Anzca Mcq 2009 B

Front 1

MH56 (NEW) Bleeding patient. What is relative contraindication to Prothrombinex?
A. History of HITS
B. Von Willebrands
C. Haemophilia B
D. Warfarin overdose
E. Renal failure
F. Overdose vit K (not warfarin)

Back 1

Answer is A (it contains 192 IU heparin per vial)

PROTHROMBINEX-VF is a sterile lyophilised (freeze-dried) prothrombin complex concentrate (PCC) containing purified human coagulation factors II, IX, X and low levels of factor VII.
PROTHROMBINEX-VF distributed in Australia, is prepared from plasma collected from voluntary and non remunerated Australian donors.
When reconstituted as recommended, each vial of PROTHROMBINEX-VF contains 500 IU of factor IX, approximately 500 IU of factor II, 500 IU of factor X, 25 IU of antithrombin III, 192 IU of heparin sodium and ≤ 500mg of plasma proteins (which includes low levels of factor V & VII.) Other ingredients include sodium citrate, sodium phosphate and sodium chloride.
PROTHROMBINEX–VF is manufactured using two dedicated pathogen inactivation/ reduction steps which contribute to the clearance of viruses:
 dry heat treatment at 80C for 72 hours, and
 nanofiltration.
The nanofiltration step (size-based removal) is complementary to the dry heat treatment step. This increases the spectrum of pathogens that can potentially be eliminated and hence further enhances the safety profile of PROTHROMBINEX-VF.

Front 2

TMP-128 [Aug09] Indication for percutaneous closure of ASD
A. Ostium primum < 3cm
B. Ostium primum > 3cm
C. Ostium secundum < 3 cm
D. Ostium secundum > 3cm
E. Sinus venosus ASD

Back 2

C
CEACCP Anaesthesia for percutaneous closure of atrial septal defects 2008
Only an ostium secundum ASD is suitable for percutaneous closure.
If the defect is very large (>3 cm) or complicated (associated with other abnormalities), or an incomplete rim is detected, referral for surgical closure is indicated.

Front 3

TMP-129 [Aug09] Methylene blue given intravenously has the effect:
A. Pulse oximetry goes down
B. Blood Gas Pa02 decrease
C. Hypotension
D. Metabolic acidosis
E. Increased heart rate

Back 3

A
Update in Anaesthesia Pulse Oximetry 1995
A source of light originates from the probe at two wavelengths (650nm and 805nm).
Intravenous dyes such as methylene blue, indocyanine green, and indigo carmine can cause falsely low SpO2 readings [30], an effect that persists for up to 20 min [31]
Methylene Blue Administration is associated with decreased cerebral oximetry values A&A 2007
Methylene blue has a dose- and time-dependent effect on plasma light absorbance, with a spectral absorption peak at 668 nm, resulting in falsely low pulse oximetry readings.

B. False: no impact on PaO2
C. False: Methylene blue inhibits the enzyme guanylate cyclase, avoiding the cyclic guanosine 3'5'-monophosphate (cGMP)-dependent vasorelaxant effects of nitric oxide in the smooth muscle of vessels. methylene blue has been used to treatrefractory vasoplegia after cardiopulmonary bypass (CPB), anaphylaxis, and septic shock. (refractory hypotension)
J Thorac Cardiovasc Surg 2003;125:426-427
D False: Methylene blue is indicated for methemoglobinaemia causing metabolic acidosis, cardiac ischaemia, dyspnea or methemoglobin level >30%.
E. Heart rate, cardiac filling pressures, cardiac output, oxygen delivery and consumption did not change. Brazillian journal of medical and biological research 1999

Front 4

TMP-130 [Aug09] Essential diagnostic criteria on ECG for LBBB
A. Loss of septal Q's in V5 and V6
B. RSR in V1
C. Large slurred S in V6
D. T-waves opposite to direction of QRS
E. QRS duration minimum 0.2 s

Back 4

A or D
Previously, stem has not included option D. Both appear to be correct.

