Anzca Mcq 2008 A

Front 1

Anaphylaxis, which is wrong:
A. higher incidence in females (females have a higher incidence of anaphylaxis to neuromusclar drugs)
B. ??avocados, bananas and latex (edit: cross reactivity between...)
C. vecuronium - more likely to cause an anaphylactoid reaction than anaphylaxis
D. 99% within mast cells
E. peak tryptase in 1hr

Back 1

c
CEACCP Volume 4, No 4, 2004
Steroid based compounds (vec and panc) cause anaphylactic reasons, whereas benzyls (miv and atrac) tend to cause anaphylactoid reactions. Of drug reactions caused by NMBD, 43% are caused by sux, 37% vec, and 7% atrac. The quaternary ammonium group found in NMBD is widely present in other drugs, foods, cosmetics and hair care products. This could explain why anaphylaxis to NMBD is 5-10x more common in females.

Front 2

Sepsis from Yersinia infection from blood transfusion, mortality?
A. <5%
B. 20%
C. 40%
D. 60%
E. 80%

Back 2

D
"The onset of clinical symptoms typically occurs acutely during transfusion, with a mortality rate of 60% and a median time to death of only 25 hrs (27)." (Goodnough, Risks of blood transfusion, in Crit Care Med 2003 Vol. 31, No. 12 (Suppl.))

Front 3

Obese female having gynae surg. Uneventful induction. Anaesthetic stable. Goes into reverse trendelenberg and pneumoperitoneum and then 10 mins later desats to about 80%. BP 120/80. pCO2 44 mmHg: What is most likely cause?
A. Pneumothorax
B. Endobronchial intubation
C. Air embolus
D. Hypoventilation
E.

Back 3

B
CEACCP 2004 Laparoscopic Abdominal surgery:
Risk of trendelenberg = endobronchial intubation due to cephalad movement of diaphragm

Front 4

Patient, 60 year old, renal failure. Has had a total knee replacement. Three days postop, pt develops SOB, chest pain and tachycardic. Shown an ECG - RBBB, R wave in VI, S wave in I, Q wave in III, t wave inversion in III (i.e. S1Q3T3). What is the diagnosis? (also had widespread ST elevation)
A. Myocardial infarction
B. Pulmonary embolus
C. Hyperkalemia
D. pericarditis
E. ?

Back 4

b
Electrocardiography
• Shows a deep S wave in lead I with a Q wave and inverted
T wave in lead III (S1Q3T3 complex)
• May be right bundle-branch block and right axis deviation

(Prevention of DVT and PE< AICM, 7:12, 2006)

Front 5

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

Back 5

E

"Histologic examination by itself cannot be used to diagnose MHS specifically—the defect is functional, not structural."
Anesthesiology 2002; 96:232–7
Testing for Malignant Hyperthermia, Henry Rosenberg et al

MRI = Several studies have shown delayed reconstitution
of pH, adenosine triphosphate, and increased phosphocreatine in MH patients during and after graded exercise.
Caffeine/halothane = The caffeine– halothane contracture test (CHCT) requires approximately 2 g of muscle excised from the vastus lateralis or vastus medialis muscle. In the North American protocol, halothane (3%) is added
to the gas flow to three baths via an in-line vaporizer,
while caffeine is added incrementally to the other three.
The diagnostic end point is the development of a contracture, which is an increase in baseline muscle tension. If a contracture of 0.7 g or greater develops in any halothane-exposed muscle strip or if a contracture of 0.3 g or greater develops in any strip exposed to caffeine at 0.5, 1, or 2 mM, then the test is considered to be positive and pt has MHS.
CK = Creatine kinase concentrations are chronically increased in perhaps 50% of MH patients. However, creatine
kinase is increased in many myopathic diseases and may be increased secondary to trauma. Therefore, its sensitivity and specificity are not satisfactory for it to be
used for routine testing.

Recently, Sei et al.22 have shown RYR-1 receptors on B
lymphocytes in humans. This implied that these cells
might demonstrate changes in calcium flux similar to
those demonstrated in muscle.

The diagnostic thresholds are adjusted to maximize sensitivity, thereby minimizing false negatives. Currently, the North American and European tests are 97–99% sensitive (i.e., 1–3% false negatives). This sacrifices specificity, so that 10–15% of normal patients will have false-positive tests.

Front 6

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

Back 6

B
"there is no good evidence that giving antidepressants to people with chronic low back pain improves pain relief - Level I"...Acute Pain Management: Scientific Evidence (2010), p xxiv

Front 7

During which is procedure is it most important to re-program a pacemaker?
A. ECT
B. MRI
C. Lithotripsy
D. Percutaneous transhepatic cholangiogram
E. ?

Back 7

Consensus seems to be C
MILLER:
Situations Probably Requiring Pacemaker Reprogramming
Any rate-responsive device—see text (problems are well known and have been misinterpreted with the
potential for patient injury; the Food and Drug Administration has issued an alert regarding devices with minute ventilation sensors)
Special pacing indication (HOCM, dilated cardiomyopathy, pediatric patients)
Pacemaker-dependent patients
Major procedure in the chest or abdomen
Rate enhancements present that should be disabled
Special procedures = Lithotripsy, TURP, Hysteroscopy
Electroconvulsive therapy
Succinylcholine use
Magnetic resonance imaging (generally contraindicated by device manufacturers)
In some situations and for certain patients, a pacemaker should be reprogrammed either to avoid potential patient injury or to prevent a pacemaker rhythm that could be confused with pacemaker malfunction.

Front 8

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

Back 8

c
C1 doesn't have a spinous process
Wilson score = weight; upper c-spine mobility; jaw movement; receding mandible; buck teeth all 0-2; >= 2 predicts 75% difficult intubations
OHA

Front 9

With regard to surgical antibiotic prophylaxis, which of the following statements is LEAST correct?

A. cephalosporins can usually be safely administered to penicillin allergic patients
B. clindamycin can be indicated in penicillin allergic patients
C. they should be administered at the time of surgical incision
D. the ideal timing of administration is less than 30 minutes prior to surgical incision
E. vancomycin should be given routinely in MRSA (methicillin resistant staphylococcus aureus) prevalent areas

Back 9

E

A = 8% cross reactivity
B = True
C = should be given 0-2 hours pre-incision
D = yes
E =
vancomycin should be used only if: -Patients are infected/colonised with an MRSA strain -Patients are having MAJOR surgery and are at high risk for colonisation (eg spent longer than 5 days in hospital with endemic MRSA) -Patients undergoing prosthetic valve/joint/vascular surgery where procedure is a reoperation or revision -Hypersensitvity to penicillins and or cephalosporins

Antibiotic guidelines
James M, Martinez E. Antibiotics and perioperative infections, Best Practice & Research Clinical Anaesthesiology. Vol. 22, No. 3, pp. 571–584, 2008

Front 10

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

Back 10

b
Apparently carotid artery - if blood flowing towards doppler then = RED, away = BLUE

Front 11

BP measurement - overestimates with:
A. big (wide) cuff
B. skinny arm
C. severely peripherally vasoconstricted
D. atherosclerosis (it was arteriosclerosis)
E. slow cuff deflation

Back 11

D

Small cuff would overestimate
Overestimate at low pressures eg ? C

Interpretation of haemodynamic monitoring (Mark): http://www.iars.org/2003RCLtest/pdftext/mark2003.pdf
• Extrinsic cuff compression (Auscultatory, NIBP).
• Overly rapid cuff deflation leading to BP underestimation
(Auscultatory).
• Calcified, noncompressible arteries leading to BP overestimation (Auscultatory, NIBP).
• Intense vasoconstriction leading to BP underestimation
(Auscultatory).
• Use of inappropriately small cuff leading to BP overestimation (Auscultatory, NIBP).
• Dysrhythmias (Auscultatory, NIBP).
• Shivering and patient movement (Auscultatory, NIBP).
• Beat-to-beat BP variations, as in pulsus alternans (Auscultatory, NIBP).
• Rapid BP changes not detected

The maximal pressure under the cuff is proportional to the inflation pressure and cuff width. A cuff that is too narrow generates lower tissue pressures than indicated and thus overestimates blood pressure. Conversely, a very wide cuff slightly underestimates blood pressure. A correctly fitted cuff should cover two-thirds of the upper arm or should be roughly 20% wider than the diameter of the limb. (AICM 2005 6 (12); 405-7)

Front 12

The most sensitive monitor for detecting venous gas embolism during neurosurgery is a:
A. Capnograph
B. Praecordial Doppler transducer
C. Praecordial stethoscope
D. Pulmonary Artery Catheter
E. Transoesophageal echocardiograph

Back 12

E

Gas embolism in anaesthesia BJA CEPD Review Vol2 Number 2 2002 for all your needs

TOE ...................... Sensitivity : 0.02ml/kg ... Specificity : Not Absolute
Precordial Doppler .. Sensitivity : 0.2mg/kg .....Specificity : Moderate
End Tidal N2 .......... Sensitivity : 0.1ml/kg ..... Specificity : Absolute

Front 13

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

Back 13

d

http://www.anaesthesia.med.usyd.edu.au/resources/lectures/electricity.html

Residual Current Devices (RCD's)
RCD's's are the cheaper way to do this. Since normally all the current leaving a piece of electrical equipment goes back to ground by the Neutral wire, then the current flowing through the Active and Neutral wires should at all times be equal. Should a fault exist in which electricity is leaking to ground by any other route, then the currents in the Active and Neutral wires will no longer be equal, and under these circumstances the RCD will be "tripped" and both the Active and Neutral supply will be disconnected from the socket providing power to the faulty device. The RCD will disconnect power within 10 to 20 milliseconds when a leak current of 5 to 10 mA is detected. Thus it will protect against most cases of macroshock. An audible alarm will sound and a loud thump will be heard when the relay is tripped, and power can only be restored manually, by pushing the switch back to the "on" position. Usually a test button is available to check the correct operation of the RCD.

The RCD will not detect faults in which electricity passes through the body and back through the Neutral wire, however these are very infrequent. It will not protect against microshock as up to 10 times the required current for fibrillation may pass through the patient without tripping the relay.

RCD's are generally wired to several power outlets, and if tripped will disconnect power from them all, and keep on doing so until the faulty device is removed. This is not desirable in some patient care areas, where a different type of system may be used.

Front 14

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

Back 14

b
Increased frequency increases resolution, decreases penetration.
? Reference (same in Rhys')

Front 15

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

Back 15

E
ACA PCI guidelines 2005 - "An analysis of the randomized controlled trials comparing fibrinolysis with primary PCI suggests that the mortality benefit with PCI exists when treatment is delayed by no more than 60 min. Mortality increases significantly with each 15-minute delay in the time between arrival and restoration of TIMI-3 flow." and: "Primary PCI should not be performed in asymptomatic patients more than 12 hours after onset of STEMI who are hemodynamically and electrically stable."

Front 16

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

Back 16

b
Wiki:
Hyperparathyroidism is overactivity of the parathyroid glands resulting in excess production of parathyroid hormone (PTH). The parathyroid hormone regulates calcium and phosphate levels and helps to maintain these levels. Excessive PTH secretion may be due to problems in the glands themselves, in which case it is referred to as primary hyperparathyroidism and which leads to hypercalcemia (raised calcium levels). It may also occur in response to low calcium levels, as encountered in various situations such as vitamin D deficiency or chronic kidney disease; this is referred to as secondary hyperparathyroidism.
Symptoms/signs:
weakness and fatigue, depression, bone pain, muscle soreness (myalgias), decreased appetite, feelings of nausea and vomiting, constipation, polyuria, polydipsia, cognitive impairment, kidney stones and osteoporosis

Front 17

Haemophilia A associated with
A. haemarthroses in infant female
B. haemarthroses in infant male
C. factor IX deficiency
D. Incr APTT but not PT
E. Incr APTT and PT

Back 17

d
Article by Lee - search haemophilia_VWD

Hemophilia A is an X-linked recessive hereditary disorder characterized by a deficient or defective factor VIII coagulant. The disorder occurs in roughly 1 out of every 10,000 live male births. Carriers of the deficiency have over 50% of normal factor VIII levels and are generally asymptomatic. However, female patients with hemophilia A can occur with Turner syndrome and X mosaicism.
Clinically, soft-tissue hematomas and hemarthroses leading to hemarthropathy are characteristic of the disorder. The features of hemophilia A generally correlate with factor VIII levels. Patients with a mild disease and 6% to 30% of the normal factor VIII level rarely have spontaneous hemorrhages and may experience major bleeding only with trauma or surgery. Patients with a moderate disease and 1% to 5% of the normal activity will occasionally have spontaneous hemorrhages. And patients with a severe disease and less than 1% of activity will develop spontaneous hemorrhages from early infancy, usually with the onset of ambulation, and require factor replacement therapy.
Patients with hemophilia A have a normal prothrombin time (PT), thrombin clotting time, and bleeding time and a prolonged partial thromboplastin time (aPTT). The definitive diagnosis relies on the assay for factor VIII coagulant activity.

