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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 ? |
ANSWER B
Patient is symptomatic -3% Saline at 1-2ml/kg/hr (stop as soon as symptoms resolve) Use of hypertonic saline - For treatment of Na < 120 mmol/L or symptoms - Maximum rate of correction = 1 mmol/L/hour - Correction to normal is not indicated: the aim is clinicalimprovement - Calculate TBW = 0.6 x weight (kg) = 42 L for 70 kg man - 2 x TBW is the number of mL of NaCl 3% which will raiseserum Na by 1 mmol/L - E.g. 2 x 42 = 84 mL of NaCl 3% over 1 hour will raiseserum Na by 1 mmol/L - Need to give via large vein
Use of diuretics - Only for treatment of APO caused by the transienthypervolaemia - Frusemide worsens hyponatraemia, but is effective atremoving free water - Mannitol causes less Na loss than loop diuretics
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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:
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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 |
A - CEACCP
The steps are as follows (CPAP works really well clinically and barely blows up lung allowing surgeons to continue to work): •Administer 100% Oxygen •Check Ventilator, Circuit and catheter mount •Clear secretions and debris by suctioning dependent lung •Check tube position •Apply CPAP or entrain Oxygen to non dependent lung •Perform recruitment manoeuvre and apply PEEP to dependent lung •Revert to two lungventilation •Clamp non-dependentpulmonary artery |
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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
O2 flush valve - Allows direct communication between the O2 high-pressurecircuit and the low-pressure circuit - Flow enters the low-pressure circuit downstream from thevaporisers - Activation of the valve delivers 100% O2 at 35-75 L/min tothe breathing circuit
Hazards - O2 flushing during the inspiratory phase of PPV can →barotrauma and volutrauma, particularly in children - This Is less likely to occur if the anaesthesia machineincorporates fresh gas decoupling (which diverts O2 flush flow to the reservoirbreathing bag) - Therefore, the O2 flush should never be activated duringthe inspiratory phase of mechanical ventilation - Can also result in awareness because O2 flow dilutes
- Miller’s |
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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
- Fontan repair = palliative procedure that leads topatients having a univentricular circulation e.g. for hypoplastic left heartsyndrome, pulmonary atresia - Blood flows from the vena cavae into the pulmonary artery:it only passes into the heart after passing through the lungs, then theremaining ventricle pumps blood around the body - Therefore, pulmonary blood flow is dependent solely on CVP
Complications - Ventricular dysfunction: dilation, hypertrophy, and ↓contractility - Atrial arrhythmias: common (~50%), poorly tolerated so mayneed cardioversion - Shunts: right → left → desaturation; left → right → volumeoverload - Protein losing enteropathy: from ↓ drainage by thoracicduct by high SVC pressure and mesenteric vascular inflammation → oedema,immunodeficiency, ascites, fat malabsorption, hypercoagulopathy, hypocalcaemia,hypomagnesaemia; poor prognosis - Developmental deficit: due to CPB, thrombotic events,chronic hypoxaemia - Thromboembolism: therefore on warfarin or antiplateletagents
Considerations - Maintain adequate venous return: hypovolaemia → hypoxiaand ↓ cardiac output, but they are also prone to fluid overload; CVP monitoringis useful and is best done via the femoral vein; also maintain sinus rhythm - Keep PVR ↓: blood flow across the lungs depends on thedifference between CVP and atrial pressure, therefore blood flow is essentiallypassive and ↑ PVR → ↓ flow, so avoid IPPV where possible - Work out which ventricle remains: a morphological RV isless able to cope with systemic pressures so it may fail earlier and posefurther problems
Ventilation - For short procedures, are better off breathingspontaneously as long as severe hypercarbia is avoided - For major surgery, need controlled ventilation and activeprevention of atelectasis, but ↑ mean intrathoracic pressure → ↓ venous return→ ↓ pulmonary blood flow → cardiac output - ↓ RR, ↓ inspiratory times, ↓ PEEP and VT 5-6 mL/kg usuallyallow adequate pulmonary blood flow, normocarbia and ↓ PVR - Hyperventilation tends to ↓ pulmonary blood flow (despiterespiratory alkalosis) because of ↑ mean intrathoracic pressure
- Dr Podcast - Oxford handbook - Nayak S, Booker PD. The Fontan circulation. CEACCP 2008; 8(1): 26-30. |
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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
- Infrared analysis = technology most often used to measureCO2, nitrous oxide, and volatile anaesthetics