Diagnostic criteria for LBBB:
1. Total QRS duration >0.12 s.
2. No secondary R wave in V1 to indicate RBBB.
3. No septal q wave in V5, V6 or in leads further to the left (lead I and aVL in horizontal hearts).
4. T-waves in opposite direction to QRS (look for neg T where QRS is fully positive)

Front 5

MH57 (NEW) Patient over-warfarinised and is for surgery. Prothrombinex 50U/kg may NOT reverse an INR of 5.5 because it contains:
A. Citrate
B. Heparin
C. Anti-thrombin III
D. Not enough Factor VII
E. Not enough Factor X

Back 5

D

Front 6

PL29 (NEW) Ventricular fibrillation (VF) following caudal anaesthesia in 20kg six year old child. The recommended dose of of Intralipid 20% is:
A. 10mls
B. 20mls
C. 30mls
D. 40mls
E. 50mls

Back 6

C
Weight = (Age(y) + 4) x 2 which is 20kg
Dose of Intralipid 20% is 1.5 ml/kg = 30ml
AAGBI guidelines 2010 - Immediately give iv 1.5ml/kg over 1 min and start and iv infulsion of 15 ml/kg/hr

Front 7

7. (NEW) Regarding College Professional Document PS9 – sedation for colonoscopy – the following equipment must be present (NB: The wording was 'present', not 'ready access to' as used for defib in PS9)
a. Defibrillator
b. Mechanical ventilator
c. Anaesthetic machine
d. Suxamethonium
e. Dantrolene

Back 7

A
Ready access to a defibrillator
A means of inflating the lung is "a self-inflating bag and advanced airway management.
Emergency drugs that must be present did not include sux or dantrolene

Front 8

8. (NEW) According to PS9 for sedation with Propofol for colonscopy, the staff required is/are:
a. Medical practitioner other than proceduralist
b. Nurse other than proceduralist
c. Anaesthetist in addition to the proceduralist
d. Assistant
e. Proceduralist alone

Back 8

Answer is A
PS9
Propofol may be used by a medical practitioner with airway and resuscitation skills, and training in sedation for conscious sedation in ASA P 1-2 patients.
Intravenous anaesthetic agents such as propofol must only be used by a second medical practitioner trained in their use because of the risk of unintentional loss of consciousness. These agents must not be administered by the proceduralist

Front 9

TMP-131 [Aug09] Troponin is elevated post-infarct
A. 1-2 days
B. 2-5 days
C. 5-14 days
D. 7-21 days
E ?

Back 9

C

Front 10

TMP-132 [Aug09] Laparoscopic cholecystectomy patient with hyperparathyroidism and ionised calcium of 2.0 mmol/l. The BEST initial treatment is:
A. Calcitonin
B. Magnesium
C. Dialysis
D. IV fluids
E. Frusemide

Back 10

D.
OHA - Initial management should be rehydration; as Ca++ inhibits ADH.
Promotion of a diuresis also increases excretion of Calcium. Texts then defer as to the next treatment; OHA says Pamidronate IV, but also states a saline diuresis with frusemide is 2nd line. Calcitonin is temporary.

Front 11

11. (NEW) Your patient given thiopentone by mistake has a porphyric (acute intermittent) crisis with abdominal pain and then seizures. What drug is contraindicated?
a. Phenytoin
b. Morphine
c. can't remember others
d. ?
e. ?

Back 11

A

Front 12

*12. (NEW) Fit lady for elective laparoscopic cholecystectomy seen in PreAdmission Clinic. ECG shows LAD ?(LAFB), RSR in V1, wide slurred S in V6 and QRS duration 0.2 msec. Your options
a. Refer to cardiology
b. Crack on
c. Place permanent pacemaker
d. Place temporary pacing wires
e. Give atropine premedication

Back 12

Ans B
OHA
Preoperative management
1. First degree heart block in the absence of symptoms is common. No investigation or treatment is necessary is asymptomatic.
2. Second or third degree heart block may need pacemaker insertion. If surgery is urgent this may be achieved quickly by inserting a temporary transvenous wire prior to definitive insertion.
3. Bundle branch, bifascicular, or trifascicular block will rarely progress to complete heart block during anaesthesia and so it is not normal practice to insert pacing wire unless there have been episodes of syncope.