Front 18

Carcinoid syndrome - finding on examining heart:
A. Fine inspiratory crepitations
B. Systolic murmur at apex
C. Systolic murmur at left sternal edge
D. Murmur at apex with opening snap
E. Pericardial rub

Back 18

c - Tricuspid regurg

"Carcinoid syndrome is a disease consisting of a combination of symptoms, physical manifestations, and abnormal laboratory chemical findings caused by a carcinoid tumour.
A carcinoid tumor is a tumor that secretes large amounts of the hormone serotonin. These
tumors usually:
* arise in the gastrointestinal tract and
* from there may migrate (metastasize)to the liver.
Carcinoid tumors also sometimes develop in the lung.
Only about 10% of the people with carcinoid tumors will develop the carcinoid syndrome.
Major symptoms of this syndrome include:
* hot, red facial flushing,
* diarrhea and
* wheezing.

Carcinoid syndrome occurs when the tumors produce excessive amounts of serotonin or other substances.
Notes:
The presence of carcinoid syndrome suggests:
• the presence of liver secondaries
• a non-GI carcinoid tumour
• massive mediator release by tumour
The liver normally breaks down the mediators (vasoactive compounds) secreted by the tumour. As most carcinoid tumours are in the GIT, the mediators are released into the portal veins, and broken down in the liver. To cause carcinoid syndrome then indicates the liver is being bypassed or overwhelmed.

Carcinoid Heart Disease This has generated a few MCQs over the years.
• Develops in 50% of patients with carcinoid syndrome
• hence in about 5% of people with a carcinoid tumour
• It results in fibrosis of myocardial tissues, especially on the Right side of the heart
• tricuspic regurgitation is the most common finding
• pulmonary regurg and/or stenosis also occurs
• less than 10% of patients with carcinoid have mitral or aortic regurg
• constrictive pericarditis has also been described

Front 19

You are anaesthetising a patient with acute intermittent porphyria. Which drug will most likely cause an attack of porphyria?
A. Droperidol
B. prochlorpazine
C. ondansetron
D. metoclopramide
E. tropisetron

Back 19

d
OHA p 204
= minimise preop fasting
regional anaesthesia - bupivacaine safe
GA - propofol induction agent of choice, maintain with N2O and propofol.
NMBD - sux, vec, fentanyl, morphine and pethidine safe

Problems - hypertension, tachycardia (use b blockers), convulsions (treat with diazepam, propofol or magsulph - avoid barbiturates and phenytoin)

UNSAFE =
barbiturates, etomidate, enflurane, alcuronium, pentazocine, ropivacaine, nitrazepam, cimetidine, metoclopramide, hydralazine, nifedipine, phenoxybenzamine, aminophylline, OCP, phenytoin, sulphonamides
www.drugs-porphyria.com

Front 20

Capnograph -
This is most likely caused by
A. leaking gas sample line
B.
C.
D.
E.

Back 20

a

Front 21

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

Back 21

a
Does not cross BBB - see aug 2010

Front 22

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

Back 22

a

Lambert-Eaton myasthenic syndrome (LEMS) is a rare autoimmune disorder that affects voltage-gated calcium channels on the pre-synaptic membrane of the nerve-muscle (neuromuscular) junction. The inhibition of the voltage-gated calcium channels prevents acetylcholine from being released from the presynaptic terminal and the subsequent stimulation of the post-synaptic terminal which would lead to muscle contraction.
While LEMS may be found as a solitary disease, 50% of cases have an associated small-cell lung cancer. Other malignancies associated with LEMS are extremely rare. The myasthenic syndrome associated with thymoma is actually true myasthenia gravis, where weakness worsens with repeated activity (as opposed to LEMS, where weakness improves with repeated activity).
Whether solitary or cancer-associated, the disease is believed to be of autoimmune origin.

From word doc in files:
Affected patients have a decreased release of acetylcholine at the neuromuscular junction. With repeated stimulus the concentration is the clefts is sufficient for normal strength. Guanidine therapy enhances release of acetylcholine from nerve terminals + improves strength.
EMG recordings show
- post-tetanic facilitation
- decreased action potentials
(Harrison 2081)
Anaesthetic management:
show abnormal response to suxemethonium
increased sensitivity to NDNMB
myoneural block not reversed by neostigmine, weakness persists for many days.
Avoid GA if possible. Avoid muscle relaxants if possible. Assess reversal state prior to extubating.

Front 23

Hyponatraemia and hypovolaemia all except
A. SIADH
B. Pancreatitis
C. Nephritis
D. Renal tubular acidosis
E. Addisons

Back 23

A
Not hypovolaemia
CEACCP article on sodium disorders after brain injury
SIADH
Most common neurological causes are SAH, traumatic brain injury, brain tumour and meningitis, or from drugs esp carbamazepine.
Lower threshold for thirst in pts with SIADH; loss of control of ADH release and plasma ADH release is unaffected by continued fluid administration/osmotic stimulus.
Diagnosis:
1. hypotonic hyponatraemia (<135mmol/L) and osmol < 280mosm/kg
2. urine osmol > serum osmol
3. urine Na > 18mmol/L
4. normal thyroid/adrenal/renal function
5. clinical euvolaemia

Front 24

After 3L normal saline, expect to see:
A. hyponatremic acidosis
B. hyponatremic alkalosis
C. hyperchloremic acidosis
D. hyperchloremic alkalosis
E. none of the above

Back 24

c
The advent of balanced solutions for i.v. fluid resuscitation and replacement is imminent and will affect any specialty involved in fluid management. Part of the background to their introduction has focused on the non-physiological nature of ‘normal’ saline solution and the developing science about the potential problems of hyperchloraemic acidosis.
Br J Anaesth 2008; 101: 141–50

Front 25

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

Back 25

E
CEACCP article + June notes

NMS has much higher mortality therefore C false
Treatment is withdrawal of causative agents, supportive +/- ICU care. Cyproheptatine has been used previously.

Front 26

What increases the risk of threading an epidural catheter into a blood vessel?
A. not doing a CSE
B. injecting saline prior to threading catheter
C. LOR to saline instead of air
D. paramedine instead of midline approach
E. sitting position instead of lateral

Back 26

A - true
B - no, decreases
C - no change
D - no change
E - ?
AICM Bell and Leslie 2007
Review: Detection of intravascular catheter placement
- distension of epidural veins due to the effects of an intraabdominal mass. This especially applies during pregnancy and during labour; uterine contractions cause further distension of these vessels.
- The use of a combined spinal-epidural technique has been reported to decrease the incidence of intravascular placement, possibly by ensuring that the epidural catheter is inserted in the midline, avoiding the laterally located venous plexuses.
- The use of loss of resistance to saline, as opposed to air, and the midline approach, as opposed to the paravertebral approach, have no effect.
- Injection of saline may decrease risk
- Soft pliable catheters less risk

NB. After this in 2009: A & A
The risk of intravascular placement of a lumbar epidural catheter in pregnancy may be reduced with the lateral patient position, fluid predistension, a single orifice catheter, a wire-embedded polyurethane epidural catheter and limiting the depth of catheter insertion to 6 cm or less.

Front 27

38yo obese female with DM, other comorbidities, undergoing LSCS with spinal anaesthetic with a 27G whitacre needle, having this and that, blah, blah. then two days later complains of numbness on a small patch on lateral aspect of mid-thigh. On full neuro exam - no other signs/symptoms.
A. conus medullaris injury
B. L2 nerve root compression
C. L3 root lesion
D. L4 root lesion
E. meralgia paraesthetica

Back 27

E
Meralgia paraesthetica - from Int J Obs Anaes Review: Neurological complications in obstetric regional anaesthesia;
All anaesthetists should be familiar with meralgia
paraesthetica as the condition is frequently confused
with regional anaesthesia-induced neuropathy. Meralgia
paraesthetica is a term used to describe a sensory
mononeuritis involving the lateral femoral cutaneous
nerve (L2 and L3). It is usually caused by trauma or
compression of the lateral femoral cutaneous nerve at
one of many possible sites of entrapment along its
variable and angulated course. In most cases, the
nerve is injured as it passes beneath the inguinal ligament.

Front 28

Each of the following statements regarding the haemodynamic changes during pneumoperitoneum
for laparoscopy is true EXCEPT:

A. in patients with severe cardiac disease changes are qualitatively similar to those in normal patients
B. right atrial pressure is NOT a reliable indicator of cardiac filling
C. they are well tolerated by morbidly obese patients
D. they are well tolerated in cardiac transplant patients with good ventricular function
E. they are well tolerated in patients with low cardiac output secondary to low preload

Back 28

A - true statement (not the answer); direct quote from Miller
B - true statement (not the answer); direct quote from Miller
C - direct quote from Miller
D - direct quote from Miller
E - FALSE - The most severe haemodynamic changes are patients with depleted intravascular volume

Front 29

At what level of intra-abdominal does cardiac output fall? (this exam was definitely cardiac output rather than BP as in other exams)
A. 10 mmHg
B. 20 mmHg
C. 30 mmHg
D. 40 mmHg
E. 50 mmHg

Back 29

a
"Initially, owing to autotransfusion of pooled blood from the splanchnic circulation, there is an increase in the circulating blood volume, resulting in an increase in VR and cardiac output. Further increases in the IAP (greater than 10mmHg) result in the compression of the IVC, reduction in VR return and subsequent decrease in cardiac output. Continuing Education in Anaesthesia, Critical Care & Pain | Volume 4 Number 4 2004

BP doesn't fall until IAP > 20mmHg

Front 30

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

Back 30

a
Same CEACCP article
"The increasing SVR, systolic and diastolic blood pressures and tachycardia, result in a large increase in myocardial workload"

Front 31

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

Back 31

VAE
A - yes
B - yes
C - ?
D - yes
E - no - Miller clearly states that Valsalva worsens venous return/cardiac performance, and promotes paradoxical embolus

Front 32

Maximum time for arterial tourniquet for upper limb
A. 60 min
B. 90 min
C. 120 min
D. 150 min
E. 180 min

Back 32

c OHA p450

Only pneumatic tourniquet should be used
Expressive exsanguination using Esmarch bandage is contraindicated in cases of tumour or severe infection or if DVT suspected, or can cause LVF if both legs done (add 15% to VR)
Peripheral arterial disease = relative CI
Avoid in crush injuries or sickle cell

Protect with cotton wool - wide 90mm for arm and 105mm for leg, exceed circumference by 7-15cm
Pressures = UL SBP + 50; LL 2 x SBP
2 hr is the maximum
PE can occur following release
Pain at 30-60 mins even with GA (not spinal)

Front 33

20 year old male, 8 hrs post admission for motorbike accident, # femur now in traction. Had femoral nerve block, plus 40 mgs dose morphine IV. Admission CXR normal. Now decreasing level of consciousness, decreasing sats (~85%) despite 6 lts O2, crackles both lungs. what is it?
A. Fat embolus syndrome
B. Pulmonary contusion
C. ?narcotized (drowsy and hypoventilating)
D. Pneumothorax
E. Aspiration

Back 33

FES or contusion or aspiration???

All supported by normal initial CXR
If aspiration, unilateral crackles more likely
Can get contusion without rib fractures
Not narcotised with RR 25
B - ATLS guidelines: Pulm contusion may occur without rib fractures or flail chest, and flail chest may not be apparent initially due to splinting.... is most common potentially lethal chest injury... resultant resp failure can be subtle, and it develops over time... ABG suggest hypoxia.

