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150 Cards in this Set
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- Back
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What is the best measure of the anticoagulant effect of Dabigatran? OR The diluted thrombin time measures the anticoagulant activity of A apixaban B rivaroxaban C dabigatran D warfarin E heparin
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B - Dilute Thrombin Time
Dabigatran, an oral direct thrombin inhibitor,does not require routine monitoring;however, it is readily measured by many available coagulation assays. The partial thromboplastin time (APTT) gives an approximation of dabigatran activity but is not linear over dabigatran concentrations used clinically. The prothrombin time should not be used to determine dabigatran concentrations because it is insensitive to its effects. The thrombin time (TT) is overly sensitive for dabigatran but useful to identify low levels of the drug. The diluted thrombin time (dTT) is a sensitive method to measure the anticoagulation ef- fect of dabigatran and is increasingly used to determine its effect when needed.
Clin Lab Med 34 (2014) 479–501 |
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Small air bubbles in the arterial line system will reduce
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E Resonant Frequency A small air bubble markedly dampens the system but lowers natural frequency and causes an artifactual 25 mm Hg increase in systolic pressure. Air bubble in system Increases damping, reduces natural frequency and may therebyparadoxically increase resonance in system causing systolic overshoot.( lower naturalresonant frequency means more resonance) ( graphs given) http://web.squ.edu.om/med-Lib/MED_CD/E_CDs/anesthesia/site/content/v03/030263r00.HTM |
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Term neonate, noted to have intermittent stridor few days after birth, then parents also notice stridor during feeding and sleep. Otherwise normal and healthy. Most likely condition is
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B - Laryngomalacia Laryngomalacia stridor is strictly inspiratory, and generally intermittent, worse during feeding and sleeping, but abating during crying.
Tracheomalacia is characterized by abnormal tracheal collapse secondary to inadequate cartilaginous and myoelastic elements supporting the trachea. Tracheal narrowing occurs with expiration and causes stridor. The stridor may not be present at birth but appears insidiously after the first weeks of life. The stridor is usually aggravated by respiratory tract infections and agitation.
* Infants present after a few weeks of life with expiratory stridor (also called laryngeal crow). |
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Cryoprecipate, once thawed must use within
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D - 6 hours CRYOPRECIPITATE (CRYO)When FFP is thawed slowly at 4o C, a white precipitate forms at the bottom of the bag, whichcan then be separated from the supernatant plasma. This “Cryoprecipitated Anti-Hemophilic Factor” is 15-20 ml in volume and contains: 150-250 ml of fibrinogen, 80-100units of Factor VIII, von Willebrand’s Factor, Factor XIII, and fibronectin. It is stored frozenand must be transfused within 6 hours of thawing or 4 hours of pooling. ( transfusionmedicine updates) |
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Glycine 1.5% used for TURP, osmolality is
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A - 200 mosm/L
hypotonic |
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Blue urticaria is a complication of
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C
PB V injection or isosulfan blue Patent blue V/ isosulphan blue is the dye used for sentinel nodemapping and has caused urticaria/ anaphylaxis |
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In patients with inoperable AS, compared to medical treatment TAVI has significantly lower incidence in 30 days of
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PARTNER A Trial TAVI vs SAVR PARTNER B Trial TAVI vs maximal medical therapy Patients with TAVI vs medical therapy have higher mortality, higher stroke and same risk MI. But they have lower AF onset and lower AKI - however, neither of these was statistically significant!! Maybe pick AF??? By 1 year though mortality less with TAVI though still higher incidence TIA/Stroke 30 day mortality - SAVR > TAVI > Medical TAVI 3.4% vs Surgery 6.5% TAVI 5% vs Medical 2.8% 1 year mortality TAVI 24.2% vs Surgery 26.8% TAVI 30.7% vs Medical 49.7% Major stroke - 30 days TAVI > SAVR > Medical TAVI 3.8% vs Surgery 2.1% TAVI 6.7% vs Medical 1.7% Major stroke - 1 year TAVI 5.1% vs Surgery 2.4% TAVI 10.6% vs Medical 4.5% New onset AF TAVI 8.6% vs Surgery 16% New AF at 30 days TAVI 0.6% vs Medical 1.1% New AF at 1 year TAVI 0.6% vs Medical 1.7% MI - exactly the same in both arms 30 days 0% 1 year 0.6% AKI - 30 days TAVI 0% vs Medical 0.6% AKI - 1 year TAVI 1.1% Medical 7.3% D - AF
The incidence of new onset AF after TAVI is 10% within the first 30 days. This risk is 70% lower in patients undergoing TAVI compared to SAVR.
CVA, AKI are higher in TAVI Check - whether compared with surgical or maximal medical therapy??????? |
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EVAR, best method to reduce risk of renal impairment 2011A: 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
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N/Saline to maintain renal perfusion and decrease contrast nephropathy. |
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EVAR is preferred over open AAA repair because
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A - no has higher cost B - lower operative mortality at 30 days but not long term C - need more follow up as more surveillance due to higher risk endoleak D - More re-intervention due to endoleaks E - True - as shorter ICU stay
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Laser flex tube with double cuffs - how to inflate cuff(s)?
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B - Distal then Proximal |
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Version A: Forceps delivery. Loss of sensation medial thigh with loss of adduction at hip joint - resulted from injury to Version B: Fit and well G1P0 post epidural complaining of loss of sensation over posterior leg, lateral thigh and foot with weak flexion of knee. Which best explains the findings? (Not remembered quite correctly.) A. Femoral neve B. Obturator nerve C. Sciatic nerve D. Lumbosacral plexus E. Peroneal nerve Version C: LUSCS for failure to progress. Spinal is inserted uneventfully. Next day the patient has foot drop. The most likely cause is? A. epidural haematoma B. lumbosacral palsy C. sciatic nerve palsy D. common peroneal palsy E. ? Version D: A 30 year old lady has a vaginal forceps delivery without neuroaxial blockade. The next day she is noted to have loss of sensation over the anteriolateral aspect of her left thigh. There are NO motor symptoms. The is best explained by damage to the left sided: A. Lumbosacral trunk B. Lateral cutaneous nerve of the thigh C. Pudendal nerve D. L2/3 Nerve root E. Sciatic nerve Version E: RB38d Post partum foot drop is most frequently caused by A.compression of the lumbosacral trunk by the foetal head or forceps B.damage to the common peroneal nerve from lithotomy position.... C.damage to the conus medullaris by misplaced spinal anaesthesia D.L4 Nerve root damage from epidural analgesia E.the excessive lumbar lordosis of pregnancy stretching nerve roots Version F: You are asked to review a patient on the day after an uneventful Caesarean section under spinal anaesthesia.She is complaining ofpain and numbness on the upper, outer aspect ofher right thigh which she first noticedon the night ofthe delivery. On further questioning you establish that she has not been incontinent. Reviewofthe medical record reveals that the spinal anaesthesia was administered through a27 galge pencil-pointneedle at the L3l4 intervertebral space and was atraumatic. On examination she is moderately obese. Younote some oedema of her hands and feet. The power and reflexes in her lower limbs are normal. She has anarea of numbness to pin prick on the outer upper right thigh as shown in the illustration below. The mostlikely diagnosis is: A. A conus medullaris lesion B. a first lumbar (L1) nerve root lesion C. a second lumbar (L2) nerve root lesion D. a third lumbar (L3) nerve root lesjon E. meralgia paraesthetica
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Multiple versions and answers Version A: Obturator Nerve (L2 - L4) Damage from: Lithotomy position, acute flexion of hip, trauma from forceps blades Effect: Loss of sensation medial thigh. Inability to adduct leg Version B: Sciatic Nerve (L4 - 5, S1 - 3) Cause: Traction from Lithotomy position, mid forceps. Incorrect IM injection Pain from gluteal region down foot. Inability to flex leg. Version C: Lumbosacral Palsy Compression of foetal head against sacrum, common in mid pelvic operative NVD, may occur after epidural Loss of sensation over posterior leg (posterior cutaneous nerve), loss of sensation over lateral aspect of thigh, calf, foot. Foot drop. Weakness of quadriceps - knee flexion (L4), slight weakness of hip adductors (L4,5) Postpartum foot drop is caused by damage to the lumbosacral trunk or, less frequently, the common peroneal nerve. The lumbosacral trunk (L4, L5) is compressed between the ala of the sacrum and the descending fetal head. It may also occur during a forceps delivery. The result is a unilateral foot drop with loss of sensation and/or paraesthesia along the lateral calf and foot.""Common peroneal nerve damage may occur due to improper or prolonged positioning during lithotomy and the sensory deficit may be limited to the dorsum of the foot."Epidural haematomas extremely rare (1:168,000 from review in Anaesthesiology 2006; 105: 394)and obstetric palsies are much more common than complications related to neuraxial blocks.Sciatic nerve injury would cause a foot drop but would also affect knee flexion (hamstrings) and all muscles in lower leg and foot.Common peroneal nerve palsy less likely in this case as there is no mention of stirrups or 'excessive knee holding' Version D: Answer B: Lateral cutaneous nerve of thigh (L2-3) (Lateral femoral cutaneous) From incorrect lithotomy position, retractors at LSCS Lateral femoral cutaneous nerve arises from L2+L3 is a direct branch of the lumbar plexus. It supplies sensation to the lateral and anterior aspects of the thigh Neurologic Complications of Regional Anesthesia in Obstetrics: A Current Review Peripheral nerve injuries may occur. 1) Common peroneal nerve is prone to compression at the fibular head during positioning in stirrups. Symptoms include lateral calf paresthesia, dorsal sensory loss between the 1st and 2nd toes, along with foot drop and inversion. 2) Pressure on the lateral femoral cutaneous nerve as it passes under the inguinal ligament produces numbness along the lateral aspect of the thigh. This usually recovers spontaneously within 6 weeks. 3) The femoral nerve may be compressed by the inguinal ligament during flexion of the hip. Symptoms include quadriceps weakness and hyperalgesia in the thigh and calf. 4) The lumbosacral trunk may be injured within the pelvis by the fetal head (especially with forceps or occiput postero-lateral position). Symptoms may be unilateral (75%) or bilateral (25%) and may affect the quadriceps, hip adduction and cause foot drop. Version E: Answer is A D affects Lateral Cutaneous Nerve of thigh leading to meralgia paraesthetica Conus is at L1, so spinal below this point ---- Common peroneal nerve * dorisiflexion * sensation to anterior calf and dorsum of foot * prolonged lithotomy Lumbar sacral plexus * quadraceps * dorsiflexion * hip abduction Risk factors - primip, vertex presentation, forceps, prolonged labour and CPD Femoral nerve (lithotomy damage) * quadraceps * loss of patella reflex * hyperalgesia ant thigh and med calf Anterior spinal syndrome * loss of motor function, pain and temperature, but touch retained TNS - pain and dysaesthesia in the bum, thigh or calf, usually within 24hrs and resolves in 72hrs Risk factors - lignocaine, small needles, hyperbaric solution, high conc, lithotomy Version F: Answer E - meralgia parasthestica A : Conus medullaris ends at L1/L2Sudden bilateral pain with dural puncture,Reflex : knee jerk preserved, ankles affectedRadicular pain : minimalLumbargo : severeSensroy : saddle numbness, symmetrical and bilateralMotor : symmetric, hyperreflexic distal paresis Sphinter dysfunction E: Meralgia Paresthetica Mono neuropathy of lateral cutaneous nerve (purely sensory over anterolateral thigh, no motor) Focal entrapment as it passes through inguinal ligament Causes : DM, pregnancy, tight clothing, obesity, fetal position Treatment is conservative, lignicaine + steriod injection if paraesthesia is bad.PDF Expert - Obst - CEACCP 2003 3(4): Neurological Complications after Obstetric Regional Anaesthesia |
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Called to cath lab because patient became agitated. Unstable angina having PCI, difficult right coronary stenting. Patient was hypotensive 80/40, HR 80/min in SR. What is the next best management step?
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D TOE - possible perforation |
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A printout of 12-lead ECG
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Looked like Torsades |
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Venous air embolism during liver surgery. What is the most appropriate position to place them in? OR A patient having a liver resection suffers a haemodynamically significant venous air embolism. During resuscitation how do you best position the patient? A head up, right side down B head up, left side down C head up, no lateral tilt D head down, right side down E head down, left side down
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Answer is head down and right side up/left side down Air embolism can occur during any surgical procedure in which the operative site is 5 cm or higher above the right atrium. If possible, the operative site should be positioned below the level of the heart. This will increase venous pressure at the operative site and reduce air entrainment. If a large volume of air has been entrained, and surgical conditions permit positioning the patient in the left lateral decubitus position will help to keep air in the right atrium from entering the ventricle. The right atrial catheter should be aspirated until no more air can be obtained |
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TBI. What fluid not to give? A 23 yo has a traumatic brain injury. Which fluid is relatively contraindicated? a) Albumin b) Normal saline c) CSL d) Colloid e) Something else
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ABSOLUTE contraindication is Colloid - NOT RELATIVESome would consider CSL a RELATIVE contraindication because it becomes somewhat hypotonic. Depends on whether question says it is relative or absolute Albumin increases mortality in TBI (SAFE study). HES and gelatin worsen 6 month outcome in SAH patients.As above the BBB is disrupted in TBI which would allow colloids to cross and exacerbate cerebral oedema. Colloids are therefore absolutely contraindicated in TBI. Manipulation of osmotic forces is still universally practiced with efforts to keep serum osmolality 300-320 with mannitol or hypertonic saline.CSL is hypotonic after metabolism of the lactate so is avoided by some but used by others.0.9% saline has an osmolality of 308 so is considered by some to be ideal.Which should be used is unclear and there is no evidence either way. |
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A 6 week old baby is booked for an elective right inguinal hernia repair. An appropraite fasting time is
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ANZCA Statement on their website: Answer: BFrom ANZCA PS15 Healthy adultssolids 6 hoursclear fluids <200mL up to 2 hours Healthy children > 6/52 for elective Solid food and formula up to 6 hours Breast milk up to 4 hours Clear fluids up to 2 hours Healthy infants <6/52 for elective Formula and breast milk up to 4 hours Clear fluids up to 2 hours Consider PPI for patients with GORD |
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Hyperkalaemia of 7 or 8. Most appropriate therapy to decrease Potassium. d) Calcium
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A - insulin/glucose - 10 units Actrapid and 50mL 50% Glucose. |
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A: CTG with early decelerations. Most likely due to
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o Early decelerations (Type 1) are transient decreases in FHR (≤ 60 beats), occurring with and mirroring uterine contractions. They are nearly always benign and indicate vagal response to head compression, a normal part of the labour procress. Typical Variable - umbilical cord compression Atypical Variable - fetal hypoxaemia o Late decelerations - utero-placental insufficiency - usually bad. Fetal bradycardia indicates hypoxia General anaesthesia causes reduced variability (From AAFP article) The classically described cause of late decelerations is uteroplacental insufficiency (UPI). In UPI,there may be a problem with a uterine perfusion or uterine activity or there may be a problem withthe placenta, or both. LATE DECELERATIONSLate decelerations are associated with uteroplacental insufficiency and are provoked by uterinecontractions. Any decrease in uterine blood flow or placental dysfunction can cause latedecelerations. Maternal hypotension and uterine hyperstimulation may decrease uterine blood flow.Postdate gestation, preeclampsia, chronic hypertension and diabetes mellitus are among thecauses of placental dysfunction. Other maternal conditions such as acidosis and hypovolemiaassociated with diabetic ketoacidosis may lead to a decrease in uterine blood flow, latedecelerations and decreased baseline variability. A late deceleration is a symmetric fall in the fetal heart rate, beginning at or after the peak of theuterine contraction and returning to baseline only after the contraction has ended. Thedescent and return are gradual and smooth. Regardless of the depth of the deceleration, all latedecelerations are considered potentially ominous. A pattern of persistent late decelerations isnonreassuring, and further evaluation of the fetal pH is indicated. Persistent late decelerationsassociated with decreased beat-to-beat variability is an ominous pattern Perinatology.Com - Fetal Heart Rate Monitoring“Early decelerations appear to be caused by vagal discharge produced when the head is compressed by uterine contractions. The onset and depth of early decelerations mirror the shape of the contraction, and tend to be proportional to the strength of the contraction.Late decelerations occur when a fall in the level of oxygen in the fetal blood triggers chemoreceptors in the fetus to cause reflex constriction of blood vessels in nonvital peripheral areas in order to divert more blood flow to vital organs such as the adrenal glands, heart, and brain. Constriction of peripheral blood vessels causes hypertension that stimulates a baroreceptor mediated vagal response which slows the heart rate. The time consumed in this two step process accounts for the delay in the timing of the deceleration relative to the contraction”
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A: Infective endocarditis prophylaxis indicated in a) Uncorrected CHD b) Bicuspid valve c) Patch Repair of VSD d) Previous Mitral valve ring annuloplasty OR B: Infective endocarditis in patient with MVR appropriate for a) Dental procedure
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91a A - uncorrected CHD. Not Biscuspid valve and not Patch Repair after 6 months when should have endothelialised.