Indications for preoperative pacing
1. symptomatic first degree heart block
2. symptomatic second degree Mobitz I heart block
3. Second degree Mobitz II heart block
4. Third degree heart block
5. Symptomatic bifascicular block or symptomatic first degree heart block plus bifascicular block (trifascicular block)
6. Slow rate unresponsive to drugs

Front 13

13. (NEW) All these nerves provide some sensation to upper arm EXCEPT
a. Musculocutaneous
b. Intercostobrachial
c. Radial
d. Circumflex
e. Median antebrachial?

Back 13

Ans A
NB: Musculocutaneous nerve is: musculo- (ie motor) ABOVE the elbow THEN
sensory (as lateral cutaneous nerve of the forearm) BELOW the elbow -ie NO sensory above elbow.
Innervates the coracobrachialis, biceps brachii, and brachialis muscles,
Sensation to the lateral cutaneous aspect of the forearm.

Front 14

Radial Sensory Nerve (Sensory Branch of the Radial nerve)
14. (NEW) Advantage if supraclavicular over interscalene nerve block for shoulder surgery
a. Less phrenic nerve block
b. Easier landmarks in obese patient
c. Arm can be in any position for block
d. Less risk pneumothorax
e. Better cover for shoulder surgery?

Back 14

Ans A probably
Given that phrenic nerve block is an expected outcome of the interscalene block.
Doesn't matter where the arm is, and in the fat patient both might be difficult.
Closer to pleura with SCB ie higher risk of pneumothorax
Might miss supraclavicular with SCB as it comes off early from the superior trunk.

Front 15

15. (Variation of old question NV27) The basilic vein
a. Arises from the dorsum of the hand
b. Follows the superficial radial artery
c. Pierces the clavipectoral fascia
d. Becomes the brachial vein at the cubital fossa
e. Arcs around the radial side of the forearm

Back 15

Ans A
wiki
A It arises from the medial (ulnar) side of the dorsal venous of plexus of veins;
B False as above hence does not follow the superficial radial artery.
C False Cephalic vein pierces clavipectoral fascia not basilic
D False It joins the brachial vein to become the axillary vein in the axilla.
E False it is the ulna side
The cephalic vein does B,C and E.

Front 16

AC158 [Aug09] [Aug10] Long duration of surgery, arms stretched out, head turned 30 degrees to right. On waking patient has a neurological deficit. Sensory loss over ventral lateral palm and 3 fingers, some weakness of the hand, weakness of the wrist, some paraesthesia of the forearm and weak elbow flexions. Most likely injury is
A. Median nerve
B. Ulnar nerve
C. C5 nerve root
D. Upper cervical trunk
E. Musculocutaneous

Back 16

D
Elbow flexors (Brachialis, Biceps, Coracobrachialis) and some parasthesia of forearm is in the distribution of the musculocutaneous nerve.
Ventral lateral palm amd 3 fingers is median nerve distribution. So the lesion must be proximal to the formation of the terminal nerve roots; C5 and 6 nerve root, upper trunk or lateral cord (and upper trunk is the only option available).

Front 17

17. (Variation of old Question). Paediatric ALS – 20 kg, VF has had 2 shocks only. Next step
a. Adrenaline
b. Amiodarone
c. Shock 50J
d. Shock 100J

Back 17

D
It depends on the question
1st shock 2J/kg
subsequent shocks 4J/kg
80 J is close enough to 100 J
Adrenaline after 2 mins and reassess rhythm.