CEACCP Fat Embolism
Incidence greatest with long bone fracture - increases with number of fractures (1-3% with single bone --> 33% if bilat femoral fractures)
Mortality 5-15%
Usually 24-72h post injury
Triad = respiratory changes (dysnpea, tachypnoea, hypoxaemia - 50% to point needing ventilation) + neurological abnormalities (from cerebral emboli - from mild confusion and drowsiness through to seizures, most commonly confusion + hemiplegia, aphasia, apraxia etc are described) + petechial rash (last component, in 60%)

Front 34

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

Back 34

D
Nose: Trigeminal V1 and V2
Nasopharnyx: Glossopharyngeal and V2/V3
Pharynx: superior laryngeal nerve
Larynx: vagus [superior/internal/recurrent laryngeal nerves]

Front 35

A thoracic epidural inserted for pain relief:
A. Allows earlier return of bowel function
B. Prevents wasting of total body protein
C. Does NOT reduce the incidence of MI
D. Epidural opioids alone provide better analgesia than systemic opioids alone
E. Addition of adrenaline significantly reduces local anesthetic dose requirement

Back 35

A

From pain book:
Better pain relief at rest and with movement - lower N/V and sedation; higher pruritis, retention and motor block
Increased PaO2 levels and decrease pulmonary infections/complications
Reduced duration of IPPV, CV complications, MI, acute respiratory failure, GI complications and renal sufficiency after AAA - did not translate into reduced mortality
Colorectal = reduced pain scores and duration of ileus, 7 and 30day mortality
Lung resection = improved mortality and pulm function, if pre-op reduced acute post thoracotomy pain but not chronic pain
After major abdo surgery with NSAIDs and IV nutrition = prevent protein loss compared with epidural analgesia alone or PCA; increased anabolic effect of amino acid infusions
Thoracic = improved bowel recovery, decrease MI if extended more than 24 hr

Front 36

Man with peripheral vascular disease, post unilateral lumbar sympathectomy injection - most likely Cx:
A. orthostatic hypotension
B. genitofemoral nerve neuralgia
C. ?L2-L4 paraesthesia
D. psoas haematoma
E.

Back 36

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

Front 37

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

Back 37

C seems reasonable

Front 38

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

Back 38

C
in CEACCP: “Needle damage to the globe is about 30 times more common if the block is administered via the inferotemporal approach.4 Blocks done at the medial canthus or sub-Tenon’s are safe.” It is specifically talking about in long axial length eyes, but it’s enough for me to go

Ophthalmologica 2006 (220) p 73 "complications of ophthalmic regional anaesthesia"
Perforation more likely in myopic eyes, >26mm increases risk, Retinal detachment patients more likely to have longer axial length, occurs with both peribulbar and retrobulbar injections, incidence ~ 1/12000, more likely with unco-operative patient or inexperienced operators.

NYSORA
The most common sites fot needle insertion are (1) medial canthus peribulbar anaesthesia, (2) Lacrimal caruncle, (3) inferior and temporal peribulbar injections. Clinical Pearls: Needle insertion through the superior nasal site should be avoided. At this level, the distance between the globe and the orbital roof is reduced, theoretically increasing the risk of globe perforation. Aditionally, the superior oblique muscle may be injured by the needle. The inferior nasal puncture should be used instead.

Front 39

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

Back 39

b
The superior oblique muscle is situated outside the fibrotendinous ring and is the most difficult muscle to anaesthetize completely...Continuing Education in Anaesthesia, Critical Care & Pain | Volume 5 Number 3 2005

Front 40

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

Back 40

D
"the pericardium may ascend alongside the medial wall of the SVC by up to 5 cm (mean 3 cm). Thus, placement just proximal to the atrium does not obviate the risk of tamponade".

Front 41

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

Back 41

C.
ANZCA Neuroanaesthesia Podcast Handout - Section on Hypertonic Therapy
"Mannitol (or sometimes hypertonic saline 1.6-20% (HTS) in trauma), ± loop diuretics if the above measures by themselves are not enough or on surgeon’s request" "Renal failure may occur, especially if dehydrated, pre-existing renal failure or osmolality >320 in adults. Some work suggests that even higher osmolality may be tolerated if dehydration is meticulously avoided."

Front 42

A patient is ventilated and invasively monitored in intensive care following a traumatic brain injury. Systemic arterial blood pressure is 140/80 mmHg with a mean pressure of 100 mmHg. Central venous pressure is 8 mmHg and intracranial pressure is 15 mmHg. The cerebral perfusion pressure (CPP) for this patient is:

A. 72 mmHg
B. 85 mmHg
C. 92 mmHg
D. 125 mmHg
E. 132 mmHg

Back 42

cpp = map - jvp or icp
= 100 - 15 = 85
= B

Front 43

Patient on ward, collapsed. nurse calls code blue when finds pt unresponsive. no signs of life. After ensuring airway is clear, 1st action?
A. DCR x3 200J
B. DCR x1 200J
C. praecordial thump
D. CPR
E. Adrenaline 1mg

Back 43

d

Front 44

Improved neurological outcome has been demonstrated with the use of hypothermia soon after:
A. asystolic cardiac arrest
B. cerebrovascular accident
C. perinatal complications causing ischaemic encephalopathy
D. rupture of an intracranial aneurysm
E. traumatic brain injury

Back 44

C
Clinical Indications for Induced Hypothermia = CEACCP

A - only VF
B - nope
D - nope
E - controversial

Front 45

12 year old child with hip dislocation at 4pm. Ate 1 hour after injury. Now 11 pm. Best anaesthetic:
A. RSI with ETT
B. delay until next day then treat elective
C. inhalational induction and continue with face mask
D. Reduce immediately with iv sedation
E. inhalational induction and continue with face mask

Back 45

A = safest

Front 46

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

Back 46

D
Otherwise well etc - use least invasive approach / don't instrument airway
If very febrile and unwell with productive cough /unclear chest then delay

Front 47

When using a T piece for a small child, which is not an advantage?
A. Can use low gas flows
B. Feel compliance
C. Assess tidal volume
D. Can rapidly change levels of CPAP
E. low resistance

Back 47

a

Front 48

Regarding the normal term infant:
A. Foetal haemoglobin (HbF) comprises approximately one-third the total haemoglobin at birth and falls to negligible levels by 3 months of age
B. foetal haemoglobin (HbF) comprises approximately 70% of the total haemoglobin at birth and falls to negligible levels by 6 months of age
C. Hb 90 at 6 months normal doesn't need Investigation
D. normal haemoglobin at birth should be greater than 200 g.l-1, unless there has been delay in umbilical cord clamping
E. total blood volume is approximately 70 ml.kg-1 body weight

Back 48

C
Power and Kam, p 361. "At birth, HbF forms 75-80% of the total haemoglobin, but this gradually decreases so that at 6 months after birth it is replaced by adult haemoglobin (HbA)."

Front 49

Clonidine is
A. Alpha 2 agonist centrally that acts presynaptically
B. Alpha 1 agonist
C. Alpha 2 antagonist
D. Alpha 1 antagonist
E. ?

Back 49

a

Front 50

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

Back 50

C
Levosimendan is a calcium sensitiser that can be administered intravenously (IV) to patients with acute decompensated congestive heart failure (CHF). At therapeutic dosages levosimendan enhances myocardial contractility without increasing oxygen requirements, and causes coronary and systemic vasodilation.
The drug works via a dual mechanism of action which enhances cardiac contractility and vasodilatation without affecting intracellular free calcium, and so should have reduced proarrhythmic potential. It can be administered intravenously (IV) which makes it a therapeutic option for acute decompensated CHF.

**"Levosimendan causes conformational changes in cardiac troponin C during systole, leading to sensitisation of the contractile apparatus to calcium ions"
Anaesthesia: Volume 61(1) January 2006 p 61-63 ...

Front 51

When used for treatment of neuropathic pain, the dose of gabapentin should be modified if the patient:
A. Has impaired hepatic function
B. has impaired renal function
C. is also receiving amitriptyline
D. is also receiving a proton-pump inhibitor
E. is also receiving fentanyl transdermally

Back 51

B
Almost entirely renally excreted

Uses of Gabapentin:
- improved analgesia and reduced postop opioids but increased sedation + decrease nausea (NNT 25) vomiting (6) and urinary retention (7).
- Specifically after hysterectomy and spinal surgery, improved pain relief and opioid sparing, nausea was less and no difference in sedation
- good following burns
- incidence of postamputation pain not reduced by gabapentin in the first 30 days after amputation
- is effective in treatment of phantom limb pain

Front 52

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

Back 52

c
3.5ml O2/kg/min

Front 53

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

Back 53

C
NNT = 1 / ARR

Front 54

Q106
The commonest initial presenting feature in anaphylaxis is
A. coughing
B. desaturation
C. hypotension
D. rash
E. wheeze

Back 54

c

Front 55

Investigation of a suspected anaphylactic reaction requires measurement of tryptase levels. Correct statements regarding tryptase include each of the following EXCEPT:
A. 99% of body tryptase is in mast cells
B. a concentration of greater than 20 ng.ml-1 suggests an anaphylactic reaction
C. blood samples should be repeated 24 to 48 hours after the reaction
D. maximum blood concentrations occur within 1 hour of the reaction
E. tryptase concentrations rise after both anaphylactic and anaphylactoid reactions

Back 55

C
1, 6 and 24

Front 56

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

Back 56

E
See CEACCP article

D - true as quaternary ammonium in lots of cosmetics
C - have their own anaphylactic issues
A and B = true

Front 57

In Australasia all of the following tests are routinely performed before releasing blood for transfusion EXCEPT
A. indirect antiglobulin test to cross match ABO and Rh compatible blood
B. screening the recipient serum for red cell antibodies using the indirect antiglobulin test and red cells of known antigen phenotype
C. testing donor blood for Hepatitis C antibody
D. testing donor blood for HIV 1 and 2 antibody
E. testing donor blood for syphilis

Back 57

a

Front 58

Patient having platelet transfusion. Develops fever, tachycardia, and hypotension. Very unwell - NOT a mild reaction. Most likely cause:
A. ABO incompatibility
B. Bacterial infection in platelets
C. Anaphylaxis
D. leucocyte mediated transfusion reaction
E. ?

Back 58

d
ARC Transfusion Medicine Manual:
A - 1:12,000 - 77,000
B - 1:100,000
C - 1:20,000 - 170,000
D - Nonhemolytic febrile transfusion reactions (ie leucocyte mediated) 1:100

Front 59

Features of the transurethral resection of the prostate (TURP) syndrome include all of the following EXCEPT
A. agitation
B. angina
C. bradycardia
D. nausea
E. tinnitus

Back 59

E

1. TURP syndrome
CVS – hypertension and bradycardia : volume overload a balance between absorption and loss +/- increased ADH (from stress and glycine)
Neurological : N, weakness, confusion, agitation, seizures and coma, from :
Dilutional hyponatraemia and hypoproteinaemia à cerebral oedema (controversy here because osmolality is normal)
Glycine toxicity – direct and from ammonia

2. Glycine Toxicity – direct effects on eye and heart (depressant – reversed by arginine)
Transient blindness from glycine toxicity (? An inhibitory neurotransmitter), last 12-24 hrs
Increased ammonia – biotransformation of glycine -> 500 mmol/L à N+V and coma (awakens when < 150 mmol/L), more likely if arginine deficient (as normally ammonia -> urea via ornithine cycle of which arginine important intermediary)
Transient hyperkalaemia has been reported (more than with mannitol)

3. Bladder perforation (1%) – traumatic or overdistension or rarely explosion of hydrogen (cautery – plus need O2 to enter system)
Extra-peritoneal – peri-umbilical pain
Intra-peritoneal – symptoms faster - generalised abdo and shoulder tip pain, N+V, abdo rigidity, pallor, sweating and hypotension
Management – cystourethography will diagnose and Rx : supra-pubic cystostomy (for intra-peritoneal rupture at least ? conservative Mx with IDC for extra)

4. Bacteraemia/Septicaemia – in 6-7% : chills, fever and tachycardia ; rarely septic shock (high mortality) – prostate often has bugs, +/- pre-op IDC
pre-op antibiotics – do not sterilise prostate as difficult penetration, but is recommended to decrease bacteraemia

5. Hypothermia – should use warmed fluids (does not increase bleeding due to v/d)

6. Bleeding and coagulopathy – commonly bleed postop
Very vascular and blood loss difficult to estimate as mixes with irrigation fluid
Dilutional thrombocytopaenia
Abnormal bleeding in < 1%, possibly either :
Local fibrinolysis due to release of plasminogen activator and urokinase from mucosa of urinary tract
Systemic absorption of resected prostate rich in thromboplastin (with assoc. low platelet count and low fibrinogen) and can lead to secondary fibrinolysis (giving high levels of FDP)
If suspect 1o fibrinolysis could give aminocaproic acid 5g in first hr then 1g/hr, (but beware DIC : Amicar contra-indicated, instead give platelets, FFP and cryoprecipitate, pc as needed – HEPARIN is controversial)

7. Hypotension
Several causes :
Blood loss -> hypovolaemia
CCF – due to volume overload
Anaemia and myocardial ischaemia or infarction
Hyponatraemia (? mechanism)