Technology - Based on the principle that gases with two or moredissimilar atoms in the molecule absorb infrared radiation at a characteristicwavelength - Since the amount of IR rays absorbed is proportional tothe concentration of the absorbing molecules, the concentration can bedetermined by comparing the IR absorbance in the sample with that of a knownstandard
Disadvantages - Cannot measure nitrogen, oxygen, helium, xenon - Water vapour can absorb IR light, causing anoverestimation of CO2 - Inaccuracy with rapid respiratory rates
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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. (see below explanations)
Definitions - Pre-eclampsia = HT (≥ 140/90) arising after 20 weeks’gestation, with one or more organ system involvement - Severe pre-eclampsia = marked HT ≥ 160/110 and extremederangements of organ function - HT crisis = SBP ≥ 180: medical emergency because it isassociated with increased risk of ICH and mortality if left untreated
Treatment - Aim for BP 140-150/90-100 at a rate of 10-20 mmHg every10-20 minutes to avoid maternal and fetal complications - Non-severe HT (< 160/110): usually labetalol PO; othersinclude methyldopa, nifedipine, some β blockers (metoprolol, pindolol,propranolol) and low dose diazoxide - Severe HT: labetalol (PO/IV), nifedipine (PO), orhydralazine (IV 5 mg boluses: causes tachycardia, so give up to 500 mLcrystalloid concurrently)
Other drugs - SNP: causes hypotension and paradoxical bradycardia insevere pre-eclampsia and fetal cyanide toxicity in prolonged treatment; shouldbe used with extreme caution in life-threatening HT immediately before deliverywith experienced clinicians - GTN: drug of choice in pre-eclampsia and APO
Drugs to avoid for BP reduction - MgSO4: does not reverse or prevent disease progression anddoes not significantly lower BP - Labetalol: avoid in severe asthma - Atenolol: causes fetal growth restriction - High dose diazoxide, ketanserin, nimodipine, ACEinhibitors, ARBs
- Dennis AT. Management of pre-eclampsia: issues for anaesthetists.Anaesthesia 2012; 67(9): 1009-1020. |
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18. NEW. Ageing (adult) causes:
A: Decreased FRC B: Decreased Cardiac output C: Diastolic dysfunction D: Increased creatinine |
ANSWER C
Respiratory changes in elderly - ↓ lung volumes: ↓ TLC, ↓ VC (from ↑ thoracic cage and lungparenchymal rigidity and kyphosis) - ↓ alveoli: ↑ RV/TLC and ↑ FRC/TLC - ↓ radial traction of terminal bronchioles → ↑ closingvolume → ↑ V/Q inequalities - ↑ alveolar capillary membrane thickness → ↑ diffusionimpairment
CV changes in elderly - ↓ maximum HR and SV - ↑ connective tissue in the heart - LVH due to ↑ impedance to LV output - Fibrosis of the endocardium → ↓ compliance of the heart - Calcification in the heart valves can distort the valvecusps and produce valvular incompetence - Recent studies suggest that there is no significant ↓ incardiac output in healthy subjects! - Healthy elderly people can ↑ their cardiac output by ↑reliance on the Frank-Starling mechanism, primarily by ↑ing SV in response to ↑LVEDV and P - ↓ large artery elasticity → ↑ MAP and SBP - Diastolic BP may ↑ (↑ TPR) or ↓ (rapid run-off of blood inthe stiff large arteries) - Impaired baroreceptor mechanisms → postural hypotension - ↓ β adrenergic responsiveness of the heart
Renal changes in elderly - ↓ functional glomeruli → ↓ GFR by 1%/year from the age of30 years - ↓ tubular excretion
Body compartment changes in elderly - ↓ skeletal muscle mass - ↑ body fat - ↓ intracellular water - ↓ blood volume - ↓ albumin concentration
- Power and Kam |
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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
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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 D
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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
Considerations in postoperative pneumonectomy - Higher mortality than lobectomy (cardiac complications andALI) - No consensus on managing the post pneumonectomy space: ifa chest tube is placed, a balanced drainage system must be used or themediastinum will shift to the operative side, creating adverse hemodynamicconsequences - A CXR is mandatory after the patient arrives in PACU orICU to assess the mediastinal shift - Immediately after pneumonectomy, there is ↑pulmonaryartery pressures →↑ RV afterload → potential for RV dysfunction - Fluid restrict: reduces risk of ALI but may requireinotropes/vasopressors to maintain HD stability - Protective ventilation: 6 mL/kg IBW to minimise risk ofrespiratory failure
Kam on pleural tubes - Use is controversial post pneumonectomy - On the first postoperative day, should be clamped andreleased intermittently every 2-4 hours to drain blood or fibrin - Suction is absolutely CI: predisposes to mediastinal shift
- Miller’s - Kam AC, O'Brien M, Kam PC. Pleural drainage systems. Anaesthesia 1993;48(2): 154-61. |
