 - 5 mmol/L
C: 5 - 7 mmol/L
D: 7 - 9 mmol/L
E: 9 - 11 mmol/L
ANSWER B

Achieved with a 4g loading dose followed by 1g/hr infusion. If this is not enough, further 2g loading and increase to 2g/hr infusion.
15. New? What is NOT true for PDPH following puncture

A: Prophylactic bed rest
B: Catheter in intrathecally
C: Oral caffeine
D: IV caffeine
E:
ANSWER A

in Section 9.6.5 Acute Pain Management: Scientific Evidence (2005) and Update (2007)
Incidence of headache following dural puncture 0.4-24%

* postural in nature
* commoner in patients under 50 yrs
* commoner in parturients
* significanntly less common in males than non-pregnant females (level 1 evidence - 2007 update)
* 90% resolve spontaneously within 10 days

Incidence may be reduced by using: (level I)

* 26 gauge or smaller needle (NNT=13)
* use of needle with a non-cutting bevel (NNT=27)

No evidence that bed rest is beneficial in preventing PDPH (Level I)

* PDPH may causes difficulty mobilising, and headache may then subside with bed rest
* Non-opioid and opioid analgesics may provide temoporary relief
* Preventive role of fluid therapy unclear (Level I)

NO evidence to support the use of:

* Sumatriptan (Level II)
* ACTH
* Epidurally administered saline, dextran, fibrin glue or neuraxial opioids

IV and oral caffeine (both level II) are:

* effective in treating PDPH
* do not reduce blood patch rate

Epidural blood patches:

* are common practice but further high quality trials are required to determine efficacy (level I)
* significant symptomatic relief obtained in 75-95% of patients given a 15 mL blood patch (level IV, three studies)
* conflicting evidence regarding use of prophylactic blood patches - one trial showed decreased incidence of PDPH (level III)

Autologous epidural blood patches may be contra-indicated in:

* leukaemia
* coagulopathy
* infection, including HIV
28. NEW. During scoliosis surgery with monitoring of somatosensory evoked potentials, which tract are they mainly monitoring?

A: Dorsal column
B: Spinothalamic tract
C: Lateral Corticospinal tract
D: Cerebrospinal tract
E: Anterior horn cells
ANSWER A

A. dorsal column r
-white matter in the dorsomedial side of the spinal cord
-fasciculus gracilis and fasciculus cuneatus
-ascending pathway
-fine touch and proprioception

B Spinothalamic
-sensory for pain, temperature, itch and crude touch
-two main parts
1. lateral spinothalmic: pain and temp
2. anterior spinothalamic: crude touch

C. lateral corticospinal tract controls movement of ipsilateral limbs
-Control of more central axial and girdle muscles

D. Cerebrospinal tract ??
6. NEW: ECG- which does NOT have abnormal Q waves:

A: Digoxin toxicity
B: Anterior myocardial infartion
C: Previous AMI
D: LBBB
E: Wolff-Parkinson-White syndrome
ANSWER A

Type A (left atrioventricular connections: positive atrioventricular connections)  positive delta wave positive R wave V1.
Type B (right atrioventicular connections: negative delta wave in V1 similar to a Q wave.
TMP-Jul10-056

Thallium scan:
A. High negative predictive value
B. High positive predictive value
C. Not as good as a dobutamine stress echocardiography
D. ?
E.
ANSWER A

NPV 95%
PPV 30%

Probably the same as dobutamine stress echo
TMP-Jul10-033 Subtenon’s block. What is the worst position to insert block?

A. Inferonasal
B. Inferotemporal
C. Superonasal
D. Supertemporal
E. Medial / canthal
ANSWER E

Answer E as might strike medial rectus insertion

A sub-Tenon's block can be done in any of the 4 quadrants (options A-D above).

These positions avoid the insertions of the rectus muscles which pierce the Tenon's capsule and insert into the sclera. Thus, for example, if you tried to do a block superiorly you would hit the superior rectus insertion.
10. NEW. Petit mal epilepsy - Which is true? (or words to that effect)

A: Most common in child <2 years old
B: Can precipitate seizures by hyperventilating (+/- deliberately???)
C: Often seizures last for more than 30 seconds
D: Rarely familial
E: Isoelectric EEG during seizure (burst suppression)
ANSWER B

Absence seizures
-abrupt and sudden onset of impairment of consciousness (blank stare, possible upward rotation of eyes)
-usually brief <20sec
-EEG generalised spike and slow wave discharges
-hyperventilation triggers in 90%
-treatment mainly valproate (second line lamotrigine)
-should not use carbamazepine, vigabatrin, tiagabine, phenytoin, gabapentin and pregabalin --> not effective in treatment
SN18 Absolute contraindication to sitting position for posterior fossa craniotomy for meningioma

A: Prescence of patent ventriculo-atrial drain/shunt
B: PFO
C: Oesophageal stricture so transoesophageal echo placement is out
D: ?
E: ?
ANSWER A or B

ABSOLUTE CONTRAINDICATIONS

* Patent ventriculo-atrial shunt
* Severe cardiovascular disease
* Large patent foramen ovale or other pulmonary-systemic shunt
* Cerebral ischaemia when upright and awake
* Anaesthesia or surgical team not familiar with the position
17. NEW. Autonomic dysreflexia. Which ONE is true?