Front 18

18. (NEW) Patient with known severe aortic regurgitation. Auscultation reveals loud mid diastrolic murmur in aortic area. You also hear a quiet mid diastolic murmur in the apex. This is
a. Functional mitral stenosis
b. Mitral valve incompetence
c. Impaired LV function
d. Papillary muscle dysfunction

Back 18

Ans A
Sounds like they're talking about the "Austin-Flint" murmur, where the regurgitant jet strikes the anterior leaflet of the mitral vale. A
Austin Flint - Classically, it is described as being the result of mitral valve leaftlet displacement and turbulent mixing of antegrade mitral flow and retrograde aortic flow.
Displacement: The blood jets from the aortic regurgitation strike the anterior leaflet of the mitral valve, which often results in premature closure of the mitral leaflets. This can be mistaken for mitral stenosis. (Wikipedia) Disco 27/6/10

Front 19

TMP-133 [Aug09] Hetastarch 130/0.4. The 0.4 means:
A. 40 mg/l
B. 40 g/l
C. 4 hydroxylations of every 10 glucose molecule
D. every 4the glucose is hydroxyethylated
E. ?

Back 19

C.
The 130 is the molecular weight of the starch, while the 0.4 is the molar substitution.
To clarify, the MS (molar substitution) is the ratio of hydroxyethyl groups to glucose residues

Front 20

TMP-134 Hetastarch. What one to use for intermediate plasma expansion and intermediate plasma half life
A. 450/0.4 (10%)
B. 130/0.7 (6%)
C. 130/0.4 (6%)
D. ?
E. ?

Back 20

C
I'm presuming they mean Voluven[1]. 130/0.4

Front 21

TMP-134 A Hetastarch of intermediate plasma expansion and intermediate plasma duration is
A. 10% HES 250/0.6
B. 10% HES 200/0.5
C. 6% HES 450/0.7
D. 6% HES 130/0.4
E. 3% HES 200/0.5

Back 21

D
I'm presuming they mean Voluven[1]. 130/0.4

Front 22

21. (NEW) Maternal collapse post-delivery. What is NOT consistent with Amniotic fluid embolism?
a. Seizure
b. Petechial rash
c. Hypotension
d. Coagulopathy
e. Cardiac arrest

Back 22

B

Front 23

22. (Repeat) Trauma with # pelvis and femur. Has a splenectomy. Day 2 patient thrombocytopenia, confused and hypoxic. Diagnosis is
a. fat embolism syndrome
b. pneumcoccal pneumonia
c. thromboembolism

Back 23

A

Front 24

23. (NEW) Indications for steroids in neurosurgery
a. Cerebral abscess
b. Subdural haematoma
c. Meningioma
d. SAH
e. Traumatic brain injury

Back 24

C
Treatment of cerebral oedema The neurologist 2006
Useful in tumours and radiation therapy
Meningitis and abscess in adults steroid use is controversial
Not recommended in head injury CRASH trial increased 2 week mortality rates
No role in treatment of ischaemic stroke or intracerebral hemorrhage

Front 25

24. (NEW) Rate of phenytoin administration:
a. 50 mg/min
b. 70 mg/min
c. 100 mg/min
d. Over 5 minutes
e. As fast as possible

Back 25

A
Admin by slow IVI (max 50 mg/min) into large vein via catheter (from MIMS)

Front 26

25. EV08 Hypothetical anaesthetic agent. Flows 2 L oxygen and 2L nitrous. Copper kettle vaporiser flow 0.5 L. Volatile with SVP 380 mmHg. Inspired volatile concentration (no numbers were exactly correct)
a. 2%
b. 5%
c. 10%
d. 11%

Back 26

Ans C
380/760=0.5
0.5+0.5=1L from vaporiser
4L fresh gas
0.5/5L= 10%

This question is word-for-word from Kerry Brandis's book Physiology Viva, RE...Ch 12, p280
Important points to note:

The vapourizer is a copper kettle, not a variable bypass vaporiser. In the copper kettle, the vaporiser has a separate gas flow (given in our example). The kettle will pick up vapour so the flow out of the kettle will be higher than the flow in

The SVP of the agent is 380 mmHg at 20C means that the saturated % concentration will be 50% at 20°C (760/380 = 0.5)
So:
If 500 ml liquid is bubbled through the copper kettle per minute, another 500 ml will be picked up to make a total volume of 1000 ml per minute @ 50% volatile concentration.

If an additional 4L fresh gas flow is added to this, the total volume will be 5L per minute, diluting the volatile concentration 5 times to finish at 10%.