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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
AAGBI algorithm 1. Recognition Signs of severe toxicity: - Sudden alteration in mental status, severe agitation orLOC, +/- GTCS - CV collapse: SB, conduction blocks, asystole andventricular tachyarrhythmias may occur - LA toxicity may occur some time after an initial injection
2. Immediate management - Stop injecting the LA - Call for help - Maintain the airway and, if necessary, secure it with anETT - 100% oxygen and ensure adequate lung ventilation(hyperventilation may help by ↑ing plasma pH in the presence of metabolicacidosis) - Confirm or establish IV access - Control seizures: give a benzodiazepine, thiopental orpropofol in small increments - Assess CV status throughout - Consider drawing blood for analysis, but do not delaydefinitive treatment to do this
3. Treatment In circulatory arrest: - Start CPR - Manage arrhythmias using the same protocols, recognisingthat arrhythmias may be refractory to treatment - Consider cardiopulmonary bypass - GIVE IV lipid emulsion - Continue CPR - Recovery may take > 1 hour - Lignocaine should not be used as an anti-arrhythmictherapy
Without circulatoryarrest: - Use conventional therapies to treat hypotension,bradycardia, tachyarrhythmia - CONSIDER IV lipid emulsion
4. Follow-up - Arrange safe transfer to a clinical area with appropriateequipment and suitable staff until sustained recovery is achieved - Exclude pancreatitis by regular clinical review, includingdaily amylase or lipase for two days - If Lipid has been given, report its use to theinternational registry at www.lipidregistry.org
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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
Time constant definitions - τ = The time itwould have taken for an exponential process to complete, had the initial rateof change continued - The time for the value of an exponential to fall to 37% ofits previous value - The reciprocal of the rate constant
- Part I notes |
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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
- Postoperative HT = common after CEA, due to impairedbaroreceptor function - Predisposes to wound haematoma, MI and may be followed bycerebral hyperperfusion - In the absence of definitive data, target SBP < 160mmHg or within 20% of preoperative values, with a lower threshold for patientsat risk for cerebral hyperperfusion or wound haematoma
Cerebral hyperperfusion syndrome - Due to ischaemia-reperfusion injury with loss ofautoregulation in areas of the brain which were previously under-perfused - Occurs in 1% - Clinical features: headache, seizure, focal neurologicsigns, cerebral oedema, and ICH - Does not occur until several days after CEA - Risk factors: severe postoperative HT, severe preoperativecarotid stenosis, recent contralateral CEA - Treatment: aggressive BP control can reverse cerebraloedema; titrate to avoid hypotension and watershed cerebral ischaemia |
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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
Cardiac dysfunction in SAH - Systemic and pulmonary HT - Arrhythmias - Troponin positive in 15-30% - Neurogenic pulmonary oedema - ECG abnormalities in 25-100% (QTC prolongation,repolarisation abnormalities) - LV dysfunction in 10-30% - Neurogenic-stunned myocardium = most severe form (LVsystolic dysfunction, cardiogenic shock, APO)
Mechanism - Excess myocardial release of catecholamines fromsympathetic nerve terminals → calcium overload and necrosis of myocytes - Correlates with the severity of intracranial injury
Prognosis - Mostly resolves over time and does not directly affectmorbidity and mortality - May impact upon triple-H therapy: ↑ BP and cardiac fillingpressures and ↓ haematocrit is contrary to a cardioprotective strategy of ↓preload, afterload and contractility
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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
- Sepsis = systemic, deleterious host response to infection - Severe sepsis = acute organ dysfunction secondary toinfection - Septic shock = severe sepsis plus hypotension not reversedwith fluid resuscitation
Goals during the first 6 hours - CVP 8-12 mmHg - MAP ≥ 65 mmHg (NA = first line, adrenaline when anadditional agent is required, vasopressin 0.03 units/min can be added) - UO ≥ 0.5 mL/kg/h - Central venous (SVC) or mixed venous O2 saturation 70% or65% respectively - In patients with ↑ lactate targeting resuscitation tonormalise lactate