Front 60

Post-operative delirium in the elderly is associated with all of the following factors EXCEPT
A. pre-existing cognitive deficit
B. pre-existing hearing impairment
C. pre-existing visual impairment
D. post-operative urinary tract infection
E. use of general anaesthesia rather than regional anaesthesia

Back 60

e
EACCP(June2012 12 (3)) has an article on POCD it includes this table
Table 2 Predisposing factors for POCD

Early POCD
-Increasing age
-General rather than regional anaesthesia
-Increasing duration of anaesthesia
-Respiratory complication
-Lower level of education
-Re-operation
-Postoperative infection
Prolonged POCD (months postoperatively)
-Increasing age only

Front 61

Serious post-operative epidural infection
A. is rarely due to Staphylococcal species
B. is associated with epidural catheter disconnection
C. occurs with an incidence in the range 1-2 per 10,000
D. is usually reported in obstetric cases
E. mandates surgical drainage if an abscess is present

Back 61

c

Incidence 0.2 - 1.2 per 10000 hospital admissions
Staph > 90%
Conservative management if:
Poor surgical candidate
Abscess over too many segments
No spinal cord symptoms
Complete paralysis > 3 days

Front 62

The BEST method of preventing of post-operative nausea & vomiting (PONV) in a female having a volatile anaesthetic is:
A. Omit N2O
B. Dexamethasone
C. Droperidol
D. Ondansetron
E. Dexamethasone AND droperidol

Back 62

e
NEJM (June 2004) 350; 24 2441-2451. "A factoral trial of six interventions for the prevention of PONV". Figure 2 shows combinations of antiemetics, including dexamethasone and droperidol, superior to any single agent. The reason "female" is specified in the question is that droperidol was not shown to be effective in reducing PONV in men

"Administration of anti-emetic prophylaxis to patients with a low baseline risk for PONV is not justified, whereas high-risk patients should be treated with an anti-emetic combination (multimodal approach)...Based on the results from the IMPACT study, each tested anti-emetic agent (dexamethason, droperidol, ondansetron) and the use of total intravenous anaesthesia reduced the relative risk of nausea and vomiting to a similar extent, i.e. by 26%....The resulting relative risk of nausea and vomiting associated with a combination of interventions can thus be directly calculated as the product of the individual relative risks. As a consequence, the absolute risk reduction provided by a second or third intervention is less than that provided by the initial intervention (irrespective of which combination is chosen). A 70% reduction in the relative risk of postoperative nausea and vomiting is thus the best that can be expected, even when total intravenous anaesthesia is used in combination with three anti-emetics.
"PONV: A problem of inhalational anaesthesia?" Christian C. Apfel Best Practice & Research Clinical Anaesthesiology Vol. 19, No. 3, pp. 485–500, 2005

Front 63

A patient with severe COPD on home oxygen is having an excision of a submandibular tumour under local anaesthesia. The best way to prevent fire in the operating room is:
A. seal the surgical site from the patients airway with adhesive drapes
B. use bipolar instead of monopolar diathermy
C. decr FIO2 to maintain sats 97% and less to 100%
D. use alcoholic chlorhex instead of iodine
E. add nitrous oxide to the inhaled gases to reduce the FiO2 and provide sedation

Back 63

b
"The cutting mode of diathermy is more likely to ignite fuels than the coagulation mode, and fires are more likely with monopolar diathermy than bipolar" (Muchatuta and Sale, Fires and explosions, Anaesth&IC, 2007, 8:11)

Not C:
"Strategies to reduce the risks posed by high oxygen concentrations include (the) judicious use of oxygen (using the lowest oxygen concentration that provides acceptable haemoglobin oxygen saturations" (Muchatuta and Sale, Fires and explosions, Anaesth&IC, 2007, 8:11) The key here is acceptable haemoglobin oxygen saturations. "Long term continuous oxygen therapy should be considered for patients with stable chronic lung disease, particularly COPD, who have an arterial PO2 (PaO2) consistently less than or equal to 55 mm Hg when breathing air, at rest and awake. ...Flow rate should be set to maintain PaO2 > 60mmHg (8 kPa) (oxygen saturation level, measured by pulse oximetry [SpO2]> 90%) during waking rest." (McDonald et al, Adult domiciliary oxygen therapy. Position statement of the Thoracic Society of Australia and New Zealand, MJA 2005; 182: 621–626) Note that PO2=55mmHg is equivalent to SaO2 88%
Not D:
"Alcohol-based antibacterial skin preparations are one of the more common causes of surgical fires since the withdrawal of flammable anaesthetic agents. They can pool on the body surface (especially umbilicus and suprasternal notch), be wicked into surgical drapes and produce flammable vapours that can accumulate beneath the drapes." (Muchatuta and Sale, Fires and explosions, Anaesth&IC, 2007, 8:11)
Not E:
Nitrous oxide also supports combustion and is broken down to produce oxygen, nitrogen and heat." (Muchatuta and Sale, Fires and explosions, Anaesth&IC, 2007, 8:11)

Front 64

In an acute malignant hyperthermia episode
A. the serum creatine kinase level peaks within one hour
B. the peak serum creatine kinase level is a good indicator of the amount of muscle involved
C. elevated creatine kinase levels contribute to acute renal failure
D. the serum myoglobin level does NOT peak for at LEAST 24 hours
E. muscle rigidity occurs in 75% of cases

Back 64

E: "The occurrence of generalized muscle rigidity is the most specific sign of MH"

Additional features that increase the likelihood of underlying MH are signs of metabolic stimulation and grossly elevated plasma CK and myoglobin concentrations. There may also be evidence of myoglobinuria; this occurs earlier than CK increases. CK reaches a peak approximately 24 h after the insult and, even in patients with no muscle disorder, can reach 50 times the upper limit of normal."
B: false - can be from surgery / bowel ischaemia / brain / labour / MI / fever / CVA
C. "Plasma myoglobin concentrations are sufficient to cause renal tubular damage and acute renal failure."
D: "Increases in serum myoglobin occur earlier after muscle injury than increases in CK. Peak levels of CK may not be observed until 12 to 24 hours after muscle injury."
(Malignant hyperthermia and myotonic disorders, Anesthesiology Clinics of North America - Volume 20, Issue 3 (September 2002))
(Malignant hyperthermia BJA CEPD Reviews 2003 Feb 01, 3: 5-9.)

Front 65

6 year old boy coming for routine operation. Maternal Great Grandfather has had a malignant hyperthermia reaction under GA. Which of the following is most likely to rule out that the 8 year old will NOT suffer a MH reaction
A. 8 year old has negative resting CK level
B. 8 year old has had a previous operation before with no problems
C. mother has had negative genetic testing
D. maternal grandfather has had negative muscles testing
E. father has had an operation before with no problems

Back 65

Whilst yes, it would be nice to see the family tree, I think that you could safely say that someone that has undergone muscle biopsy has done so as they are a relative of someone with an MH reaction - people don't randomly have these tests - I think we could safely assume that the grandfather is the one related directly to the great grandfather with the problem, and not the "other" grandfather. This comes down to what's the most sensitive - remember SnNout ("a senstive test with a negative result rules the diagnosis OUT"), and muscle biopsy is over the genetic testing (as genetic testing does not yet identify enough ryanonidine receptor mutations to explain all MH cases).

"Current Diagnostic Testing for Malignant Hyperthermia" Molecular genetic screening for malignant hyperthermia (MH) susceptibility is not an option today. The gene coding for the ryanodine receptor calcium release channel (Ry1) is on chromosome 19 and, at the present time, 15 different mutations in Ry1 have been linked to MH susceptibility. However, about 50 percent of susceptible families do not have linkage of MH to chromosome 19. What is evident at this stage of our understanding is that MH is genetically heterogeneous and that simple genetic screening will not be complete for several years.

Front 66

All of the following are recognized complications of mediastinoscopy EXCEPT:
A. Cardiac laceration
B. Air embolism
C. Pneumothorax
D. tracheal compression
E. recurrent laryngeal nerve damage

Back 66

a

Death
MAJOR complications
Major haemorrhage
Tracheobronchial laceration
Oesophageal perforation
Recurrent nerve paralysis
Phrenic nerve paralysis
Thoracic duct injury
Cerebrovascular accident
Mediastinitis
Venous air embolism
Tumour implantation
MINOR complications
Pneumothorax
Superficial wound infection
Recurrent nerve paresis
Minor bleeding
Autonomic reflex braydcardia
Mediastinal lymph node necrosis

Continuing Education in Anaesthesia, Critical Care & Pain 2007 7(1):6-9

Front 67

Early complications following pneumonectomy include all of the following EXCEPT

A. Broncho-pleural fistula
B. Respiratory failure
C. Right heart failure
D. Right to left shunt
E. Supraventricular arrhythmia

Back 67

Going D as ? occurs later

A: "Bronchopleural fistula occurs with a frequency ranging from 1.5 to 4.5 percent, and is associated with a mortality ranging from 29 to 79 %. Bronchopleural fistulas occurring within one week of surgery are not necessarily associated with an empyema, whereas those occurring more than two weeks after surgery are associated with an empyema." (Uptodate)
B. "Respiratory failure is a leading cause of postoperative morbidity and mortality in patients undergoing pneumonectomy. A retrospective report involving 170 pneumonectomy patients showed that patients that received median tidal volumes greater than 8 mL/kg had a greater risk of respiratory failure in the postoperative period after pneumonectomy." (Miller Ch 59 7th Ed)
C. Right heart failure - true:
"A major lung resection, such as pneumonectomy, decreases ventilatory function and has significant effects on the right ventricular function.[172] Immediately after pneumonectomy, the right ventricle may dilate and the right ventricular function decreases. Increased right ventricular afterload is due to an increase in pulmonary artery pressure and pulmonary vascular resistance. This is considered to be one of the main causes of right ventricular dysfunction after a major lung resection." (Miller 7th Ed Ch59)
D. Right to left shunt - true but unusual, and can be early or late:
"An unusual complication following pneumonectomy is a right-to-left shunt that develops through a patent foramen ovale or an atrial septal defect. Although such right-to-left shunting can be precipitated by elevation in right heart pressures, it can also occur in the absence of elevated right atrial pressure due to a change in cardiac geometry, directing flow from the inferior vena cava across the interatrial communication.
"Symptoms of right-to-left shunting include dyspnea and platypnea, typically developing between 2 days and one year following surgery. Diagnosis of a right-to-left shunt can be made on a nuclear medicine scan or by performing a shunt study on 100 percent oxygen." (Uptodate)
E. Supraventricular arrhythmia - true
"The charts of 62 patients with primary lung cancer who underwent a pneumonectomy at our department from 1979 through 1992 were reviewed for the evaluation of postoperative morbidity and mortality. The 30-day mortality was 3/62 or 4.8%. Postoperative complication occurred in 37 of 62 patients (60%). The most common complication was a supraventricular tachyarrythmia." (Postoperative complications after pneumonectomy for treatment of lung cancer: Multivariate analysis, Journal of Surgical Oncology, Volume 61 Issue 3, Pages 218 - 222)
"Cardiac arrhythmias occur in approximately 20 percent of patients following pneumonectomy, with most (80 percent) presenting within 72 hours of surgery. Atrial fibrillation is by far the most common arrhythmia following lung resection." (Uptodate)

Front 68

In patients undergoing thoracotomy, techniques which reduce the incidence of intraoperative atrial fibrillation include
A. hyperventilation
B. pre-operative loading with digoxin
C. rocuronium, rather than pancuronium
D. thoracic epidural bupivacaine
E. thoracic epidural morphine

Back 68

d
"The continuous infusion of thoracic epidural bupivacaine can reduce supraventricular tachyarrhythmias compared with epidural morphine infusion, presumably because of attenuation of the sympathotonic status after pulmonary resection." (Thoracic Epidural Bupivacaine Attenuates Supraventricular Tachyarrhythmias After Pulmonary Resection, in Anesthesia & Analgesia Issue: Volume 93(2), August 2001, pp 253-259)

Front 69

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

Back 69

A as per college doc's - has to be 'available'

Front 70

The BEST indication of a difficult intubation in morbid obesity:
A. Mallampatti Score
B. Neck circumference
C. Limited neck movement
D. TMD
E. Body weight

Back 70

b
Morbid Obesity and Tracheal Intubation (Anesth Analg 2002)
Factors looked at included: "height, weight, neck circumference, width of mouth opening, sternomental distance, thyromental distance and Mallampati score"
"Logistic regression identified neck circumference as the best single predictor of problematic intubation. Mallampati score inclusion did not further improve the model in our limited study with only 12 problematic intubations. In patients with a large neck, the view during direct laryngoscopy was poorer."