91b - Dental procedure in some circumstances. Not rigid bronch. Not endoscopy and biopsy per new guidelines. Not usually given for lithotripsy. So most likely answer is DENTAL Antibiotic prophylaxis is recommended in patients with the following cardiac conditions who are undergoing certain dental procedures (see Table 2.2) or other procedures (see Table 2.3 and Table 2.4) * prosthetic cardiac valve or prosthetic material used for cardiac valve repair * previous infective endocarditis * congenital heart disease but only if it involves:unrepaired cyanotic defects, including palliative shunts and conduits * completely repaired defects with prosthetic material or devices, whether placed by surgery or catheter intervention, during the first 6 months after the procedure (after which the prosthetic material is likely to have been endothelialised) * repaired defects with residual defects at or adjacent to the site of a prosthetic patch or device (which inhibit endothelialisation) * rheumatic heart disease in high-risk patients |
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Prothrombinex VF is useful in the perioperative period to correct the coagulopathic defect of all of the following except ▪ A. Isolated factor II deficiency |
B - does not contain enough Factor 7. |
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Paeds pt # arm 2 days ago. Current URTI. lowest risk of laryngospasm. A. ETT B. LMA with IPPV C. LMA with spont vent D. Mask with spont vent |
D - lowest with mask Risk was lower with intravenous induction compared with inhalational induction (all p<0·0001), inhalational compared with intravenous maintenance of anaesthesia (all p<0·0001), airway management by a specialist paediatric anaesthetist compared with a registrar (all p<0·0001), and use of face mask compared with tracheal intubation (all p<0·0001). |
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Mid procedure patient with CVC in situ. LIM alarms indicate loss of floating circuit. What is most appropriate mx? A. Stop surgery B. Disconnect with CVC C. Immediately ground the patient D. Disconnect non essential equipment from circuit until fault identified Seems similar to 2007B: Adult male who isintubated and ventilated, with CVL in situ. Just before surgeon starts the LineIsolation Monitor alarms about a leak at 5mA. What do you do? A. stop procedure and move to a safe location B. sequentially remove non essential monitors from the circuit until fault isidentified C. unplug the CVL to electrically isolate it until fault is identified D. ensure the patient is earthed E. Check the diathermy pad
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Could be to unplug CVL due to risk of micro shock? Or to sequentially remove non-essential monitors until fault found - theoretically with last one plugged in first... The LineIsolation MonitorBasically,the line isolation monitor determines the degree of isolation between the twopower wires and the ground and predicts the amount of current that could flowif a second shortcircuit were to develop. An alarm is activated if anunacceptably high current flow to the ground becomes possible (usually 2 mA or5 mA), but power is not interrupted unless a ground-leakage circuit breaker(also called a ground-fault circuit interrupter) is also activated. The latteris usually not installed in locations such as operating rooms, wherediscontinuation of life support systems is more hazardous than the risk ofelectrical shock. The alarm of the line isolation monitor merely indicates thatthe power supply has partially reverted to a grounded system. In other words,while the line isolation monitor warns of the existence of a single fault(between a power line and a ground), two faults are required for a shock tooccur. If an alarm is activated, the last piece of equipment that was pluggedin is suspect and should be removed from service until it is repaired. |
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What is the mechanism for heat loss under GA? A. Redistribution of body heat B. Decreased production C. Increased heat loss |
A - redistribution body heat |
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In a 140kg obese patient, compared to a 70 kg person ▪ A. cardiac output >20% lower A morbidly obese 140kg, 40-year-old male is scheduled forcholecystectomy. He has no history of cardiac disease. His ideal body weight is 70kg. Compared to his resting cardiac output at ideal body weight, his resting cardiac output at his weight of 140 kg would be A. decreased by 20% or more B. decreased by 10% C. unchanged D. increased by 10% E. increased by 20% or more
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Either D or E depending on what source!!! Obesity is associated with an increase in blood volume and cardiac output, the latter rising by 20–30 ml per kilogram of excess body fat BJA Volume 85, Number 1 Pp. 91-108 but Miller : 10ml/min per kg of fat 140kg total weight IBW = 70kg LBW = IBW + 20% = 84kg Fat mass = 56kg * 20mL/kg = 1.1L extra CO when normal is 5L - this is about 20% but if Miller says only 10mL/kg - this would be about 10% extra. |
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Best option to reduce risk of ventilator induced pneumonia?
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C - oral hygeine to prevent aerodigestive colonisation Not A because head up Not B because won't change anything. Not E because not recommended. Numerous google search says C probably best. Although antacids are also prescribed. |
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Which drug should be avoided both intra- and post operatively in a woman having surgery who is breast feeding a 6 week old baby?
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A - Codeine -can cause deaths. Pethidine not included in some remembered sets of options. From Acute Pain Management Scientific Evidence 2010:A. There has been a death in a child of a rapid metaboliser, and other babies have shown decreased alertness, poor feeding, and lethargyB. Morphine: Safe (The recommended opiod for use in breastfeeding mothers)C. Paracetamol: SafeD. Parecoxib not specifically mentioned. Celecoxib and most other NSAIDs: Safe (Ibuprofen safest)E. Tramadol is concentrated in breast milk, but appears to be safeF. (If this was even an option): Infants are detectably more drowsy, and norpethidine excretion in neonates is slow. Pethidine is not recommended.Aspirin: UnsafeIndomethacin: Associated with maternal psychosis in the post-natal period.Fentanyl, Midaz, propofol: so safe that mothers probably don't need to discard breast milk after a GA. |
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The clinical sign that a lay person should use to decide whether to start CPR is:
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Both C and E are true. But if unconscious and breathing you don't do CPR. So E is more true. |
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An 80yo man is having a transuretheral bladder resection, the surgeon is using diathermy close to the lateral bladder wall which results in patient thigh adduction. The nerve involved is: A. Inferior gluteal B. Obturator C. Pudendal D. Scaitic E. Superior gluteal |
B. Obturator Regional anaesthesia does not abolish the obturator reflex ( external rotation and adduction of the thigh secondary to stimulation of the obturator nerve by electrocautery current through the lateral bladder wall). |
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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 |
E - ideally spontaneous ventilation but as patient may be non-fasted and surgeons may want paralysis for procedure then probably C - short I time is best (if PPV used). This decreases thoracic pressures and promotes passive venous return CEACCP 2008Fontan procedure is to divert all systemic venousblood into the pulmonary arteries, without the interposition of a ventricle. Inpatient with a single ventricle the pulmonary and systemic circuit runs inparallel. So change the system into a single pump instead of two pumps inseries. Goals: 1.Maintain ventricular function 2.Minimise V/Q mismatch 3.Optimise pulmonary blood flow a.Avoiddecrease intravascular volume. i.e. Avoid hypovolaemia. b.MinimisePVR i.Avoidacidosis ii.Avoidhypoxia iii.Avoidhypercarbia i iv.Minimalincrease in mean intrathoracic pressure v.Avoidvasoactive drugs vi.Adequateanalgesia and anaesthesia Forrelatively short procedures, Fontan patients are probably better off breathing spontaneously, as long assevere hypercarbia is avoided. For major surgery, or when prolonged anaesthesia isrequired, control of ventilation and active prevention of atelectasis is usuallyadvisable. Potential disadvantages of mechanical ventilation in Fontan patientsrelate to the inevitable increase in mean intrathoracic pressure. This causes decreased venous return, decreasedpulmonary blood flow, and hence, decreased cardiac output. Low respiratoryrates, short inspiratorytimes, low PEEP, and tidal volumes of 5 - 6 ml kg usually allow adequatepulmonary blood flow, normocarbia, and a low PVR. Hyperventilation tends toimpair pulmonary blood flow, despite the induced respiratory alkalosis, becauseof the increased mean intrathoracic pressure. |
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Young man has removed his buprenorphine patch on the morning of surgery. What time till PLASMA reaches half original level A. 12 hours B. 18 hours C. 24 hours D. 30 hours E. 36 hours |
Answer: A - 12 hours Reference: Acute pain management scientific evidence 2010 p163. (From 2013B) Norspan product information“After removal of a NORSPAN patch, buprenorphine concentrations decline, decreasing approximately 50% in 12 hours (range 10 - 24 h)” |
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A 58yo with solitary hepatic metastasis from colon cancer scheduled for resection of R lobe of liver. Inorder to manage the risk of intra-operative haemorrhage, it is most important to maintain: A. High CVP in anticipation of heavy blood loss B. Decreased MAP to reduce arterial bleeding C. Decreased CVP to reduce venous bleeding D. Normal MAP in anticipation of heavy blood loss E. Normal CVP to ensure adequate filling of the heart. |
Decreased CVP to reduce venous bleeding - as per below Blood loss is significantly reduced using temporary occlusion of the blood supply to theliver during parenchymal resection. This may involve total inflow occlusion of the portalvein and hepatic artery (Pringle manoeuvre). The resulting decrease in cardiac output of upto 10% and increase in left ventricular afterload of 20–30% may cause cardiovascularcompromise. Segmental vessels can also be identified and selectively occluded, causingless cardiovascular disturbance. Very occasionally, total hepatic vascular occlusion isrequired to access tumours close to the vena cava, which involves clamping of the supraand infra-hepatic vena cava and also the hepatic pedicle. However, this technique isassociated significant haemodynamic compromise, with reductions in cardiac output of upto 60% and severe hypotension. During parenchymal resection hepatic inflow occlusion, the main source of bleeding isbackflow from the valveless hepatic veins. The control of central and thus hepatic venouspressure is crucial to reduce the blood loss. It has been well documented that a CVP of >5cm H2O significantly increases bleeding. However, the risks of maintaining a low CVPinclude cardiovascular instability and air embolism, but the theoretical risk of increasingpostoperative renal dysfunction does not appear to be clinically important. Some patientsrequire a CVP of >5 mm Hg for cardiovascular stability, and in these patients an individuallytailored compromise needs to be achieved. Most patients will become hypotensive afterinduction, especially if an epidural is used, which can initially be treated with head down tiltand infusions of vasoconstrictors such as phenylephrine or an inotrope such as low-dosedobutamine (<3 μg kg−1 min−1). Pre-resection fluid transfusion should be restrictedalthough small colloid boluses may be appropriate if urine output falls to <0.5 ml kg−1 h−1or in the presence of refractory hypotension. High CVP can be treated with diuretics ornitrate infusion. After the resection phase, circulating blood volume can be restored as therisk of bleeding, while still present, is much reduced. Surgical access to posterior liver tumours may involve transient compression of the inferiorvena cava, which can cause profound hypotension. Fluid transfusion will maintain bloodpressure during these episodes but will also elevate CVP and promote bleeding. The bestmanagement of this situation involves cautious fluid transfusion and close communicationwith the surgical team. Positive end expiratory pressure not only reduces lung atelectasisbut also elevates CVP and reduces liver blood flow, so should be avoided during theresection process. Mortality ~3% in selected population (otherwise healthy patients with resections <50% of non-cirrhotic livers)Child-Pugh B+C contraindicatedPre-existing cirrhosis confers 32% chance of post-operative liver failureHepatic pedicle clamping - warm ischaemic time max 60 mins. If intermittent (15 on 5 off) then up to 90 mins.Clamping makes BP go up.Theoretical concerns re: epidurals given post-op coagulopathyUse tranexamic acidCVP and IABP monitoringTemp and NMB monitoringMonitor closely for hypoglycaemiaAim CVP < 5 (May cause low BP and air embolism but reduces bleeding)Minimise mean airway pressure and PEEPBeware of IVC compression with posterior tumours -> profound hypotensionN-acetylcysteine infusions might help liver recover. Evidence is equivocal.Avoid paracetamol until liver dysfunction has resolved post-op.May develop ascites transiently post-op and become intravascularly dry - consider 20% albumin.Likely to need FFP |
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In Conn's syndrome, the usual derangement is: A. Hypoglycaemia, hypokalaemia and hypernatraemia B. Hypoglycaemia, hyperkalaemia and hyponatraemia C. Normoglycaemia, hypokalaemia and hypernatraemia D. Normoglycaemia, hyperkalaemia and hyponatraemia E. Hyperglycaemia, hyperkalaemia and hyponatraemia |
C - Normal sugar, increased Na, decreased K Primary hyperaldosteronism - Aldosterone has effects on most or all cells of the body but, clinically, the most important actions are on cells of the late distal tubule and medullary collecting duct. In the principal cells aldosterone increases activity of basolateral membrane sodium-potassium ATPase and apical epithelial sodium channels, ENaC, as well as potassium channels, ROMK. These actions increase sodium reabsorption and potassium secretion. Since more sodium is reabsorbed than potassium secreted, it also makes the lumen more electrically negative, causing chloride to follow sodium. Water then follows sodium and chloride by osmosis. In Conn syndrome, these actions cause increased extracellular sodium and fluid volume and reduced extracellular potassium. Aldosterone also acts on intercalated cells to stimulate an apical proton ATPase, acidifying urine and alkalizing extracellular fluid causing a metabolic alkalosis. |
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NEW A 60 year old woman is admitted to hospital with subarachnoid haemorrhage. Her GCS is 11, and her blood pressure is 175/110 mmHg. She is administered oral nimodipine. The main reason for this treatment is: A. Control her blood pressure B. Manage acute hydrocephalus C. Prevent delayed cerebral ischaemia D. Reduce the risk of rebleeding E. Treat angiographically-proven cerebral vasospasm |
Treat angio-graphically proven cerebral vasospasm |
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NEW You are inducing a 20-year-old female who has an IV cannula in her antecubital fossa which was inserted in the emergency department. She complains of pain after 10mL of propofol and it becomes clear that cannula is intraarterial. The best management option is: A. Intraarterial injection of 5mL 1% lignocaine B. Intraarterial injection of 30mL Normal Saline C. Intraarterial injection of 50mg paperverine D. Intraarterial injection of 500u heparin E. Observation(this may not be worded correctly - feel free to correct) |
Lignocaine - possibly but can cause vasoconstriction and decreased blood supply (see below) N/S - no Papaverine - dose sounds reasonable per google search - probably correct answer Heparin - give to prevent thrombosis - but not arterially. From CEACCP article There is no universally accepted treatment protocol; most interventions attempt to maintain perfusion distal to the site of injury. The affected extremity should be elevated to improve venous and lymphatic drainage, and analgesia given as a priority. The extent of the injury should be identified and documented carefully and plastic surgery advice sought. As thrombosis is ultimately the cause of the tissue injury, anticoagulation with heparin should be considered in an attempt to limit the extent of the ischaemia. Other specific interventions include:Local anaesthetic injectionIA injection of lidocaine through the implicated cannula may prevent reflex vasospasm. However, this procedure may actually damage the artery and compromise the blood supply to the already affected limb. Extremity sympatholysisStellate ganglion blocks and lower-extremity sympathetic blocks will produce sustained arterial and venous vasodilatation, but the potential benefit must be weighed against the risks of the procedure.Other pharmacological therapies Calcium channel blockers have been tested with varying results. Thromboxane promotes vasoconstriction, and drugs which inhibit thromboxane (aspirin, methylprednisolone) may help to reverse the tissue ischaemia. Iloprost is a prostacycline analogue with vasodilatory and platelet-inhibiting properties and IA papaverine facilitates vascular smooth muscle relaxation; both these have been used as part of a multimodal approach to treatment with varying success. |
