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98 Cards in this Set
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AC01a ANZCA version
Features of the transurethral resection of the prostate (TURP) syndrome include a11 of the following EXCEPT A. agitation B. angina C. bradycardia D. nausea E. tinnitus |
ANSWER E
1. TURP syndrome * CVS – hypertension and bradycardia : volume overload a balance between absorption and loss +/- increased ADH (from stress and glycine) * Neurological : N, weakness, confusion, agitation, seizures and coma, from : o Dilutional hyponatraemia and hypoproteinaemia à cerebral oedema (controversy here because osmolality is normal) o Glycine toxicity – direct and from ammonia 2. Glycine Toxicity – direct effects on eye and heart (depressant – reversed by arginine) * Transient blindness from glycine toxicity (? An inhibitory neurotransmitter), last 12-24 hrs * Increased ammonia – biotransformation of glycine -> 500 mmol/L à N+V and coma (awakens when < 150 mmol/L), more likely if arginine deficient (as normally ammonia -> urea via ornithine cycle of which arginine important intermediary) * Transient hyperkalaemia has been reported (more than with mannitol) 3. Bladder perforation (1%) – traumatic or overdistension or rarely explosion of hydrogen (cautery – plus need O2 to enter system) * Extra-peritoneal – peri-umbilical pain * Intra-peritoneal – symptoms faster - generalised abdo and shoulder tip pain, N+V, abdo rigidity, pallor, sweating and hypotension * Management – cystourethography will diagnose and Rx : supra-pubic cystostomy (for intra-peritoneal rupture at least ? conservative Mx with IDC for extra) 4. Bacteraemia/Septicaemia – in 6-7% : chills, fever and tachycardia ; rarely septic shock (high mortality) – prostate often has bugs, +/- pre-op IDC * pre-op antibiotics – do not sterilise prostate as difficult penetration, but is recommended to decrease bacteraemia 5. Hypothermia – should use warmed fluids (does not increase bleeding due to v/d) 6. Bleeding and coagulopathy – commonly bleed postop * Very vascular and blood loss difficult to estimate as mixes with irrigation fluid * Dilutional thrombocytopaenia * Abnormal bleeding in < 1%, possibly either : o Local fibrinolysis due to release of plasminogen activator and urokinase from mucosa of urinary tract o Systemic absorption of resected prostate rich in thromboplastin (with assoc. low platelet count and low fibrinogen) and can lead to secondary fibrinolysis (giving high levels of FDP) If suspect 1o fibrinolysis could give aminocaproic acid 5g in first hr then 1g/hr, (but beware DIC : Amicar contra-indicated, instead give platelets, FFP and cryoprecipitate, pc as needed – HEPARIN is controversial) 7. Hypotension Several causes : * Blood loss -> hypovolaemia * CCF – due to volume overload * Anaemia and myocardial ischaemia or infarction * Hyponatraemia (? mechanism) |
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AC01b
Which of the following is likely to be caused by water intoxication during transurethral resection of the prostate? A. Hypertension B. Nausea C. Confusion D. Headache E. Convulsions |
ANSWER A
A : May occur but hypotension is more common: Volume overload -> HT and bradycardia but also CCF and pulmonary oedema depending obviously on volume absorbed and the heart's ability to cope with the volume load (also if Na falls rapidly < 120 , then a negative inotrope) B : True C : True dilutional hyponatraenia -> cereberal oedema D : True E : True |
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Regarding TURP syndrome, all are correct EXCEPT
A. May occur as quickly as 15 minutes B. May occur 24 hours post operatively C. Mortality 10% D. lacks sterotypical presentation E. has been reported to occur with endometrial ablation and ureteroscopic procedures |
ANSWER C
A. TRUE B. TRUE C. FALSE : 0.2 to 0.8% D. TRUE : lacks sterotypical presentation resulting in delayed diagnosis E. TRUE |
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AC02b ANZCA version
The use of large quantities of isotonic non-electrolyte solution for irrigation during prolonged transurethral resection of the prostate often results in 1. hyponatraemia 2. haemolysis 3. haemodilution 4. hyperkalaemia |
ANSWER 1 and 3
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AC03
Glycine, if absorbed into the circulation in large amounts during trans-urethral prostatic surgery, may cause: A. Hyperphosphataemia B. Nausea and vomiting C. Disseminated intravascular coagulation D. Anuria E. Temporary blindness |
ANSWER E
A. False B. True – Glycine’s metabolism to ammonia can cause hyperammonaemia leading to N&V and coma C. False - DIC has been reported after TURP and generally is thought to be a result of the release of thromboplastins from the prostate into the circulation during surgery. As many as 6% of patients may develop subclinical intravascular coagulopathies D. False - Anuria may occur following absorption of irrigant fluid affecting the kidney's, but this effect is not due to glycine. no mention of renal effects in the big texts. Roizen says glycine causes a brisk osmotic diuresis. E. True- glycine acts endogenously as an inhibitory neurotransmitter in the retina. Blood levels >8mmol/L are associated with transient (<24hrs) blindness due to suppression of impulses from the retina to the cortex. |
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AC150 [Mar06] ANZCA version
Q142 A female patient with a history of severe postoperative nausea and vomiting presents for abdominal surgery. If a volatile agent is used for maintenance of anaesthesia the most effective treatment to reduce her risk of postoperative nausea and vomiting would be A. avoidance of nitrous oxide B. prophylactic dexamethasone (4 mg) C. prophylactic droperidol (1.25 mg) D. propylactic ondansetron (4 mg) E. a combination of prophylactic dexamethasone and droperidol |
ANSWER E
IMPACT trial A Factorial Trial of Six Interventions for the Prevention of Postoperative Nausea and Vomiting by Apfel et al 5199 high risk patients for PONV Randomised into 1 of 64 combinations of 6 prophylatic interventions 1. 4mg ondancetron or no ondancetron 2. 4mg dexamethasone or no dexamethason 3. 1.25mg droperidol or no droperidol 4. propofol or volatile anaesthetic 5. nitrogen or nitrous oxide 6. remifentanyl or fentanyl Results 1. Ondancetron, dexamethasone and droperidol reduced PONV risk by 26% 2. Propofol reduced risk by 19% 3. Omitting nitrous oxide reduced risk by 12% 4. TIVA reduced risk by 25% 5. relative risks associated with the combined interventions can be estimated by multiplying the relative risks associated with each intervention 6. Absolute risk reduction is based on patient's baseline risk. |
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Added. ANZCA version
Q40 Regarding postoperative nausea and vomiting (PONV), it has been demonstrated that A. A repeat dose of a 5HT3 antagonist is useful if an initial prophylactic dose was not successful B. Dexamethasone is best given at the end of surgery C. Metocloperamide is effective for PONV prophylaxis D. 5HT3 antagonists are best given at the beginning of surgery E. The efficacy of droperidol is equivalent to ondansetron for PONV prophylaxis |
ANSWER E
SAMBA 2011 Guidlines Pharmocological Prevention -Dexamethasone, 5-HT3 and droperidol shown to be all equally effective in preventing PONV -Risk reduction by 25% Dexamethasone -given at start of surgery -NNT=6 -no harm documentsed with single dose of dexa 5-HT3 -given at the end of surgery (except dolasetrong, long acting tron) -ondancetron most studies, better at preventing vomiting than nausea NNT Vomit =6, Nausea=7 NNH Headache = 36, LFT = 31, Constipation =26 -Ondancetron 4mg, Granistron 1mg, Dolesatrong 12.5mg, Tropisetron 2mg Butyrophenones -given at end of surgery -protective against headache -nausea > vomiting -NNT = 5 for PONV -NNT =3 for opoid induced nausea (used in combo with PCA, droperidol 2.5mg per 100mg morphine bag) -Haloperidol 0.5-2mg equally as effective, no sedation Combination Therapy Include 1. Dexamethasone + Droperidol 2. 5-HT3 + Droperidol 3. Dexamethasone + 5-HT3 4. Dexamethasone + 5-HT3 + Droperidol |
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ANZCA March 2006 Q104
The most common site of injury to the airway during anaesthesia is A. larynx B. oesophagus C. pharynx D. temporomandibular joint E. tongue |
ANSWER A
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AC04 [1989]
Patient having TURP becomes restless, dyspnoeic and hypertensive. Which test would be most useful? A. Haematocrit B. Arterial blood gases C. Sodium D. Plasma Hb |
ANSWER C
Serum Na usually drops 5-8 mmol/L during TURP. |
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AC08 [1987]
The initial treatment of oculocardiac reflex is: A. Deepen anaesthesia B. Retrobulbar block C. IV lignocaine D. Carotid sinus pressure |
ANSWER A
Retrobulbar can cause OCR IV lignocaine makes no difference Carotid sinus massage will worsen symptoms Oculocardiac reflex * Mediated by the trigeminal and vagal nerves * Occurs is up to 30-90% of opthalmic surgery (?ref) * 1:2200 experience transient cardiac arrest in strabismus surgery * Exacerbated by: o young age o hypercapnoea o propofol TIVA o hypoxia o light anaesthesia o beta blockers o calcium channel blockers o potent narcotics o type of stimulus-medial rectus most sensitive Management 1. Stop stimulation 2. Gentle manipulation-reflex fatigues with repetition 3. Local infiltration around muscle 4. IV/IM atropine or glycopyrrolate 5. If refractory, ventilate to normocapnoea and deepen anaesthesia. 6. May cause other arrhythmias |
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AC09
Immediate treatment of oculocardiac reflex is: A. IV atropine B. Deepen anaesthesia C. Beta-blocker D. Stopping muscle traction E. Retrobulbar block |
ANSWER D
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AC10 [1985] [Mar90] [Jul00]
Oculocardiac reflex: A. Deepening anaesthesia abolishes the reflex B. Requires intact III, IV and VI nerves C. Can be abolished by IV Atropine (OR: Can be attenuated by IV atropine adinistration prior to surgery) |
ANSWER ??