Front 71

What is NOT an appropriate action for infection control:
A. must wash hands and should use gloves to place IVL
B. Sterile procedure, including gown, to place CVL
C. Sterile procedure, including gown, to place epidural
D. Preservation of sterility of any airway device which will come into contact with blood interface
E. If appropriate HME filter, can use same circuit with subsequent patients.

Back 71

d
"Devices passing through the mouth or nose will become contaminated in the upper airway. Endotracheal tubes, nasal and pharyngeal airways should be kept sterile until used.
"Reusable face masks must be thoroughly decontaminated and then undergo disinfection prior to each use. Items to be placed in the upper airway which may cause bleeding e.g. laryngoscope blades and temperature probes, must be disinfected before reuse." PS 28 3.2.2
"Disinfection: The inactivation of non-sporing micro-organisms using either thermal or chemical means." PS28 2
"Sterilisation: Complete destruction of all micro-organisms, including spores." PS28 2.

Front 72

When placing a patient in the lithotomy position
A. the femoral nerve is NOT at risk to be damaged
B. the common peroneal nerve is NOT at risk of injury
C. flexion at the hips of greater than 90 degrees will protect the obturator nerve
D. damage to the sciatic nerve may be prevented by exaggerated external rotation of the hips
E. damage to peripheral nerves is more commonly due to compression of blood supply, rather than direct pressure

Back 72

E: "The mechanism of injury to superficial nerves is usually compression of the vasa vasorum and subsequent ischaemia....Superficial nerves (e.g. ulnar and common peroneal) are especially vulnerable in thin patients." from 'Injury during anaesthesia.' S Contractor, JG Hardman. BJA CEA CCP Volume 6 Number 2 2006 Loum 05:45, 4 Apr 2008 (EST)
E>A: Another CEACCP article "Patient Positioning in Anaesthesia" Knight D, Mahajan R, October 2004 Number 4 160-163. Says regarding "extreme flexion of hip joints" that there is risk of compression of femoral nerve under inguinal ligament.

Front 73

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

Back 73

???

Haslam et al. Intragastric pressure & its relevance to protective cricoid force Anaesthesia 58 2003:1012-1015
There were two parts to the study performed on human cadavers. The first was to see how much pressure applying different forces generated at the upper oesophagus. For 40N this was 38mmHg. However a key part of the study seems to have been how much intragastic pressure different cricoid forces could resist:
"The oesophageal pressures at which cricoid pressure failed was as follows (mean [range])
20N 39mmHg [26-60]
30N 56mmHg [42-85]
40N 74mmHg [53-120] "

Front 74

During elective major vascular surgery the best way to reduce the risk of acute renal failure is
to maintain a normal
A. central venous pressure
B. mean arterial blood pressure
C. renal blood flow
D. systemic vascular resistance
E. urine output

Back 74

C
Lots of controversy but needs volume (CVP) + adequate MAP

Front 75

A fourteen-year-old girl is scheduled to have a termination of pregnancy. With regard to consent for this procedure, which of the following statements most truly reflects the law in Australasia?
A. A fourteen-year-old girl is able to give consent independently of her parents/guardians if she is considered, by her treating doctors, to be of sufficient maturity to understand the issues.
B. A fourteen-year-old girl is able to give consent independently of her parents/guardians, only if a court deems her sufficiently mature.
C. Minors are not able to give consent, independently of parents/guardians, until sixteen years of age.
D. Minors are not able to give consent, independently of parents/guardians, until eighteen years of age.
E. Only life-saving treatment may be administered to a fourteen-year-old without parental/guardian consent.

Back 75

A
All persons are presumed to be competent to give consent, unless there are reasonable grounds for believing otherwise.... The age at which a young person is able to consent independently to medical treatment depends not only upon their age, but also the nature of the proposed treatment, and local legislative requirements. To be able to give consent, the young person should be able to understand the nature, purpose and possible consequences of the treatment as well as the consequences of non-treatment."
ANZCA professional document "Guidelines on Consent for Anaesthesia or Sedation"

Front 76

A healthy 25 year male (80kg) has ECT and the psychiatrist thinks the seizure duration was inadequate. You used thiopentone 350mg and suxamethonium 50mg. To prolong it next time you should:
A. Use remifentanil so that the dose of thio can be reduced
B. Give IV lignocaine
C. Hypoventilate
D. Use propofol instead of thio
E ?

Back 76

a
Anaesthesia Secrets' p513: Remifentanil 1 mcg/kg (makes it) possible to reduce the doses of methohexitone and propofol required to induce unconsciousness by 33% thus resulting in prolongation of ECT induced seizure duration. Adjunctive use of potent rapid and short acting opioid analgesics has become an effective way of extending siezure times in patients with short seizure duration.

Suggests about 100mcg (less if old etc) then wait until glazed then give 100-150mg STP

Front 77

Which of the following is not an absolute contra-indication for MRI?
A. cochlear implant
B. heart valve prosthesis
C. ICD
D. pacemaker
E. intracranial clips

Back 77

b

2005 MRI ANZCA 'Blue Book':
a) Pacemakers: A permanent pacemaker constitutes a contra-indication to MRI scanning. Currents generated in the pacemaker circuitry, even at low field strengths (e.g. 17 Gauss), can cause serious malfunctions. This has resulted in at least one death in Australia. Reports exist of patients with pacemakers being scanned in low field strength scanners (0.5T), but the risk-benefit ratio needs to be seriously considered.
b) Cochlear implants: These devices contain a magnet that holds the external component to the subcutaneous receiver and is also involved in signal transmission. This magnet may move and cause injury. If it is known at the time of cochlear implant insertion that future MRIs will be required, the internal magnet can be omitted and the external component secured with adhesive patches. In such a case, an MRI could be performed, although significant artefact could be expected in head scans.
c) Orthopaedic prostheses: The metal components of these prostheses are generally titanium or chromium/cobalt. Screws and plates are stainless steel. While these implants may cause some image artefact, they are safe in the MRI scanner. External fixation devices often contain iron, so are contraindicated.
d) Prosthetic heart valves: These valves and annuloplasty rings undergo minimal heating and torque and are safe in MRI, although some artefact may be caused.
e) Aneurysm clips: These are variable. Earlier models were ferromagnetic, so could move in the magnetic field, with potentially disastrous consequences. Most modern clips are non-ferromagnetic and are safe in MRI. Due to this variability, manufacturers’ specifications should be checked.
This makes out that the only ABSOLUTE CONTRAINDICATION is PPM + Implantable defib but certainly safest seems to be Heart valves.

Front 78

Circuit disconnection during spontaneous breathing anaesthesia
A. will be reliably detected by a fall in end-tidal carbon dioxide concentration
B. will be detected early by the low inspired oxygen alarm
C. will be most reliably detected by spirometry with minute volume alarms
D. may be detected by an unexpected drop in end-tidal volatile anaesthetic agent concentration
E. can be prevented by using new, single-use tubing

Back 78

d
Any disconnect will allow entrainment of room air into the circuit and allow escape of the volatiles, thus a drop in the ET-agent.

Front 79

The strongest indication for the use of transoesophageal echocardiography during major non-cardiac surgery is
A. recent myocardial infarction (less than six weeks old)
B. acute significant intra-operative ST segment depression on the ECG
C. massive intra-operative blood loss
D. valvular heart surgery
E. unexplained significant intra-operative hypotension

Back 79

e

Applications for TOE in non-cardiac surgery
1. Vascular patient
Risk assessment
Assess global and regional ventricular performance
2. High risk patient (general,obstetric)
Preload
Systolic function
Ischaemia
3. Neurosurgical/Orthopaedic
Diagnose PFO → may influence patient positioning
Air embolism
Fat embolism
4. ICU - unstable patient
Intra and extra cardiac anatomy and function
Preload
5. Diffential dx of hypotension easily determined

ACC/AHA/ASE 2003 Guideline Update for the Clinical Application of Echocardiography

Recommendations for Intraoperative Echocardiography
Class I
1. Evaluation of acute, persistent, and life-threatening hemodynamic disturbances in which ventricular function
and its determinants are uncertain and have not responded to treatment.
2. Surgical repair of valvular lesions, hypertrophic obstructive cardiomyopathy, and aortic dissection with possible aortic valve involvement.
3. Evaluation of complex valve replacements requiring homografts or coronary reimplantation, such as the Ross procedure.
4. Surgical repair of most congenital heart lesions that require CPB.
5. Surgical intervention for endocarditis when preoperative testing was inadequate or extension to perivalvular tissue is suspected.
6. Placement of intracardiac devices and monitoring of their position during port-access and other cardiac surgical interventions.
7. Evaluation of pericardial window procedures in
patients with posterior or loculated pericardial effusions.

Class IIa
1. Surgical procedures in patients at increased risk of myocardial ischemia, myocardial infarction, or hemodynamic disturbances.
2. Evaluation of valve replacement, aortic atheromatous disease, the Maze procedure, cardiac aneurysm repair, removal of cardiac tumors, intracardiac thrombectomy, and pulmonary embolectomy.
3. Detection of air emboli during cardiotomy, heart transplant operations, and upright neurosurgical procedures.

Front 80

Significant differences between the LMA-ProSeal™ and the standard laryngeal mask (LMA-Classic™) include all of the following EXCEPT
A. a built in bite-block
B. a double cuff arrangement
C. an improved seal pressure at a given cuff pressure
D. an independent oesophageal drain tube
E. improved aperture bars to prevent the epiglottis occluding the airway tube

Back 80

e

Front 81

An INCORRECT statement regarding patent foramen ovale (PFO) in adults is that:
A. it is found in 5% of patients at postmortem examination
B. it can cause hypoxaemia
C. it is best seen using transoesphageal echocardiography
D. an asymptomatic PFO requires no intervention
E. the sitting position should be avoided in patients with a PFO

Back 81

a
: " Anatomic closure of the foramen ovale occurs between 3 months and 1 year of age, although 20% to 30% of adults have probe-patent foramen ovales." (Stoelting Ch24)

A: 30% have a probe PFO on autopsy, and in vivo, 20% can detect on sensitive tests e.g colour Doppler
B : True - minor R-> L shunt occurs commonly with a large ASD -> mild decrease in SpO2 to 93-95%, and any increase in right sided pressure (e.g Valsalva, PE, volume overload) -> shunt
C : True - "Transesophageal contrast echocardiography provides superior visualization of the atrial septum and therefore is preferred to transthoracic contrast echocardiography for detecting patent foramen ovale." EMedicine
D : True - "Most patients with a patent foramen ovale as an isolated finding receive no special treatment" EMedicine
E : True a relative C/I as risk of air embolism is high -> risk of paradoxical embolism with a PFO

Front 82

Electrocardiographic changes in acute hyperkalaemia include
A. the appearance of a J wave
B. loss of P waves
C. flattening of the T wave
D. a prominent U wave
E. a prolonged QT interval

Back 82

b
Hyperkalaemia: peaked T waves, widened QRS, sine wave, smaller P waves (or loss)
Hypokalaemia: flat/inverted T waves, U wave, ST depression and wide PR (may look like long QT with U on T)

Front 83

Characteristic cardio-pulmonary effects of pulmonary thrombo-embolism include
A. hypoxaemia due to excess perfusion of lung units with a low V/Q ratio
B. hypercarbia due to an increase in physiological dead-space
C. reverse splitting of the second heart sound
D. an increase in compliance of the left ventricle
E. an increase in coronary blood flow to the right ventricle during systole

Back 83

A

PE physiology (Nunn p551)
↑ PVR
Physical occlusion
Platelet activation in thrombus → 5HT and TXA2 release → vasoconstriction → ↑ PVR
Respiratory lesion
↑ alveolar deadspace
↑ A-a gradient
Normal to low PaCO2 (in SV) because ↑ RR ? due to J-receptor stimulation + hypoxia
↓ PaO2
Deranged V/Q relationships
↓ CO → low mixed venous O2
Bronchospasm due to 5HT release from platelets
↓ pulmonary compliance (still unknown mechanism)

Front 84

In the management of torsades de pointes (polymorphic ventricular tachycardia), all the following drugs may be useful EXCEPT
A. amiodarone
B. isoprenaline
C. lignocaine
D. magnesium
E. phenytoin

Back 84

A

Antiarrhythmic classes 1A,1C and 3 are to be avoided, so procainamide, disopyramide and amiodarone are the options to look out for here. Class 1B antiarrhythmics (lignocaine, phenytoin)shorten the QT. See www.torsades.org

Front 85

In providing anaesthesia for a patient with Eisenmenger's syndrome, it is NOT true that
A. an important goal is to maintain an optimal shunt, by preventing changes to pulmonary vascular resistance (PVR) or systemic vascular resistance (SVR)
B. the patient's high haemoglobin should be maintained and blood loss monitored closely
C. a gaseous induction with sevoflurane presents an effective method for anaesthesia and avoids cardiovascular compromise
D. if general anaesthesia is required, ketamine is an - appropriate choice of drug
E. careful attention to intravenous infusions and drug administration is needed to prevent paradoxical air embolism

Back 85

B or C - more towards C because it does cause CVS issues

D true = "Ketamine has been the most popular agent for anesthetic induction in patients with cyanotic conditions because it increases SVR and cardiac output, thereby diminishing the magnitude of R-L shunting." (Miller p.2020)

"Life expectancy is markedly shortened in patients with Eisenmenger syndrome; however, meticulous medical management can result in improved longevity in adults with this and other forms of cyanotic heart disease. The causes of death include pulmonary infarction with uncontrollable hemoptysis, arrhythmias with sudden death, progressive RV failure, and brain abscess." (Current Dx and Tx in Cardiology)

A - "Management of anesthesia for patients with Eisenmenger's syndrome undergoing noncardiac surgery is based on maintenance of preoperative levels of systemic vascular resistance and recognizing that increases in right-to-left intracardiac shunting are likely if sudden vasodilation occurs"
B - "Minimization of blood loss with the development of hypovolemia and the prevention of iatrogenic paradoxical embolization are important considerations. It may be useful to perform prophylactic phlebotomy with isovolumic replacement in patients with hematocrits higher than 65%."