Other management issues - Cultures before antibiotics, with at least 2 sets of bloodcultures - Early imaging to confirm a potential source of infection - Empiric antibiotics within the first hour - Source control within the first 12 hours - Crystalloids = initial fluid of choice; avoid HES; albuminin patients requiring substantial amounts of crystalloids - Trial dobutamine up to 20 mcg/kg/min in the presence ofmyocardial dysfunction or ongoing signs of hypoperfusion, despite adequateintravascular volume and MAP - Don’t use hydrocortisone if fluid resuscitation andvasopressors are able to restore HD stability; if not achievable use IVhydrocortisone 200 mg/day; ACTH stimulation test not recommended - Once tissue hypoperfusion has resolved and in the absenceof extenuating circumstances (IHD, haemorrhage, hypoxaemia), transfuse only toHb 7-9 g/dL - Minimise sedation - Avoid muscle relaxants if possible in patients withoutARDS - Others: glucose control, DVT prophylaxis (LMWH and CCs),stress ulcer prophylaxis with PPIs, nutrition, setting goals of care - Dellinger RP, Levy MM, Rhodes A, Annane D, Gerlach H, Opal SM, et al.Surviving sepsis campaign: international guidelines for management of severesepsis and septic shock: 2012. Critical care medicine 2013; 41(2): 580-637. |
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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
Eisenmenger’s syndrome - = Reversal of a left-to-right intracardiac shunt due to ↑PVR, to a level that equals or exceeds SVR - Due to obliteration of the pulmonary vascular bed - In 50% of untreated VSDs and 10% of untreated ASDs
Anaesthetic management - Aim = maintain preoperative levels of SVR (to prevent ↑right-to-left shunt) because their pulmonary vascular bed is fixed - Minimise blood loss - Prevention of paradoxical embolism (e.g. avoid bubbles inlines) - Prophylactic phlebotomy with isovolaemic replacement ifhaematocrit > 65% - Early extubation because of the deleterious effects of PPV
Prognosis - 20% die during a medical procedure: extreme caution shouldbe observed when contemplating anaesthesia - Mean age of death = 45 years (mean of 6 years fromdiagnosis)
- Stoelting’sanaesthesia and coexisting disease - Kelleher AA. Adult congenital heart disease (grown-up congenital heartdisease). CEACCP 2012; 12(1): 28-32. |
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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
- Mechanical trauma during airway management (particularlyuse of adjuncts during intubation) can lead to major trauma including trachealand oesophageal perforation, mediastinitis and death
- NAP4
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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
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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
- In contrast to heparin and LMWH, fondaparinux is synthetic - Is an analog of the pentasaccharide found in heparin thatbinds antithrombin - The fondaparinux-antithrombin complex inhibits factor Xabut has no direct activity against thrombin (because it is too short) - Administered SC, it is rapidly absorbed and has a t1/2 of15 hours, making it acceptable for daily dosing - Metabolism does not occur and it is eliminated by thekidneys - Approved for thromboprophylaxis in patients undergoing hipor knee surgery and hip fracture
- Stoelting - Goodman and Gilman’s 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) |
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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 (L2-4) - Largest nerve of the lumbar plexus - Supplies muscles and skin of the anterior compartment ofthe thigh - Enters the thigh beneath the inguinal ligament - Within the femoral triangle, it breaks up into itsterminal branches which stem from an anterior and posterior division
Anterior division - Muscular branches to pectineus, sartorius - Cutaneous branches to intermediate and medial nerve of thethigh
Posterior division - Muscular branches to quadriceps (= rectus femoris, vastusmedialis, vastus intermedius, vastus lateralis) - Cutaneous branch – saphenous nerve - Articular branches to hip and knee
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109.Reverse splitting of the second heart sound occurs with:
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ANSWER A
S2 - Due to closure of the aortic and pulmonary valves - The pulmonaryvalve procrastinates because of thelow pressure in the pulmonarycirculation (i.e. aortic closes before pulmonary) - In inspiration, the pulmonary valve procrastinates evenmore because of ↑ venous return to the RV = normal splitting
Splitting of S1 - Usually not detectable - Due to RBBB
Splitting of S2 - ↑ normal (in inspiration): pulmonary stenosis (pulmonaryprocrastinates more), RBBB, mitral regurgitation (earlier aortic valve closuredue to more rapid LV emptying), VSD (↑ RV volume load) - Reversed (in expiration): aortic stenosis, LBBB (aorticdelayed past pulmonary) - Fixed (no respiratory variation): ASD
- Talley and O’Connor - http://www.youtube.com/watch?v=Nz54yqldtR8 |
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40. NEW. What makes tramadol less effective?