A. Deeping anaesthesia does not abolish the reflex B. Trigeminal (CN 5) and Vagus (CN 10) C. IV atropiine attenuates but does not abolish the risk of OCR |
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AC11 [Mar94] [Aug99] (type A)
The oculocardiac reflex is: A. More common with LA than GA B. Caused by retrobulbar block C. Caused by pulling on medial rectus muscle D. Most commonly caused by pulling on lateral rectus muscle E. Not in children |
ANSWER C
A. More common with LA than GA - False Uncommon with LA B. Caused by retrobulbar block - Rare with regional technique (Using belows reference) C. Caused by pulling on medial rectus muscle - True D. Most commonly caused by pulling on lateral rectus muscle - False E. Not in children - False, more common in children |
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AC12
The oculocardiac reflex is enhanced by: A. Traction on the medial rectus muscle B. Adrenaline injected into the lacrimal sac C. Pressure on the eyeball D. More common over twelve years of age |
ANSWER A and C
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AC13 [Apr97] [Aug99]
The following methods can be used to prevent postoperative hypoxia in patients having upper abdominal surgery: A. Avoid hyperventilation and hypocarbia B. IPPV with PEEP C. Sit up postoperatively D. Continuous epidural postoperatively E. Increased inspired oxygen F. Forced expiration exercises |
ANSWER C
* Likely causes of hypoxia: atelectasis and FRC<CC à shunt and decreased V/Q units. * Risk factors include: age, body habitus, pulmonary disease, general anaesthesia rather than regional, supine/trendelenberg, * Best prevented by maintaining a clear airway, supplemental oxygen and ensuring adequate ventilation. * Intraoperative manoeuvres to prevent atelectasis: benefits of PEEP are quickly lost, high FiO2 increase atelectasis, * Postoperative treatment of atelectasis: physiotherapy (deep breathing exercises, incentive spirometry, intermittent PPV etc) have questionable evidence according to review in Chest 2001 but the review on atelectasis 2005 says they are the most important. Simply changing from supine to seated can improve gas exchange. Sternal or thoracic traction and aminophylline infusions have been used (with effect). (Atelectasis review 2005) Epidural anaesthesia increases FRC (despite intercostal paralysis) because of caudad diaphragm displacement and decreased central blood volume. See: Human chest wall function during epidural anesthesia * Hyperventilation and hypocarbia cause apnoea which can cause hypoxia. |
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AC14
Causes of postoperative hypoxaemia: A. Diminished tidal volume B. Posture C. Inspired oxygen concentration D. Hypercarbia |
ANSWER A
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AC15 [Apr99]
Postoperative hypoxaemia may be reduced by: A. Epidural analgesia B. PEEP C. Narcotic analgesia D. IPPV with intermittent sighs of twice tidal volume E. None of the above work |
ANSWER A and B
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AC16 [Jul98]
Postoperative diffusion hypoxia is associated with: A. Prolonged operation with N20 B. High concentrations of N20 C. Low cardiac output D. Postoperative hypoventilation |
ANSWER D
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AC17
Hypoxaemia may be relieved by assisted ventilation with: A. Rapid early inspiratory phase B. Steady rise in inspiratory pressure C. Inspiratory phase of less than one second D. PEEP |
ANSWER D
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AC18a
Bronchospasm may be induced in the asthmatic patient by: A. Suxamethonium B. Intubation C. Tubocurarine D. Halothane E. Opiate premed |
ANSWER B
A. Suxamethonium - false: Administration of neuromuscular-blocking drugs relieves the difficulty of ventilation due to light anestheis but has no effect of bronchospasm B. Intubation - true: During induction and maintenance of anesthesia in asthmatic patients, it is necessary to suppress airway reflexes to avoid bronchoconstriction in response to mechanical stimulation of these hyperreactive airways C. Tubocurarine - false: Administration of neuromuscular-blocking drugs relieves the difficulty of ventilation due to light anestheis but has no effect of bronchospasm D. Halothane - false: The lesser pungency of halothane and sevoflurane (compared with isoflurane and desflurane) may make coughing, which can trigger bronchospasm, less likely E. Opiate premed - false |
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AC18b ANZCA version
When providing general anaesthesia to a patient with a history of asthma A. thiopentone should not be used as it may cause bronchospasm B. intravenous and topical tracheal lignocaine are equally effective in preventing bronchial hyperreactivity C. ketamine provides little benefit in a patient with active wheezing D. induction with propofol is effective in reducing the incidence of wheezing following intubation E. isoflurane is as effective a bronchodilator as halothane when given in MAC equivalent doses |
ANSWER D
A. False. When compared with propofol it seems to; this however may just be because propofol is a bronchodilator. Thiopental itself does not cause bronchospasm. B. Probably false. Depends on your source. Both sides are presented in Burburan et al. C. Definitely false. It is a widely recommended and used treatment for severe asthma not responding to normal Rx. D. Probably true. It depends on what you compare it to! Compared with thio and etomidate, yes. Compared with ketamine and volatiles, no. Go figure. E. Maybe true. |
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AC19
In asthmatic patients having anaesthesia, the most significant factor in bronchospasm production is: A. Thiopentone B. Suxamethonium C. Intubation D. Opiate premedication |
ANSWER C
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AC20
Cause of generalised convulsions 20 minutes postop: A. Pre-existing Grand mal epilepsy B. Local anaesthesia with lignocaine C. Enflurane D. Intraoperative use of vasoconstrictors E. Post intracranial surgery |
ANSWER E
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AC21
Effects of hypothermia include: A. Increase in blood sugar level B. Oxygen dissociation curve moved to the right C. Increase in stroke volume D. Decrease in serum potassium |
ANSWER A and C
A: hypothermia inhibits insulin release à hyperglycaemia. B: moves to left C: decreased heart rate but increased cardiac output (increased contractility and stroke volume) D: there is loss of Na and K with the cold diuresis (decrease Na resorption + dec ADH) but plasma electrolytes remarkable preserved |
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ANZCA April 2007 [5]
The most commonly reported cause of awareness during general anaesthesia for a non-obstetric procedure is A. equipment failure B. human error C. lack of premedication D. recreational drug use E. the use of total intravenous anaesthesia |
ANSWER B
Incidence -1:1000 who receive general anaesthesia (0.1-0.2%) -higher incidence among obstetric (0.4%) and cardiac (1.5%) cases -higher in children (1%) Caused by administering an amount of anesthesia that is inadequate to maintain unconsciousness and prevent recall during surgical stimulation 1. selection of inadequate dose : frequently associated with poor anaesthetic techinique -errors include omission or late commencement of volatile agent, inadequate dosing or failure to recognize the signs of awareness -under dosing due to hypotension : cardiac, emergency surgery or LUSCS -TIVA : higher risk of underdosage, unfamiliarity, no ability to monitor concentrations in blood Resistance of anaesthetic agents -Factors associated with increase in MAC include: pyrexia; hyperthyroidism; obesity; anxiety; young age; tobacco smoking; regular, heavy alcohol use; use of recreational drugs (e.g. opioids, amphetamines, cocaine); chronic use of sedatives (e.g. temazepam); and previous and repeated exposure to anaesthetic agents -Factors associated with a reduction in MAC include: hypocapnia, pregnancy, hypothyroidism, hypothermia, hypotension, increased atmospheric pressure and old age. No effect : Increased atmospheric pressure does not alter brain sensitivity to anaesthetic agents, but increases the inspired and brain partial pressures for given inspired concentration. Equipment Malfunction -empty vaporizer -miscalibration -impurities in volatile agent -disconnection from machine |
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ANZCA April 2007 ] Q15