A: 50% of patients with a level below T6
B: Unlikely if below T10
C: Can be prevented??
D: Can be precipitated by light touch
E. ?
ANSWER B
31. NEW. Which of the following causes the most heat loss in a neonate?

A: conduction
B: convection
C: evaporation
D: radiation
E: vasodilation
ANSWER D
TMP-Jul10-045 How quickly does the CO2 rise in the apnoeic patient ?

A. 1 mmHg per min
B. 2 mmHg per min
C. 3 mmHg per min
D. 4 mmHg per min
E. 5 or ?8 mmHg per min
ANSWER C
21. NEW? Post scoliosis repair, decreased movement bilaterally in the legs with decreased pain and temperature sensation but spared joint position sense and vibration. What is at fault?

A: Posterior spinal arteries
B: Anterior spinal arteries
C: Epidural haematoma
D: Misplaced pedicle screw
E: Lateral cord syndrome
ANSWER B

Anterior Spinal Cord Syndrome
# Complete motor paralysis below the level of the lesion due to interruption of the corticospinal tract
# Loss of pain and temperature sensation at and below the level of the lesion due to interruption of the spinothalamic tract
# Retained proprioception and vibratory sensation due to intact dorsal columns

Typical causes include acute disc herniation or ischemia from anterior spinal artery occlusion.
TMP-Jul10-054 Malignant hyperthermia. The number of people in the community at any given time with a predisposition is called the:

A. Prevalence
B. Incidence
C. Occurance
D. Event rate
E. Denominator
ANSWER A
45. NEW. How far to insert PICC line in a kid beyond the carina

A: At the carina
B: 1cm below
C: 1cm above
ANSWER A

The ideal position is above the pericardial reflection in the SVC which in most patients would be at the level of the tracheal bifurcation.
http://www.anzca.edu.au/news/e-newsletter/e-news-articles/Coroners%20report%20PICC%20line%20AR%20summary%20Feb%2010.doc/view?searchterm=picc%20coroners
TMP-Jul10-043 Young asthmatic male in emergency department. RR 26, pCO2 27, SAO2 92%, struggling talking in sentences. Given nebulised salbutamol, and ipratropium, 200mg IV hydrocortisone. After 30 minutes - no improvement. Further management:

A. IV salbutamol
B. IV aminophylline
C. IV magnesium
D. Intubate and ventilate
E. ???IV adrenaline?
ANSWER C
27. NEW. Popliteal block placed from the lateral approach:

A: Passes through semimembranosus
B: Has eversion of the foot as the end point
C: Has increased failure rate compared to a posterior approach
D: ?
E: Can be performed supine or prone
ANSWER

A FALSE, semmembranosus is muscle on the back of thigh

B. FALSE
Common peroneal : dorsiflesion and eversion
Tibial nerve: plantar flexion and inversion

C FALSE intermediate block, easier to perform, higher success rate

D ?

E. TRUE
ET02 An 85y.o for open AAA repair. Refuses blood because of risk of vCJD. You tell him you won't anaesthetise him as the risk is too high. This is an example of:

A: Autonomy
B: Beneficence
C: (?non) Malevolence
D: Coercion
E: Paternalism
Pt is exercising autonomy.
We are exercising non-maleficience (not doing harm). If that's not an option, beneficience is probably next best (doing good)
9. NEW. You get a TOE on a patient with aortic stenosis. What is the finding most likely to indicate that the valve needs replacement? possibly same as TMP-Jul10-010

A: Average pressure gradient 30mmHg
B: Valve area 1.2cm(squared)
C: dyspnoea
C
ACC/AHA 2007 guideline on perioperative cvs evaluation and care for noncardiac surgery
In symptomatic aortic stenosis, elective noncardiac surgery should generally be postponed or canceled. Such patients require aortic valve replacement before elective but necessary noncardiac surgery.