If this was a variable bypass vaporiser 500mls of inflow plus 500mls of picked vapour (which is 50% saturated) gets added back to the 3500mls of the diverted FGF to give a final volume of 4500mls. Then, 500/4500 x 50% = 11.1% (E) as the concentration of vapour. But it is not. It is a copper kettle.

Front 27

26. (NEW) Negative pressure leak test in a Boyles type machine. This means
a. Vaporiser leak
b. Circuit leak
c. Brain leaking out of my ears by now
d. Leak in non return valve

Back 27

A
Checking anaesthetic machine
It is a low pressure system test.

Front 28

27. (NEW) As per ANZCA Acute Pain Guidelines (2nd ed update), after a prophylactic subcutaneous dose of heparin, minimum time before you can remove epidural catheter is
a. 2 hours
b. 4 hours
c. 6 hours
d. 8 hours
e. 10 hours

Back 28

C.
ANZCA Acute Pain Guidelines 3rd ed p198
"Thromboprophylaxis with SC heparin is not a contraindication to neuraxial blockade. To identify heparin-induced thrombocytopenia, a platelet count should be done prior to removal of an epidural catheter in patients who have had more than 4 days of heparin therapy. Epidural catheters should be removed a minimum of 6 hours after the last heparin dose and not less than 2 hours before the next dose."

Interestingly this does not correspond with most of the world wide guidelines who say 4 hours.

also: LMWH - wait 12 hrs after dose to insert
first dose 2hrs after removal

Front 29

28. (NEW) Utility of BNP (brain naturietic peptide) is for
a. Dyspnoea after pneumonectomy
b. Loss of consciousness after ..
c. Confusion after CABG

Back 29

Likely A
Both BNP and NT-proBNP levels in the blood are used for screening, diagnosis of acute congestive heart failure (CHF) and may be useful to establish prognosis in heart failure and in Anesthesiology, preoperative BNP independently predicts in-hospital ventricular dysfunction, hospital length of stay (HLOS) and mortality up to 5 years after primary CABG surgery. So hard to know without the real question.
Other things I've read suggest that BNP can help differentiate dyspnoea due to cardiac failure from other causes. After pneumonectomy, there is a sudden increase in PVR, so perhaps this is indicative of whether the right heart is coping. I think the key is dyspnoea; when the real answers appear (in the next exam no doubt) its utility is to suggest whether the dyspnoea is related to cardiac failure or something else.

Front 30

29. (NEW) Which patients do not get pulmonary hypertension
a. ASD
b. Chronic thromboembolism
c. Tetralogy
d. MR
e. MS

Back 30

C
As you have some degree of RVOT obstruction thus pulmonary blood flow is decreased, and your mitral valve is competent so there is no increase in LA pressure.

Front 31

30. (NEW) Drug LEAST likely to cause hypoxia in ARDS
a. Noradrenaline
b. Milrinone
c. Isoprenaline
d. Isoflurane
e. SNP

Back 31

A.
All the others would bugger up your HPV.

Front 32

31. PI82 (NEW) Pulmonary hypertension, which will affect PVR the most
a. Isoflurane
b. Sevoflurane
c. Desflurane
d. Propofol
e. Remifentanil

Back 32

Ans ?C
Anaesthesia and right ventricular failure AIC 2009
Inhaled anaesthetics
All of the volatile anaesthetics may worsen RV dysfunction by reducing preload, afterload and contractility. Halothane, enflurane, isoflurane and sevoflurane do not adversely affect PVR.
However, PVR is increased by both desflurane, and nitrous oxide, hence these agents should be avoided in patients who are at risk of RV decompensation.