A diagnosis of pulmonary embolism is most strongly suggested by A. intraluminal filling defects or vascular cutoffs on angiography B. PaO2 less than 85 mmHg and an abnormal lung perfusion scan C. PaO2 less than 85 mmHg and an elevated PaCOz D. right ventricular hypertrophy with right ventricular strain and right axis deviation on electrocardiography E. "unmatched" ventilation-perfusion defects |
ANSWER A
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NV36a [Jul98] [Apr99] [Aug99] [Mar00]
During anaesthesia, damage to the ulnar nerve (ulnar neuropathy) is more likely if: 1. Male (?female) 2. Diabetes mellitus 3. Prone position 4. Nerve located outside ulna groove (OR: Dislocatable ulnar nerve from groove in epicondyle 5. Jugular CVL insertion 6. Peripheral vascular disease 7. Morbid obesity 8. Brachial plexus block 9. Surgery longer than 2 hours |
1. TRUE : marked male preponderance (5 : 1) Sawyer etal “Peripheral Nerve Injuries” Anaesthesia 2000, 55 p985
ASA closed claims 79% of ulnar nerve injuries were to men 2. True : metabolic problems and chronic illness e.g DM, alcoholism, Vitamin defic and anaemia may predispose to postop ulnar lesion 3. True : although rarely esp if have arms hyperabducted esp when humeral heads are externally rotated 4. True :hypermobility due to laxity of supporting ligaments, leaves nerve prone to injury from mild trauma 5. FALSE ulnar nerve doesn’t form until well below the clavicle 6. TRUE 7. TRUE : at risk if very thin or very obese 8. TRUE : especially axillary nerve blocks 9. FALSE : the length of surgery may not be a major factor since many cases occur after Sx < 2 hrs |
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NV36b ANZCA version [2001-Apr] Q69, [2001-Aug] Q41, [2002-Aug] Q42, [2003-Apr] Q24
Recognised factors that predispose upper limb nerves to compression, under anaesthesia include A. forearm extension and supination B. extreme flexion of elbows across chest C. internal rotation of abducted arm D. lateral position - uppermost arm flexed in arm support E. prone position - arms by side and fingers flexed |
ANSWER B
According to the Anaesthesia article (Peripheral nerve injuries associated with anaesthesia), the following positions are a problem: * abduction of shoulder > 90 degrees, especially if elbow fully extended or externally rotated * forearm should not be extended and pronated * extremes of elbow flexion should be avoided |
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NV36c ANZCA version [2001-Aug] Q73, [2002-Apr] Q12
Post-operative ulnar neuropathy A. usually presents within 48 hours of surgery B. symptoms usually persist for over two years C. is more common in men D. can usually be avoided by careful positioning E. can usually be avoided by protective padding of the elbow |
ANSWER C
A. FALSE : Usually present after 24hrs & within seven days B. FALSE : 53% asymptomatic within 1 year. Another study showed 50% improved within 8 weeks, the rest had symptoms after 2years. C: TRUE (5:1) D. FALSE : insufficient evidence to prove that positioning strategies work E. FALSE : AA |
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NV36d ANZCA version [2003-Aug] Q78, [2004-Apr] Q99, [2004-Aug] Q70, [Apr07] Q78, [Jul07]
The best predictor of poor outcome for a peri-operative ulnar nerve injury is A. a delay in symptom onset to more than 48 hours postoperatively B. association with anaesthesia lasting more than 2 hours C. association with a brachial plexus block D. presence of bilateral injury E. presence of mixed sensory and motor deficit |
ANSWER E
E. Only 36% recovered at one year with a mixed sensory loss, |
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NV36e ANZCA version [2005-Apr] Q42, [2005-Sep] Q47, [2008-Apr] Q31
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 |
ANSWER D
Risk factors * Male * Diabetes (due to preexisting neuropathy) * Positioning * Operations e.g. cardiac surgery with midline sternotomy * Direct trauma e.g. needles such as IJ cannulation * Thermal injury e.g. diathermy * Surgical trauma e.g. orthopaedics |
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ANZCA July 2007 Q67
Post-transfusion hepatitis in Australia is associated with A. jaundice in over 50% of patients B. development of chronic disease in less than 10% of patients C. hepatitis B in the majority of patients D. the presence of antigen or antibody to hepatitis C E. elevation of serum alkaline phosphatase |
ANSWER C
A. FALSE : less than 1/3 will have jaundice B. FALSE : 25% will develop chronic liver disease, of these * 20% cirrhosis after 20 years * 10% hepatocellular carcinoma after 30 years C. and D. From Australian Red Cross HIV 1 in 5.4 million Hepatitis C 1 in 2.7 million Hepatitis B 1 in 739,000 HTLV Approx 1 in 17.5 million Malaria 1 in 4.9 to 1 in 10.2 million Variant CJD Possible and cannot be excluded E. FALSE : ALT and AST 400-4000 |
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ANZCA April 2007 Q14
Detrimental post-operative effects of hypothermia following general anaesthesia in the elderly include each of the following EXCEPT A. delayed emergence B. hypercoagulability C. increased body metabolism D. reduced elimination of anaesthetic agents E. shivering |
ANSWER B
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ANZCA April 2007 Q18
The most effective method of deep venous thrombosis (DVT) prophylaxis for a fifty-year-old woman presenting for anterior resection for cancer of the colon would be A. electrical calf stimulation B. Dextran 70 infusion C. graduated compression stockings D. intermittent pneumatic leg compression E. low dose heparin (5000 units bd) |
ANSWER E
Refer to NHMRC 2009 Guide to prevention of VTE - Clinical Practice Guide LMH > H > mechanical |
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TMP-Jul10-024
A 78 year old man with past history of a difficult intubation presents for arm surgery. Technique is supraclavicular block using 0.5% bupivacaine. Shortly after, started convulsing. INITIAL management? A. Midazolam 5mg B. Intralipid 20% 1.5 ml/kg C. Thiopentone 150mg D. Suxamethonium E. Propofol 50mg |
ANSWER A
Initial management should be ABC and terminate seizures. Midazalam is preferred as it has the least cardiovascular depression. -2-5mg IV Propofol 1mg/kg and thiopentone 50mg doses can be used as boluses can be used, however they cause hypotension and can lead to refractory CV collapse ASRA Practice Advisory Guidlines on LA toxicity |
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TMP-Jul10-042
Patient post anterior cervical fusion. Patient in recovery. Confused and combative. Nurse concerned about haematoma Taken to theatre: Most appropriate way of securing airway: A. Gas induction / laryngoscopy / intubate B. Awake tracheostomy C. Awake fibreoptic intubation using minimal sedation D. Thiopentone, suxamethonium, direct laryngoscopy and intubation E. Retrograde intubation |
ANSWER ?A
Post ADCF : long procedure with significant manipulation around trachea = edematous airway +possible haematoma distorting airway Possible difficult intubation Safest treatment would be AFO but patient is confused and combative. Gas induction would be the next most appropriate step if patient is fasted. |
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TMP-Jul10-044
Called to emergency department to review a 20 year old male punched in throat at a party. Some haemoptysis / hoarse / soft voice. Next step in management: A. CT to rule out thyroid cartilage fracture B. XR to rule out fractured hyoid C. Rapid sequence induction / laryngoscopy / intubation D. Awake fibreoptic intubation E. Nasoendoscopy by ENT in emergency department |
ANSWER E
Initial treatment 1. history, examination, XR 2. nasoendoscopty 3. CT scan Laryngeal trauma 1. impending airway => surgical tracheostomy 2. patent airway => AFO 3. AFO fails => surgical tracheostomy |
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ANZCA 2007 Q72.
The American Heart Association guidelines for pre-operative cardiac risk assessment define poor functional capacity as being only able to exercise at a level of less than 4 METS (metabolic equivalents). An exercise capacity of 4 METS would correspond to A. light housework such as dishwashing B. heavy work around the house such as moving heavy objects C. jogging for 2 kilometres D. walking briskly on level ground (6 kilometres per hour) E. walking slowly on level ground (3 kilometres per hour) |
ANSWER D
1 MET = 3.5 ml O2 per kg/min = 1 kCal/kg/hr =resting metabolic rate |
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ANZCA 2007 Q72.