A: ondansetron B: prochlorperazine C: metoclopramide |
ANSWER A
Factors which ↓ effectiveness of tramadol - Poor metabolisers (→ ↓ conversion to O-desmethyltramadol,or M1 by CYP2D6 → ↓ μ opioid receptor effects) - Coadministration with CYP2D6 inhibitors e.g. paroxetine - 5HT3 receptor antagonism e.g. ondansetron - Acute pain management: scientific evidence |
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TMP-Jul10-062 In pregnancy the dural sac ends at:
A. T12 B. L2 C. L4 D. S2 E. S4 |
ANSWER D
- Below, the spinal cord tapers into the conus medullaris,from which a glistening thread, the filum terminale, continues down to becomeattached to the coccyx - The filum terminale is mainly pia mater invested in asheath of dura, but it does contain a prolongation of the central canal of thecord in its upper part - In neonates, the cord terminates at the lower border ofL3, and in an adult, at the disc between L1 and L2 - The dural sac terminates at S2 |
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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. |
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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) |
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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
Mechanism - Calcium sensitiser (low doses) and PDE inhibitor (higherdoses) - Also causes vasodilation through blocking ATP sensitive Kchannels
Uses - Mainly chronic heart failure
Dose - Loading dose then infusion
PD - Does not ↑ myocardial O2 consumption
PK - t1/2 = 1 hour - Active metabolite = 80 hours which results in ↑contractility sustained for several weeks
- Oh’s |
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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. |
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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
- Airway compromise may be due to haematoma or supraglotticoedema secondary to venous and lymphatic obstruction; bilateral RLN palsy israre - Presents within 6 hours with neck swelling, change invoice quality, agitation, and signs of respiratory distress - Tracheal deviation may occur and compression of thecarotid sinus can cause bradycardia and hypotension - Worth trying helium, dexamethasone, nebulised adrenaline(but priority is opening the wound) - The use of sux in myelopathic patients is hazardousbecause of K+ shifts |
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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 Sickle Cell disease:
- Sickle cell disease = disorder caused by the substitutionof valine for glutamic acid in the β-globin subunit - Autosomal inheritance: heterozygotes = sickle cell trait;homozygotes = sickle cell disease - When deoxygenated, the haemoglobin in a sickle cellaggregates, resulting in the distortion of the sickle shape, which is morerigid than normal RBCs - The sickle cell has a shortened life span
Complications 1. Haemolysis: haemolytic anaemia 2. Impaired blood flow: episodic painful crises(vasoocclusive crises) associated with dehydration, acidosis and hypothermia 3. End organ damage: CNS (strokes), respiratory (infarcts,pulmonary HT, RV failure), renal (infarcts, CKD), musculoskeletal (AVN), GI(splenic infarcts), CV (MI, high output cardiac failure)
Role of transfusions - Transfusions are required only as needed in moderate(intraabdominal) to high risk (intracranial, intrathoracic, hip) operations toachieve a preoperative haematocrit of 30% - Low risk: extremity surgery, inguinal hernia repair
Risk factors for complications - Dehydration, acidosis and hypothermia - Tourniquets (but not CI)
Anaesthetic technique - Does not affect risk of complications! - Regional anaesthesia is not CI and may offer advantages inpain control (patients are often opioid tolerant)
- Stoelting’sanaesthesia and coexisting disease - Dr Podcast |
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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.