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NEW When is it necessary to use glycine as irrigation fluid for TURP? A: For monopolar diathermy B: For bipolar diathermy C: For Nd:Yag laser D: Greenlight laserI'm 90% sure bipolar diathermy was not an option, making monopolar the best answer. |
Googled....answer appears to be Glycine for Monopolar Diathermy Types of TURP Monopolar TURP: Conventional TURP removes tissue with a wire loop that has electrical current flowing in one direction (monopolar) through the resectoscope to cut the tissue. The surgical site is irrigated with nonconducting fluid. The fluid prevents the electrical current from disturbing surrounding tissues, but it can damage surrounding tissue after prolonged exposure, resulting in TUR syndrome. This limits surgery time. Bipolar TURP: A newer technique, Bipolar TURP uses bipolar current to remove the tissue. Because it allows for saline irrigation (instead of nonconducting glycine as in monopolar TURP) it reduces complications such as TUR syndrome. This allows for longer procedure length. |
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A 39 yo man is brought into ED by ambulance with a compound fracture of his forearm from an unwitnessed fall. Has a history of schizophrenia and depression with uncertain medication compliance. He is confused and agitated with generalised rigidity but no hyperreflexia.Obs - HR 120, BP 160/90, RR 18, Sats 98 Temp 38.8 Likely Dx? A. Heat stress from anticholinergic therapy B. Hypoxic ischaemic encephalopathy C. Neuroleptic malignant syndrome D. Serotonin syndrome E. Pain from the compound fracture |
NMS from history - NMS has rigidity but not hyperrelexia. Serotonin Syndrome is similar but has HYPER-REFLEXIA/CLONUS Neuroleptic malignant syndrome rigidity, tachypnoea, tachycardia, hypertension,hyperthermia, autonomic lability, altered level of consciousness, raised creatinine kinase. NMS c.f. MH - MH has all above EXCEPT not autonomic lability and ?level of consciousness. This is because NMS is a central pathophysiology and MH is peripheral (Ryanodine receptor) NMS c.f. SS - SS has: Cognitive effects: headache, agitation, hypomania, mental confusion, hallucinations, coma Autonomic effects: shivering, sweating, hyperthermia, vasoconstriction, tachycardia, nausea, diarrhea. Somatic effects: myoclonus (muscle twitching), hyperreflexia (manifested by clonus), tremor. |
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NEW With surgical bleeding, the first clotting factor to reach a critical level is A. I B. II C. VII D. X E. XIII |
Fibrinogen is first factor to decline "Fibrinogen deficiency can develop in the event of massive transfusions in the context of loss and dilution coagulopathy, because primary replacement by crystalloids, colloids and red blood cell concentrates is performed almost exclusively without plasma. In such situations fibrinogen, the coagulation factor most quantitatively represented, is the first procoagulant factor to decline, dropping to a critical level of 1.5–2 g/L" And Fibrinogen is FACTOR 1 - so here answer is A |
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RPT Anaesthetic and respirable gas supplies to wall outlets in the operating theatre is at pressures of A. 200kPa B. 400kPa C. 500kPa D. 750kPa E. 1200kPa |
Per Miller - 50 psi which is 350 kpa - so answer presumably is B - 400kpa |
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NEW The most useful sign to distinguish between severe serotonin syndrome and malignant hyperthermia are A. Clonus B. Hyperthermia C. Metabolic acidosis D. Muscle rigidity E. Wheeze |
A - Clonus Both have Hyperthermia, Metabolic Acidosis and Muscle Rigidity BUT Serotonin Syndrome is characterised by Hyperreflexia/Clonus and MH by decreased reflexes. |
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NEW Patient having a laparotomy. On prednisolone for 6/12, 10mg/day. What is the equivalent dose of dexamethasone? A) 2mg B) 4mg C) 6mg D) 8mg E) 10mg (or was the option 12mg?) |
Plugged into Dose Conversion Prednisone 10mg/day is 1.5mg Dex 40mg Hydrocortisone so pick 2mg/day |
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Patient having an operation of a lacerated index finger under regional anaesthesia. Which combination will provide adequate cover? |
Per graphic you need to block MN and RN - so above/below the artery - whichever numbers corresponded to this - had choice of only two numbers. |
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Child 20kg having a caudal. Has a VF arrest post non-responsive to usual treatments. What dose of intralipid 20% would you give? A) 10mL B) 20mL C) 30mL D) 40mL E) 50mL |
Initial dose is 1.5mL/kg - thus 20kg * 1.5 = 30mL |
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Labour epidural placed. Headache postpartum. Which of the following is inconsistent with post partum dural puncture headache. (a) Headache located frontal only (b) Presents > 24 hrs post partum (c) presents immediately post partum (d) associated with auditory symptoms (e) associated with neck stiffness |
Best answer is C - presents immediately post-partum A=Partly True. Typically fronto-occipital, but can be frontal, occipital or nuchal (Evidence-Based Obstetric Anaesthesia, Halpern & Douglas, BMJ Books; Blackwell, 2005; p.192) • B=True - Usually starts 24-48 hrs after dural puncture. • C=False. Most commonly starts 24-48 hrs later. • D=True. Hearing loss and/or tinnitus are features. E=True. Neck stiffness and photophobia are common. |
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NEW Eclamptic patient. Given Magnesium intravenously. Which of these symptoms is often associated with magnesium administration? (a) Bradyarrhythmia (b) Cardiac arrest (c) Hypotension (d) Depressed respiratory effort (e) |
C - Hypotension - guess from googling... Magnesium Concentration (mmol/L) Effects 0.8 – 1.0 Normal plasma levels 1.7 – 3.5 Therapeutic range 2.5 – 5.0 ECG Changes * P-Q interval prolongation * Widened QRS complex 4.0 – 5.0 Reduction in deep tendon reflexes > 5.0 Loss of deep tendon reflexes > 7.5 SAN and AVN blockade Muscle paralysis Respiratory and CNS Depression > 12 Cardiac Arrest Common side effects of this medicine include:Muscle weakness and lack of energy. Blurry vision. Slurred speech. Headache. Nausea and vomiting. Flushing. Stuffy nose. |
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What is the maintenance fluid rate for a 15kg child? A. 40mls/hr B. 50mls/hr C. 90mls/hr D. 300mls/hr (Options above may not be correctly remembered..) |
10 * 4 + 5 * 2 = 50mL/hr using 4:2:1 rule |
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RPT A 63 yo lady has a difficult thyroidectomy for cancer. Immediately post extubation she develops stridor and respiratory distress.The most likely cause is A) Hypocalcaemia B) recurrent laryngeal nerve palsies c) tracheomalacia d) Neck oedema and haematoma e) Vocal cord oedema |
Answer is B, as only RLN palsies and vocal cord oedema would give stridor Get hypocalcaemia (not hypercalcaemia) usually at 24hrs and this is a rare complication Bilateral recurrent laryngeal nerve palsies usually present with stridor and occur in 5-20% surgeries for cancer - clue here is that this was a difficult surgery ie increased risk nerve damage Tracheomalacia secondary to long standing goitre very rare and requires immediate re intubation |
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NEW 50 something yr old smoker presents for laparotomy. RFTs given, what is the cause? FEV1, FVC both reduced, FEV1/FVC 98%. TLC, RV, DLCO 8 (pred = 30) (a) PE (b) Obesity (c) Bilateral phrenic nerve palsies (d) Pulmonary fibrosis (e) COPD |
I think D |
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Patient with traumatic brain injury has the following readings. Global CSF flow measured at 15ml/100gm/min while the CMRO2 is measured at 3.5ml/100gm/min. There is A appropriate coupling of cerebral perfusion and cerebral metabolism B autoreguation of cerebral vasodilation C cerebral hypoperfusion D cerebral ischaemia E reperfusion injury |
D - ischaemia means inadequate blood supply which this is. Hypo perfusion (C) means inadequate oxygen to tissues From wiki: 15 ml of blood carries 0.015 X 200ml (normally about 200 ml of O2 per litre of blood) = 3 ml. Delivery ~ 3 ml/100g/min : Requirement 3.5 mL/100g/min. Normal CBF = 50ml/100g/kg or 15%CO or 750ml/min, if less than 20ml/100g/kg this represents ischaemia. No electrical activity below 18 as anaerobic with EEG flat Normal CMR02 = 3.5ml/100g/kgIn this instance there is reduced flow with normal extractionIn traumatic brain injury there is oedema leading to increased ICP and low CPP and therefore decreased CBF NB normal CBF is 750 ml/min or 50 ml/100g/min not 15 |
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FFP is given to a patient to treat hypofibrinogenaemia. The volume required to raise the fibrinogen by 1g/L is A 1mL/kg B 5mL/kg C 10mL/kg D 20mL/kg E 30mL/kg |
E - 30mL/kg Efficacy of standard dose and 30 ml/kg fresh frozen plasma in correcting laboratory parameters of haemostasis in critically ill patients. British Journal of Haematology. 2004In this study administration of 33ml/Kg of FFP increased Fibrinogen by 1g/L“In group 2, all seven of the patients who had had low coagulation factor levels before FFP had levels above 30 IU/dl post-FFP (33 ml/kg). The median increment for group 2 for the individual coagulation factors was between 17 and 44 IU/ dl. The fibrinogen increased by a median of 1 g/l, although this was not significantly different from group 1” |
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In a trauma patient the main mechanism by which hypothermia exacerbates bleeding is by A altered blood viscosity B causing DIC C inhibition of clotting factors D potentiation of anticoagulant effect of drugs used to treat DVT E decreases platelet number and function |
C - per below Even mild hypothermia in a trauma patient can result in devastating physiologic consequences. Of particular concern is the effect of hypothermia on the coagulation system. The coagulation system is a temperature- and pH-dependent series of complex enzymatic reactions that result in the formation of blood clots to stop both internal and external hemorrhage.Coagulopathy is the term used to describe a broad group of disease states in which there is an impaired ability of this coagulation system to synthesize blood clots. It’s been repeatedly demonstrated that as a patient’s core temperature decreases, so does the body’s ability to stop bleeding. This is a result of impaired platelet function, inhibition of the clotting factors, and inappropriate activation of clot breakdown. Not E as only inhibits function not number. |
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NEW In a normal adult what amount of IV potassium chloride is needed to raise the serum potassium from 2.8 to 3.8mmol/L? A 10mmol/L B 20mmol/L C 50mmol/L D 100mmol/L E 200mmol/L |
Best answer is 100 mmol - see below Medscape: In general, a 1 mEq/L drop in potassium correlates to a loss of 100-200 mEq of total body potassium Elsewhere on web: 10 mEq will raise by .1 mEq/L - so to raise by 1mEq/L multiply by 10 - so 100 mEq - i.e. 100 mmol. Maximum rate peripheral 10 mmol/hr Maximum rate CVC 20 mmol/hr |
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In a haemodynamically stable 20 year old man with blunt chest trauma, the best screening test to diagnose cardiac injury requiring treatment is: A CXR B serum CK-MB C serum troponin D 12 lead ECG E Transthoracic Echocardiogram |
E - Per article. Others may or may not indicate damage but will not be accurate enough to tell you treatment is needed. Heart. 2003 May; 89(5): 485–489.PMCID: PMC1767619Diagnosing cardiac contusion: old wisdom and new insightsK C Sybrandy,1 M J M Cramer,1 and C Burgersdijk A - CXR "Chest radiography and thoracic computed tomography provide no additional information for the diagnosis of cardiac contusion but may show associated injury of the great vessels, or skeletal or pulmonary structures" B - Serum CK "However, in multitrauma with high CK concentrations many false positive increases were found. The usefulness of CK-MB determination seemed to be restricted to the detection of myocardial trauma in case of mild non-cardiac injuries. More recent studies reported low sensitivity and specificity of CK-MB for cardiac injury in this category of mildly injured patients. Therefore, CK-MB determination is of limited value in the detection of myocardial injury. C - Troponin - Serum cardiac troponins, troponin I and troponin T, are highly specific to myocardial injury. They are myocardial regulatory contractile proteins not found in skeletal muscles and are released into the circulation only after loss of membrane integrity. The latest studies showed high accuracy of both troponin I and troponin T in the diagnosis of cardiac injury. Moreover, a normal concentration of cardiac troponin I or T has been reported by several investigators to be a strong indicator for the absence of cardiac injury in patients with blunt chest trauma D - Because of its anterior position in the thorax and proximity to the sternum, the right ventricle is far more frequently injured than the left ventricle. The ECG mainly reflects the electrical activity of the left ventricle because of its greater mass. The ECG is relatively insensitive to right ventricular electrical activity. For that reason, a cardiac contusion usually results in moderate right ventricular damage with only minor electrical changes, which can easily be missed on an ECG. E - "Contused myocardial tissue not only resembles infarcted myocardial tissue histologically but also functionally. A myocardial contusion can be recognised by localised myocardial wall dysfunction. Consequently, two dimensional echocardiography, which provides a direct view of wall motion abnormalities, has been shown in several studies to be an excellent tool in the detection of cardiac injury. In addition, echocardiography may show associated valvar lesions, intracardiac shunts or thrombosis, pericardial effusion or tamponade, and ventricular dilatation. From a practical standpoint, other important advantages of echocardiography are its non-invasive nature and its ease of use at the bedside and in the emergency department." |
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NEW With regards to medical ethics, the concept of fidelity involves: A equitable distribution of resources B following a professional code of conduct C promoting well being D wise use of resources E witholding of futile treatments |
Fidelity means to maintain trust with patient / honouring trust placed in practitioner / being trustworthy. By elimination has to be B - following professional code of conduct Non-malificence - avoiding harm - E Benificence - promoting client's well being - C Justice - fair and impartial treatment - equal allocation of resources. - A |
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What is the correct position for the tip of a PICC in a child a) Carina b) Below right tracheobronchial angle c) Above right heart border d) Sternoclavicular junction e) ?? can't remember |
Answer appears to be A - carina Coroners report PICC line AR summary Feb 10.doc from ANZCA website “Even though the tip is considered to be adequately positioned when at the SVC/RA junction this position is still within the pericardial reflection and erosion could still result in tamponade. As mentioned by one of the independent experts, 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/communications/anzca-e-newsletter/e-news-articles/Coroners%20report%20PICC%20line%20AR%20summary%20Feb%2010.doc/view |
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Image of a lateral C-spine Xray. Asked what the diagnosis was.[Terrible image quality. When will anzca learn that you can't just photocopy an x-ray!! Seemed to have anterior atlantoodental interval >9mm.] a) Atlantoaxial instability b) Retropharyngeal haematoma (?or abscess) c) Tear drop fracture d) Epiglottitis e) unilater facet joint dislocation |
Unknown - maybe A |
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According to the ANZCA endorsed guidelines, what is the correct colour for the label for a subcutaneous ketamine infusion a) Pink b) Red c) Beige d) Blue e) Yellow National labelling standards endorsed by ANZCA. What colour should the label on a brachial plexus catheter infusion be? A. Red B. Blue C. Beige D. Yellow E. Pink Another one asked about intra-osseus = pink |
From http://www.safetyandquality.gov.au/wp-content/uploads/2012/03/Labelling-Recommendations-2nd-edition-February-2012.pdf red = arterial blue = venous yellow = perineural/nerve catheter beige = subcutaneous pink = other |
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New Prior to nasal intubation you spray Lignocaine/Phenylephrine preparation (CoPhenylcaine) into the nose. Some lands in the eye. What happens? a) Ecchymosis b) Myosis c) Mydriasis d) Proptosis e) Nistagmus |
Phenylephrine dilates the eye (as used for Eye Surgery) so answer C |
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NEW-ish (same question with different numbers previously) You trial a new drug to prevent PONV. It is 50% more effective than the current drug. Four percent of people still experience PONV with the new drug. How many people need to receive the new drug in place of the current drug to have one person less suffering from PONV? |