The American Heart Association guidelines for pre-operative cardiac risk assessment define poor functional capacity as being only able to exercise at a level of less than 4 METS (metabolic equivalents). An exercise capacity of 4 METS would correspond to A. light housework such as dishwashing B. heavy work around the house such as moving heavy objects C. jogging for 2 kilometres D. walking briskly on level ground (6 kilometres per hour) E. walking slowly on level ground (3 kilometres per hour) |
ANSWER D
1 MET = 3.5 ml O2 per kg/min = 1 kCal/kg/hr =resting metabolic rate |
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Added Mar 06. ANZCA version
Q118 The commonest cause of visual deficit following anaesthesia for major surgery is A. central retinal artery occlusion B. central retinal vein occlsuion C. cortical blindness D. glycine toxicity E. ischaemic optic neuropathy |
ANSWER E
Ischemic optic neuropathy is the most common diagnosis in postoperative visual loss. Ischemic optic neuropathy is divided into anterior and posterior, depending upon the location of the lesion on the optic nerve. Anterior ischemic optic neuropathy -53% cardiopulmonary bypass procedures -12% prone Posterior ischemic optic neuropathy -48% neck, nose or sinus operations -16% prone -11% cardiopulmonary bypass procedures |
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AC111 ANZCA version [2002-Mar] Q71
Acute visual loss after non-ocular surgery is most commonly caused by A. ischaemic optic neuropathy B. prolonged direct compression of the globe C. cortical blindness D. retinal artery occlusion E. electrolyte imbalance |
ANSWER A
Ischemic optic neuropathy is the most common diagnosis in postoperative visual loss. Ischemic optic neuropathy is divided into anterior and posterior, depending upon the location of the lesion on the optic nerve. Anterior ischemic optic neuropathy -53% cardiopulmonary bypass procedures -12% prone Posterior ischemic optic neuropathy -48% neck, nose or sinus operations -16% prone -11% cardiopulmonary bypass procedures |
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AC111b ANZCA version [2002-Aug] Q125, [2003-Apr] Q45
Acute visual loss following surgery in the prone position is most commonly caused by A. trauma to the cornea B. compression of the globe C. ischaemia of the visual cortex D. retinal detachment E. ischaemia of the optic nerve |
ANSWER E
Ischemic optic neuropathy is the most common diagnosis in postoperative visual loss. Ischemic optic neuropathy is divided into anterior and posterior, depending upon the location of the lesion on the optic nerve. Anterior ischemic optic neuropathy -53% cardiopulmonary bypass procedures -12% prone Posterior ischemic optic neuropathy -48% neck, nose or sinus operations -16% prone -11% cardiopulmonary bypass procedures |
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AC111c ANZCA version [2004-Aug] Q106, [2005-Apr] Q50,
The most common diagnosis of the cause of blindness following anaesthesia in the prone position is: A. drug effect B. emboli C. globe compression D. ischaemic optic atrophy E. psychiatric disturbance |
ANSWER D
Ischemic optic neuropathy is the most common diagnosis in postoperative visual loss. Ischemic optic neuropathy is divided into anterior and posterior, depending upon the location of the lesion on the optic nerve. Anterior ischemic optic neuropathy -53% cardiopulmonary bypass procedures -12% prone Posterior ischemic optic neuropathy -48% neck, nose or sinus operations -16% prone -11% cardiopulmonary bypass procedures |
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AC120 [2003-Apr] Q92, [2003-Aug] Q3, [Mar06] ANZCA version
Q16 A 52 year old asthmatic female has a difficult intubation for laparascopy. After 4 attempts at intubation over three minutes, the saturation has decreased from 98% to 73%. The physiological change most likely to have occurred as a consequence is: A. decrease in systemic blood pressure B. decrease in cardiac output C. displacement of the haemoglobin-oxygen dissociation curve to the left D. decrease in pulse rate E. increase in pulmonary artery pressure |
ANSWER E
Summary from Nunn (p479): * Hyperventilation once PaO2 52.5mmHg * Increased pulmonary artery pressure * Increased cardiac output improves regional blood flow * Sympathetic activation * Vasodilation in every organ except pulmonary vasculature * Right shift of O2 curve by increased 2,3 DPG and acidosis if present * Anaerobic metabolism. Hypoxic Pulmonary vasoconstriction as a result of decreased oxygen tension within the alveoli leading to increased pulmonary artery pressure |
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AC22a [1989] [Mar94] [Aug94] [Mar95] [Aug95]
Effects of hypothermia at 25C: A. Hyperglycaemia B. Oxygen consumption is decreased by greater than 50% C. Cerebral blood flow is decreased by 25% D. Coronary blood flow is decreased E. Increased coagulability of blood F. Decreased viscosity G. Increased BSL H. ? Decrease in K+ |
Effects of hypothermia at 25C:
* A. Hyperglycaemia - most true: "At 32 degrees, hyperglycaemia is common due to decreased insulin release and lowered peripheral utilisation * B. Oxygen consumption is decreased by greater than 50% - false; increased oxygen consumption by as much as 400% to 700% * C. Cerebral blood flow is decreased by 25% - ? * D. Coronary blood flow is decreased - ? * E. Increased coagulability of blood - partly true: "Intravascular rouleaux formation and red blood cell aggregation occur in peripheral microcirculation at 28C, and microvascular sludging may become a problem. Coagulation changes also occur during progressive cooling as platelets, coagulation cascade proteins, protein clearance by the liver, and coagulation inhibitors are affected. Progressive thrombocytopenia occurs as platelets are sequestered in the portal circulation and liver. Hepatic function is directly depressed during cooling, and coagulation degradation products are cleared less repidly. This effect may lead to regional hypercoagulable states and, in extreme cases, DIC. * F. Decreased viscosity - false: Blood viscosity increases 173% in dogs cooled from 37 degrees to 25 degrees Celsius * G. Increased BSL - true: see answer to A * H. ? Decrease in K+ - ? |
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AC22e [Jul06] [Apr07]
Detrimental post-operative effects of hypothermia following general anaesthesia in the elderly include each of the following EXCEPT: A. delayed emergence B. hypercoagulability C. increased body metabolism D. reduced elimination of anaesthetic agents E. shivering |
ANSWER B
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AC143 ANZCA version [2005-Sep] Q146, [March 2006] Q40
Regarding postoperative nausea and vomiting (PONV), it has been demonstrated that A. a repeat dose of a 5HT3 antagonist is useful if an initial prophylactic dose was not successful B. dexamethasone is best given at the end of surgery C. metoclopramide is effective for PONV prophylaxis D. 5HT3 antagonists are best given at the beginning of surgery E. the efficacy of droperidol is equivalent to ondansetron for PONV prophylaxis |
ANSWER E
AC143 ANZCA version [2005-Sep] Q146, [March 2006] Q40 Regarding postoperative nausea and vomiting (PONV), it has been demonstrated that A. a repeat dose of a 5HT3 antagonist is useful if an initial prophylactic dose was not successful B. dexamethasone is best given at the end of surgery C. metoclopramide is effective for PONV prophylaxis D. 5HT3 antagonists are best given at the beginning of surgery E. the efficacy of droperidol is equivalent to ondansetron for PONV prophylaxis |
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MM18 ANZCA Version [Jul06] Q130, [Apr07] Q19
Findings in a patient with serotonin syndrome include each of the following EXCEPT A. clonus B. diaphoresis C. hyperreflexia D. miosis E. tachycardia |
ANSWER D
Serotonin toxicity has now been more clearly characterized as a triad of neuro-excitatory features. 1. Neuromuscular hyperactivity -tremor -clonus -myoclonus -hyper-reflexia -pyramidal rigidity (advanced) 2. Autonomic hyperactivity; -diaphoresis -fever -tachycardia -tachypnoea. 3. Altered mental status -agitation -excitement -confusion (advanced) |
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AC132 ANZCA version [2004-Aug] Q136, [Jul06] Q76, [Apr07]
During surgery for tracheostomy insertion surgical diathermy is being used at the tracheal incision. You are ventilating with 100% oxygen. As the trachea is opened you notice a blue flame shooting up from the incision. Your first action should be to A. disconnect the breathing circuit from the endotracheal tube B. douse the wound with saline C. insert a tracheostomy tube D. remove the endotracheal tube E. turn off oxygen and ventilate with air |
ANSWER B
Muchatuta N & Sale S - Fires & explosions Management of airway fire • Disconnect the breathing circuit • Flood oropharynx with sterile water or saline • Consider flushing saline down tracheal tube to extinguish intraluminal fire • Consider removing tracheal tube (potential source of further thermal injury or toxic products) • Re-intubate and ventilate (airway swelling may make intubation difficult) • Perform bronchoscopy to inspect for damage and remove foreign bodies (e.g. tube debris) • Consider steroids and antibiotics • T ransfer to critical care if patient at risk of upper airway swelling or acute lung injury The following anaesthetic and surgical recommendations are suggested. * Anaesthetic 1. Use the minimum concentration of oxygen to maintain arterial saturation. 2. Use other non-oxidizing agents such as helium, air or nitrogen in place of nitrous oxide. 3. Position the ETT near the carina to minimize exposure of the cuff to injury in opening the trachea. 4. A good seal on the cuff is essential to prevent leaking of anaesthetic gases. 5. Fill the cuff with water to act as a fire retardant. 6. Consider using fire resistant ETT (silicone/metallic) often used in laser surgery. * Surgical 1. Minimize use of diathermy particularly once the trachea is opened. 2. Use bipolar diathermy if bleeding occurs once the trachea is opened. 3. Use suction to remove oxygen rapidly from the field. 4. Surround the operating field with moist pack if diathermy has to be used. 5. Always have sterile saline at hand in case of fire. |