For example, while propofol has no effect on PVR normally, in the presence of α-adrenoreceptor activation it produces pulmonary vasoconstriction.
Remifentanil produces minor pulmonary vasodilation, which is mediated by histamine release and opiate receptor pathways

Front 33

32. (NEW) In body protected OR with a Line Isolation Monitor reading 0 mA. If you touch one active wire what will happen.
a. nothing, because no connection to earth is completed
b. you get shocked
c. nothing because the floor is insulated
d. nothing because your shoes are nonconductive
e. RCD trips

Back 33

A.
0mA means everything is fine and properly isolated so the circuit is not earth referenced.
This link explains line isolation monitors nicely http://biomedgbis.com/line_isolation.htm

Front 34

33. (NEW) Best way prevent first phase of heat loss after induction
a. Prewarming the patient with forced air warming
b. Warm blankets
c. Warm fluids
d. Warm theatre
e. Humidified gases

Back 34

A
Pre-warming eliminates the gradient between core and peripheries thus the redistribution phase does not occur.

Front 35

34. (NEW) Best way to assess fluid resuscitation after burns is
a. Urine output
b. mixed venous sats
c. blood pressure
d. cvp
e. capillary refill

Back 35

A - urine output - from Blue Book 2005 –
"End points of resuscitation The optimal end points for burns resuscitation continue to generate much debate. Despite the administration of fluid therapy according to prescribed guidelines, problems frequently noted at the end of the burn resuscitation are generalized oedema, decreased efficiency of pulmonary gas exchange, hypoalbuminaemia and intermittent episodes of hypotension and oliguria. Some problems may indicate over resuscitation, whereas others are suggestive of ongoing hypovolaemia. Clinical examination, together with assessment of end organ perfusion (urine output 1⁄2 to 1 ml/kg/hr; intact sensorium), is the minimum assessment possible to guide burn resuscitation. Pulmonary artery catheters and other more invasive forms of monitoring of haemodynamic parameters have not been shown to improve outcome in surgical, medical or burns patients. Both subcutaneous and splanchnic oxygenation are sensitive indicators of evolving haemorrhagic shock, and have been used in burn care to monitor tissue oxygenation indices during burn shock and resuscitation.15 Recently, Rivers et al investigated the use of central venous oxygen saturation (ScvO2) as part of a package to guide therapy for severe sepsis, and showed an improvement in outcome when it was used in a single centre.16 However, the role of ScvO2 to guide resuscitation of burn shock is not established. A single centre Australasian study is planned.

And from UpToDate 2009: Monitoring fluid status — Confirmation of adequate resuscitation is more important than strict adherence to Parkland or any fluid resuscitation formula. Monitoring urine output using an indwelling bladder catheter (eg, Foley catheter) is a readily available means of assessing fluid resuscitation. Hourly urine output should be maintained at 0.5 mL/kg in adults and 1.0 mL/kg in children who weigh less than 25 kg. Patients with minimal or no urine output following severe burns, despite fluid resuscitation, generally do not survive.

Front 36

35. (NEW) Emergence delirium in a kid in recovery. To treat
a. Fentanyl 1mc/kg
b. Midazolam 0.1 mg/kg
c. Propofol
d. Clonidine 1mc/kg
e. Sucrose

Back 36

Ans E
Emergence Delirium in Children: Many Questions, Few Answers states
"Rescue" medication includes analgesics, benzodiazepines, and hypnotics. Fentanyl IV 1–2 µg/kg (22), propofol IV 0.5–1.0 mg/kg (39), and midazolam IV 0.02–0.10 mg/kg (12,84) have all been used for the treatment of ED. A single bolus dose of dexmedetomidine 0.5 µg/kg was also shown to be efficient in the PACU for ED (85). Perhaps in the age group likely to get ED, sucrose probably isn't going to do the trick as usually that's reserved for the neonates.

Emergence agitation in children: an update - Current Opinion in Anaesthesiology 2005, 18:614–619
Possibly key is patient in recovery - fentanyl, midazalom and clonidine are referenced in above article for prevention. Not much is mentioned about PACU except..."all possible causes, such as physiologic compromise, physical discomfort or pain should be ruled out."