Assume 100 people in trial. 50 get each drug. New drug - 4% people get symptoms But it is 50% more effective than old drug - so old drug 8% get symptoms ARR = 0.08 - 0.04 = 0.04 NNT = 1/ARR = 1/0.04 = 25 (which was one of the options) |
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What does a white cylinder with a Grey coloured shoulders/neck contain? a) Medical air b) Carbon Dioxide c) Helium d) Oxygen e) Argon |
CO2 is White cylinderwith grey shoulder? CO2 - white with grey shouldersis Air - white with black and whiteshoulders Oxygen - All white (old cylinders areblack with white shoulders) N2O - White with blueshoulders entonox is blue/white shoulders Nitrogen - White with black shoulders |
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The best solution to ensure asepsis prior to neuraxial anaesthesia is A. 0.5% Chlorhexidine B. 0.5% Chlorhexidine with 70% alcohol C. 5% Povidine Iodine D. 5% Povidine Iodine with 70% alcohol E. 10% Povidine Iodine |
PS28 recommends 0.5% chlorhexidine in 70% alcohol |
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Repeat Apr09 You are anaesthetising a 70 year old woman for CABG with a pulmonary artery catheter in situ. After separation from bypass you notice frank, copious blood rising in the endotracheal tube. Your immediate action should be to: A. Check ACT B. Insert a double lumen tube C. Reinstate bypass D. Administer protamine E. Pull back the pulmonary artery catheter several centimetres |
C - Reinstate Bypass
From Journal of Cardiothoracic and Vascular Anesthesia, Vol.15, Issue 3, Pg 377-380:Massive tracheobronchial hemorrhage during weaning from CPB is a rare but well-known and feared complication because of the high mortality rate. The largest number of reported cases have involved PA perforation from a PA catheter. The authors present 2 cases that illustrate there are other causes (this is presumed because there is no mention of the use of a PA catheter in either patient). These cases point out that there are general principles of management that apply whatever the cause of airway hemorrhage during CPB.First, these patients usually die from hypoxemia, not from hypovolemia, if the underlying cause of the hemorrhage is not diagnosed and treated. Second, oxygenation can be assured by resumption of CPB, and the anesthesiologist and surgeon must resist the temptation to wean rapidly and reverse the anticoagulation inthe hope that this will stop the hemorrhage...If the patient is being weaned from CPB and extensive bleeding through the endotracheal tube is seen, the patient should be returned to CPB. This approach allows 2 maneuvers to occur: (1) determine site and mechanism of airway injury, and (2) initiate additional maneuvers that reduce the soilage of the lung by blood. Certain unique aspects of the management of PA perforation are subsequently discussed |
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Which volatile agent has got minimum effect on ICP at 1 MAC a) isoflurane b) sevoflurane c) desflurane d) enflurane e) halothane |
B -- Sevo. Current Opinion in Anaesthesiology: October 2006 - Volume 19 - Issue 5 - p 504-508 |
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New You are inserting a right internal jugular vein CVL. Why is it important to avoid turning the patient's head extremely to the left? a) Uncomfortable for the patient b) Increases risk of internal carotid artery puncture c) Compresses internal jugular vein and makes it more difficult to puncture d) Distorts the anatomy, making the vein more difficult to correctly identify e) Increases risk of external jugular vein puncture |
B - from google search below Article Contralateral rotation of the head brings the sternocleidomastoid muscle into an anterior position over the internal jugular vein impeding cannulation, especially from the anterior approach. Contralateral rotation beyond 40° increases the anterior-posterior overlap of the internal jugular vein with the carotid artery, increasing the risk of arterial puncture. Medscape: In addition, extreme rotation of the neck may bring the internal jugular vein more anterior to the carotid artery, thus increasing the chances of arterial puncture. |
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New Patient two hours after bilateral crush injuries to lower limbs. What would you expect to see? a) Hypocalcaemia b) Hypokalaemia c) Hypophosphataemia d) Hypouricaemia e) Metabolic alkalosis |
A - True - as Hyperphosphataemia - which would bind with Calcium B - False- HYPERkaleamia C - False - HYPERphosphataemia D - False E - False - Metabolic Acidosis Wiki: These systemic effects are caused by a traumatic rhabdomyolysis. As muscle cells die, they absorb sodium, water and calcium; the rhabdomyolysis releases potassium, myoglobin, phosphate, thromboplastin, creatine and creatine kinase The clinician must protect the patient against hypotension, renal failure, acidosis, hyperkalemia and hypocalcemia. |
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Repeat Delivery of neonate. Meconium liqour. Baby floppy, blue, apnoeic, pulse rate 90bpm. What is the next step in management? a) Commence PPV b) Suction the trachea c) Commence CPR d) Dry and stimulate e) Give Naloxone |
Best answer is B - suction trachea Pharyngealsuctions can cause bradycardia, laryngospasm, trauma and can delay the onset ofspontaneous breathing. Therefore any suction should be done briefly.- In general suction should only beused in when babies show obvious signs of obstruction- Intrapartum suctioning (iesuctioning prior to delivery of shoulders) does not improve outcome and is notrecommended- Routine suctioning of meconiumstained babies who are vigorous does not improve outcome and is not recommended- Depressed babies born withmeconium staining are at increased risk of Meconium Aspiration Syndrome (MAS).In non-vigorous infants available evidence does not support or refute thebenefits of endotracheal suction. Therefore there is insufficient evidence tochange the current practice of endotracheal suction in non-vigorous infantswith mec stained liquor (ie they stillrecommend suctioning the trachea) - If suctioning if performed itshould be done quickly and before spontaneous or assisted breaths and prior tostimulation. |
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?New, You inject 10ml ropivicaine into a T5 paravertebral block. Patient becomes bradycardic, hypotensive and apnoeic. What is the cause. A. Contralateral spread B. Intrathecal spread C. Inadvertent intravascular injection D. Local anaesthetic toxicity |
Probably B A - Contralateral spread could occur but dose should not make these symptoms occur B - Yes - all symptoms listed are classic of high spinal C/D - basically same thing - but respiratory depression is late and often after seizures - although bradycardia and hypotension can occur. |
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Volatile analysis in most anaesthetic machines is done via which method? A Gas chromatography B Infrared analyser C Raman spectometry D E 2011A 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: infraredE: piezoelectric |
Per CEACCP article - answer is Infra-red analyser CEACCP 2009 – Respiratory Gas Analysis• For carbon dioxide, nitrous oxide, and volatile agents – “Most in-theatre side-sampling benches presently utilize infrared absorption”• For Oxygen – In theatre, gas analysis usually takes the form of a paramagnetic cell” |
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New (I didn't remember this one) What is not a constituent of Prothrombinex VF? A. Antithrombin III B. Factor II C. Factor X D. Protein C E. Heparin Factor VII definitely not an option |
A - Yes B - Yes C - Yes D - NO - does not contain Protein C E - Yes From product brochure Each vial of Prothrombinex®-VFcontains 500 IU of factor IX approximately 500 IU each offactors II and X It also contains25 IU of antithrombin III 192 IUof heparin sodium. Other ingredientsinclude ≤500 mg of human plasmaproteins (which includes low levelsof factors V and VII), sodium citrate,sodium phosphate and sodiumchloride. The factors II, IX, X, theantithrombin III and the plasmaproteins are all of human origin. Theheparin sodium is of porcine origin. |
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You are performing epidural anaesthesia on an adult patient. To minimize the chance of inserting the epidural catheter into a blood vessel you would: A. Inject saline through the epidural needle prior to threading the catheter B. Perform the procedure with the patient lateral rather than sitting (also remembered as sitting not lateral) C. Use a loss of resistance to air technique instead of loss of resistance to saline. (also remembered as saline not air) D. avoid using a combined spinal-epidural technique E. use a midline rather than a paraspinous (paramedian) approach |
Probably inject with saline best Anesth Analg 2009;108:1232–42“Injecting fluid through the epidural needle before catheter insertion decreases risk (OR 0.49)” “The risk of epidural vein cannulation was significantly higher in the sitting group (16 of 102 = 15.7%) compared with the lateral position group (4 of 107 = 3.7%)”“Adoption of the lateral recumbent head-down position for the performance of lumbar epidural blockade, in labour at term, reduces the incidence of lumbar epidural venous puncture in these obese parturients.” Canadian Journal of Anesthesia From the black bankAnesthesia& Analgesia 2009.: "The risk of intravascular placement of a lumbarepidural catheter in pregnancy may be reduced with the lateral patientposition, fluid predistension, a single orifice catheter, a wire embeddedpolyurethane epidural catheter and limiting the depth of catheter insertion to6 cm or less". Five strategies reduce therisk of epidural vein cannulation: 1. the lateralas opposed to sitting position (six trials, mean (sd) quality score = 35%[11%], odds ratio (OR) 0.53 [95% confidence interval (CI) 0.32–0.86]) 2. fluid administered through the epidural needle before catheterinsertion (8 trials, quality score 48% [18%], OR 0.49 [95% CI 0.25–0.97]) 3. single rather than multiorifice catheter (5 trials, quality score30% [6%], OR 0.64 [95% CI 0.45–0.91]) 4. a wire-embedded polyurethane compared with polyamide epiduralcatheter (1 trial, 31%, plus 4 unscored abstracts, OR 0.14 [95% CI 0.06–0.30]) 5. catheter insertion depth ≤6 cm (2 trials, 47% [11%], OR 0.27 [95% CI0.10–0.74]). The paramedian as opposedto midline needle approach and smaller epidural needle or catheter gauges donot reduce the risk of epidural vein cannulation. |
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Repeat Failed intubation. Difficult ventilation. Rescued with a Classic(R) LMA. Decide to use a bronchoscope to intubate down the LMA. Which device will allow you to intubate the patient safety? A. Aintree catheter B. Airway exchange catheter C. Gumelastic bougie D. Some angiogram wire I’ve never heard of! E. Two paediatric endotracheal tubes side-by-side |
TheAintree Intubation Catheter (AIC, Cook Medical, USA) is a bougie tube designedfor use with a fiberoptic bronchoscope (FOB) to facilitate endotrachealintubation through the standard Classic or Ambu laryngeal mask airway (LMA). The bronchoscope is placed through the lumen of the AIC (white tube) as shownbelow.TheAIC is an adaptation of the Cook airway exchange catheter with a largerinternal diameter (4.8 mm) to allow it to be pre-loaded onto a pediatricfiberoptic bronchoscope. Its external diameter allows its use with endotrachealtubes whose inner diameter is 7 mm or larger and it is 56 cm long and so willcover almost all pediatric bronchoscopes except the distal end. There areseveral reports of using it in unexpected difficult airways [1,2,3,4]. |
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Blalock-Taussig shunt inserts into the right pulmonary artery, originating from the: a) Right subclavian artery b) IVC c) SVC d) Aorta e) Axillary artery |
A - Right Subclavian Artery From Wiki: The Blalock–Thomas–Taussig shunt (commonly called the Blalock–Taussig shunt) is a surgical procedure used to increase pulmonary blood flow for palliation in duct dependent cyanotic heart defects like pulmonary atresia, which are common causes of blue baby syndrome. In modern surgery, this procedure is temporarily used to direct blood flow to the lungs and relieve cyanosis while the infant is waiting for corrective or palliative surgery.One branch of the subclavian artery or carotid artery is separated and connected with the pulmonary artery. The lung receives more blood with low oxygenation from the body. The first area of application was tetralogy of Fallot.The Blalock–Taussig shunt may be used as the first step in the Fontan procedure |
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NEW. Time taken for insulin to reduce K+ in hyperkalaemia A. 2 mins B. 4 mins C. 10 mins D. 20 mins E. 30 mins |
Best answer is probably D - 20 mins From Stoelting: " Stoelting's Anesthesia and Co-Existing Disease, 5Th Edition Potassium can be driven intracellularlyby the action of insulin with or without glucose. This will beeffective within 10 to 20 minutes." LITFL: Dose: IV fast acting insulin (actrapid) 10-20 units and glucose/dextrose 50g 25-50ml Insulin drives potassium into cells and administering glucose prevents hypoglycaemia. Begins to work in 20-30mins reduces potassium by 1mmol/L and ECG changes within the first hour (image from AAFP - which says 15 - 30 minutes) |
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RPT 2/12 old baby. Initially on 20th centile and now on 5th. Murmur, systolic, loud at apex. Pulses are weak, "most easily felt at the femoral". A: VSD B: Co-arctation C: Venous hum D: PDA |
A - VSD Firstlyyou’d want to know sats to determine if cyanotic (TOF, TGA, Tricuspid orpulmonary atresia) or acyanotic. - Questionalludes to pt being peripherally shut down (ie weak peripheral pulses)
Murmursbased on location: Apical murmurs: Mitral prolapse, MR, AS,vibratory innocent murmur LLSE: VSD, Vibratory innocent murmur, HOCM,TOF, TR Under right clavicle: AS Under left clavicle: Pulmonary stenosis,ASD, pulmonary flow murmur (Coarctation, PDA) Causes of right to leftshunt?- TGA- TOF- Eisenmenger Causes of left to rightshunt?- ASD- VSD- PDA Pansystolic (Holosystolic) murmur along lower left sternal border(depending upon the size of the defect) +/- palpable thrill. Heart sounds are normal. Larger VSDs may cause a parasternal heave, a displaced apex beat. An infant with a large VSD will fail to thrive and become sweaty and tachypnoeic with feeds.The restrictive VSDs (smaller defects) are associated with a louder murmur and more palpable thrill (grade IV murmur). Larger defects may eventually be associated with pulmonary hypertension due to the increased blood flow. Over time this may lead to an Eisenmenger phenomenon: Eisenmenger syndrome refers to any untreated congenital cardiac defect with intracardiac communication that leads to pulmonary hypertension, reversal of flow, and cyanosis.[1, 2, 3] The previous left-to-right shunt is converted into a right-to-left shunt secondary to elevated pulmonary artery pressures and associated pulmonary vascular disease. |
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Some diathermy pads have two separate electrodes on the patient pad, each with it's own cable back to the machine. Why? A: In case one fails the other can serve as a back-up B: One for coag and one for cutting C: For bipolar? - worded slightly differently D: For capacitance measurement - again wording not right E: For return electrode monitoring |
E - Return electrode monitoring to confirm the plate is in good contact with the patient - to prevent localised burns. |
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New Cisatracurium left out of fridge for 4 days. It’s efficacy is now: A. 60% B. 70% C. 90% D. 50% E. 99% |
99% (can be left out of fridge for 21 days) |
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New In which type of von willebrand's disease is DDAVP contraindicated? A. Type 1 B. Type 2a C. Type 2b D. Type 3 E. None of the above |
C - Type 2b vWD is divided into three major categories: (1) partial quantitative deficiency (type I), (2) qualitative deficiency (type II), and (3) total deficiency (type III). vWD type II is further divided into four variants (IIA, IIB, IIN, IIM), based on characteristics of dysfunctional vWF. These categories correspond to distinct molecular mechanisms, with corresponding clinical features and therapeutic recommendations. Treatment of choice for Type I vWD type IIResponses to DDAVP are variable in patients with type II disease. A trial infusion may be performed to evaluate the potential efficacy for a particular patient.Many individuals with vWD type IIA have a response to DDAVP, with peak vWF and FVIII levels at 30-60 minutes. This is similar to responses observed in patients with vWD type I. However, rapid loss of vWF, FVIII, and, particularly, RCoF activity, occurs as the high ̶ molecular weight multimers are degraded, with return to baseline levels at 4 hours post infusion. Although the response is transient, it may be adequate therapy in certain clinical situations. DDAVP trials may be contraindicated in patients with type IIB, because of thrombocytopenia and possible thrombotic complications. DDAVP is probably not effective in patients with type IIM and is rarely effective in patients with type IIN. Patients with type 3 VWD do not respond to desmopressin and therefore substitution therapy with purified human VWF associated, at least for the first injection, with FVIII is the principle preventative or curative treatment. Some patients (7.5-9.5% of cases) develop alloantibodies against VWF rendering the substitution treatment ineffective and resulting in an anaphylactic response associated with the formation of immune complexes. In these cases, alternative treatments, such as continuous infusion of recombinant factor VIII or recombinant activated factor VII, should be considered. Long-term prophylactic treatment with regular injections of purified human VWF may be required for patients with recurrent bleeding events. Type 3 VWD is the most severe form of VWD and in the absence of appropriate management in specialized hemostasis and thrombosis hospital centers the manifestations can be life-threatening and lead to functional impairment. |