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AZ69a ANZCA version [2003-Apr] Q137
During elective major vascular surgery the best way to reduce the risk of acute renal failure is to maintain a normal A. cardiac output B. central venous pressure C. mean arterial blood pressure D. pulmonary capillary wedge pressure E. renal blood flow |
ANSWER E
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AZ69b ANZCA version [2003-Aug] Q129, [2004-Apr] Q77, [Mar06] Q71, [Apr07] Q129, [Jul07]
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 |
ANSWER C
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NV36a [Jul98] [Apr99] [Aug99] [Mar00]
During anaesthesia, damage to the ulnar nerve (ulnar neuropathy) is more likely if: 1. Male (?female) 2. Diabetes mellitus 3. Prone position 4. Nerve located outside ulna groove (OR: Dislocatable ulnar nerve from groove in epicondyle 5. Jugular CVL insertion 6. Peripheral vascular disease 7. Morbid obesity 8. Brachial plexus block 9. Surgery longer than 2 hours |
ANSWERS 1, 2, 3, 4, 6, 7, 8
Risk factors for ulnar neuropathy Preexisting problems (PATIENT FACTORS) 1. neuropathy 2. malnutrition 3. cervical rib 4. male sex identified in Mayo clinic study 5. peripheral vascular disease (according to the practice advisory) 6. alcohol dependency 7. arthritis Surgical injury (SURGICAL FACTORS) 1. direct including CVL 2. sternal retraction 3. tourniquet Intraoperative conditions (?ANAESTHETIC FACTORS) 1. hypothermia – particularly surface cooling 2. hypotension 3. anaemia 4. electrolyte abnormalities Position (ANAESTHETIC FACTORS) 1. internal rotation (pronation) with arm abducted >90 degrees 2. pronation when by side (should be neutral) 3. compression or stretch 4. Elbow flexion greater than 90 degrees increases risk. |
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NV36b ANZCA version [2001-Apr] Q69, [2001-Aug] Q41, [2002-Aug] Q42, [2003-Apr] Q24
Recognised factors that predispose upper limb nerves to compression, under anaesthesia include A. forearm extension and supination B. extreme flexion of elbows across chest C. internal rotation of abducted arm D. lateral position - uppermost arm flexed in arm support E. prone position - arms by side and fingers flexed |
ANSWER B
Position (ANAESTHETIC FACTORS) 1. internal rotation (pronation) with arm abducted >90 degrees 2. pronation when by side (should be neutral) 3. compression or stretch 4. Elbow flexion greater than 90 degrees increases risk. |
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NV36c ANZCA version [2001-Aug] Q73, [2002-Apr] Q12
Post-operative ulnar neuropathy A. usually presents within 48 hours of surgery B. symptoms usually persist for over two years C. is more common in men D. can usually be avoided by careful positioning E. can usually be avoided by protective padding of the elbow |
ANSWER C
Usually present after 24hrs & within seven days. 53% asymptomatic within 1 year. Another study showed 50% improved within 8 weeks, the rest had symptoms after 2years. The 2000 practice advisory says that there is insufficient evidence to prove that positioning strategies work. Mayo Clinic Study: male, body habitus (thin or obese) and length of hospital stay (increased chance during hospitalisation). |
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NV36d ANZCA version [2003-Aug] Q78, [2004-Apr] Q99, [2004-Aug] Q70, [Apr07] Q78, [Jul07]
The best predictor of poor outcome for a peri-operative ulnar nerve injury is A. a delay in symptom onset to more than 48 hours postoperatively B. association with anaesthesia lasting more than 2 hours C. association with a brachial plexus block D. presence of bilateral injury E. presence of mixed sensory and motor deficit |
ANSWER E
Miller Only 36% recovered at one year with a mixed sensory loss, |
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NV36e ANZCA version [2005-Apr] Q42, [2005-Sep] Q47, [2008-Apr] Q31
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 |
ANSWER C
Risk factors for ulnar neuropathy Preexisting problems (PATIENT FACTORS) 1. neuropathy 2. malnutrition 3. cervical rib 4. male sex identified in Mayo clinic study 5. peripheral vascular disease (according to the practice advisory) 6. alcohol dependency 7. arthritis Surgical injury (SURGICAL FACTORS) 1. direct including CVL 2. sternal retraction 3. tourniquet Intraoperative conditions (?ANAESTHETIC FACTORS) 1. hypothermia – particularly surface cooling 2. hypotension 3. anaemia 4. electrolyte abnormalities Position (?ANAESTHETIC FACTORS) 1. internal rotation (pronation) with arm abducted >90 degrees 2. pronation when by side (should be neutral) 3. compression or stretch 4. Elbow flexion greater than 90 degrees increases risk. |
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NV36f ANZCA version [2006-March] Q139, [Jul06] Q13
Perioperative ulnar neuropathy A. is more common in diabetics B. is more common in women C. is often associated with contralateral clinical neuropathy D. is usually found to be the result of excess external pressure E. usually presents within 24 hours |
ANSWER A
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AB51 ANZCA Version [Jul06] Q103, [Apr07]
A fifty-five-year-old man on antihypertensive medication, including an ACE inhibitor, has a total knee replacement. Red cell transfusion is begun in recovery through a leukocyte reduction filter after brisk bleeding into his drains. A recognised complication of the use of this filter in this situation is A. air embolism B. clotting factor depletion C. haemolysis D. increased risk of postoperative infection E. severe hypotension |
ANSWER E
Profound hypotension has been reported in patients taking angiotension-converting-enzyme (ACE) inhibitors and receiving pretransfusion leukocytereduced blood products—platelets in particular (96). Presumably, ACE inhibitors decrease bradykinin degradation thereby prolonging its intravascular half-life. |
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SN17 [Apr07]
A patient is having posterior fossa surgery in the sitting position. Which of the following changes would make you suspect a venous air embolism: |
ANSWER C
End tidal carbon dioxide falls... In 25% of patients the CVP is elevated and the pulmonary artery pressure rises in 50%. Arterial blood gases may reveal hypoxaemia and, less commonly hypercarbia. |
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AC154 [Apr07] Q128
In modern anaesthetic practice, mortality from myocardial infarction after non cardiac surgery is A. 2.5-5% B. 5-10% C. 10-15% D. 20-30% E. approximately 50% |
ANSWER C
Mortality from myocardial infarction (MI) after noncardiac surgery is believed to be 10 to 15%,1 similar to that in nonsurgical patients. |
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April 2007 Question 132
132. You are anaesthetizing a patient for a laparoscopic fundoplication. During the case you suspect a tension capnothorax is developing. Which of the capnograph traces below is consistent with this diagnosis? |
ANSWER B
If a pneumothorax is small : no changes However, as the pneumothrorax increases in size, the changes depend on mode of ventilation PCV or VCV Pressure controlled -tidal volume will decrease, -gradual increase in the PaCO2 and ETCO2 as well (hypoventilation). -However, ETCO2 may decrease due to inadequate sampling of alveolar CO2 due to the tidal volume becoming progressively smaller. -as tension pneumothorax increases in size, thereby decreasing cardiac output, ETCO2 decreases. A volume controlled ventilation is more likely to increase intra-thoracic pressure with increasing pnuemothorax which imposes a mechanical impedance to the circulation and results in a decrease in ETCO2. Pneumothorax can also cause an obstructive capnograph pattern. Carbon dioxide pneumothorax complicates the matter. -increase in the ETCO2 -associated increase peak inspiratory pressures |
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ANZCA July 2007 Q62. Femoral artery cannulation for arterial pressure monitoring
A. is associated with more major complications than radial artery cannulation B. is frequently unreliable in the immediate post-bypass period C. should be performed with an approach from above the inguinal ligament D. should be performed with a large bore cannula to avoid erosion of the vessel wall E. should not be used for over 24 hours because of the risk of infection |
ANSWER A
A. Is associated with more major complications than radial artery cannulation - true Femoral has more MAJOR complications -permanent ischaemic damage, fem 0.18% cf rad 0.09% -sepsis fem 0.44% cf rad 0.13% -pseudoaneurysm fem 0.3% cf 0.09% rad) Complications of direct arterial pressure monitoring (Miller) 1. Distal ischemia, pseudoaneurysm, arteriovenous fistula 2. Hemorrhage 3. Arterial embolization 4. Infection 5. Peripheral neuropathy 6. Misinterpretation of data 7. Misuse of equipment B. Is frequently unreliable in the immediate post bypass period - false C. Should be performed with an approach from above the inguinal ligament - false: o It is the external iliac above the ligament D. Should be performed with a large bore cannula to avoid erosion of the vessel wall - depends on the def'n of large bore, likely false o Definitely won't be sticking a 16G cannula in E. Should not be used for over 24 hrs because of the risk of infection - false o Happens all the time in ICU |
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AT20a ANZCA version [2002-Mar] Q150, [2002-Aug] Q149 (This is a type K MCQ)
Recognised complications of mediastinoscopy include 1. major haemorrhage 2. pneumothorax 3. damage to the phrenic nerve 4. bronchial rupture |
ANSWER 4
Complications as follows : DEATH MAJOR complications -Major haemorrhage -Tracheobronchial laceration -Oesophageal perforation -Recurrent nerve paralysis -Phrenic nerve paralysis -Thoracic duct injury -Cerebrovascular accident -Mediastinitis -Venous air embolism -Tumour implantation MINOR complications -Pneumothorax -Superficial wound infection -Recurrent nerve paresis -Minor bleeding -Autonomic reflex braydcardia -Mediastinal lymph node necrosis |
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AT20a Black Bank version [Jul98] [Mar00]
In mediastinoscopy, what is NOT likely to be a complication? A. Air embolism B. Major haemorrhage C. Phrenic nerve damage D. Decreased output from great vessels & heart E. Pneumothorax F. Tracheal rupture G. Recurrent laryngeal nerve inury H. Bronchial Injury |
