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113 Cards in this Set

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Which of the following statements regarding anaphylactic 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

E

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.
Sepsis from Yersinia infection from blood transfusion, mortality?

A. <5%
B. 20%
C. 40%
D. 60%
E. 80%
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.))
Obese female having gynae surg. Uneventful induction. Anaesthetic stable. Goes into 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. Aspiration
B

CEACCP 2004 Laparoscopic Abdominal surgery:
Risk of trendelenberg = endobronchial intubation due to cephalad movement of diaphragm
A 65 -year-old female patient with known chronic renal disease and a normal resting preoperative
electrocardiogram (ECG) has undergone total hip replacement. Three days postoperatively she complains of chest pain and breathlessness. Her pulse rate is 110 min-1 and blood pressure 130/90 mmHg. The following
ECG is recorded. The diagnosis is most likely to be:

A. Atrial fibrillation
B. hyperkalaemia
C. myocardial infarction
D. pericarditis
E. pulmonary embolus
E

PE = 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)
Definitive evaluation of malignant hyperthermia (MH) susceptibility does NOT include observing:

A. abnormalities on magnetic resonance imaging (MRI) spectroscopy
B. calcium release from B lymphocytes in response to caffeine stimulation
C. certain mutations in the ryanodine receptor gene
D. myofibrillar necrosis on muscle biopsy
E. plasma creatine kinase (CK) levels above 800 units.l-1
D
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. Chronic pain after breast surgery
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
During which is procedure is it most important to re-program a pacemaker?

A. ECT
B. MRI
C. Lithotripsy
D. Percutaneous transhepatic cholangiogram
E. Laser therapy to a laryngeal papilloma
C

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.
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
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 intubation
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
E least correct

Vancomycin -
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
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
B
BP measurement - overestimates with:

A. big (wide) cuff
B. skinny arm
C. severely peripherally vasoconstricted
D. atherosclerosis (it was arteriosclerosis)
E. slow cuff deflation
D
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
E

Gas embolism in anaesthesia BJA CEPD Review Vol2 Number 2 2002

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
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
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.
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
B

Increased frequency increases resolution, decreases penetration.
In acute coronary syndromes with ST elevation on ECG:

A. Aspirin should be administered only after reperfusion strategies have commenced
B. patients can wait up to 24 hours from onset of ischaemic 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
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."
Hyperparathyroidism and increased Ca+

A. Long QT
B. Polydipsia and polyuria
C. Short PR
D. Increased GFR
B
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
D

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.
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
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.
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
D

= 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
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
A
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
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.
Hyponatraemia and hypovolaemia all except

A. SIADH
B. Pancreatitis
C. Nephritis
D. Renal tubular acidosis
E. Addisons
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
After 3L normal saline, expect to see:

A. hyponatremic acidosis
B. hyponatremic alkalosis
C. hyperchloremic acidosis
D. hyperchloremic alkalosis
E. none of the above
C
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
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.
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. paramedian instead of midline approach
E. sitting position instead of lateral
E

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.

Anesthesia and Analgesia 2009
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
E

Meralgia paraesthetica - from Int J Obs Anaes Review:
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.
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
E
At what level of intra-abdominal pressure does cardiac output fall?

A. 10 mmHg
B. 20 mmHg
C. 30 mmHg
D. 40 mmHg
E. 50 mmHg
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
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
E

Miller clearly states that Valsalva worsens venous return/cardiac performance, and promotes paradoxical embolus
Maximum time for arterial tourniquet for upper limb

A. 60 min
B. 90 min
C. 120 min
D. 150 min
E. 180 min
C

Pressures = UL SBP + 50; LL 2 x SBP
2 hr is the maximum

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

PE can occur following release
Pain at 30-60 mins even with GA (not spinal)
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. Hypoventilation
D. Pneumothorax
E. Aspiration
A

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%)
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
D

Nose: Trigeminal V1 and V2
Nasopharnyx: Glossopharyngeal and V2/V3
Pharynx: superior laryngeal nerve
Larynx: vagus [superior/internal/recurrent laryngeal nerves]
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
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
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
b (5%)

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).
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
C
Globe perforation with eye blocks is most likely with:

A. Axial length <25mm
B. Medial canthus peribulbar injection
C. Inferotemperal peribulbar injection
D. Age < 40 years
E. Sub-Tenons
C

in CEACCP: “Needle damage to the globe is about 30 times more common if the block is administered via the inferotemporal approach. Blocks done at the medial canthus or sub-Tenon’s are safe.”