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This ECG with AAI pacing shows: The 12-lead ECG showed pacing spikes followed by p-waves, with QRS's following the p-waves with progressive prolongation of the PR until a QRS was dropped. In other word, second degree heart block (type 1, although the type was not required to answer the question). The ECG looked very much like "Example 8" from lifeinthefastlane. I think it was lifted from this website. A. Failure to capture B. CHB C. 2nd degree HB D. AF |
Probably 2nd degree HB Per LITFL: "Atrially paced patients often have evidence of 1st degree AV block or Wenckebach conduction on their paced ECG that is not apparent on their baseline tracing. This is because the sort of patients that require atrial pacing (e.g. post-op cardiac surgery) commonly have some degree of AV node dysfunction (e.g. due to age-related AV-nodal degeneration / their underlying cardiac condition / post-operative ischaemia / AV-nodal blocking drugs). When these patients are paced at a faster rate than their AV node can handle, the AV node becomes “fatigued” resulting in 1st degree AV block or Wenckebach phenomenon on the paced ECG. This abnormality is not clinically important provided that the patient’s cardiac output is not compromised." http://lifeinthefastlane.com/ecg-library/pacemaker/ |
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NEW The NAP4 audit showed that the most common cause of airway problems/complications/disasters in INTENSIVE CARE is: A. Aspiration B. Dislodged tracheostomy tube |
NAP 4 Summary says "displaced tracheostomy tube or tracheal tube + RSI + failure to use capnography" Answer is probably B - tracheosomy tube dislodged |
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The target serum magnesium level in a patient with pre-eclampsia receiving a magnesium infusion is A. 1-2 mmol/l B. 2-3.5 mmol/l C. 3-6 mmol/l D. 4-6 mmol/l E. 5-8 mmol/l"I remembered C+D being an option for 4-5mmol/L just to make it more confusing..." |
Answer is B Magnesium Concentration (mmol/L) and Effects 0.8 – 1.0 Normal plasma levels 1.7 – 3.5 Therapeutic range 2.5 – 5.0 ECG Changes * P-Q interval prolongation * Widened QRS complex 4.0 – 5.0 Reduction in deep tendon reflexes > 5.0 Loss of deep tendon reflexes > 7.5 SAN and AVN blockade Muscle paralysis Respiratory and CNS Depression > 12 Cardiac Arrest |
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Timing of peak respiratory depression after intrathecal 300 mcg morphine: A. < 3.5 hours B. 3.5 – 7.5 hours C. 7 - 12.5 hours D. 12.5 -18 hours E. > 18 hours |
B - 3.5 - 7.5 hours In ANZCA Blue Book 3rd edition page 195 "Respiratory depression occurs in up to 1.2% to 7.6% of patients (Meylan et al, 2009 Level I)given intrathecal morphine. When measured in opioid-naive volunteers, respiratory depressionpeaked at 3.5 to 7.5 hours following intrathecal morphine at 200 to 600 mcg doses (Bailey et al,1993 Level IV). Volunteers given 600 mcg had significant depression of the ventilatory responseto carbon dioxide up to 19.5 hours later” |
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New What part of a modern anaesthesia machine allows jet ventilation to be performed using the oxygen flush button? A. Non-return valve downstream of the vaporisers B. Pressure-limiting valve at the outlet C. The presence of a common gas outlet D. Presence of auxillary oxygen flowmeter Exact wording and options not recalled, but A and B were certainly options, and I think A (non-return valve downstream of vaporiser) was the answer.Pretty sure D is actually the correct answer (least pressure drop across the flowmeter and essentially connected to wall O2 supply...)The question definitely specified "allows jet ventilation VIA THE OXYGEN FLUSH BUTTON", so D can't be the answer. |
Per notes from Barasch Clinical Anaesthesia.... Vaporiser - one way check valve - oxygen flush valve - so A could be right? OR Vaporiser - positive pressure relief valve - outlet check valve - oxygen flush valve - so B is wrong! But either way you definitely need a CGO or it won't work - because this is how gas comes out - so maybe this is right answer?? Auxillary oxygen flowmeter is considered a better method of jet ventilation source as less pressure drop across flow meter BUT it does not require use of oxygen flush at all! A one-way outlet check valve is positioned between the vaporizers and flush valve in the Ohmeda Modulus II and Drager Narkomed 2 anesthesia machines which directs the entire flow of oxygen (45-75 L/min at approximately 50 psi) out the common gas outlet when the flush valve is activated. There is no such valve in the Ohmeda Modulus II Plus or Drager Narkomed 2A anesthesia machines, so that activating the flush valves directs oxygen toward both the vaporizers and the common gas outlet. Each of these anesthesia machines has a pressure-limiting mechanism so that the pressure out of the common gas outlet of both anesthesia machines is only 7 and 18 psi, respectively, resulting in dramatically lower VT and subsequent flow. In conclusion, the Ohmeda Modulus II Plus anesthesia machine is not an acceptable power source for providing total ventilatory support by activating the flush valve for jet ventilation, although the Drager Narkomed 2, 2A, and Ohmeda Modulus II anesthesia machines are all acceptable power sources for jet ventilation for providing partial, if not total, ventilatory support in most clinical situations. (Anesth Analg 1993;76:800-808) |
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New (Don't remember this one) Patient with IgA deficiency. What is the main issue in anaesthesia? A. Anaphylaxis to blood products B. Renal impairment C. D. Sensitivity to opioids E. Sensitivity to muscle relaxants |
A - This is true. Patients with IgA deficiency can have anaphylaxis to blood products - esp. if sensitive with prior transfusion or pregnancy - it is to the IgA in the blood. |
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New Designing a study on PONV. What is the advantage of designing a study incorporating multivariate analysis? A Less type 1 error B Less complex C Less difficult to interpret D Less confounding E Fewer patients required |
Using information below: Less Type 1 error TRUE Less complex - FALSE it is more complex Less difficult to interpret - FALSE it is more difficult Less confounding - unsure/maybe not relevant? Fewer patients - no need more From googling: Why not MV? 1. Ambiguity◦ MV analysis may result in a less clear understanding of the data E.g. group differences on a linear combination of DVs (Manova) Differences are easily interpreted in a univariate sense ◦ Ambiguity because of ignorance of the technique is not a validreason however 2. Unnecessary complexity◦ Just because SEM looks neat/is popular doesn’t mean you have to do one, or that it is the best way to answer your research question 3. No free lunch ◦ MV analyses come with their own rules and assumptions that may makeanalysis difficult or not as strong Advantages of using a multivariate statistic ◦ Richer realistic design ◦ Looks at phenomena in an overarching way (providesmultiple levels of analysis) ◦ Each method differs in amount or type of IndependentVariables (IVs) and DVs ◦ Can help control for Type I Error Disadvantages◦ Larger Ns are often required ◦ More difficult to interpret◦ Less known about the robustness of assumptions |
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Decreased MA on TEG correlates best to needing to give a) Platelets b) TXA c) FFP d) Cryoprecipitate e) PCC New version: Bleeding intraopratively. TEG shown. What should be used to treat?The image itself was useless because there was no normal reference to compare it to. However there were numerical figures at the bottom of the image, but difficult to read on the photocopied paper. Normal R, K, angle and MA vales. LY30 and LY60 were low, CL30 and CL60 high.It didn't take me long to Google the TEG image that ANZCA lifted for this question! I'm almost certain it was Figure 1B from: Pepperell 2014, "Clinical Application of Fibrinolytic Assays".Only the bottom image was shown, not the top reference version A TXA B Platelets C Cryo D FFP E |
Long R-time - need more coagulation factors - give FFP Steep alpha or low alpha - need for fibrinogen -give Cryo Decreased MA - not enough platelets Rapid lysis - need to stabilise - give TXA First version with decreased MA Platelets Second version with increased lysis: TXA |
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Repeat A size C oxygen cylinder (in New Zealand, "A") that reads 5000kpa contains approximately how many litres of oxygen a. 100 b. 150 c. 200 d. 350 e. 600 |
Full size C (13700 kPa) = 420 L So 5000/13700 x 420 = 153L - ANSWER B 16000 x 85% = 13600 Cylinders for gases are filled to 13,700 kPa (2/3 of rated pressure). Cylinders for liquids are filled by weight so that (in Aust) a cylinder at 65°C reaches 85% of rated pressure. For both CO2 and N2O this means, in practice, filling to about 2/3 of the cylinder's water capacity in kg. The filling ratio is the weight of nitrous usually added compared to the water capacity of the cylinder. 1.87 kg of N20 in the 2.8 kg C size cylinder gives a filling ratio of about 2/3. In cooler climates e.g. UK the filling ratio is 75%. A C size nitrous cylinder holds about twice as much nitrous as oxygen (in litres of gas). |
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4-chamber TTE view. What lesion is present?Image showed mitral regurg. Think the image was from this here (but was black-and-white of course) |
Think its Mitral Regurg |
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Appropriate infection control measures when anaesthetising a patient with iatrogenic variant-CJD, the airway equipment should be: a. thrown away b. plastic sheath c. sterilization with ethylene oxide d. sterilization with heat at 134 degrees for 3 minutes. e. autoclave |
Answer is THROW AWAY CEACCP With the advent of CJD, there has been a need for all airway equipment to become single-use only. In most centres, disposable laryngoscope blades and single-use laryngeal masksare now in routine use. While fibreoptic intubating endoscopes have until recently beensterilized and reused, disposable endoscopes are now available. Reusable endoscopesmust be traceable to assist with CJD monitoring and surveillance. Surgical instrumentsAbnormal prion protein is not completely removed by conventional sterilization methods,including autoclaving. This poses problems for transmission of prion disease bycontaminated surgical equipment. This is relevant when a patient with CJD, or at increasedrisk of CJD, has a procedure involving tissue which is deemed of medium or high risk(Table 2 and http://www.dh.gov.uk/ab/ACDP/TSEguidance/index.htm).14 Decisions around the use of surgical instruments are complex and must be made on anindividual patient basis, taking into account: the likelihood of the patient having CJD; the tissues involved in the operation and whether these are deemed likely to harbour high,medium, or low levels of prion infection; the type of prion disease—patients with vCJD, or those at-risk of vCJD, may havelymphoreticular and central nervous system involvement; the feasibility of performing surgery using all or some disposable instruments; the possibility of destroying parts or some of the instruments which are in contact withhigh-risk tissue if disposable instruments cannot be used. The World Health Organization surgical safety checklist is a tool used to improve surgicalsafety by reducing operative mortality and complications and is now implemented routinelythroughout the UK. In the final part of the checklist, clinicians are asked to considerwhether there is a risk of CJD transmission during the operation. In general terms, if thepatient is considered to be at increased risk of CJD, and the operation involves tissues athigh or medium risk of CJD infectivity, consideration must be given to using single-useinstruments, quarantining instruments, or destroying instruments. However, in tissuesconsidered to be low risk, instruments can be sterilized and reutilized in a conventionalmanner, even if the patient is considered to be at high risk of CJD. Further information isavailable at http://www.dh.gov.uk/ab/ACDP/TSEguidance/index.htm and the National PrionClinic (www.nationalprionclinic.org) can also offer individual advice. Some single-use surgical instruments are more expensive, of inferior quality or both whencompared with standard, reusable instruments. Where disposable instruments areconcerned, NICE recommends only the use of those disposable instruments that are of anequally high standard to reusable ones. |
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Rot A variant on the theme of the previous question referring to PS9. Minimum requirements to provide sedation. This time asked who is necessary to provide conscious sedation, using propofol. A) medical practitioner trained in use of propofol B) medical practitioner trained in use of propofol + their assistant Previous question: According to PS09, the minimum requirement for administering propofol for conscious sedation is A. Medical practitioner with a skilled assistant that is seperate from the assistant to the proceduralist B. Medical practitioner C. Nurse supervised by proceduralist with recent ALS training D. Specialist anaesthetist E. Nurse with advanced airway skills Another version: According to PS9 for sedation with Propofol for colonscopy, the staff required is/are: a. Medical practitioner other than proceduralist b. Nurse other than proceduralist c. Anaesthetist in addition to the proceduralist d. Assistant e. Proceduralist alone |
March 2014 PS9: 5.1 Except for techniques such as inhaled nitrous oxide, inhaled methoxyflurane orlow dose oral sedation (see scenario 0, appendix 3), there must be a minimum ofthree appropriately trained staff present (see scenarios 1-2, appendix 3): theproceduralist, the practitioner administering sedation and monitoring the patient,and at least one additional staff member to provide assistance to theproceduralist and/or the practitioner providing sedation as required. 5.2 The assistant to the practitioner administering sedation must be exclusivelyavailable to that practitioner at induction of and emergence from sedation, andduring the procedure as required. If general anaesthesia is intended, andespecially in emergency situations where endotracheal intubation is planned, aperson to specifically assist the anaesthetist, or other trained and credentialedmedical practitioner within his/her scope of practice, is required throughout theprocedure (see ANZCA professional document PS08 Recommendations on theAssistant for the Anaesthetist). PS09 pp8: "Intravenous anaesthetic agents such as propofol must only be used by a second medical or dental practitioner trained in their use because of the risk of unintentional loss ofconsciousness. These agents must not be administered by the proceduralist." But also see Scenario 2 of Appendix 1 of PS09: the assistant can be shared between both ends for conscious sedation in ASA 1-2 patients only. Therefore best answer would be a medical or dental practitioner trained in its use with an assistant who may be shared with the proceeduralist. |
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Repeat Intubation view: Little space between epiglottis and posterior pharyngeal wall. What is the modified C&L classification? A 2A B 2B C 3A D 3B E 4 Has also been asked as: When performing laryngoscopy using a Macintosh blade, your best view is of the patient's epiglottis touching the posterior pharyngeal wall. Using the Cormack and Lehane scale this is grade A. 1 B. 2 C. 3a D. 3b E. 4 |
Cormack and Lehane  This classification describes the best view possible at laryngoscopy.  Grade I: complete glottis visible  Grade II: anterior glottis not seen  Grade III: epiglottis seen, but not glottis  Grade IV: epiglottis not seen Cormack and Lehane system should be subdividedfurther into 3a and 3b (denoting, respectively, only epiglottis visible and only epiglottis visible but adherent to theposterior pharyngeal wall). 2a (part of the cords visible) and 2b (only the arytenoids or the veryposterior origin of the cords visible) |
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New What feature most increases vasospasm in setting of SAH? A. Size of aneurysm B. Age of patient C. Position of Aneurysm D. large amount of blood on CT E. GCS on arrival to ED |
From below (from article) Probably D - large amount of blood But Age, position (due to where blood is) and GCS probably also true. Risk factors for vasospasm and DID are amount and duration of exposure to subarachnoid blood, thick blood collections in basal cisterns and fissures, and intraventricular blood [31-34]. Interestingly, however, endovascular coiling of the ruptured aneurysm, a procedure that does not involve a craniotomy and washing out of the subarachnoid blood, does not increase the risk of vasospasm in comparison to surgical clipping [35,36]. Advanced age [37], race [29], poor neurological status on admission [17,37,38] and use of antifibrinolytic agents [16,33,39] are also associated with the development of DID. Factors less robustly linked to a higher incidence of DID are a longer duration of unconsciousness following the initial hemorrhage [40], history of hypertension [37,41], smoking [42,43], and excess weight [41]. |