Complications as follows :
DEATH MAJOR complications -Major haemorrhage -Tracheobronchial laceration -Oesophageal perforation -Recurrent nerve paralysis -Phrenic nerve paralysis -Thoracic duct injury -Cerebrovascular accident -Mediastinitis -Venous air embolism -Tumour implantation MINOR complications -Pneumothorax -Superficial wound infection -Recurrent nerve paresis -Minor bleeding -Autonomic reflex braydcardia -Mediastinal lymph node necrosis |
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AT20b ANZCA Version [Jul06] Q77, [Apr07] Q73
Major complications of mediastinoscopy include all of the following EXCEPT A. compression of the great vessels B. air embolism C. pneumothorax D. major haemorrhage E. phrenic nerve damage |
ANSWER A
Compression of major vessels is noted to be a reason for invasive blood pressure monitoring in the CEACCP article but is not listed in the table of complications, perhaps because it is a transient phenomenon rather than a complication per se. Complications as follows : DEATH MAJOR complications -Major haemorrhage -Tracheobronchial laceration -Oesophageal perforation -Recurrent nerve paralysis -Phrenic nerve paralysis -Thoracic duct injury -Cerebrovascular accident -Mediastinitis -Venous air embolism -Tumour implantation MINOR complications -Pneumothorax -Superficial wound infection -Recurrent nerve paresis -Minor bleeding -Autonomic reflex braydcardia -Mediastinal lymph node necrosis |
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AT20c ANZCA Version [Jul07]
Complications of mediastinoscopy include all of the following EXCEPT A. air embolism B. cardiac laceration C. pneumothorax D. recurrent laryngeal nerve palsy E. tracheal compression |
ANSWER B
Complications as follows : DEATH MAJOR complications -Major haemorrhage -Tracheobronchial laceration -Oesophageal perforation -Recurrent nerve paralysis -Phrenic nerve paralysis -Thoracic duct injury -Cerebrovascular accident -Mediastinitis -Venous air embolism -Tumour implantation MINOR complications -Pneumothorax -Superficial wound infection -Recurrent nerve paresis -Minor bleeding -Autonomic reflex braydcardia -Mediastinal lymph node necrosis |
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AC156 ANZCA Version [Jul07]
Possible mechanisms of post operative visual loss include each of the following EXCEPT A. atherosclerosis causing decreasing blood flow to the optic nerve B. fluid overload C. Isovolaemic haemodilution D. Postually induced raised venous pressure E. Variations in the number of posterior ciliary arteries |
ANSWER C
Causes of postoperative visual loss Ischemic optic neuropathy Anterior ischemic optic neuropathy Non-arteritic Arteritic Posterior ischemic optic neuropathy Central retinal artery occlusion Central retinal vein occlusion Cortical blindness Hypotensive Embolic Miscellaneous Glycine toxicity Complications of eye surgery Etiology of anterior ischemic optic neuropathy Predisposing factors Variable blood supply (posterior ciliary arteries) Small optic disc size Age Hypertension Smoking Diabetes Vascular disease Precipitating factors Acute systemic hypotension Venous obstruction Raised intraocular pressure Lowered hematocrit Increased blood viscosity |
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AC105 ANZCA version [2001-Apr] Q73, [2002-Mar] Q49, [2003-Apr] Q68, [2003-Aug] Q77
Risk factors for post-operative delirium include all the following EXCEPT A. age greater than 70 years B. history of alcohol abuse C. perioperative morphine administration D. electrolyte disturbance E. benzodiazepine administration |
ANSWER C
Risk factors In all likelihood, patient predisposition, type of surgery and postoperative factors may be more important to the development of delirium than the choice of anaesthesia. A painstaking prospective study of the risk factors for postoperative delirium has been carried out. Independent predictors of delirium were: 1. Age appears to place patients at greatest risk. Usually, elderly patients (more than 65 years) are on polypharmacy. However, they have decreased ability to metabolize drugs. Furthermore, visual and hearing impairments predispose elderly to disorientation. Postoperative hypoxia is more common in the elderly given the higher incidence of cardiovascular, respiratory and cerebrovascular diseases in this group. 2. Existence of underlying brain disease (cerebrovascular accident, dementia); psychiatric illness or other medical conditions (congestive heart failure, liver disease, renal failure). 3. History of taking medicines causing altered mental status (e.g., benzodiazepines, antidepressants). 4. Patients with preexisting central nervous system disorders (dementia, Parkinson's disease) have higher rates of postoperative delirium. 5. Type of surgery: a) Procedures, longer in duration place patients at increased risk of intraoperative hypoxia. b) Cardiac surgery can result in hypoperfusion and microemboli formation, causing cerebral ischaemia. c) Orthopaedic procedures (repair of femoral neck fracture) chances of fat embolism, may cause delirium. d) Cataract surgery is often associated with delirium due to age, loss of vision and anticholinergic side-effects of the used ophthalmic drugs. 6. Metabolic insults include dehydration, hyponatremia, hyperglycemia, hypoglycemia, acid - base disorders, hepatic disease, renal disease and endocrine disease can cause delirium. 7. Infections like pneumonia, urinary tract infections, intra-abdominal infections and wound infections all can cause confusion in susceptible patients. 8. The sensory overload in the ICU can lead to sleep deprivation, which is a risk factor for developing delirium. 9. Postoperative pain, either uncontrolled or unaddressed has been shown to increase delirium rates. 10. Abuse of alcohol/benzodiazepines, can become delirious secondary to withdrawal symptoms. 11. Type of anaesthesia - sometimes it is stated that delirium is less common after regional as opposed to general anaesthesia. In a large randomized controlled-study of patients undergoing elective total knee replacement, Williams - Russo et al found no statistical difference between the incidence of postoperative delirium in patients following general anaesthesia and that following epidural anaesthesia. |
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AC105b ANZCA version [2005-Apr] Q142, [2005-Sep] Q54, [Jul07]
Post-operative delirium in the elderly is associated with all of the following factors EXCEPT A. pre-existing cognitive deficit B. pre-existing hearing impairment C. pre-existing visual impairment D. post-operative urinary tract infection E. use of general anaesthesia rather than regional anaesthesia |
ANSWER E
Risk factors In all likelihood, patient predisposition, type of surgery and postoperative factors may be more important to the development of delirium than the choice of anaesthesia. A painstaking prospective study of the risk factors for postoperative delirium has been carried out. Independent predictors of delirium were: 1. Age appears to place patients at greatest risk. Usually, elderly patients (more than 65 years) are on polypharmacy. However, they have decreased ability to metabolize drugs. Furthermore, visual and hearing impairments predispose elderly to disorientation. Postoperative hypoxia is more common in the elderly given the higher incidence of cardiovascular, respiratory and cerebrovascular diseases in this group. 2. Existence of underlying brain disease (cerebrovascular accident, dementia); psychiatric illness or other medical conditions (congestive heart failure, liver disease, renal failure). 3. History of taking medicines causing altered mental status (e.g., benzodiazepines, antidepressants). 4. Patients with preexisting central nervous system disorders (dementia, Parkinson's disease) have higher rates of postoperative delirium. 5. Type of surgery: a) Procedures, longer in duration place patients at increased risk of intraoperative hypoxia. b) Cardiac surgery can result in hypoperfusion and microemboli formation, causing cerebral ischaemia. c) Orthopaedic procedures (repair of femoral neck fracture) chances of fat embolism, may cause delirium. d) Cataract surgery is often associated with delirium due to age, loss of vision and anticholinergic side-effects of the used ophthalmic drugs. 6. Metabolic insults include dehydration, hyponatremia, hyperglycemia, hypoglycemia, acid - base disorders, hepatic disease, renal disease and endocrine disease can cause delirium. 7. Infections like pneumonia, urinary tract infections, intra-abdominal infections and wound infections all can cause confusion in susceptible patients. 8. The sensory overload in the ICU can lead to sleep deprivation, which is a risk factor for developing delirium. 9. Postoperative pain, either uncontrolled or unaddressed has been shown to increase delirium rates. 10. Abuse of alcohol/benzodiazepines, can become delirious secondary to withdrawal symptoms. 11. Type of anaesthesia - sometimes it is stated that delirium is less common after regional as opposed to general anaesthesia. In a large randomized controlled-study of patients undergoing elective total knee replacement, Williams - Russo et al found no statistical difference between the incidence of postoperative delirium in patients following general anaesthesia and that following epidural anaesthesia. |
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ANZCA Version [Jul07]Q.150
You are asked to see a 60 y.o. male 2 days following a cervical laminectomy because he has new new neurological symptoms in his right arm. The surgical team think these may be due to poor patient positioning. The sign that would most help differentiate c C8-T1 nerve root injury from an ulnar nerve injury is A. loss of sensation in the index finger B. loss of sensation in the little finger C. weakness of the abductor digiti minimi muscle D. weakness of the abductor pollicis brevis m E. weakness of the first dorsal interosseous m. |
ANSWER D
A. would both be affected by both C8/T1 lesion (C8 dermatome) AND ulnar nerve lesion - so not differentiating B. would be affected but neither (index finger = C7 and median nerve) - so not differentiating C. would both be affected by both C8/T1 lesion AND ulnar nerve lesion - so not differentiating D. abductor pollicus brevis = T1 myotome and median nerve T1 and ulnar nerve have very similar sensory and motor distribution. HOWEVER, the one difference is that the LOAF muscles are supplied via the median nerve and provide a point of differentiation. E. would both be affected by both C8/T1 lesion AND ulnar nerve lesion - so not differentiating |