- Light reflex (pupil constriction with light): optic nerve,superior quadrigeminal brachium, Edinger-Westphal nucleus and efferentparasympathetic fibres which terminate in the ciliary ganglion; no corticalinvolvement - Accommodation reflex (pupil constriction withaccommodation): originates in the cortex and is relayed via parasympatheticfibres in the third nerve |
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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
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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" |
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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) |
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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)) |
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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
(B also true)
Suxamethonium-induced rhabdomyolysis, hyperkalaemia andcardiac arrest may occur when administered to male children with an undiagnosedmyopathy
Mechanism - Proliferation of extrajunctional cholinergic receptors →more sites for potassium to leak outward from cells during depolarisation
Risk factors for hyperkalaemia - Muscular dystrophy (Duchenne, Becker): some cliniciansavoid suxamethonium in male children in case of occult myopathy - Unhealed third-degree burns - Denervation leading to skeletal muscle atrophy - Severe skeletal muscle trauma - UMN lesions - Severe abdominal infections
NOT risk factors for hyperkalaemia (CAMP) - Cerebralpalsy - Cerebral Aneurysmsurgery - Myelomeningocoele - Parkinsondisease - Stoelting |
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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 A
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. From the Women’s guidelines: Mg conc (mmol/L) - Effects 0.8 - 1.0 normal plasma level 1.7 - 3.5 therapeutic range 2.5 - 5.0 ECG changes (P-Q interval prolongation, widen QRS complex) 4.0 - 5.0 reduction in deep tendon reflexes > 5.0 loss of deep tendon reflexes > 7.5 sinoatrial and atrioventricular blockade. Respiratory paralysis and CNS depression > 12 cardiac arrest Most common side effects post administration are:
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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 |
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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
- SSEP monitoring involves stimulation of a peripheralnerve, usually the posterior tibial nerve, and detecting a spinal response withepidural electrodes or a cortical response with scalp electrodes: only thedorsal sensory pathways are monitored, not the most vulnerable anterior motorpathways - MEP monitoring involves stimulation of the motor cortex byelectrical impulses transcranially and detecting the resulting signal at spinallevel with epidural electrodes or from muscles as a compound muscle actionpotential: monitor the more vulnerable anterior cord - These are standard of care for spinal corrective surgery -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 |
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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
Normal Q waves - Due to depolarisation of the interventricular septum fromleft to right - Seen in the left-sided leads (I, aVL, V5, V6)
Pathological Q waves - > 1 mm depth - > 1 mm (= 40 ms) across
Digoxin ECG changes - Therapeutic: prolonged PR interval (AV nodal delay),shortened QTC intervals (rapid ventricular repolarisation), ST depression (↓slope of phase 3), T wave inversion - Toxic: atrial or ventricular arrhythmias (↑ automaticity),prolonged PR interval → heart block, SA node inhibition → sinus arrest - Atrial tachycardiawith block = most common arrhythmia attributed to digoxin toxicity - VF = most frequent cause of death - QRS = normal!
Q waves in MI - Occur with transmural infarctions, and are less likelywith subendocardial infarctions - Develops days after the onset of AMI, and is usuallypermanent - Indicates the part of the heart that has been damaged Diagnostic criteria for LBBB - QRS > 0.12 - No secondary R wave in V1 to indicate RBBB (= QS complex) - No septal Q wave in V5 and V6 or in leads further to theleft (I and aVL)
Wolff-Parkinson-White syndrome - Due to the presence of an accessory bundle between theatrium and ventricle, which has no AV node to delay conduction - Short PR interval - Early slurred upstroke of the QRS complex due to deltawave |
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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 |
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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 |
C - Supernasal
Why to avoid superonasal? - Globe is positioned closer to the roof than the floor ofthe orbit: risks globe perforation - Shorter distance to the deep orbit due to angle of bones:↑ risk of complications - Can damage superior oblique muscle - Can damage the origins of the ophthalmic artery and vein
Anatomy - The fascial sheath (Tenon capsule) is a thin membrane thatenvelops the eyeball and separates it from the orbital fat, thus forming asocket for the eyeball - It is separated from the outer surface of the sclera by apotential space called the episcleral space (sub-Tenon’s space)