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New ECG rhythm strip. Showed regular pacing spike followed by wide QRS complexes. But once there is a narrow QRS occurring without a pacing spike, followed shortly-after by a pacing spike but no capture. What does ECG show? A. AAI with failure to capture B. AAI with failure to sense C D. VVI with failure to capture E. VVI with failure to sense |
VVI with failure to sense, I think is the answer. The narrow QRS complex was an intrinsic beat, but the pacer didn't sense so paced shortly after at its regular interval. The myocardium was still refractory so there was no capture, but failure to sense was the original problem. |
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Repeat SC31 Relative contraindications to mediastinoscopy include A. Cervical spondylosis B. Emphysema C. Mediastinal lymphadenopathy D. Poor left ventricular function E. Superior vena cava syndrome |
E CEACCP 2007:“Contraindications to Mediastinoscopy: Previous mediastinoscopy is a relatively strong contraindication to a repeat procedure because scar tissue eliminates the plane of dissection. Superior vena cava (SVC) syndrome increases the risk of bleeding from distended veins and is a relative contraindication. Other relative contraindications include severe tracheal deviation, cerebrovascular disease, severe cervical spine disease with limited neck extension, previous chest radiotherapy, and thoracic aortic aneurysm.” |
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NEW How should you dose suxamethonium for intubation in an obese patient? a) Lean body weight b) Ideal body weight c) Ideal body weight + 25% d) Actual body weight e) Actual body weight + 25% |
CEACCP: "Succinylcholine is an exception, dosage should be calculated using TBW." Therefore D - actual body weight |
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Repeat Time to onset of TRALI with transfusion? a) 2 hours b) 4 hours c) 12 hours d) 24 hours e) 48 hours |
???A - 2 hours?? The symptoms begin usually within 2 hours after transfusion and well established by 6 hours but may extend up to 24 hours. Resolves within 96 hours. TRALI is associated with a high morbidity with the majority of patients requiring ventilatory support. However, the lung injury is generally transient with PO2 levels returning to pretransfusion levels within 48 -96 hours and CXR returning to normal within 96 hours. TRALI is associated with a significant mortality rate, often approximated at 5 to 10%. Given the gains in safety made within the blood component production industry, particularly with respect to transmission of infectious diseases, TRALI is now among the three leading causes of transfusion related fatalities along with ABO incompatibility and bacterial contamination. Clinical PresentationSymptoms of TRALI typically develop during, or within 6 hours of a transfusion. Old question used the terms: "within X hours"....of which best answer would be 6 |
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When performing regional anaesthesia for eye surgery, needle damage to the globe of the eye is more common with: A. a globe axial length of less than 25 mm B. patients aged less than 45 years C. peribulbar block using the inferotemporal approach D. peribulbar block using the medial canthus approach E. sub-Tenon block |
A - NO - globe length > 25mm B - Unknown but unlikely?? C - Peribulbar using inferotemporal - YES D - Peribulbar using medial canthus - less likely than above route E - Sub-Tenon - less likely than Peribulbar |
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Best method to assess reversal of neuromuscular blockade? A. Sustained head lift 5 sec B. Sustained leg lift 5 sec C. TOF 0.9 with accelerometer D. DBS no fade E. Tetanus 50Hz F. Tidal volumes... ? |
TOTW/FRCA: C - TOF/accelerometer Objective measurement of neuromuscular monitoring is the only way of accurately assessing residualneuromuscular blockade. CEACCP: Quantitative methods of measuring evoked responses, for the example, acceleromyography or mechanomyography, are necessary to ensure adequate recovery from block. |
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Repeat The Neonatal Facial Coding Scale (NFCS), used to assess pain in neonates, includes all of the following EXCEPT A. brow bulge B. chin quiver C. closed mouth D. deep nasolabial fold E. eyes squeezed shut |
Per Scale at left. A - brow bulge - YES B - chin quiver - YES C - Closed mouth - NO - listed as open lips D - deep nasolabial fold - YES E - Eye squeeze - YES |
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Repeat Mar11 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 |
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 |
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Subtenon’s block. What is the BEST position to insert block? A. Inferonasal B. Inferotemporal C. Superonasal D. Superotemporal E. Medial / canthal |
Inferonasal |
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Repeat Most cephalic interspace in neonate to perform spinal while minimising the possibility of spinal cord puncture A. L1-L2 B. L2-L3 C. L3-L4 D. L4-L5 E. L5-S1 |
Adults L1/2 for Spinal Cord (L2/3 in neonates) S1 for Dural Sac (S3 neonates) Inter-Cristine line is L3/4 adults but L4/5 or L5/S1 in children - but therefore suitable landmark for both. So answer is L4/5 - D From anatomy for the anaesthetist:The relations of the cord to the vertebral column differ greatly in foetal, infant and adult life (Fig. 98). Up to the third fetal month, the cord extends the length of the vertebral canal. The vertebrae then grow considerably faster than the cord, so that the cord terminates in the newborn at the lower border of the 3rd lumbar vertebra and, in the adult, on average, at the disc between the 1st and 2nd lumbar vertebral bodies. However, there is considerable variation in this level (Fig. 99); frequently the cord ends opposite the body of L1 or 2, or, rarely T12 or even L3. |
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New With respect to a patient with Multiple sclerosis, which of the following alters the risk of a flair post partum a) An Epidural b) A spinal c) A flair in the year pre-partum d) A general anaesthetic e) Breast feeding I'm pretty sure the stem said "alters the risk", i.e. the correct answer could be something which either increases or decreases the risk. Although someone else remembered it as "increases" the risk. |
C - Flair in year before There was no evidence that women who breastfed had a lower risk. Instead, the only factor that seemed to predict post-pregnancy relapse was a woman's symptom history: if she'd had a relatively higher number of relapses in the year before pregnancy, or during pregnancy, her risk of post-childbirth relapse was higher. All anesthetic techniques used in patients with MS may lead to the exacerbation of MS symptoms. In a study by Barbosa et al. (2), subarachnoid anesthesia was performed with hyperbaric bupivacaine for a cesarean section in a pregnant woman with MS treated with methylprednisolone. No exacerbation of symptoms was noted in this patient. However, because the toxic effects of local anesthetics used for spinal anesthesia on demyelinated neurons may trigger MS attacks, MS is considered to be a relative contradiction to spinal anesthesia (1, 3). Furthermore, needle induced trauma and stress, the difficulty of the technique and hypotension during neuraxial anesthesia may lead to relapses in MS (3). Epidural anesthesia is considered to be safer than spinal anesthesia due to the lower prevalence of hypotension, and penetration of lower dose of local anesthetics into the intrathecal space (3). General anesthesia has its own advantages and disadvantages in patients with MS. There are studies reporting successful administration of inhalation anesthetics for the induction and maintenance of general anesthesia in patients with MS |
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Repeat Mar14 Adenosine can be used to terminate an arrhythmia due to: A. Atrial fibrillation B. Atrial flutter C. WPW D. ??VTE. ??Torsafes |
Definitely said "terminate" the arrhythmia, so the only possible answer I think can be WPW. In AF/flutter it may help diagnose, but not terminate. Adenosine is considered safe in ORTHODROMIC SVT in WPW by some authors (but not all) -- may have increased risk but is still the best answer. Never use adenosine in antidromic SVT though!! |
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Mast cell tryptase half life: 1 hours 3 hours 6 hours 12 hours |
Older article says 3 hours - newer article says 2 hours Anaphylaxis Contin Educ Anaesth Crit Care Pain (2004) 4 (4): 111-113. Immediate investigation: Three blood samples need to be taken in order to analyse the mast cell tryptase concentration. Tryptase is a neutral protease released from secretory granules of mast cells during degranulation. Approximately 99% of the body's total enzyme is located within the mast cell. In vivo half-life is 3 h (compared with 3 min for histamine) and maximum concentrations occur rapidly within 1 h of degranulation. It is stable in isolated plasma or serum. As it is not present in red or white cells, it is not affected by haemolysis. Basal plasma tryptase concentration is 0.8–1.5 ng ml−1. It increases after both anaphylactic and anaphylactoid reactions and helps to distinguish these from other causes of an adverse event (i.e. it defines the mechanism, but does not identify the causative agent). Concentrations up to 15 ng ml−1 are seen both in pseudoallergy (non-specific or anaphylactoid reactions) and mild anaphylaxis. A higher value (>20 ng ml−1) is more likely to indicate an IgE (hence anaphylaxis) response.Each sample should be 5–10 ml of blood in a clotted tube and taken at the following times, with the appropriate time recorded on the sample: (i) immediately after the reaction has been treated; (ii) about 1 h after the reaction; and (iii) about 6 h or up to 24 h after the reaction.The samples should be separated and stored at 4°C if they can be analysed within 48 h. Otherwise they should be stored at −20°C until they can be sent for analysis. The rise in tryptase is transient, so timing is important. Anaesthesia-related anaphylaxis:investigation and follow-up CEACCP September 2013 Mast cell tryptase (MCT) is a protease enzyme with two subtypes alpha and beta. Alphaand pro-Beta are secreted constitutively by tissue-bound mast cellsand mediate intestinal and bronchial smooth muscle relaxation.Mature b-tryptase stored in granules is released during anaphylaxisand stimulates the release of pro-inflammatory mediators. MCT hasa half-life of 2 h, peaking at 1 h after anaphylaxis onset NICE Guidelines Anaphylaxis“Very low-quality evidence from six observational studies including 147 patients showed that the half-life of tryptase ranged from 30 minutes to 300 minutes (median 90 minutes)”Mayo Medical LaboratoriesAfter anaphylaxis, mast cell granules release tryptase; measurable amounts are found in blood, generally within 30 to 60 minutes. The levels decline under first-order kinetics with half-life of approximately 2 hours. |
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New Best indicator of Severe pulm HT: mean PA pressure 45mmHg orthopnoea PND ex tol less than 4 mets fev1, ... |
NO ANSWER YET - may be mean PA pressure 45mmHg?? its mostly true where-as others may not be true. Uptodate:Functional impairment and hemodynamic derangement are the key determinants of disease severity. Stoelting's Anesthesia and Co-Existing Disease, 5Th Edition:PAH often presents with vague symptoms including breathlessness, weakness, fatigue, and abdominal distention. Syncope and angina pectoris are indicative of severe limitationsof cardiac output and possible myocardial ischemia. PerWiki:Pulmonary venous hypertension typically presents with shortness of breath while lying flat or sleeping (orthopnea or paroxysmal nocturnal dyspnea), while pulmonary arterial hypertension (PAH) typically does not. |
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Repeat Young pregnant patient with mild mitral regurgitation and moderate mitral stenosis, normal LV function. The best delivery method: A. Epidural anaesthesia LSCS B. Spinal with LSCS C. Epidural analgesia and normal vaginal delivery D. GA LSCS E. Normal vaginal delivery with remifentanil PCA |
EDB with NVD - Answer C MS is a fixed output valvular disease-transmitral gradient is proportional toCO squared, therefore increasing CO by 50% will increase the gradient 2.3 fold-generally pregnancy will increase NYHAclass by One Aims are to keep the patient as they are-maintain preload-normal HR-maintain afterload MS should be evaluated before pregnancy-prophylactic percutaneous mitralballoon valvotomy-NHYA 2-4 or high PTH high risk ofcomplications and death Treat antenatal with diuretic and betablockers-care should be taken to avoidhypovolaemia-ACEI are contraindicated in pregnancy Labour and post partum are the mostdangerous times-Epidural to blunt sympathetic response(attenuate HR, CO, therefore minimised increasing transmitral gradient)-Post delivery, sudden increase inpreload with autotransfusion can lead to APO-Cautious use of Syntocinon during 3rdstage. Vasodilation can cause hypotension with compensatory tachycardia leadingto overdistention of LA (due to MS) and AF => APO-AF should beelectrically cardioverted |
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Repeat St John's Wort (Hypericum perforatum) potentiates the effects of A. Dabigatran B. Heparin C. Warfarin D. Aspirin E. Clopidogrel St John's wort will reduce the effect of A. aspirin B. clopidogrel C. dabigatran D. heparin E. warfarin |
Note — two very similar but different questions!! St. John's Wort potentiates sedatives, clopidogrel, antidepressants St. John's wort:- decreases effectiveness of digoxin, antihistamines, immunosuppressants, warfarin, anticonvulsants - WARFARIN St Johns Wort is a potent inducer of hepatic cytochrome P450 CYP3A4 isoform. Hence, it may significantly increase the metabolism of many concomitantly administered drugs such as alfentanil, mida- zolam, and lidocaine. It also induces the P450 2C9 isoform that results in the reduction in effect of warfarin and NSAIDs.The sedative properties of St John’s Wort may potentiate or prolong anaesthetic agents’ effect.Pharmacokinetic data suggest that St John’s Wort should be stopped for at least 5 days before surgery. This discontinuation is especially important for patients awaiting organ transplant and hence requires immunosuppressants and patients who may require oral anticoagulation.Potentiates clopidogrel. (clopidogrel is a prodrug, and St John's Wort induces the enzyme that activates it) |
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New, post laparotomy platelet - patient has been on Heparin. Platelets down to 40, no bleeding or bruising, but has painful swollen lower leg, most appropriate tx? A) Fondaparinux B) lepirudin C) IV heparin D) clexane E) warfarin |
Fondaparinux - has been used off-licence Lepirudin - as with Danaparoid is a Direct Thrombin Inhibitor - so can be used - BUT it is no longer being made. However, was probably the answer as back when question written it was still available. IV Heparin - NO! Clexane - LMWH - too similar. Warfarin - causes necrosis unless Plt > 150 |
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Repeat Three year old girl for an elective hernia repair is seen immediately prior to surgery. It is revealed she had 100mL of apple juice 2 hours ago. The best course of action is to: A. Postpone surgery for 2 hours B. Postpone surgery for 4 hours C. Postpone surgery for 6 hours D. Cancel surgery E. Continue with surgery |
Continue as it is a clear fluid and has been 2 hours. |
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NEW Acute intermittent porphyria - will see all of the following except: A) abdominal pain B) hypotension C) confusion D) tachycardia E) peripheral neuropathy |
As a result of below - only answer is hypotension - because get HTN not Hypotension Per Wiki: Symptoms in AIP can be variable. They include:Abdominal pain which is severe and poorly localized (most common, 95% of patients experience)Urinary symptoms (Dysuria, urinary retention/incontinence or dark urine)Peripheral neuropathy (patchy numbness and paresthesias)Proximal motor weakness (usually starting in upper extremities which can progress to include respiratory impairment and death)Autonomic nervous system involvement (circulating catecholamine levels are increased, may see tachycardia, hypertension, sweating, restlessness and tremor)Neuropsychiatric symptoms (anxiety, agitation, hallucination, hysteria, delirium, depression)Electrolyte abnormalities (Hyponatremia may be due to hypothalamic involvement leading to SIADH that may lead to seizures).[6] Unlike other porphyrias, rash is not typically seen in AIP. |
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NEW Audit in department of prevalence of acute myocardial ischaemia in vascular surgery. What type of data is this? Nominal ordinal categorical non-parametric numerical |
Probably has to be Nominal?? Two main types of Data A. Categorical - values sorted into groups B. Numerical?? - values can be measured and/or ordered Subtypes of Categorical 1. Nominal data - can count it but not order it or measure it 2. Ordinal data - can count AND order but not measure Non-parametric - tests used to analyse categorical data. Parametric - tests for numerical data |