Front 86

In patients with mitral regurgitation
A. left ventricular damage does NOT occur before the onset of symptoms
B. mitral valve replacement has a lower operative mortality and incidence of late adverse outcomes compared to mitral valve repair
C. an ejection fraction of less than 60% may be an indication for surgery, even in the absence of symptoms
D. long term vasodilators have been shown to delay the need for surgery
E. the presence of a third heart sound always indicates heart failure

Back 86

C
A. False "Unlike stenotic cardiac valve lesions, regurgitant cardiac valve lesions often progress insidiously, causing left ventricular damage and remodeling before symptoms have developed." (Stoelting)
B. False: "Mitral valve repair is preferred to mitral valve replacement because it restores valve competence, maintains the functional aspects of the mitral valve apparatus, and avoids insertion of a prosthesis."
C. True: "Survival may be prolonged if surgery is performed before the ejection fraction is less than 60% or before the left ventricle is unable to contract to an end-systolic dimension of 45 mm (normal < 40 mm). Symptomatic patients should undergo mitral valve surgery even if they have a normal ejection fraction." (Stoelting Ch2)
D. False: "Although vasodilators are useful in the medical management of acute mitral regurgitation, there is no apparent benefit to long-term use of these drugs in asymptomatic patients with chronic mitral regurgitation."
E. False: "S3 can be heard and recorded in healthy young adults. However, it is usually abnormal in patients over the age of 40 years, suggesting an enlarged ventricular chamber" (Uptodate)

Front 87

An elective surgical patient with hypertrophic obstructive cardiomyopathy becomes hypotensive (systolic pressure 70 mmHg and heart rate 60 beats.min-1) during intravenous induction of anaesthesia. The most appropriate initial therapy would be aimed at increasing
A. blood volume
B. degree of myocardial depression
C. heart rate
D. myocardial contractility
E. vasoconstriction

Back 87

E

Aims with HOCM are slow, full and tight, avoid increases in contractility.
IV induction will typically cause decreased contractility (good) and vasodilation (can be bad if afterload drops).
Options for treating this case of hypotension would be either volume or vasocontriction. Given HOCM's are prone to ischaemia I would give a vasoconstrictor first and then fill appropriately, so E

Front 88

This ECG (Lead V5) most likely represents
A. Wolff-Parkinson-White (WPW) syndrome
B. atrial fibrillation
C. complete heart block
D. atrio-ventricular junctional rhythm
E. sinoatrial block

Back 88

d

Front 89

The diagram below is of a transgastric short axis view obtained during a transoesophageal echocardiography examination. Which letter corresponds to the area supplied by the right coronary artery?
A. A
B. B
C. C
D. D
E. E

Back 89

a see link http://www.anesthesia-analgesia.org/content/89/4/870/F5.large.jpg

Front 90

Regarding patients aged 65 years or older with recurrent atrial fibrillation (AF)
A. amiodarone and digoxin have similar efficacy in restoring sinus rhythm
B. patients who have been reverted to sinus rhythm should still remain on warfarin therapy
C. patients who remain in atrial fibrillation with heart rates less than 80 beats per minute do NOT require long term warfarin therapy
D. peri-operative therapy with a beta-blocker will commonly lead to restoration of sinus rhythm
E. restoration of sinus rhythm with electrical DC cardioversion improves long-term survival in comparison to controlling heart rate alone

Back 90

B

A - no, digoxin is just for rate control
B - maybe - need for 3-4 weeks before (if > 48 hrs of AF) and after the procedure
C - nope, not rate dependent, still get atrial thrombus
D - nope, just slow down
E - no survival benefit as per CEACCP article
eTG "a very large multinational study with over 4000 patients randomised to these treatment options for a mean of four years follow-up (the AFFIRM trial) [Note 1] showed no statistically significant difference in mortality or in quality of life between the two groups, with a trend favouring the rate control arm in terms of mortality. A more recent meta-analysis of this and similar smaller studies confirmed this view. However, trials such as AFFIRM are aimed largely at patients who have prolonged paroxysms of atrial fibrillation or persistent atrial fibrillation or atrial flutter, or patients whose chronic atrial fibrillation has been of reasonably recent onset, and therefore may not be directly applicable to patients with short-lived paroxysms of atrial fibrillation or patients with many years of chronic atrial fibrillation.... "The results of AFFIRM indicate that there is no imperative to attempt cardioversion with patients who tolerate atrial fibrillation well, although at least some studies suggest quality of life may be improved by being in sinus rhythm"

Front 91

The most important aspect of the peri-operative management of a patient with Gilbert's syndrome is

A. avoidance of fasting
B. avoidance of stress
C. pre-operative transfusion of fresh frozen plasma (FFP)
D. prophylaxis against hepato-renal syndrome
E. recognition of aetiology of the laboratory abnormality

Back 91

Going with E but jaundice can be brought on by fasting / stress

Front 92

A multi-trauma patient opens his eyes and withdraws to painful stimuli, but does not respond to voice. He is moaning but makes no comprehensible sounds. His Glasgow Coma Score is
A. 5
B. 6
C. 7
D. 8
E. 9

Back 92

8
E=2/4 V=2/5 M=4/6
Eye Opening (E)
* 4=Spontaneous
* 3=To voice
* 2=To pain
* 1=None
Verbal Response (V)
* 5=Normal conversation
* 4=Disoriented conversation
* 3=Words, but not coherent
* 2=No words (sounds only)
* 1=None
Motor Response (M)
* 6=Normal
* 5=Localizes to pain
* 4=Withdraws to pain (Normal flexion)
* 3=Decorticate posture (Abnormal flexion)
* 2=Decerebrate (ie Extension)
* 1=None

Front 93

Cauda equina syndrome
A. involves large sensory fibres initially
B. is not associated with back pain
C. results from compression of nerve roots
D. results in loss of sensation confined to the foot
E. results predominantly in an upper motor neuron lesion

Back 93

c
"Cauda equina lesions feature back pain; asymmetrical, atrophic, areflexic paralysis of the legs; sensory loss in a root distribution and sphincter disturbance"

Front 94

Respiratory function in quadriplegics is improved by
A. abdominal distension
B. an increase in chest wall spasticity
C. interscalene nerve block
D. the upright position
E. unilateral compliance reduction

Back 94

b

Front 95

An INCORRECT statement regarding the autonomic nervous system is that
A. autonomic dysfunction is a predictor for worse long term survival after myocardial infarction
B. heart rate responses are primarily mediated through the sympathetic nervous system
C. inhalation anaesthetics all impair autonomic reflex responses
D. autonomic dysfunction is a predictor for haemodynamic instability following anaesthetic induction
E. low heart rate variability is associated with worse cardiac outcomes following non-cardiac surgery

Back 95

B = false = correct answer

Anesthesiology: Volume 90(3) March 1999 pp 651-653:
- There also is strong evidence in patients that autonomic balance and vagal reflexes influence morbidity and mortality after MI. Patients surviving MI who had either low HRV or low baroreflex sensitivity had an increased risk of subsequent sudden cardiac death
- The sympathetic component is primarily involved in adjusting peripheral vascular tone and plays a lesser role in the reflex regulation of HR and cardiac output. The vagal component is primarily involved in regulating HR.
- it is well documented that patients with impaired autonomic reflexes (e.g., patients with diabetes) have greater intraoperative BP lability compared with autonomically intact patients. [2,3] In addition, it now is clear that many of the sedative, hypnotic drugs used for induction of anesthesia and all of the potent inhaled anesthetic gases in clinical use impair autonomic reflex responses.
- low HR variability (HRV), an index of impaired cardiac-vagal tone, is an independent predictor of mortality after non-cardiac surgery

Front 96

Cerebral palsy is associated with each of the following EXCEPT
A. gastro-oesophageal reflux
B. increased sensitivity to non-depolarising muscle relaxants
C. malnutrition
D. recurrent aspiration
E. scoliosis

Back 96

B
CEACCP article

Front 97

A 33-year-old chronically spinally injured patient becomes hypertensive and sweaty
during general anaesthesia for urinary sphincterotomy. His level of spinal cord injury
is T4 and it is complete. You consider the diagnosis of autonomic hyperreflexia.
Autonomic hyperreflexia
A. could have been prevented by performing subarachnoid anaesthesia
B. is unlikely with a T4 lesion
C. should be treated by administration of a beta-blocker
D. should be treated by administration of an opioid analgesia
E. will resolve once the surgical stimulus ceases

Back 97

A: "Spinal anaesthesia...can reliably prevent autonomic dysreflexia and spasm"...Anaesthesia for Patients with Chronic Spinal Cord Injury; Current Anaesthesia and Critical Care; 2001 (12); p154-57 (references Int Anaesth Clinics, 1993 (31), p87-102)

"Increased sensitivity of sympathetic reflexes in patients with spinal cord injury above T5/6. Cutaneous or visceral stimuli below the level of the lsion may result in mass discharge of sympathetic nerves, causing sweating, vasoconstriction and hypertension, with high levels of circulating catecholamines. Baroreceptor stimulation results in compensatory bradycardia. Distension of hollow viscera, especially the bladder, is a potent stimulus. It may occur during abdominal surgery and labour. Onset of susceptibility is usually within a few weeks of injury."...Yentis 3rd Ed p51
Most recent reviews quote an incidence of 85% of those with a lesion higher than the seventh thoracic vertebral level (T7)...(but)...The incidence is related to level of lesion and the condition affects 60% of patients with cervical lesions but only 20% of those with thoracic lesions. It can occur in patients with incomplete lesions. The onset of symptoms can occur at any time from 3 weeks to 12 years after injury'...'Anaesthesia for chronic spinal cord lesions' Hambly, P. R., Martin, B Anaesthesia Volume 53(3) March 1998 pp 273-289

'Management of an episode of autonomic dysreflexia should always begin with removal of the precipitating stimulus, if known. This alone may be sufficient and blood pressure often returns to baseline levels immediately.'.
'Where autonomic dysreflexia occurs during surgery, management should begin with removal of the precipitating stimulus, if possible. Dysreflexia occurring under general anaesthesia is best treated with increasing anaesthetic depth in the first instance. Where drug therapy is required, nifedipine and labetalol are used most commonly, though propranolol, midazolam, spinal anaesthesia and transdermal glyceryl trinitrate patches were all used on survey patients.'
"Nifedipine (10mg SL) or GTN (SL or TD) or alpha-blockers are all used in first-line therapy"

Anaesthesia for Patients with Chronic Spinal Cord Injury; Current Anaesthesia and Critical Care; 2001 (12); p154-57

Front 98

Correct statements regarding expiratory-inspiratory flow-volume loops include all of the following EXCEPT
A. in obstructive disease the expiratory curve has a scooped out or concave appearance
B. in restrictive disease expiratory flows are usually decreased in relation to lung volume
C. in restrictive disease the expiratory curve has a convex appearance
D. the expiratory curve is largely effort independent
E. the inspiratory curve is effort dependent

Back 98

b
Restrictive lung disease maintain flow rates, it just decreases in volume, FEV1 is maintained, a major difference between obstructive and restrictive lung disease.-

Front 99

Hepatitis B virus survives outside the body for
A. Less than 4 hours
B. 6-12 hrs
C. 1-2 days
D. 2-7 days
E. more than 7 days

Back 99

e
"How long can HBV survive outside the body?
HBV can survive outside the body at least 7 days and still be capable of causing infection."