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AC157 ANZCA version [Apr08] Q99
An obese 40-year-old woman is having laparoscopic surgery for endometriosis. She is intubated and ventilated with a mixture of oxygen and air. The ventilator is set to provide a tidal volume of 600ml at 12 breath.min-1 with 5 cm H2O positive end-expiratory pressure (PEEP). The peak inspiratory airway pressure is 35 cm H2O. She was stable on induction and during preparation for surgery but 10 minutes after introduction of the pneumoperitoneum and being placed in the Trendelenburg position, her arterial oxygen saturation (SaO2) falls to 80%. The SaO2 remains unchanged despite ventilation with 100% oxygen. Her blood pressure is 130/80, pulse 100 min-1 and end-tidal carbon dioxide 44 mmHg. The most likely cause of her desaturation is: A. Aspiration B. endobronchial intubation C. gas embolism D. hypoventilation E. pneumothorax |
ANSWER B
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ANZCA Version [Apr 08]
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: RBBB, R wave in VI, S wave in I, Q wave in III, t wave inversion in III A. Atrial fibrillation B. hyperkalaemia C. myocardial infarction D. pericarditis E. pulmonary embolus |
ANSWER E
S1Q3T3 |
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ANZCA Version [Apr08]
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 |
ANSWER E
The release of a valsalva manouver promotes paradoxical embolism. the impairment of systemic venous return caused by the sudden application of substantial PEEP may be undesirable in the face of the cardiovascular dysfunction already caused by the VAE |
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ANZCA April 2009
Visual loss post-operatively a. more common after external ocular compression b. incidence 1 in 200,000 c. most common after spinal surgery d. incidence independent of duration of surgery e. more common after isovolaemic haemodilution |
ANSWER E
A False: Ischaemic optic neuropathy(ION) more common(89%), bilateral, systemic causes( atherosclerosis, antihypertensives); Central retinal artery occlusion(CRAO) less common 11% and there is an association with external compression but it occurs less often than ION B False 1:125 000 overall surgery( CEACCP) C TRUE : spine operations (67 percent) followed distantly by cardiac bypass procedures (10 percent). The remaining 23 percent of cases are composed of liver transplants, thoracoabdominal aneurysm resections, peripheral vascular procedures, head and neck operations, prostatectomies and miscellaneous cases. D False association with surgery> 6hrs or blood loss > 1L( above reference) E FALSE : Hct does not play a factor Risk Factors include -large blood loss -systemic hypotension -anaemia -duration of surgery -smoker -atherosclerosis -diabetes -obesity External ocular compression is not a risk factor |
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AC130 ANZCA version [2004-Apr] Q125, [2004-Aug] Q47
Post-operative ischaemic optic neuropathy A. has a good visual prognosis if optic nerve decompression is performed within 24 hours B. is an uncommon cause of post-operative blindness C. is commonly due to emboli to the ophthalmic artery D. is not associated with hypotension and low haematocrit E. may present as a confusional state |
ANSWER E
A. FALSe : Recovery is poor. ION is not associated with compression of the optic nerve B. FALSE : ION is the commonest cause of post operative blindness C. FALSE : can be use to emoblism, but ti is not the commonest cause D. FALSE E. TRUE Ischaemic Optic Neuropathy (ION) * Commonest cause of post-operative blindness * Divisible into anterior ION and posterior ION * Anterior & Posterior ION furthur divisible into arteritic and non-arteritic forms * Arteritic forms associated with inflammation of arteries. Diagnosis proven by temporal artery biopsy and steroid treatment * The non-arteritic form is much more common, and anterior ION is the commonest form of ION. Anterior ION usually arises from decreased O2 delivery to the watershed areas of the short posterior ciliary arteries. This has been associated with * Hypotension * Haemorrhage * Anaemia Prognosis varies, but recovery is usually poor |
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AC155 [Apr07]
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% D. use alcoholic chlorhex instead of iodine E. add nitrous oxide to the inhaled gases to reduce the FiO2 and provide sedation |
ANSWER B
A. FALSE sealing may cause gas / oxygen entrapment, creating a reservoir. This accumulation may be reduced by the use of ‘incise drapes’ that protect the wound from high oxygen concentrations and by tenting surgical drapes to dilute oxygen with room air.. B. TRUE : fires are more likely with monopolar diathermy than bipolar C. FALSE :Strategies to reduce the risks posed by high oxygen concentrations include (the) judicious use of oxygen (using the lowest oxygen concentration that provides acceptable haemoglobin oxygen saturations. Aim for SatO2 88% or PO2 55mmHg. D. FALSE : alcoholic chlorhex more flammable than traditional iodine in potassium iodide E. FALSE : nitrous oxide supports combustion |
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AC109 [2001-Apr] Q77, [2001-Aug] Q58, [2002-Aug] Q73, [2004-Apr] Q117
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 |
ANSWER 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 |
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Black Bank April 2009
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 |
ANSWER C
SVC is obstructed |
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Black Bank April 2009
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 |
ANSWER B
In this case a shunt should be placed as the carotid is clamped and open. |
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Black Bank August 2009 Q29
(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 |
ANSWER C
Intralipid 20% Bolus 1.5ml/kg over 1 minute Infusion 0.25 ml/kg/min Repeat bolus every 5 minutes X2 There after 0.5mk/kg bolus Stop infusion 10 minutes after ROSC Do not exceed maximum cumulative dose of 12ml/kg |
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Black Bank August 2009 Q7. (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 |
?incorrectly remembered
PS9 Sedation Guidlines : Facilities and Equipment Must be present 1. Appropiate lighting 2. Operating table, trolley or chair with head down capacity 3. Suction and suction catheters 4. Oxygen supply and masks 5. A means of inflating the lungs with oxygen : Air Veva and mask 6. Drugs : adrenaline, atropine, dextrose 50%, lignocaine, naloxone, flumazenil, portable emergency O2 7. Pulse oximeter and blood pressure 8. A means of summoning emergency assistance Must be readily available 1. Advanced airway management equipment : masks, oropharyngeal airways, LMA, ETT and larngoscopes) 2. ECG and debrilllator 3. device for measuring ETCO2 |
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Black Bank August 2009 Q8. (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 |
ANSWER A
Scenario 0: Two personnel – sedation by proceduralist *Medical or dental practitioner proceduralist with airway and resuscitation skills, and training in nitrous oxide or low dose oral sedation techniques *Assistant with training in monitoring sedation *Conscious sedation using nitrous oxide alone and/or low dose oral sedation alone in ASA P 1-2 patients *Heavy oral sedation and intramuscular or intravenous sedative/anaesthetic/analgesic agents must not be used Scenario 1: Three personnel – sedation by proceduralist *Medical or dental practitioner proceduralist with airway and resuscitation skills, and training in sedation *Assistant with training in monitoring sedation *Assistant to assist both *Conscious sedation in ASA P 1-2 patients *Propofol, thiopentone and other intravenous anaesthetic agents must not be used Scenario 2: Three personnel – sedation by medical or dental practitioner * Proceduralist * Medical or dental practitioner with airway and resuscitation skills, and training in sedation * Assistant to assist both * Conscious sedation in ASA P 1-2 patients * Propofol, thiopentone and other intravenous anaesthetic agents may only be used by a medical or dental practitioner trained in their use Scenario 3: Four personnel – sedation by medical or dental practitioner *Proceduralist * Medical or dental practitioner with airway and resuscitation skills, and training in sedation * Assistant to assist each* * Conscious sedation in ASA P 1-3 patients # * Propofol, thiopentone and other intravenous anaesthetic agents may only be used by a medical or dental practitioner trained in their use Scenario 4: Three personnel – sedation by anaesthetist * Proceduralist * Anaesthetist * Assistant to assist both * Conscious, deep sedation or general anaesthesia in all patients * All approved anaesthetic drugs may be used Scenario 5: Four personnel – sedation by anaesthetist * Proceduralist * Anaesthetist * Assistant to assist each* * Conscious sedation, deep sedation or general anaesthesia in all patients * All approved anaesthetic drugs may be used |
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Black Bank August 2009 Q44.
Disease associated with malignant hyperthermia a. central core disease b. myasthenia gravis c. myotonia congenita d. ? |
ANSWER A
MH susceptibility -central core -multiminicore myopathies -King-Denborough syndrome, -Brody myopathy Duchenne and Becker muscular dystrophy are at risk for life-threatening hyperkalemia and rhabdomyolysis when anesthetized with MHtriggering drugs. No connections with MH -mitochondrial myopathies -glyocogen storage myopathies -Noonan syndrome -Myotonic dystrophy Patients with myotonia will likely develop muscle rigidity with succinylcholine that is not related to MH. |
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Black Bank EM66
Aneurysm clipping. Best monitor of depth of block during this is: A. TOFR B. TOFC C. DBS D. PTC |
ANSWER D
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Black Bank August 2009 Q53.