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New Preop clinic carotid endarterectomy asks about GA vs LA, you tell her: A) GA and LA has similar risk of stroke B) GA has slightly increased risk of stroke than LA C) LA has slightly increased risk of stroke than GA D) GA has significantly increased risk of stroke than LA E) LA has significantly increased stroke than GA |
A - GALA Trial showed no difference in risk of stroke. |
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New Threshold for micro shock: 1uA 10uA 1mA 5mA 10mA But I remembered as the amount of mA that will cause VF |
From below - 10 microA if microshock may cause VF but 100 milliA for macroshock From Wiki on Microshock "Microshock is a largely theoretical potential risk that is supposedly present for hospital patients with externally protruding intracardiac electrical conductors, such as external pacemaker electrodes, saline filled catheters, or weak or old heart tissue within the heart. Current must be applied directly to heart" Based on studies with dogs by Prof Leslie Geddes in the middle of last century, it is theorised that a current as low as 10 μA (microampere) directly through the heart, may send a human patient directly into ventricular fibrillation. Of course, the exact outcome is dependent on the duration of the current, the exact position of contact, the frequency of current oscillation, and other factors. It is feared that such a small current may be introduced unwittingly, and unobserved, creating a very perilous situation for the patient. To guard against this slim theoretical possibility then, modern medical devices include a range of protective measures to limit current in cardiac-connected circuits to the assumed safe levels of below 10 μA (microampere) . These measures include isolated patient connections, high impedance connections and current limiting circuits. Despite the in-built protections, and lack of observed incidents, microshock continues to be a concern to many practitioners of the fields of Biomedical and Clinical Engineering." From the web on Macroshock - As the current approaches 100 milliamps, ventricular fibrillation of the heart occurs - an uncoordinated twitching of the walls of the heart's ventricles which results in death. |
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Asystolic arrest adrenaline just given, how often do you give adrenaline? Note, question asked about the asystole, i.e. the non-shockable side of the ALS algorithm. I remember this as being: 2 minutes 4 minutes etc. Or may have been after which loop?? |
Per ARC guidelines - Adrenaline immediately - then every 2nd loop each loop is 2 minutes so would be after another 4 minutes. |
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NEW Which is NOT included in the Child-Pugh score? (Is this July 10) |
GGT |
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?Repeat or at least similar to MC118 from 2008 B Patient with HOCM has HR 60, SBP 70 post induction, what to do:give volume adrenaline metaraminol ?beta-blocker |
From below seems Metaraminol is best answer. Stoelting's Anesthesia and Co-Existing Disease, 5Th Edition section on HOCM Hypotension that occurs in response to a decrease in pre-load or afterload should be treated with an a-adrenergic ago-nist such as phenylephrine. Drugs with b-adrenergic agonistactivity, such as ephedrine, dopamine, and dobutamine, arecontraindicated in treating hypotension in these patientsbecause the drug-induced increase in myocardial contractilityand heart rate increases LVOT obstruction. Prompt replace-ment of blood loss and titration of intravenous fluids isimportant for maintaining preload and blood pressure. How-ever, because of the diastolic dysfunction, aggressive fluidreplacement may result in pulmonary edema |
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New The following changes occur in aging except: increased CSF volume, ... |
Difficult to answer as only one stem remembered. But CSF volume does increase with age (as brain volume decreases due to cerebral atrophy and thus CSF increases to maintain the equilibrium of blood/brain/CSF as per Monroe Kellie)
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Paediatric IV paracetamol loading dose 7.5 mg/kg 10 mg/kg 15 mg/kg 20mg/kg |
IV loading is 15 mg/kg (c.f. rectal is 30mg/kg and oral is 20 mg/kg) (Reference is from textbook - Managing Pain in Children - a clinical guide |
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?New Question not recalled, but the key point was:Posterior cord of brachial plexus --> weakness of wrist extension |
Posterior cord of brachial plexus has nerves from all roots of plexus (C8 - T1).Question in previous years asked about C6/C7 dermatome - answer was wrist flexion/extension - might be same question?? |
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T1 injury. Patient now 4 weeks post and going to theatre for sacral pressure area debridement. Feature most unlikely to reflect autonomic dysreflexia A. ? B. Bradycardia C. Severe hypotension D. ? E. Goose bumps below T1 level |
SNS stimulation -HTN and reflex bradycardia Above lesion - dampened as intact reflexes so get PSNS effects. But below lesion can't get signals though so SNS prevails. C - is the answer - as they get HTN As a result, there is flushing and sweating only above the level of injury, bradycardia, pupillary constriction, and nasal congestion (unopposed parasympathetic responses); and below the level of injury, there is pale, cool skin and piloerection due to sympathetic tone and lack of the descending inhibitory parasympathetic modulation. (Piloerection - goosebumps is SNS) T6 is of particular importance in the pathogenesis of autonomic dysreflexia. The splanchnic vascular bed is one of the body’s largest reserves of circulatory volume and is controlled primarily by the greater splanchnic nerve. This important nerve derives its innervation from T5-T9. Lesions to the spinal cord at or above T6 allow the strong and uninhibited sympathetic tone to constrict the splanchnic vascular bed, causing systemic hypertension. Lesions below T6 generally allow enough descending inhibitory parasympathetic control to modulate the splanchnic tone and prevent hypertension. Autonomic dysreflexia (AD), also known as autonomic hyperreflexia, is a potentially life-threatening condition which can be considered a medical emergency requiring immediate attention. AD occurs most often in spinal cord-injured individuals with spinal lesions above the T6 spinal cord level, although it has been known to occur in patients with a lesion as low as T10. From OHA page 240 Autonomic dysreflexia is characterised by massive, disordered automonic response to stimulation below the level of the lesion. It is rare in lesions lower than T7. Incidence increases with higher lesions. It may occur within 3wk of the original injury but is unlikely to be a problem after 9 months. The dysreflexia and its effects are thought to arise because of a loss of descending inhibitory control on regenerating presynaptic fibres. Hypertension is the most common feature but is not universal. Other features include headache, flushing, pallor ( may be manifest above the level of lesion, nausea, anxiety, sweating, bradycardia and penile erection. Less commonly pupillary changes or Horner’s syndrome. Dysreflexia may be complicated by seizures, pulmonary oedema, coma or death and should be treated as a medical emergency. Stimuli to trigger Urological: bladder distension, UTI, catheter insertion; Bowel obstruction; Acute abdo; Fractures From e-medicine (A) A strong sensory input (not necessarily noxious) is carried into the spinal cord via intact peripheral nerves. The most common origins are bladder and bowel. (B) This strong sensory input travels up the spinal cord and evokes a massive reflex sympathetic surge from the thoracolumbar sympathetic nerves, causing widespread vasoconstriction, most significantly in the subdiaphragmatic (or splanchnic) vasculature. Thus, peripheral arterial hypertension occurs. (C) The brain detects this hypertensive crisis through intact baroreceptors in the neck delivered to the brain through cranial nerves IX and X. (D) The brain attempts two maneuvers to halt the progression of this hypertensive crisis. First, the brain attempts to shut down the sympathetic surge by sending descending inhibitory impulses. These impulses are unable to travel to most sympathetic outflow levels because of the spinal cord injury at T6 or above. Inhibitory impulses are blocked in the injured spinal cord. In the second maneuver, the brain attempts to bring down peripheral blood pressure by slowing the heart rate through an intact vagus (parasympathetic) nerve; however, this compensatory bradycardia is inadequate and hypertension continues. In summary, the sympathetics prevail below the level of neurologic injury, and the parasympathetic nerves prevail above the level of injury. Once the inciting stimulus is removed, reflex hypertension resolves. |
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After coronary artery bypass graftsurgery, the FRC is A. increased 40% B. increased 20% C. unchanged D. decreased 20% E. decreased 40% -lung collapse |
Per attached link to textbook would appear to be decreased 40% |
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Fatigue during night shifts can be minimized by: A. Avoiding daylight B. not sleeping during day C short naps during shift D use of caffeine or stimulants E. using benzodiazepines for sleep during the day |
C - short naps Ref: ANZCA PS43 Many individuals find it difficult to reset their body time clocks to allow for effective daytime sleep after night duties. Daytime sleep is typically shorter and of inferior quality compared with sleep at night . Minimising the effects of night-time shift work may be achieved by taking a two hour afternoon sleep prior to the night duty, taking a 20-30 minute nap during the duty time, ensuring proper meals, and sleeping as soon as possible after the duty |
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Post op hip ORIF, commonest periop complication A. UTI B. PE C. Delirium D. AMI E. Pneumonia |
Delirium |
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The size (in French gauge) of the largest suction catheter which can be passed through a size 8 endotracheal tube which will take up not greater than half the internal diameter is size: A. 6 B. 8 C. 10 D. 12 E. 14 |
Answer: Endotracheal tube size refers to internal diameter in mm. French gauge requires a conversion: Fr 1 = 1/3 mm. Therefore Fr 3 = 1 mm So, Fr12 = 4 mm - and you want something no more than half the diameter - so answer is 12F |
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Fluoroscopy in the operating theatre increases the exposure of theatre personnel to ionisingradiation. Best method to minimise one's exposure to such radiation is to A. have dosimeter checked at least 6-monthly B. limit exposure time to radiation C. maximal distance from radiation source D. stand behind transmitter of C arm E. wear protective garments |
limit exposure time to radiation - first protection method but cant be altered in this case - probably applies more to not doing same lists all the time maybe??? Because the intensity of scattered radiation is inversely proportional to the square of the distance from the source, the best protection is physical separation. A distance of at least 3 feet from the patient is recommended. Six feet of air provides protection the equivalent of 9 inches of concrete or 2.5 mm of lead. maximal distance from radiation source - probably best , dose decreases with square of distance stand behind transmitter of C arm - minimal radiation , generally best to stand on the other rside as patient scatters and reflects wear protective garments - correct Reduces by 85-99% but doesn't protect everything |
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32-year-old patient is admitted with early acute liver failure (unrelated to paracetamol ingestion). Management should include A. avoidance of intubation to monitor encephalopathic progress B. consideration for liver transplantation if the INR (international normalised ratio) is over 3 C. limited use of sodium containing fluids during acute resuscitation D. N-acetyl-cysteine as a general hepatoprotective agent E. prophylactic antibiotics |
With reference to CEACCP article - D may be correct - although MCQ states as general protective agent when mechanism in non-Paracetamol is unclear. (B may also be true) But E is definitely true A – False, Grade III & IV encephalopathy may need intubation B – King’s College Criteria for liver transplantation includes INR>3.5 as a one criteria for non paracetamol aetiology liver failure. (>6.5 is paracetamol aetiology) C - As opposed to chronic liver disease, most patients presenting with ALF are not sodium overloaded, hence sodium restriction is not indicated D - There is growing evidence that NAC administration may be clinically beneficial in non-paracetamol-induced ALF, though the mechanism of action of NAC in this situation is unclear. In these cases, the usual loading and maintenance dose recommended for paracetamol overdose applies. E - Prophylactic antimicrobials with broad-spectrum coverage of gram-positive and gram-negative activity including an anti-fungal (e.g. piperacillin with tazobactam and fluconazole) should be administered on admission, as this halves the incidence of infective episodes when compared with commencement at the time of suspected infection. However, this benefit must be balanced against the risk of developing multi-resistant pathogens. |
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A 42 year oldlady presents for right pneumonectomy with a left sided double-lumen tube. Sheis 132kg and 160cm. What depth, measured at the incisors, is likely to give theideal position? A. 24cm B. 26cm C. 28cm D. 30cm E. 32cm |
Classic teaching is that 180cm patient wouldhave DLT 30cm at the teeth. Reduce 1cm for every 10cm in height. So 160cm is 28cm - ANSWER C My notes from August 2013 29cm depth for 170cm tall.+/- 1cm for every +/- 10cm of height. Good correlation between height and depth of insertion. Poor correlation between height and size of DLETT DLETT Size: (from Miller 6th ed) 137-165cm: 35-37 Fr 165-178cm: 37-39 Fr 180-193cm: 39-41 Fr Airways tend to be larger than would be predicted by height in COPD / bronchiectasis |
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NEWYou are the anaesthetist at a Caesarean Section for a 36/40 gestation pregnancy. The baby at birth is floppy and apnoea. You decide that positive pressure ventilation via mask is necessary. The recommended FiO2 is: A. 0.21 B. 0.4 C. 0.6 D. 0.8 E. 1.0 |
ARC Guidelines say start with air - 21% in both term and preterm. Then adjust as needed for sats. But pre-term not higher than 40% |
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A 20 year old man was punched in the throat 3 hours ago at a party. He is now complaining of severe pain, difficulty swallowing, has a hoarse voice and had has some haemoptysis. What is your next step in his management? A. Awake Fibreoptic Intubation B. CT scan for laryngeal fractures C. Direct laryngoscopy after topicalising with local anaesthetic D. Nasopharyngoscopy by an ENT surgeon E. Soft tissue xray of the neck |