Post anaesthesia excitation - Paediatric Anaesthesia 2002 12: 293–295
"In contrast with prevention, there is no scientific support for any method of treatment. Opioids are widely used and seem to be effective in most but not all cases"

Front 37

36. (NEW) Pain in 3 year old, best objective tool
a. FLACC (crying limbs activity consolability)
b. Wong baker Faces pain
c. Self reporting
d. Mum reporting
e. Nurse reporting

Back 37

A.
Wong Baker faces (revised) for 4 to 12 years. Any form of self reporting usually not possible until the age of 4. From APMSE 3rd edition.

Front 38

39. Best time to collect serum tryptase after suspected anaphylaxis
a. within 15 minutes
b. 1 - 3 hours
c. 3 - 6 hours
d. 12 - 24 hours
e. greater than 36 hours

Back 38

B
AAGBI safety guideline suppected anaphylactic reactions with anaesthesia 2009 Pg15
6 Take blood samples (5–10 ml clotted blood) for Mast Cell Tryptase as follows:
A Initial sample as soon as feasible after resuscitation has started – do not delay resuscitation to take the sample.
B Second sample at 1–2 h after the start of symptoms.
C Third sample either at 24 h or in convalescence (for example in a follow-up allergy clinic). This is a measure of baseline tryptase levels as some individuals have a higher baseline level.
D Ensure that the samples are labelled with the

Front 39

40. Suspect drug cardiac toxicity (can't remember which drug - please help!) Auscultation findings which support this are
a. Bibasal crackles
b. Systolic murmur LSE
c. Systolic murmur Apex
d. ?
e. ?

Back 39

Don't know

Front 40

41.(NEW) Patient with Hemophilia A with known high titres of inhibitors to factor 8. What would you give to prevent bleeding in the patient for ot
a. FVIIa
b. High dose FVIII concentrate
c. FFP
d. Cryo
e. Platelets

Back 40

A
The whole reason why novoSeven exists in the first place. A particular therapeutic conundrum is the development of "inhibitor" antibodies against factor VIII due to frequent infusions. These develop as the body recognises the "normal form" factor VIII as foreign, as the body does not have its own "copy". The problem is that in these patients, factor VIII infusions are ineffective. Recently[update] activated factor VII (NovoSeven) has become available as a treatment for haemorrhage in patients with haemophilia and factor inhibitors. Wikipedia. Disco 28/6/10

Front 41

42. (Variation) Pregnant women whose paternal uncle has MH. Nobody has been tested. What's the best test to exclude MH in this patient?
a. Genetic test lady
b. genetic test dad of lady
c. muscle biopsy lady
d. muscle biopsy dad

Back 41

Ans D
You never anaesthetise a pregnant woman unless you absolutely have to given the possibility of precipitating pre-term labour. The safest thing to do would be to do a muscle biopsy of the Dad. A genetic test can mean you are MHS if you have the same mutation but does not mean you're not sensitive if it's negative as you can have a different mutation.

British Malignant Hyperthermia Association (BMHA)
Not all patients can have a biopsy, these include children less than 10-12yrs (30kgs), pregnant women, and patients on prolonged steroid therapy. If the proband cannot be tested, eg a young child or deceased, then the nearest most appropriate relative is tested. In the case of a young child this would be the parents. Once the proband has been confirmed as MH susceptible, a blood sample taken at the time of the biopsy will be screened to see if they carry one of the genetic mutations that can be used to test for MH. At present only around 60% of families carry one of these mutations of which there are currently 27.From British Malignant Hyperthermia Association

Front 42

43. A woman is being treated for pre-eclampsi. She is given 10 grams Magnesium sulphate in 1 h, instead of 1 gr per 1 h, Mg level 5-6, and patient is hyporeflexia. The best treatment is:
a. calcium
b. IV fluid
c. Furosemide
d. ?

Back 42

Ans A
Was there an option of waiting to repeat the level a few hours later? Cos with that level but not cardiovascular instability often you'd just hold off until reflexes are normal. In many countries where serum Mg levels aren't so widely available when the original Magpie trial was done, decreased DTR was the end point in developing countries. Otherwise its A, Ca Gluconate 1g over 10 minutes,

Front 43

44. Disease associated with malignant hyperthermia
a. central core disease
b. myasthenia gravis
c. myotonia congenita
d. ?