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.
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
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
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
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".
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
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."
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
B

CPP = MAP - CVP or ICP
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
D
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
C

Also VF arrest
TBI controversial
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
A = safest
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
D

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

URTI- 2 wks LRTI- 4 wks
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
A
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
B

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)."
Clonidine is

A. Alpha 2 agonist centrally that acts presynaptically
B. Alpha 1 agonist
C. Alpha 2 antagonist
D. Alpha 1 antagonist
A
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
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 ...
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
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
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
C

3.5ml O2/kg/min
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)
C

NNT = 1 / ARR
The commonest initial presenting feature in anaphylaxis is

A. coughing
B. desaturation
C. hypotension
D. rash
E. wheeze
C
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
C
1, 6 and 24
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
a

Type and screen
1. determining the ABO and Rh(D) group of the recipient,
2. performing a red cell antibody screen on the recipient
· Patients who have a positive red cell antibody screen require antibody identification and full serological crossmatching, using the indirect antiglobulin test (IAT)

Crossmatch
Serological crossmatching techniques have been simplified in recent years, and only the IAT crossmatch and immediate spin crossmatch remain in common use. The immediate spin crossmatch is a method involving agglutination of red cells in saline following a 2-5 minute incubation. This technique has been retained to detect ABO incompatibility. The full IAT crossmatch is performed when the patient's serum/plasma contains red cell alloantibodies.

Electronic crossmatch and issue must only be used to confirm ABO and Rh(D) compatibility between donor units and a current patient sample which has completed pretransfusion testing and has a negative red cell antibody screen.
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
B
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
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
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
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
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
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)

"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."

Nitrous oxide also supports combustion and is broken down to produce oxygen, nitrogen and heat."
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
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.)
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
D
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
a

Major: Death, major haemorrhage, tracheobronchial laceration, oesophageal perforation, recurrent nerve paralysis, phrenic nerve paralysis, thoracic duct injury,
CVA, mediastinitis, VAE


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

Occurs later
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
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)
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
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)
Application of cricoid pressure with a force of 40Nwill resist reflux with an intra-oesophageal pressure of

A. 30 mmHg
B. 40 mmHg
C. 50 mmHg
D. 60 mmHg
E. 70 mmHg
A
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
C
Lots of controversy but needs volume (CVP) + adequate MAP
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.
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"
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
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.
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
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
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
e
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
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
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
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)
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
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)
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
B and C

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)

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%."
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
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)
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
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.
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
a see link http://www.anesthesia-analgesia.org/content/89/4/870/F5.large.jpg
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
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 - "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"
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
E
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
D

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
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
c

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

Inc sens to DMBs, resistance to NMBDs
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
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."
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
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.)
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
e - encephalopathy is a CI
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
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.
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
b
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
b
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
C

Should use hands not forearms
Age at which GRF = adult GFR(ml/min/m2):

A. 1 month
B. 6 month
C. 2 years
D. 4 years
E. 6 years
c
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
a
The sciatic nerve supplies the following muscles EXCEPT

A. biceps femoris
B. semitendinosus
C. semimembranosus
D. gluteus maximus
E. adductor magnus
d
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
E

= inf cervical ganglion + 1st thoracic ganglion
Regarding spinal cord blood supply, the

A. anterior spinal artery arises from the posterior inferior cerebellar arteries
B. anterior spinal artery supplies 50% of the spinal cord, while the posterior spinal arteries supply 25% each
C. largest radicular artery is usually in the lumbar region
D. posterior spinal arteries are only supplied by radicular arteries
E. upper cervical segment of the spinal cord receives most of its blood flow from the vertebral arteries
E
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
B
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
C
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
B
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%
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%.”
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
e

Tests for brain death-
Pupil fixed and unreactive
Nil corneal reflex
Nil vestibulo-ocular reflex
Nil motor responses in CNs
Nil gag reflex
Nil respiratory movements
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
C

It does bind mitochondrial cytochrome oxidase but that's not how it causes hypoxia.
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
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.
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
b = irreversible
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%
b
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
B
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
b

In vivo, this leads to both an increased clearance of platelets with resultant thrombocytopenia and venous and/or arterial thrombus formation, with the potential for severe organ damage (loss of limbs, stroke, myocardial infarction) as well as unusual sites of thrombosis (adrenal, portal vein, skin)
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
c
Established Legionnaires disease is treated with

A. Aminoglycosides
B. Cephalosporins
C. Chloramphenicol
D. Crystalline penicillin
E. Erythromycin
e
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
bd

sux to TBW up to 140mg

"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.
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
e
Pain Book
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
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) -
When a new diagnostic test is evaluated in a group of subjects in whom the diagnosis is known, the following results are obtained
Disease present Disease not present
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%
d

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