D - Nasendoscopy A - Blood in airway, likely difficult B - Patient sounds stable. This would facilitate identification of sub-glottic injuries prior to airway intervention C - LA may be dangerous. ETT may disrupt trachea D - As per blue book 2005 article E - useful for suspected radio opaque foreign bodies. May be useful in epiglottitis. See UB ‘Blunt Upper Airway Injuries’, which is a blue book article from 2005. From ATLS Handbook Laryngeal traumaAlthoughfracture of the larynx is a rare injury, in can present with acute airwayobstruction. It is indicated by the following triad:1. Hoarseness2. Subcutaneous emphysema3. Palpable fractureIf thepatient’s airway is totally obstructed, or the patient is in severe respiratorydistress, an attempt at intubation is warranted. Flexible endoscopic-guidedintubation may be helpful in this situation, but only if performedpromptly. If intubation is unsuccessful,an emergency tracheostomy is indicated, followed by operative repair. However,a tracheostomy, when done under emergency conditions, is difficult to perform,may be associated with profuse bleeding, and may be time-consuming. Surgicalcricothryoidotomy, although not preferred for this situation, may be alifesaving option. Penetratingtrauma to the larynx or trachea is overt and requires immediate attention.Complete tracheal ransection or occlusion of the airway with blood or softtissue can cause actue airway compromise that requires immdediate correction.These injuryies are often associated with oesophageal, carotid artery orjugular vein trauma, as well as extensive tissue destruction surrounding thearea due to blast effect. Noisybreathing indicates partial airway obstruction that suddenly may becomecomplete. Absense of breathing suggests that complete obstruction alreadyexists. When the level of consciousness is depressed, detection of significantairway obstruction is more subtle. Laboured respiratory effort may be the onlyclue to airway obstruction and tracheobronchial injury. If afracture of the larynx is suspected, based on the mechanism of injury and subtlephysical finding, Ct may help to identify this injury. Duringassessment of the airway, the “talking patient” provides reassurance (at leastfor the moment) that the airway is patent and not compromised. Therefore, themost important early measure is to talk to the patient and stimulate a verbalresponse. From AnAl 1998 – Anaestheticimplications of laryngeal traumaBlunt laryngotracheal traumatypically occurs in a motor vehicle accident in which the head is extended andthe larynx is exposed to a direct impact. Other mechanisms of injury includethe classic "clothesline" injury involving motorcycling, contactsports such as karate, and victims of assault or strangulation. Associatedinjuries are common and may include closed head injuries, chest trauma, anddamage to the cervical spine, esophagus, major vessels in the neck, andrecurrent laryngeal nerves.Analysis of the presentingfeatures in case series published since 1990 involving a total of 133 patientswith blunt and penetrating laryngeal trauma reveals that hoarseness was themost common symptom, seen in 54% of cases [3-7]. This was followedby tenderness (53%), surgical emphysema (43%), respiratory distress (38%),dysphagia (32%), and hemoptysis (26%). Only one published series reported thecorrelation between any sign or symptom suggestive of laryngeal trauma and theactual severity of injury [7]. In this series of 30patients, the authors found a significant correlation between the symptoms ofhemoptysis and stridor and the severity of the injury. Other authors stress thesignificance of airway compromise (dyspnea, stridor, and, in particular,inability to tolerate the supine position) [2-5]. Symptoms of voicechange (including dysphonia and aphonia) and surgical emphysema are otherhallmarks that should alert the anesthetist to the possibility of major injurywith the attendant risk of acute deterioration or loss of the airway. There mayalso be a surprising lack of clinical signs, which places the onus onthephysician to exercise a high index of suspicion when assessing patients withan appropriate history [3,8].Investigation of a patient withsuspected laryngeal injury and a stable airway should always includeradiographs of the chest and cervical spine. In addition to cervical vertebralinjuries, important findings suggestive of a breach of the airway include anabnormal tracheal outline, pneumothorax, pneumomediastinum, or cervicalemphysema.When possible, fiberoptic nasopharyngoscopy should be performed. This provides information about airway patency, endolaryngealhematomas, and mucosal lacerations without endangering the cervical spine.CT examination of the neck maybe used selectively in cases in which the result will determine furthermanagement [1,2,5] or, perhaps, even incases of severe trauma that obviously require surgery [9]. Surgicalintervention may be deferred for 48 h to reduce edema but should not be delayed>1 wk to minimize the formation of scar tissue.Airway stability and endoscopic findings are important determinantsof the anesthetic management of these patients. When the airway is stable andthe larynx is essentially normal on fiberoptic examination, orotrachealintubation under general anesthesia is a reasonable choice. |
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13. A full size C oxygen cyclinder (size A in New Zealand) has pressure regulated from A. 16000kpa to 400kpa B. 16000kpa to 240kpa C. 11000kpa to 400kpa D. 11000kpa to 240kpa E. 7600kpa to 240kpa |
Answer: A (Confirmed with Biomed) 16000 to 400kpa |
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Fit lady for elective laparoscopic cholecystectomy seen in PreAdmission Clinic. ECG shows LAD, RSR in V1, wide slurred S in V6 and QRS duration 0.2 msec. Your options a. Refer to cardiology b. Crack on c. Place permanent pacemaker d. Place temporary pacing wires e. Give atropine premedication B |
Answer could be A - refer because its ELECTIVE and you are in PAC. But could be B - because unlikely to cause problems during OT. But then why wouldn't you investigate at all? Most people seem to think the answer is B ECG description: LAD + RBBB i.e Bifascicular block LITFL: Bifascicular block is the combination of RBBB with either LAFB or LPFB (some also say LBBB is a bifascicular block because both fascicles are blocked). Conduction to the ventricles is via the single remaining fascicle.The ECG will show typical features of RBBB plus either left or right axis deviation.RBBB + LAFB is the most common of the two patterns. Bifascicular block is a sign of extensive conducting system disease, although the risk of progressing to complete heart block is thought to be relatively low (1% per year in one cohort study of 554 patients). Patterns of TFB Incomplete trifascicular block * Bifascicular block + 1st degree AV block (most common) * Bifascicular block + 2nd degree AV block * RBBB + alternating LAFB / LPFB Complete trifascicular block * Bifascicular block + 3rd degree AV block Incomplete trifascicular block may progress to complete heart block, although the overall risk is low.Patients who present with syncope and have an ECG showing incomplete trifascicular block usually need to be admitted for a cardiology work-up as it is possible that they are having episodes of complete heart block. Some of these patients will require insertion of a permanent pacemaker (class II indication).Asymptomatic bifascicular block with first degree AV block is not an indication for pacing (class III). |
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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 - they have more volume and the pH is lower (i.e. more acidic) Obesity in Anaesthesia and Intensive Care. BJA 85(1):91-108 (2000) page 101 |
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You are anaesthetizing a pregnant woman for neuro-radiological coiling. At what gestation is it important to monitor uteroplacental sufficiency? A. 22 weeks B. 24 weeks C. 26 weeks D. 28 weeks E. 32 weeks |
Answer: B - 24 weeks From CEACCP Anaesthesia for non-obstetric surgery during pregnancy Fetal monitoring Once fetal viability is assumed (24–26 weeks), the fetal heart rate (FHR) should be monitored. This may be difficult in the obese patient or during abdominal surgery. Inhalation agents typically cause a reduction in FHR variability, one of the changes indicative of fetal hypoxaemia. Intra-operative FHR monitoring requires skilled interpretation and an obstetrician with a plan of action should fetal distress be diagnosed. Uterine manipulation should be minimized in order to avoid pre-term labour. Ketamine increases uterine tone in early pregnancy and should not be used. While some advocate the prophylactic use of tocolytic agents, they are not without risk themselves and there is no proof of efficacy. |
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RPT During endovascular aneurysm repair, GA is preferred due to: A. risk of uncontrolled haemorrhage B. renal ischaemia is painful C. aorta traction is painful D. long duration of apnoea is needed E. contrast used can cause CVS instability |
Answer: probably A A. Can happen, needs GA - much easier to manage under GA than if you have to convert. But then risk of this happening is not huge?? B. No C. No D. Patient is asked to hold their breath, but normally for short periods during image acquisition - is an advantage of GA but its not a LONG duration.... E. No |
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You are anaesthetizing a patient with chronic renal failure for removal of a Tenkoff catheter and have intubated using rocuronium at a dose of 1.2mg/kg. You are immediately unable to intubate or ventilate and you decide to reverse the patient with sugammadex. What dosage would you use A. 2mg/kg B. 4mg/kg C. 8mg/kg D. 12mg/kg E. 16mg/kg |
Answer is E Normal reversal = 2mg/kg, deep 4mg/kg, CICO 16mg/kg |
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PiCCO determines cardiac output utilizing A. Thermodilution B. Pulse contour analysis C. Thermodilution and pulse contour analysis D. ? Doppler E. ? |
Answer is C - Thermodilution and Pulse Contour Analysis What is PiCCO?- Pulse countour cardiac output monitoringProvides complete haemodynamic monitoring by combining pulse contour analysis to provide acontinuous display of cardiac output using a modified version of Wesseling’salgorithm combined with a transpulmonarythermodilution technique |
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A 29 year old female undergoes craniotomy for posterior fossa tumour. Which of the following is an absolute contraindication to the sitting position A. Patent cerebrospinal ventriculo-atrial shunt B. Previous back surgery C. Pacemaker D. Small patent foramen ovale E. Oesophageal stricture contraindicated for transoesophageal echocardiogram |
A CSF V-A shunt 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 |
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A type Idiabetic is fasting pre-operatively and you decide to place them on an IVinsulin infusion to optimize their perioperative glycaemic control. Their BSLis 7 mmol/L. By what mechanism does the insulin infusion decrease their BSL A. Stimulates glucose uptake intothe liver B. Stimulates glucose uptake intoskeletal muscle C. Inhibits glucose production inthe liver D. Decreases glucose absorption from the gastrointestinal tract E. Inhibit glucagon release |
Answer is C " Direct words from Stoelting: " Stoelting's Anesthesia and Co-Existing Disease, 5Th Edition: The effects ofinsulin are surprisingly limited and primarily due to inhibitionof hepatic glucose production." The fasting hyperglycaemia of diabetes results from hepatic over‐production of glucose alone, since peripheral glucose utilization is increased despite the lack of insulin. Insulin treatment reduces glucose concentration through inhibiting hepatic glucose production. http://bja.oxfordjournals.org/content/85/1/69.long |
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In a penetrating chest injury what part of the heart is most likely to be injured a. Left ventricle b. Right ventricle c. Right coronary artery d. Right atrium e. Sinus node |
Answer is RIGHT VENTRICLE |
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Autologous transfusion results in less A. Cost B. Incompatible transfusion C. Less blood wastage D. Less unnecessary transfusion |
B - incompatible transfusion per CEACCP article CEACCP ‘Autologous blood transfusion’3 methods; cell salvage, perioperative autologous donation, and acute normovolaemic haemodilution. A – Higher than allogenic in cell salvage and PAD. B – Correct. Theoretically less, although human error can still occur in PAD C – Up to 50% of donated blood wasted in PAD. D – Higher, especially in cell salvage and ANH. |
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A nulliparous woman in labour for 8 hours with epidural analgesia has a fever 37.6 degrees. The most likely reason for this is A. altered thermoregulation B. chorioamnionitis C. urinary tract infection D. inflammatory response E. neuraxial infection |
ANSWER D - inflammatory response Epidural associated fever is common, ranging from mild hyperthermia to overt fever. Risk Factors 1. Nullparious 2. Prolonged labor 3. PROM Mechanisms postulated 1. Inflammation: most accepted explanation, unknown if it is infectious or non infectious (women with fever and epidural do not have evidence of chorioamonitis on histology) 2. Altered thermoregulation: hyperventilation during labor is diminished, resulting in reduced heat loss. 3. Effect of opioids: opioids suppress IL-2 formation www.anesthesia-analgesia.org/content/111/6/1467.full.pdf |
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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 is B - 30 - 70 L/min of ONLY oxygen as it bypasses the vaporiser. |
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Anaphylaxis to rocuronium. Which is most likely to cause cross-reactivity ? A. Vecuronium B. Pancuronium C. Atracurium D. Cisatracurium E. None of the above -cross reactivity too variable to predict |
Likely E - none of above From Allergy 2007; 62: 471-487 Review Article: Anaphylaxis during anaesthesia:diagnostic approach "Cross Reactivity between NMBA is said to be common because of ubiquitous ammonium groups in these drugs. The estimated prevalence of cross-reactivity between NMBA is about 65% by skin tests and 80% by radioimmuno assay inhibition tests. While some pairings are common, the patterns of cross-reactivity vary considerably between patients. It is unusual that an individual isallergic to all NMBA (41, 44, 45). Cross-reactivity depends on theconfiguration of the paratope of the antibody, which might either completelycorrespond to the ammonium epitope or extend to an adjacent part of the NMBAmolecule, to the structure of the NMBA (flexibility, inter-ammonium distance)and to the relative affinities of the different NMBA for their sIgE antibodies(34, 45, 46).Alternatively, it must be kept in mindthat some patients might suffer from multiple allergies (3, 14, 16).Consequently, diagnostic approach of anaphylaxis during anaesthesia cannot beconsidered as complete when it failed to address the possibility ofcross-reactivity and/or multi-sensitization, or did not involve identificationof safe alternative regimens. This assessment, unfortunately, is fraught withdifficulties, as results of skin tests, quantification of sIgE and sIgEinhibition tests do not per se reflect the clinical outcome. In the series byThacker et al. (47), no subsequent reactions were seen if NMBA were avoided inthe subsequent anaesthesia, nor were they in patients with severe reactions ifthe original intradermal test (IDT) had been equivocal or negative. In thepatients with a severe reaction and a positive IDT to one or more NMBA, six outof 40 (15%) later anaesthesia using NMBA were associated with clinicalproblems, three being probable anaphylactic reactions. In a series by Fisherand Bowey (48), one out of 65 patients that had suffered from skin testdocumented perioperative ana- phylaxis suffered from anaphylaxis duringsubsequent general anaesthesia. Actually, this patient had presentedanaphylaxis from pancuronium and reacted subsequently to alcuronium, albeitskin tests for alcuronium, remained negative on two occasions. Therefore, itmay, in any case, be safer to avoid NMBA for such a patient in futureanaesthesia whenever possible." |
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Immunity to Hepatitis B is demonstrated by the presence of A. Hepatits B core antibodies B. Hepatits B core antigens C. Hepatits B surface antibodies D. Hepatits B surface antigens E. Any of the above |
C - Hep B SURFACE ANTIBODIES http://www.cdc.gov/hepatitis/hbv/pdfs/serologicchartv8.pdf |
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A 2 year-old child has just undergone strabismus surgery. They had an URTI 1/52 prior to surgery. They had an uneventful general anaesthetic with a 4.5mm cuffed ETT, was extubated and sent to recovery. 20 minutes later they develop respiratory distress. Their saturations are 96% on room air, and there is noticeable tracheal tug. What is the most appropriate initial management that will help with their respiratory distress? A. inhalational induction B. CPAP with facemask C. propofol 1mg/kg D. dexamethasone 0.4mg/kg E. adrenaline nebuliser 1:1000 05ml/kg |
Answer: B Laryngospasm:CPAP, jaw thrust, stop painful stimulusConsider sux 0.5mg/kg IV or 2-4mg/kg IM.Low dose propofol. |
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[Repeat 2013A] A 35yo G1P0 with a dilated cardiomyopathy presents for a Caesarean section. She has an ejection fraction of 35%. The benefits of a regional anaesthetic over a general anesthetic in this patient may include: A. decreased heart rate B. decreased systolic blood pressure C. increased ejection fraction D. decreased preload E. increased myocardial contractility |
Answer: C Regional anaesthesia used alone or in combination with general anaesthesia has the advantage of reducing after load which can improve cardiac output by improving SV. However, hypotension must be prevented to avoid myocardial hypo perfusion. Treatment of arterial pressure changes should be considered if a 10% decrease in systolic pressures occurs. Aims: avoid tachycardia; † avoid/minimize the effects of negative inotropic agents, inparticular anaesthetic drugs; † prevent increases in after load; † maintain adequate preload in the presence of elevated LVEDP. Aims of DCM- avoidance of drug induced myocardial depression, maintenance ofnormovolaemia, prevention of increased ventricular afterload/ increased SVR,avoidance of sudden onset of blockade of SNS/ avoid sudden drop in SVR,maintain uteroplacental perfusion |
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A new question about bradycardia post gas insufflation/pneumoperitoneum. What to do? |
? Was the answer to release it - and then you'd re-introduce it slower. As bradycardia probably due to vagal response to peritoneal stretch. |
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A new question about which nerves the Fascia Iliaca Block blocked? |
Femoral and Lat. Femoral Cutaneous (plus obturator but this wasn't an option) |
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Something about a DES and one of the options related to epithelialising / may have been why doesn't something happen??? |
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Question about dose of Hylase for eye block may have had a dose range rather than exact amount? |
Answer probably 15 IU/mL - based on googling and asking people - although ranges/doses seem to vary greatly! Have also seen 30 - 150. |
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How to prevent breath stacking in COPD??? |
Because of airway narrowing the next inhalation occurs before expiration of the previous breath is complete and this leads to breath stacking or "air trapping" and the development of intrinsic PEEP. The primary concern when ventilating a COPD patient is maintaining as long an expiratory phase as possible (1:4). This needs to be communicated to your respiratory therapist, who may make the initial ventilator settings based on a standard protocol. Small tidal volumes and very low respiratory rates are necessary to adequately ventilate your patient. |