Back 43

A Central core disease...kingfed
MH, CEA Vol 3, No 1 5-9

Front 44

45.Endotracheal tube to circuit connectors
a. 15/22 mm
b. lots of other wrong combo's

Back 44

A

Front 45

46.Appropriate infection control measures when anaesthetising a patient with suspected variant-CJD, the airway equipment should be
a.thrown away
b.plastic sheath, reuse
c.sterilization with ethylene oxide
d. sterilization with heat at 134 degrees for 3 minutes
e. Autoclave

Back 45

Ans A
Reading a number of guidelines, it would suggest that options B through E is inadequate. Oral Tissues (unless you hit the tonsils, which are classed as medium risk) are generally low risk, and processing and reuse is acceptable. The process is particularly nasty and involved concentrated sodium hydroxide or 2% bleach heated up to various temperatures. Steam autoclave alone would mean 18 minutes at 134°C (hmm, wonder what would get through that unscathed). So A would probably be the right option. As they articles specifically state, covered items are still not guaranteed to be prion- free as there is always a bit of splashback.

Front 46

47. Mechanism of action of antiepileptics in chronic pain, which is false?
a. Phenytoin workes at Na channels
b. Gabapentin increases gaba in cns
c. Carbamazepine works at Na channels
d. Valproate increases GABA in the CNS
e. lamotrogine acts at Ca channel

Back 46

Ans E
Just noting the controversial ones, while gabapentin is not a GABA precursor, agonist or antagonist, it does seem to have some effect on glutamate carboxylase which converts glutamate to GABA increasing CNS levels. Lamotrigine is definitely wrong as it acts on a Na+ Channel.
E

Front 47

48. (Repeat) Timing of worst coagulopathy after liver transplant
a. 1-2 days
b. 3-4 days
c. 5-6 days
etc

Back 47

Ans A
Teik Oh 6E states "8-hourly for the first 24 hours, thereafter daily unless indicated. The fall in PT is more important than the actual value. FFP should be withheld to assess graft function although platelet support should be provided as usual". So that would imply the worse function is early.

Front 48

49. Anaesthetic management in patient with cardiac tamponade
a. bradycardia for the ventricle filling time
b. inotropes
c. volume loading
d. ?

Back 48

Ans B & C
Anesthestic management for suspected cardiac tamponade could include arterial monitoring and CVP. Keep the heart "fast, full, and strong". Minimize positive pressure ventilation, especially high-volumes. And avoid drugs that cause myocardial depression or bradycardia.
Reference: Miller's Anesthesia, 7th ed. Ch 60.

Front 49

50.(Repeat Apr 09) Doing an awake CEA. Patient becomes confused & combative after carotid clamped and opened. Priority is...
a) tell surgeon to release clamp
b) tell surgeon to place shunt
c) induce GA
d) give midazolam

Back 49

B
OHA pg 436

Front 50

51. (Repeat) You intubate a young male patient for a left thoracotomy with a 39FG Robert Shaw tube. When you inflate both cuffs and ventilate the bronchial lumen you get left sided ventilation. When you attempt to ventilate the tracheal lumen the pressures are very high and you get no air entry. Yet when you deflate both cuffs you can ventilate the patient through the tracheal lumen. The most appropriate step to take next is:
A. Change to a 41FG tube
B. Change to a 37FG tube
C. Deflate both cuffs and insert further cm and recheck
D. Deflate both cuffs and withdraw a few cm and recheck
E. Pull ETT out and start again.

Back 50

C
The tube is not far in enough

Front 51

52. (Repeat) Patient with IV in right arm, has mediastinal mass and SVC compression undergoing mediastinal biopsy, suddenly uncontrolled surgical bleeding in mediastinum. Next step in management prior to thoractomy: A. insert femoral cannulae and place on bypass
B. insert IV in left arm
C. insert IV into foot
D. insert jugular CVC
E. trendelenburg

Back 51

C
Miller
Mild mediastinal hemorrhage may respond to conservative measures: the patient can be placed in the head-up position, the systolic pressure kept in the 90s, and the wound tamponaded with su