If the aortic stenosis is severe but asymptomatic, the surgery should be postponed or cancelled if the valve has not been evaluated within the year.
On the other hand, in patients with severe aortic stenosis who refuse cardiac surgery or are otherwise not candidates for aortic valve replacement, noncardiac surgery can be performed with a mortality risk of approximately 10%.
If a patient is not a candidate for valve replacement, percutaneous balloon aortic valvuloplasty may be reasonable as a bridge to surgery in hemodynamically unstable adult patients with aortic stenosis who are at high risk for aortic valve replacement surgery and may be reasonable in adult patients with aortic stenosis in whom aortic valve replacement cannot be per-formed because of serious comorbid conditions.
33. NEW. If type and Rh specific blood is given to a patient, how safe is the transfusion (Can't quite remember wording, but similar to what is in Dr Brandis' physiology viva book)?

A: ?
B: ?
C: 97%
D: 98.6%
E: 99.8%
ANSWER E

a simple ABO-Rh type reduces the risk of a transfusion reaction to 99.8%. Screening lowers this risk to 99.94%, and crossmatching lowers it to 99.95%
85.If a test is negative, what proportion will NOT have the disease:
A. Sensitivity
B. Specificity
C. Positive Predictive Value
D. Negative Predictive Value
Exact wording of stem is very important and probably not quite right here.

Probability that YOUR negative test means YOU don't have the disease is the NPV.

Sensitivity and specificity are a function of a test, but positive and negative predictive values change depending on prevelance.

* Sensitivity = TP/(TP+FN), "proportion of positive cases correctly identified"
* Specificity = TN/(TN+FP), "proportion of negative cases correctly identified"

* PPV = TP/(TP+FP)
* NPV = TN/(TN+FN)
7. NEW(?) Coeliac plexus block. What is the complication?

A: Erectile dysfunction
B: Constipation
C: Hypertension which resolves spontaneously
D: Paralysis
E:
ANSWER D

* 3 common transient adverse effects
1. Local pain (96%)
2. Diarrhoea (44%)
3. Hypotension (38%)
* Other complications include
o Lower extremity weakness
o Paraplegia
o Parasthesia
o Adjacent organ puncture
o Infection
o Bleeding → retroperitoneal haematoma
o Epidural injection
o Subarachnoid injection
o Intravascular injection
o Pneumothorax
o Chylothorax

* Neurology caused by
o Direct injury to spinal cord or somatic nerves
o Spinal cord ischaemia
+ Spasm or thrombosis of the artery of Adamkiewicz → spinal cord ischaemia T8 to L4
34. NEW. Patient with Marfan's and 2 hours of severe chest pain, mild hypertension and ECG showing ischaemia. The next best step is urgent:

A: CT
B: TOE
C: ?
D: Angiography and PCI
E: Thrombolysis
Aortic dissection prompt diagnosis and emergency treatment are critical Cleveland Clinic Journal of Medicine 2011
Diagnosis and management of aortic dissection CEACCP 2009

Ans: A is probably preferred in common institution. TOE requires sedation, generally in haemodynamically unstable patient perioperatively.
TMP-Jul10-048 Amniotic fluid embolism. Cause of death in first half hour ?

A. Pulmonary hypertension
B. Malignant arrhythmia
C. Pulmonary oedema
D. Hypovolaemic shock
E.
ANSWER A
24. NEW. When compared to a non-obese patient, in an obese patient (BMI >35) when fasted for an elective procedure the gastric secretion will have:

A: more volume, higher pH
B: more volume, lower pH
C: same volume, same pH
D: less volume, lower pH
E: less volume, higher pH
Answer
B: according to Obesity in Anaesthesia and Intensive Care. BJA 85(1):91-108 (2000) page 101
CEACCP 2008 8(5) 151-156 but no reference in the article
E: according to A&A 1998 pg 147-152

According to A&A 2001 vol 93 no 6 pg 1621-1622 same volume slightly lower pH http://www.anesthesia-analgesia.org/content/93/6/1621.full
Gastric content volume was identical in the obese and lean subjects (26 ± 13 mL and 26 ± 8 mL, respectively). The values of pH were 2.3 (1.3–7.1) and 2.8 (1.6–7.1) in obese and lean patients, respectively.
13. NEW. Which have been shown to decrease vasospasm post aneurysm? All EXCEPT:

A: Antiplatelet drugs
B: Nimodipine
C: HHH therapy
D:
E:
ANSWER A
MM02a ANZCA version [2001-Apr] Q1 (Similar reported question in [1988] [Aug94] [Mar95] [Jul97] [Mar00])

In a patient with porphyria, the drug most likely to cause an acute episode is
A. morphine
B. propofol
C. propanidid
D. phenytoin
E. atropine
ANSWER D