Sub-Tenons block - Avoids complications of sharp needle techniques(retrobulbar haemorrhage, globe perforation, retinal vascular obstruction,cardiac arrest, death), more reliable compared toretrobulbar/peribulbar/topical, can safely be used in myopic patients with longglobes, does not need large injectate volume - Ensure not on anticoagulants or NSAIDS, bloods normal(block of choice if anticoagulated because bleeding points can be directlycauterised) - Sedation if explanation and reassurance is inadequate:routine use is discouraged because of ↑ intraoperative events - Topical proxymetacaine 0.5% or oxybuprocaine 0.4% toconjunctiva - Clean eye with specially formulated 5% aqueous povidoneiodine solution - Eyelid speculum is placed to retract the lids - Get patient to look superotemporally to expose inferonasalquadrant - Conjunctiva lifted with non-toothed (Moorfield’s) forceps5 mm from the limbus - A small ~2 mm incision is made in the conjunctiva withblunt-tipped (Westcott’s) scissors which are then used to dissect inferonasallyin a plane between the sclera (vascular) and Tenon’s capsule (white, avascular) - A blunt curved cannula (19G, 25 mm) is directed underTenon's fascia posteriorly, but not beyond the equator of the globe, withinjection of 3 mL of LA
LA and additives - 2% lignocaine = most commonly used and is considered thegold standard - Mixtures of lignocaine and bupivacaine, mepivacaine,etidocaine and prilocaine have also been used, but no data on relativeeffectiveness - If hyaluronidase is used, 15 IU/mL is recommended(expensive, and although SE are rare, allergic reactions, orbital cellulitisand pseudotumours have been reported)
Common complications - Chemosis - Conjunctival haemorrhage
Less common complications - Retrobulbar haemorrhage - Globe perforation - ↑ IOP - Intravascular injection with convulsions - Subarachnoid injection via the optic nerve sheath withcardiorespiratory arrest - Oculocardiac reflex
- Gayer S, Kumar CM.Ophthalmic regional anesthesia techniques. Minerva Anestesiol 2008; 74: 23-33. - Miller’s - Oxford handbook - Kumar CM, Williamson S, Manickam B. A review of sub-Tenon's block:current practice and recent development. European journal of anaesthesiology2005; 22(8): 567-77. |
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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 |
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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
Advantages - ↑ access to midline lesions - ↑ cerebral venous decompression - ↓ ICP - ↑ gravity drainage of blood and CSF
Complications - HD instability (exacerbated by anaesthetic) - Venous air embolism with the possibility of paradoxicalair embolism = most feared - Pneumocephalus - Quadriplegia - Peripheral nerve injuries: common peroneal nerve,recurrent laryngeal nerve
Indications - Posterior fossa and cervical spine surgery
Absolute contraindications 1. Patent ventriculo-atrial shunt 2. RA pressure > LA pressure 3. Cerebral ischaemia when upright and awake 4. PFO (controversial: see below)
More on PFO - Present in 25% of adults - Concern = paradoxical air embolism, but this is rare(reduced further by avoiding PEEP and administering generous fluids) - Some centres perform preoperative bubble studies toidentify PFO with a view to using alternatives to the sitting position, but thispractice is not universal - Because PAE is so rare, surgeons who are convinced thatthe sitting position is optimal for a given procedure are unlikely to bedissuaded from using it
Relative contraindications 1. Extremes of age 2. Uncontrolled HT 3. COPD 4. Degenerative disease of the cervical spine, especially inthe presence of cerebrovascular disease
- Porter JM, PIdgeonC, Cunningham AJ. The sitting position in neurosurgery: a critical appraisal.British Journal of Anaesthesia 1999; 82(1): 117-28. - Miller’s |
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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
Autonomic hyperreflexia - = Massive disordered autonomic response to stimulationbelow the level of the lesion - HT = most common and dangerous effect, and can lead tointracranial haemorrhage - Other features: reflex bradycardia, headache, sweating andsympathetic signs e.g. Horner’s syndrome - More common with high spinal lesions (85% if higher thanT7), and rare in lesions below T7 - Due to loss of descending inhibition and altered neuronalconnections within the distal spinal cord, with ↑ sensitivity to catecholamines - Most common triggers are from caudal root levels,particularly bladder distension - Other triggers: bowel distension, uterine contractions,acute abdominal pathology, UTI (cutaneous stimuli are less commonly implicatede.g. manipulation of pressure sores, ingrown toenails, sunburn) - Management: remove precipitant, upright position to ↓ BP,check IDC for blockage, loosen tight clothing, pharmacological (want rapidonset, short duration e.g. GTN patch, phentolamine 2-10 mg IV; clonidine alsotreats spasticity; deepening anaesthetic depth if GA)
Risk of hyperkalaemia with suxamethonium - Secondary to proliferation of ACh receptors - Avoid suxamethonium from 72 hours after the injury until 9months later
Other changes - CV: ↓ blood volume (as low as 60 mL/kg), abnormal responseto Valsalva (continued ↓ BP with no plateau, and no overshoot with release),postural ↓ BP - Respiratory: muscle weakness, ↓ cough, bronchialhypersecretion, paradoxical effect of posture on respiratory function (in thesupine position, the displacement of the diaphragm by abdominal contentspermits a greater excursion and forced vital capacity is optimum in thehorizontal position) - Poor thermoregulation: poikilothermic due to isolation ofhypothalamus from information pathways, inability to use muscle to generateheat, and altered peripheral blood flow - Musculoskeletal: spasms and spasticity due to intact reflexesbelow the level of the lesion, ↓ bone density → ↑ risk of fractures - Skin: poor peripheral perfusion → pressure sores,difficult IV access - Haematological: mild anaemia (associated with chronicconditions such as pressure sores and UTI), tendency to thrombosis and PE - GI: delayed gastric emptying - Chronic pain
- Dr Podcast - Oxford handbook - Hambly PR, Martin B. Anaesthesia for chronic spinal cord lesions.Anaesthesia 1998; 53(3): 273-89. |