Front 100

In Marfan’s syndrome which is NOT related:
A. If develop aortic disease most likely to be aortic stenosis
B. At risk illiac aneurysm
C. Development of mitral valve prolapse is more likely than in general population
D. Cardiac myopathy due to medial cystic necrosis/atrophy/ degeneration
E. Intracranial aneurysm

Back 100

A - Incorrect, so This is the answer
B - Correct(lots of case reports)
C - Correct(Yentis p331)
D - True - Yao (2008) Page 253
E - Correct

Front 101

With respect to intra-arterial cannulation and monitoring
A. following cardiopulmonary bypass, a cannula in the brachial artery will tend to give a more accurate blood pressure reading than in the radial artery
B. radial artery cannulation is not contra-indicated in Raynaud's Disease
C. the Allen's test is a reliable predictor of the adequacy of collateral flow
D. The axillary artery is not suitable for use in cardiac surgery
E. If use femoral must replace within 24 hours (replace, not resite) because of infection

Back 101

a

"Two minutes after separation from CPB, clinically important (greater than or equal to 10 mmHg) underestimation of systolic aortic pressures occurred in 17 of 33 (52%) radial artery catheters, while occurring in seven of 33 (21%) brachial artery catheters. Radial artery mean pressure underestimated aortic mean pressure by greater than or equal to 5 mmHg in 21 of 33 (61%) patients two minutes after CPB, while an equivalent aortic-to-brachial artery mean arterial pressure difference occurred in nine of 33 (27%) patients." (J Cardiothorac Anesth. 1989 Feb;3(1):20-6)

Ischemic complications of radial artery cannulation: an association with a calcinosis, Raynaud's phenomenon, esophageal dysmotility, sclerodactyly, and telangiectasia variant of scleroderma. (Anesthesiology. 1993 Mar;78(3):587-9)

Front 102

Factors which do NOT contribute to the increased risk of aspiration pneumonitis during pregnancy include
A. increased gastrin production
B. a tendency for the stomach to be pushed up against the left diaphragm
C. increased acidity of gastric secretion
D. increased volume of gastric secretion
E. decreased secretion of the hormone motilin

Back 102

a
Pregnancy appears to have a profound inhibitory effect on plasma motilin, and this may in part be responsible for the gastrointestinal hypomotility associated with pregnancy"
"We confirmed that pregnant women have much greater and more acidic gastric contents than the nonpregnant patients preoperatively, and it is not because of serum gastrin concentration" (J Clin Anesth. 2005 Sep;17(6):451-5.)

Front 103

Carbon dioxide is the most common gas used for insufflation for laparoscopy because it
A. is cheap and readily available
B. is slow to be absorbed from the peritoneum and thus safer
C. is NOT as dangerous as some other gases if inadvertently given intravenously
D. provides the best surgical conditions for vision and diathermy
E. will NOT produce any problems with gas emboli as it dissolves rapidly in blood

Back 103

c

Front 104

A 46 year old brewery worker has cirrhosis of the liver with oesophageal varices and has bled from these varices on one occasion. A portacaval shunt is being considered as definitive treatment for his portal hypertension. The operation would be contraindicated if he had
A. a serum bilirubin greater than 50 micromol.litre-1
B. a serum albumin less than 30 gram.litre-1
C. ascites
D. all of the above are true
E. none of the above are true

Back 104

e - encephalopathy is a CI

Front 105

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

Back 105

b

Front 106

Each of the following statements concerning surgery for correction of scoliosis is true EXCEPT
A. one third of the blood loss occurs postoperatively
B. major blood loss is frequently accompanied by a consumptive coagulopathy
C. surgery will halt progression of the restrictive lung deficit
D. the major neurological deficits that occur are usually due to damage to the posterior columns of the spinal cord
E. the use of aprotinin reduces blood loss

Back 106

d
Neurological injury can be due to:
1) direct contusion of the cord by implant or instrument.
2) reduction of spinal cord blood flow by stretching or compression of vessels or direct interruption of radicular blood flow.
3) distraction injury of the spinal cord
4) epidural haematoma.

Front 107

Lowering intra-ocular pressure by applying pressure to the globe (e.g. Honan balloon) is typically contraindicated in a patient having
A. a revision corneal graft
B. a revision trabeculectomy
C. an extra-capsular lens extraction
D. a redo vitrectomy
E. repeat retinal cryotherapy

Back 107

b

Front 108

Following a cadaveric renal transplant under general anaesthesia, your patient's plasma K+ increases to 6.0 mmol.l-1 in recovery after being 5.0 mmol.l-1 pre and intra-operatively. This patient requires
A. an intravenous infusion of CaCl2 (10 mls over 20 minutes)
B. arterial blood gases to ascertain the acid/base status
C. potassium exchange resins rectally
D. sodium bicarbonate infusion (50- 100 mEq over 5- 10 minutes)
E. urgent haemodialysis

Back 108

b

Front 109

Regarding a patient presenting for renal transplantation due to diabetic nephropathy, which of the following statements is LEAST correct?
A. angiotensin-converting enzyme (ACE) inhibitors are probably best discontinued preoperatively
B. dialysis is indicated if serum potassium concentration exceeds 6 mmol.1-l
C. intravenous access should preferably be obtained in a forearm vein of the non-fistulous arm
D. suxamethonium causes a rise in serum potassium concentration of up to 0.6 mmol.1-l
E. temporomandibular joint rigidity may be present

Back 109

c?

Stoelting & Dierdorf "Anaesthesia and Co-existing diseases " 4th Ed Pg 349 , looks like this question if taken directly from here and it states "To preserve the blood vessels for vascular access,Venepuncture should be avoided in the nondominant arm and the upper part of the dominant arm of patients with CRF"
Miller 6th edition p 2239 states: "Though unlikely after immediate preoperative completion of dialysis, potassium levels greater than 6.0mEq/L may require a delay in surgery and correction of potassium level." And "Although cases involving cadaveric donor organs are often scheduled as urgent or emergency procedures, the well tolerated prolongued cold preservation of the kidney should provide enough time to allow transplant candiates to be reasonably well prepared for surgery, and if necessary, dialysed before surgery to allow normalisation of electrolyte imbalances and volume status before surgery."

Front 110

A 4-year-old child with obstructive sleep disorder presenting for tonsillectomy:
A. is likely to suffer from daytime somnolence
B. is unlikely to have a history of snoring
C. is suitable for day-case surgery
D. has a 40% chance of postoperative vomiting without antiemetic treatment
E. is likely to lose 5% of their blood volume during surgery

Back 110

e

Front 111

Age at which GRF = adult GFR(ml/min/m2):
A. 1 month
B. 6 month
C. 2 years
D. 4 years
E. 6 years

Back 111

c

Front 112

5yo 35kg child having repair of leg laceration. gas induction with sevo N2O and oxygen. Can't get in drip. Put in LMA and immediately get stridor and airway obstruction and desaturate to 90%. Next step after increase FiO2 to 100% is:
A Remove LMA and deepen with sevoflurane
B Leave LMA and deepen with sevoflurane
C Intralingual Suxamethonium
D IM Atropine
E IM Suxamethonium

Back 112

a

Front 113

1 y.o arrest with VT. Has had 2x DC shocks, and 100 mcg adrenaline. Further 1x DC shock given. What is next step:
A. 20 J DC shock
B. 40 J DC shock
C. 50 mg amiodarone
D. 100 mcg adrenaline
E. 1000 mcg adrenaline

Back 113

c

Front 114

8 y.o with anterior mediastinal mass. CT shows compression below trachea involving the carina. Gas induction with sevoflurane. Sats drop to 75%. What should be done:
A. Provide CPAP via mask
B. Organise median sternotomy
C. Place ETT and allow to spontaneously breath
D. Place prone
E. Place ETT and IPPV

Back 114

d?
Miller says:
"The operating room team should retain the capability of changing the patient's position rapidly to the lateral or prone position. "
"If general anesthesia is required, maintain spontaneous ventilation."

Front 115

The sciatic nerve supplies the following muscles EXCEPT
A. biceps femoris
B. semitendinosus
C. semimembranosus
D. gluteus maximus
E. adductor magnus

Back 115

d

Front 116

Stellate ganglion is located:
A. At the level of the body of C6 (spine of C6)
B. Posterior to the brachial plexus sheath
C. Anterior to the dome of the pleura
D. Anterior to the thoracic duct
E. Anterior to scalenius anterior

Back 116

a

Front 117

Spinal Arterial Supply:
A. Supplied via posterior inferior cerebellar arteries. I think it was anterior spinal artery off PICAs.
B. Main radicular arterial supply is from lumbar level
C. 50% supplied by anterior artery, 25% supplied by each posterior artery
D. In neck, supplied mainly off vertebral arteries
E. ?

Back 117

d?
anterior spinal artery is from vertebrals, posterior spinal artery is from PICA which comes off vertebrals, and the segmental medullary arteries in the neck branch off the vertebrals as well

Front 118

The intercostal nerves
A. arise as the sensory fibres of the anterior primary rami from their spinal segments
B. give off a lateral cutaneous branch at the angle of the rib
C. lie in the subcostal groove in only 50% of people
D. lie between the intercostalis intimi and the pleura
E. are enclosed in a dural sheath from their origin to the angle of the rib

Back 118

c?

Front 119

Factors associated with post-operative ulnar nerve palsy include all of the following EXCEPT
A. male gender
B. sternal retraction for cardiac surgery
C. cardiopulmonary bypass for cardiac surgery
D. internal jugular vein catheterisation
E. diabetes mellitus

Back 119

C
"This bony prominence is at least 50% larger in males, consistent with their greater susceptibility to perioperative ulnar nerve damage." (Anesthesiology Clin N Am 20:(2002) 589– 603)
"Injuries may also occur when the nerve is stretched around the medial epicondyle during extreme flexion of the elbow across the chest" (Anaesthesia ume 55, Issue 10, 2000. Pages: 980–991)
"The ulnar nerve, like most peripheral nerves, is intolerant of stretch beyond 10% of its normal length. Fig. 3 illustrates the cubital tunnel retinaculum, which is lax while the forearm is extended but becomes taut as the elbow is flexed [10]. Thus, persistent elbow flexion creates two mechanisms of potential nerve injury: direct internal compression and internal fixation within the cubital tunnel, which renders the remainder of the nerve more vulnerable to stretch along its course." (Anesthesiology Clin N Am 20 (2002) 589–603)

Front 120

Post cervical spine surgery, patient has some neurology hand. Surgeon thinks this is due to an ulnar nerve palsy from poor positioning. Which sign will differentiate between a C8/T1 nerve root lesion and an ulnar nerve lesion?
A. Parasthesia in little finger
B. Parasthesia in index finger
C. Weakness in lateral interosseus
D. Weakness in Abductor pollicus brevis
E. Weakness of adductor digiti minimi

Back 120

d
T1 and ulnar nerve have very similar sensory and motor distribution. HOWEVER, the one difference is that the LOAF muscles are supplied via the median nerve and provide a point of differentiation. See below quotes from Anatomy for Anaesthetists

Front 121

Transient Neurologic Symptoms. What is NOT TRUE:
A. More likely with lignocaine
B. may progress into cauda equina syndrome
C. Unlikely due to neurotoxicity
D. More likely with lithotomy position
E. ?

Back 121

d

Front 122

In patients who have sustained a dural puncture headache following a dural puncture during epidural catheter placement (18G or greater), the percentage of patients achieving persistent relief of headache with blood patching (performed after 24 hours) is
A. less than 30%
B. 30 - 45 %
C. 45 - 60 %
D. 60 - 75%
E. more than 75%

Back 122

d
“Although early reports suggested immediate and permanent cure of PDPH after an epidural blood patch, it has recently been suggested that complete success rates are approximately 75% and that the effectiveness of an epidural blood patch is decreased if the dural puncture was caused by a large-bore needle.[220] One study reported that although immediate relief occurred in almost all patients, permanent cure after an epidural blood patch was achieved in only 61%.”