(Repeat) ASA grading was introduced to A. predict intraop anaesthetic risk B. Predict intraop surgical and anaesthetic risk C. Standardise the physical status classification of patients D. Predict periop anaesthetic risk E. Predict periop anaesthetic and surgical risk |
ANSWER C
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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 |
ANSWER D
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TMP-111 [Mar10]
Accidentally cannulate carotid artery with 5 lumen 7 Fr CVC preop for a semi urgent CABG. MOST appropriate next response is to: A. Get vascular surgeon to repair it and continue with surgery and heparin B. Leave it in. Do CABG. Pull it out post op. C. Pull it out, compress. Delay surgery for 24hrs D. Pull it out compress. Continue with surgery + heparin. E. Pull it out. Compress. Continue with surgery no heparin. |
ANSWER A
Inadvertent carotid arterial puncture -incidence 2-8% (probably lower with US) Complications -haematoma -Airway obstruction -pseudoaneurysm -arterio-venous fistula formation -retrograde aortic dissection If the carotid artery was punctured by a small bore needle or cannula (18-gauge or smaller), then serious damage was unlikely to result. Risk of complications dramatically increase with -coagulopathy -dilator =these should be surgically repaired The decision to proceed with surgery should thus be based on the following considerations: 1. The urgency of surgery. 2. The general condition of the patient. 3. The possibility that other vascular damage has occurred 4. The possibility that arterial thrombosis, dissection or embolisation might precipitate a neurological event. |
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TMP-Jul10-042
Patient post anterior cervical fusion. Patient in recovery. Confused and combative. Nurse concerned about haematoma Taken to theatre: Most appropriate way of securing airway: A. Gas induction / laryngoscopy / intubate B. Awake tracheostomy C. Awake fibreoptic intubation using minimal sedation D. Thiopentone, suxamethonium, direct laryngoscopy and intubation E. Retrograde intubation |
ANSWER A
Post ACDF -long procedure -edematous airway -anterior haematoma Safest would be AFO But in this case the patient is confused and combative -inhalation induction |
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TMP-Jul10-058
Young female having cholecystectomy. Venous air embolus: A. Mechanical ventilation and PEEP is part of treatment strategy B. Most likely to occur at initial gas insufflation, but can occur at any time C. Inert gas (argon, xenon) is safer D. ? E. |
ANSWER B
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TMP-Jul10-059 [Aug10]
LUSCS for failure to progress. Spinal is inserted uneventfully. Next day the patient has foot drop. The most likely cause is? A. epidural haematoma B. lumbosacral palsy C. sciatic nerve palsy D. common peroneal palsy E. ? |
ANSWER B
Postpartum foot drop is caused by damage to the lumbosacral trunk or, less frequently, the common peroneal nerve. Risk factors include 1. prolonged labor 2. forceps 3. lithotomy 4. LUSCS Common peroneal nerve damage may occur due to improper or prolonged positioning during lithotomy and the sensory deficit may be limited to the dorsum of the foot |
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TMP-Jul10-012
Which does NOT minimise intravenous cannulation with epidural insertion? A. Injection saline through epidural needle before catheter insertion B. Lie patient lateral C. Do combined spinal-epidural technique (CSE) D. Thread catheter slowly E. ? |
ANSWER D
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TMP-108
A 60yo man with anterior mediastinal mass, during induction for mediastinoscopy....lose cardiac output, decreased saturations, drop in ETCO2. Management: A. Adrenaline B. CPR C. CPB D. Place prone E. |
ANSWER D
Slinger describes 2 scenaros 1. airways compression -reposition lateral or prone (this should be determined before, which position is best for patient) -ventilate with rigid bronch inserted distal to obstruction 2. Cardiovascular compression -lighten anaesthesic -if this does not work : immediate sternotomy and CPB -can consider placing prone |
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ME46 Acromegaly due to excess of growth hormone. Why is it difficult to do a direct laryngoscopy?
A: Distorted facial anatomy B: Macroglossia C: Glottic stenosis D: Prognathe mandible E: Arthritis of the neck |
ANSWER B
Many typical acromegalic features are suggested to cause a difficult airway in these patients. The most discussed changes are: *macroglossia, *prognathism, *enlargement and distortion of glottic structures with additional folds, and * hypertrophy of laryngeal and pharyngeal soft tissue. |
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MZ82
Ehlers-Danlos syndrome. Most important to specifically do all EXCEPT: A: Avoid hyperextension of the neck B: Damage to the teeth C: Avoid joint hypermobility D: Gastro oesophageal reflex E: Strict temperature regulation |
ANSWER E
The Ehlers-Danlos family of disorders is a group of related conditions that share a common decrease in the tensile strength and integrity of the skin, joints, and other connective tissues. Patients can often perform "amazing, almost unnatural, contortions" and worked in circuses (eg the "The India Rubber Man," "The Elastic Lady," and "The Human Pretzel.) All forms of Ehlers-Danlos syndrome share the following primary features to varying degrees: * Skin hyperextensibility * Joint hypermobility and excessive dislocations * Tissue fragility * Poor wound healing, leading to wide thin scars ("cigarette paper scars") * Easy bruising * GORD/gastritis * high, narrow palate and dental crowding and peridontal disease |
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Black Bank March 2011 Q12.
NEW. Post CEA on ward, patient seizes. BP has been hard to control. What to do to prevent further seizures? A: Add another antihypertensive B: Start antiplatelet drugs C: Start anticonvulsants D: Do angio and stent E: Nimodipine |
ANSWER A
Cerebral hyperperfusion syndrome (most CEA neurological complications are embolic/ischemic in nature) -however small subset due to CHS -occurs in 0.75%-3% post CEA Characterised (trial) 1. ipsilateral headache (severe, pounding) 2. focal seizure actiivity 3. focal neurological deficit (hemiplegia, neglect,hemianopioa, aphasia) -possible ipsilateral intracerebral haemorrhage or edema -associated hypertension Risk factors 1. Hypertension 2. High grade stenosis with poor collateral flow 3. Decreased CVR 4. Increased peak flow velocity 5. Contralateral carotid occlusion 6. Recent contralateral CEA (<3 months) 7. Intraoperative distal carotid pressure of <40mmHg 8. Intraoperative ischaemia Detection -high flow through Trans-Cranial Doppler of MCA Prevention -early identification and control of blood pressure -aggressive BP control in HDU settling -labetolol and clonidine prefered as they not increase CBF -avoid vasodilators such as ACEI, Ca CB, nitroprusside or GTN. |
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Black Bank March 2011 Q21.
NEW? Post scoliosis repair, decreased movement bilaterally in the legs with decreased pain and temperature sensation but spared joint position sense and vibration. What is at fault? A: Posterior spinal arteries B: Anterior spinal arteries C: Epidural haematoma D: Misplaced pedicle screw E: Lateral cord syndrome |
ANSWER B
Spinal injuries may, by damaging the radicular arteries, seriously compromise the function of the spinal cord and cause weakness and paralysis of muscles. The areas that are most vulnerable to deprivation of blood supply are T1–3, T5 and L1. Blockage of a posterior spinal artery may have little effect owing to the extensive anastomoses Anterior spinal artery often produces ischaemia of the anterior central part of the cord causing flaccid paralysis and loss of pain and temperature sensation. Thrombosis of the great radicular artery of Adamkiewicz may produce a paraplegia because it makes a major contribution to the blood supply of the lower two-thirds of the spinal cord. |
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Black Bank March 2011 Q36. NEW. What is the major cause of death in a patient with perforation of the pharynx, oesophagus or trachea?
A: failure to intubate B: failure to ventilation C: sepsis |
ANSWER C
Risk factors include 1. Children and women (smaller airways) 2. Difficult intubation 3. Use of stylet or bougie 4. malpositioning of the tube tip, tube repositioning without cuff deflation 5. inadequate tube size, 6. vigorous coughing Mortality is due to innoculation of mediastinum leading to mediastinitis and sepsis |
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Black Bank March 2011 TMP-Jul10-016
TURP – patient under spinal. Confused. ABG: Na+ 117 / normal gas exchange. Treatment ? A. 10 ml 20% Saline as fast push IV B. 3% NS 100 ml/h C. Normal saline 200 ml/h D. Frusemide 40 mg IV E. Fluid restrict 500 ml/day |
ANSWER B
Treatment according to OHA 1. Alert surgeon: Stop further resection and diathermy bleeding points. Then terminate surgical procedure. 2. Stop IV fluids 3. Give frusemide 40mg (to reduce chance of APO) and check Na+ and Hb 4. Support respiration and ventilation if required 5. Administer IV anticonvulsants if fitting 6. Central pontine myelinolysis may result from BOTH over-rapid correction of chronic hyponatraemia AND acute severe hyponatraemia If the serum Na+ has fallen acutely ,120mmol/L and is assoc. with neurological signs, consider giving hypertonic saline (2N/S or 3%) to restore Na to around 125mmol/L Give 1.2-2.4 mL/kg/hr of 3% Saline until symptoms improve or Na+ >125mmol/L. This should produce a rise in serum Na+ of 1-2 mmol/L/hr Beware of compounding effects on Na+ by other simultaneous treatments (eg diuretics, colloids etc) 7. Admit to ICU/HDU for management including regular Measurement of Na+ |