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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
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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
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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. |
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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
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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 |
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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
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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 E
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 |
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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 |
E. Paternalism
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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
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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% |
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85.If a test is negative, what proportion will NOT have the disease:
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?D - NPV 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) |
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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
Coeliac plexus - Is the largest sympathetic plexus - Surrounds the origin of the coeliac artery at the level ofL1 - Nociceptive information from the abdominal viscera iscarried by afferents that accompany the sympathetic nerves - May be blocked in acute and chronic pancreatitis, or inconjunction with intercostal nerve blocks for intraabdominal surgery - Neurolytic coeliac plexus block is used for upper GImalignancy - The block is performed using image intensification withthe patient lying prone
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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 |
Ans: A is probably preferred in common institution. TOE requires sedation, generally in haemodynamically unstable patient perioperatively. Aortic dissection prompt diagnosis and emergency treatment are critical Cleveland Clinic Journal of Medicine 2011Diagnosis and management of aortic dissection CEACCP 2009 |
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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
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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 |
B “exam answer”
- More recent study shows same volume, lower pH
Conflicting evidence on aspiration risk…
For - ↑ intra-abdominal pressure - ↑ volume and ↓ pH of gastric contents (?) - ↑ incidence of hiatus hernia and GORD
Against - If no symptoms of GORD, the resistance gradient betweenthe stomach and gastro-oesophageal junction is normal - ↑ gastric emptying
Precautions (doesn’t have to be routine) - H2 receptor antagonists - Antacids and prokinetics - RSI with cricoid pressure - Extubation with the patient fully awake
- Juvin P, Fevre G,Merouche M, et al. Gastric residue is not more copious in obese patients.Anesthesia and analgesia 2001; 93(6): 1621-2. - Vaughan RW, Bauer S,Wise L. Volume and pH of gastric juice in obese patients. Anesthesiology 1975;43(6): 686-9. - Adams JP, Murphy PG. Obesity in anaesthesia and intensive care.British Journal of Anaesthesia 2000; 85(1): 91-108. |
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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
Cerebral vasospasm - Usually develops 3-13 days after SAH, but mostcommonly 7-10 days - Angiographic vasospasm in 2/3 and symptomatic vasospasm in 1/3 after SAH - Is the major cause of mortality and morbidity (up to 1/3) after SAH - Correlates with amount of subarachnoid blood on CT (Fishergrade 3) - The main cerebrovascular resistance during vasospasm isdetermined by blood vessels that have loss of autoregulation, therefore CBFbecomes pressure dependent (rationale for triple-H therapy)
Prophylaxis - Nimodipine - Avoidance of hypotension and hypovolaemia
Treatment - Triple-H therapy - Balloon angioplasty of the vasoconstricted vessels - Intra-arterial papaverine
More on nimodipine - 60 mg PO/NG 4/24 for 3 weeks or IVI commencing at 1 mg/hand slowly titrating - Is the only prophylaxis which has been shown to work - Mechanism: does not relieve vasospasm, instead it has aneuroprotective effect - SE: thrombophlebitis (administer through CVC), hypotension(BP management takes priority over nimodipine administration) - Protect infusion system from light
More on triple-H therapy - = Hypertension, hypervolaemia, haemodilution - Commenced if ↑ TCD velocities or neurological deficits - Mechanism: ↑ perfusion pressure and ↓ blood viscosity → ↑CBF (Poiseuille’s law) - Goals: SBP 120-150 mmHg (unclipped), 160-200 mmHg(clipped), CVP 8-12 mmHg, PCWP 15-18 mmHg, haematocrit 30% - Controversial: a recent systematic review found no goodevidence for a positive effect of triple-H therapy - Recent consensus guidelines from the Neurocritical CareSociety: hypertension, euvolaemia, no haemodilution
Not recommended - Antifibrinolytic drugs (worse outcome) - Antiplatelet drugs (no evidence of benefit)
- Priebe HJ.Aneurysmal subarachnoid haemorrhage and the anaesthetist. British Journal ofAnaesthesia 2007; 99(1): 102-18. - Luoma A, Reddy U.Acute management of aneurysmal subarachnoid haemorrhage. CEACCP 2013; 13(20):52-8. - |
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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
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ANSWER D
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