Front 123

To achieve maximum anaesthesia with minimal risk of trauma to veins, the tip of a needle used for a medial peribulbar injection should be advanced no further past the equator of the globe than
A. 5 mm
B. 10 mm
C. 15 mm
D. 20 mm
E. 25 mm

Back 123

b

Front 124

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

Back 124

e
The diagnosis of brain stem death is EXCLUDED by
1. normal oculo-cephalic reflexes

Front 125

Carbon monoxide poisoning results in hypoxic injury by
A. binding to mitochondrial cytochrome oxidase
B. decreasing alveolar ventilation
C. occupying oxygen binding sites on haemoglobin
D. reducing the arterial partial pressure of oxygen (PaO2)
E. shifting the oxygen-haemoglobin dissociation curve to the right

Back 125

c

Front 126

32 year old with early acute liver failure (not paracetamol related). Management includes
A. prophylactic antibiotics
B. N-acetyl cysteine as general liver protection
C. avoid early intubation so can assess for encephalopathy
D. INR> 3 means should be considered for transplant??
E. avoid saline as resuscitation fluid

Back 126

a

Front 127

What is most likely cause for INCREASED pVO2:
A. Pulmonary Embolism
B. Myocardial Infarction
C. Sepsis
D. Liver Failure
E. Tamponade

Back 127

c sepsis
situations with increased mixed venous oxygen saturations are more difficult to interpret; sepsis, A-V fistulae, cirrhosis, left-to-right cardiac shunts, cyanide poisoning, hypothermia and unintentional PA catheter wedging have all been reported as being associated with increased values'""

Front 128

At a late stage in severe septic shock
A. the myocardium becomes increasingly sensitive to catecholamines
B. adrenaline should not be infused as it is predominantly an alpha agonist at low doses
C. the infusion of endogenously occurring catecholamines is futile as blood levels are already too high
D. the infusion of dopamine is strongly recommended as it exerts its effects in high doses via different receptors than in low doses
E. inadequate catecholamine synthesis may contribute to the poor circulation

Back 128

e
Endogenous catecholamine synthesis is often a factor in sepsis, hence the theory that supplementation with glucocorticoids can maintain or enhance production of catecholamines, leading to an improved outcome.

Front 129

The peri-operative use of beta-adrenergic antagonists
A. exerts a cardioprotective effect entirely by reduction of heart rates
B. is best started intra-operatively
C. is contraindicated in patients with chronic airways limitation
D. is contraindicated in patients receiving angiotensin converting enzyme inhibiting drugs (ACE inhibitors)
E. is safe in patients with moderately impaired ventricular function

Back 129

e

Front 130

Effects of volatile anaesthetic agents on the brain include
A. maintenance of cerebral blood flow when used with hypocapnia
B. uncoupling of autoregulation, with a consequent rise in intracranial pressure
C. reduction of cardiac output and cerebral blood volume when used at concentrations of 1.3 MAC
D. maintenance of cerebral metabolic rate, but reduction of cerebral electrical activity
E. equal depression of all neurons of the brain at 1.3 MAC concentration

Back 130

A
Stoelting
hypocapnia (PaCO2 30mmHg) opposes the tendancy for inhaled anaesthetics to increase ICP (via increased CBF), emphasising that CO2 reactivity is maintained.
"Inhaled anaesthetics produce increases in ICP that parallel increases in CBF produced by these drugs... In hypocapnoeic humans with intracranial masses, desflurane concentrations of <0.8 MAC do not increase ICP whereas 1.1 MAC increases ICP by 7mmHg."

Front 131

Each of the following have been associated with Nitrous Oxide EXCEPT
A. Myocardial Ischaemia
B. reversible inhibition of methionine synthase
C. Megaloblastic Bone Marrow
D. Peripheral Neuropathy.
E. increase homocysteine levels

Back 131

b = irreversible

Front 132

What percentage of the total greenhouse gas effect is due to the use of volatile anaesthetic agents?
A. 0%
B. less than 1%
C. 2%
D. 5%
E. 10%

Back 132

b

Front 133

Naltrexone
A. given as a single usual dose antagonises the effects of opioids for approximately 8 hours
B. mainly renally metabolised
C. no hepatic side effects even at high doses
D. is mixed opioid agonist-antagonist
E. used for alcohol abuse

Back 133

e
Duration of action > 24hours (A = false)
"effective half-time for return to baseline opiate receptor occupancy after 50 mg of oral naltrexone to be 72 to 108 hr." [1]
Hepatic metabolism. (B = false)
Naltrexone has the capacity to cause hepatocellular injury when given in excessive doses. Naltrexone PI (C = false)
Opioid antagonist. (D = false)
Used for alcohol dependence and opiate dependence. (E = true)

Front 134

What is NOT true about tramadol?
A. Has active metabolite
B. Works via inhibition of NA and serotonergic reuptake
C. Causes less resp depression than other opiates
D. Metabolized in liver and excreted in the kidney
E. Structurally resemble codeine

Back 134

b
Tramadol acts as a weak agonist at all types of opioid receptor, with some selectivity for the mu-receptor. It has one-tenth the potency of morphine. Tramadol also blocks the reuptake of noradrenaline and 5-HT (serotonin) and facilitates release of the latter, to modify nociceptive transmission by activation of the descending inhibitory pathways in the CNS

Front 135

With regard to non-depolarising muscle relaxants:
A. NDMR actions are increased with hyperkalemia
B. Vecuronium exclusively (or primarily) undergoes renal elimination
C. Mivacurium half-life 10 minutes
D. Cisatracurium is metabolised to laudanosine by the liver
E. May require larger doses if treated with phenytoin and theophylline

Back 135

e
"it appears to increase the dose requirements of all of the non-depolarising relaxants (with the exception of atracurium) by 60-80%. No entry for Theophylline, but under "Aminophylline" says "in high concentrations, the drug will antagonise non-depolarising neuromuscular blockade caused by pancuronium or tubocurarine".

Front 136

Immunologically mediated heparin-induced thrombocytopaenia is characterised by
A. onset within a few days of first starting heparin therapy
B. intravascular thromboses
C. platelet count rarely reduced below 100 x 109.1-I
D. continuation of thrombocytopaenia after cessation of heparin
E. presence of non-specific (heparin-independent) platelet antibodies

Back 136

b

Front 137

Expected adverse drug effects in a geriatric population receiving a high dose of a selective serotonin reuptake inhibitor for depression would include all of the following EXCEPT
A. hyponatraemia caused by inappropriate secretion of ADH
B. impairment of platelet aggregation caused by depletion of 5HT (serotonin) stores
C. withdrawal symptoms characterised by anxiety, agitation and increased sweating
D. sedation, dry mouth, orthostatic hypotension and cardiac conduction defects
E. gastro-intestinal effects (nausea, vomiting, diarrhoea)

Back 137

d
The SSRIs do NOT cause sedation, dry mouth, orthostatic hypotension and cardiac conduction defects, all of which are seen with the tricyclics." (Selective serotonin reuptake inhibitors Pharmacology and clinical implications in anaesthesia and critical care medicine in Anaesthesia Volume 52, Issue 10, Date: October 1997, Pages: 982-988)

Front 138

Regarding Placebos
A. A fixed proportion of patients randomised in a study will experience benefit by taking placebo
B. The number of the patients experiencing benefits from a placebo will be proportional to the number of patitents randomised to the control arm of the trial.
C. A placebo is uneccessary in a trial where two different drugs are being tested
D. the proportion of patients reporting benefit from placebo will increase the more invasive (?and unpleasant) the placebo treatment is

Back 138

c

Front 139

Established Legionnaires disease is treated with
A. Aminoglycosides
B. Cephalosporins
C. Chloramphenicol
D. Crystalline penicillin
E. Erythromycin

Back 139

e

Front 140

When dealing with morbidly obese patients, there are two weight measures used to calculate drug doses, the Ideal Body Weight (IBW) and the Total Body Weight (TBW). Which ONE of the following is true?
A. The dose of atracurium should be based on IBW
B. The induction dose of propofol should be based on IBW
C. The induction dose of thiopentone should be based on TBW
D. The dose of suxamethonium should be based on TBW
E. The dose of vecuronium should be based on TBW
NB: it was definitely induction dose of propofol on IBW

Back 140

b
"In morbidly obese patients, the induction dose of propofol can be calculated on IBW. Although propofol is highly lipophilic, propofol does not accumulate in morbidly obese patients. Therefore, the dosage of propofol for maintenance of anaesthesia in obese subjects can be established on the same basis as in lean subjects, taking into account their actual body weight with no specific risk of accumulation. However, this requires administration of large doses of propofol. The haemodynamic effects of larger doses of propofol remain to be assessed in obese patients. Plasma propofol concentration at the end of surgery after a fixed rate infusion of propofol are dependent on TBW. This may imply that when obese patients are anaesthetized with propofol based on TBW, deep anaesthesia and deleterious cardiovascular effects may result.

Front 141

In patients with renal impairment, doses of all of the following may require adjustment EXCEPT
A. Carbamazepine
B. Gabapentin
C. Hydromorphone
D. Morphine
E. Oxycodone

Back 141

e
Pain Book

Front 142

The following are correct statements regarding glycoprotein IIb/IIIa antagonists EXCEPT
A. platelet dysfunction persists even at 48 hours after cessation of drug
B. their effects may be monitored by use of a platelet turbidometry aggregometer
C. they are known to cause severe thrombocytopaenia in some patients
D. they are used to treat acute coronary syndromes
E. they block fibrinogen binding to platelet glycoprotein IIb/IIIa receptors

Back 142

a
As patients receiving abciximab experience platelet dysfunction for 12–24 h after termination of the infusion, it would seem prudent that surgery should be delayed for at least 12–24 h after abciximab if the patient’s cardiac status permits. Surgery should be delayed for 4–6 h to reduce the risk for increased bleeding in patients who have received eptifibatide or tirofiban."
Platelet Glycoprotein IIb/IIIa Antagonists", Anesthesiology 2002; 96:1237–49 (P. Kam) -

Front 143

Anaesetising patient with history of regular use CNS stimulants. Will need
A. Increased induction agent and increased opioid agent
B. Increased induction agent and normal opioid agent
C. Decreased induction agent and increased opioid agent
D. Increased induction agent and decreased opioid agent
E. Decreased induction agent and decreased opioid agent

Back 143

b
CEACCP (2002) says "the main effects of stimulant drugs will be an increased MAC for anaesthetic agents and cardiovascular instability. Generous premedication and good analgesia may help to obtund major changes in heart rate and blood pressure in response to surgical pain" - suggests to me an increased dose of induction agent and increased or unchanged opiate. Combined with ANZCA pain book "these drugs do not exhibit any cross-tolerance with opioids" and "no data from the clinical setting of any difference in opioid requirements compared from patients who do not use these drugs" makes me think that increased induction dose and unchanged opiate is the best option.

Front 144

In a clinical trial, 3 out of 10 patients develop a complication in the control group, and 1 of 10 patients develops the complication in the treated group. To assess whether this is a statistically significant difference the most appropriate statistical test to use would be the
A. Chi-square Test
B. Chi-square Test with Yates correction
C. Student's t-test
D. Fisher’s Exact Test
E. Mann-Whitney Test

Back 144

d
Fisher's exact test is the best because it is an EXACT determination of the probabilities. Previously it was not commonly used because it involves use of factorials (hence the recommendation it should only be used with small numbers), but it is now more commonly used because computers can do the number crunching!

CEACCP Stats 3

Front 145

When a new diagnostic test is evaluated in a group of subjects in whom the diagnosis is known, the following results are obtained
Disease known Disease known
to be present to be absent
New test result positive 2 4
New test result negative 6 8
The specificity of the new test is closest to
A. 25%
B. 33%
C. 57%
D. 67%
E. 75%

Back 145

d
Specificity = TN / (FP+TN)
= 8 / 4+8 = 8/12 = 67%
Sensitivity = TP / (TP+FN)
= 2 / 2+6 = 25%

Front 146

A diagnostic test has a sensitivity of 90% and a specificity of 99% in detecting a certain disease. From this we can conclude that
A. the false positive rate of this test is 1%
B. the false negative rate of this test is 1%
C. the positive predictive value of this test is 90%
D. the negative predictive value of this test is 90%
E. this test would be a useful screening test for this disease

Back 146

A
Sensitivity = TP/TP+FN
Specificity = TN/TN+FP
PPV = TP/TP+FP
NPV = TN/TN+FN
False positive = 1-spec
False negative = 1-sens

Spec = 1-FPR = 0.99 = 1-0.01