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68 Cards in this Set

  • Front
  • Back

97. Glycine solution (1.5%) used for irrigation during transurethral prostatectomy (TURP) is
A. slightly hypertonic
B. associated with blindness due to neurotoxicity
C. metabolised to glucose
D. a cause of central pontine demyelination if the plasma sodium concentration falls below 120 mmol.l-1

B


 A. slightly hypertonic - false: 1.5% is hypotonic
 B. associated with blindness due to neurotoxicity - best answer: "In one publication, five cases of transient blindness were attributed to glycine toxicity." (Miller Ch 65)
 C. metabolised to glucose - false:
 glycine metabolised to CO2 and ammonia via the glycine cleavage system.
 "D. a cause of central pontine demyelination if the plasma sodium concentration falls below 120 mmol.l-1 - false
 The osmotic demyelination syndrome primarily occurs with overly rapid correction of severe hyponatremia
 E. a cause of significant haemolysis on absorption. False - haemolysis used to be a major problem when using water for irrigation BUT has been eliminated since nearly isosmolar solutions like glycine 1.5% have been used

96. Carbon monoxide production by soda lime degradation of volatile anaesthetic agents, is LEAST likely to occur with
A. the first case of the day and the use of isoflurane
B. the first case of the day and the use of sevoflurane
C. the first case of the day and the use of desflurane
D. fresh soda lime and the use of desflurane
E. fresh soda lime and the use of sevoflurane

E


CO production:
 Baralyme > Sodalime;
 Dry > fresh
 D>E>I>S=H

95. A child weighing 8 kg would be expected to need a Laryngeal Mask Airway of size
A. 0
B. 1
C. 1.5
D. 2
E. 2.5

C


LMA Size Weight
1 <5kg
1.5 5-10kg
2 10-20kg
2.5 20-30kg
3 >30kg

94. Tramadol
A. may be used with caution in patients receiving monoamine oxidase (MAO) inhibitors
B. is useful in the treatment of narcotic withdrawal
C. has no clinically significant effect on heart rate, left ventricular function or cardiac index at usual therapeutic doses
D. use in patients on selective serotonin reuptake inhibitors has
NOT been associated with signs of serotonin syndrome
E. needs to be given in reduced doses to patients with severe hepatic disease, but not to patients with impaired renal function

C

Orthostatic hypotension and tachycardia listed as “uncommon” <1:100 in MIMS. Note that there is no mention of SVR in the question. C/I in MAO, SSRI, seizure. Severe liver disease causes reduced metabolism. Renal failure prevents tramadol excretion and desmethyltramadol excretion.

93. Nitrous Oxide (N2O) does NOT
A. have an inhibitory effect on NMDA receptors
B. have a stimulatory effect on dopaminergic neurones
C. have a stimulatory effect on GABA-activated receptors
D. oxidise Vitamin B12
E. mediate some of its analgesic effects via release of endogenous opioid peptides

C


(Maze & Fujinaga 2000)
"In addition to its inhibitory effects on NMDA receptors, stimulatory effects of N2O on dopaminergic neurones have been known for a while.... Jevtovic-Todorovic et al. found that N2O significantly inhibited NMDA-activated currents, while it showed no effect on GABA-activated currents... Although the underlying mechanisms are unclear, several studies have suggested that N2O releases opioid peptides in the central nervous system."

92. The thromboelastogram pattern typical of that seen in haemophilia is labelled
A. A
B. B
C. C
D. D
E. E

B

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

B


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

90. The respiratory effects of morbid obesity include all of the following EXCEPT
A. hypoxaemia in the sitting position
B. premature airway closure in dependent lung regions
C. an increased work of breathing
D. a reduction in respiratory system compliance due mainly to the chest wall
E. a decrease in alveolar ventilation

D

88. Intra-operative hypoglycaemia in children is LEAST likely in
A. small-for-age children
B. Beckwith-Wiedeman syndrome
C. infants following an overnight fast
D. children treated with propranolol
E. Russell-Silver syndrome

C


Almost repeat
ARussell-Silver syndrome "Rapid depletion of limited hepatic glycogen stores, especially in small-for-gestational-age neonates, may predispose to hypoglycemia. The risk of hypoglycemia diminishes as the child grows and is usually absent after approximately 4 years of age" (Stoelting Ch 18)

87. Complications of attempted cervical plexus block include all of the following EXCEPT
A. ipsilateral diaphragmatic paralysis
B. total spinal anaesthesia
C. Horner’s syndrome
D. vocal cord paralysis
E. pneumothorax

E


CEACCP LA for Carotid endarterectomy
Complications:
­ Subarachnoid or epidural injection
­ Intravascular injection and local haematoma
­ Phrenic nerve palsy affecting diaphragm ipsilaterally in 60% of
­ Transient recurrent laryngeal nerve palsy
­ Horner's syndrome and stellate ganglion block

86. In a patient with aortic stenosis,
A. aortic regurgitation is rarely seen
B. the characteristic compensation of the left ventricle is dilatation
C. presentation is usually with a cerebrovascular accident
D. a valve area of < 0.8 cm2 represents severe disease
E. atrial arrhythmias are commonly seen

D

85. The stellate ganglion
A. is the middle cervical ganglion
B. is blocked 1 cm lateral to the cricoid process
C. is blocked on the right side to treat intractable angina
D. may be blocked unilaterally to treat sudden deafness
E. when blocked, results in exophthalmos

D


Anatomy for Anaesthetists:
“The inferior cervical sympathetic ganglion is fused with the 1st thoracic ganglion in about 80% of subjects. This combined structure is termed the stellate ganglion”

“Indications for stellate ganglion block include refractory angina pectoris, complex regional pain syndromes in the arm, vascular insufficiency in the arm, acute or chronic post-herpetic neuralgia and frostbite”

­ A – False
­ B – 2cm lateral
­ C – blocked to the left for angina
­ D – True according to article cited on wiki
­ E – False, Causes Enophthalmos

84. A twenty-year-old woman undergoes cardiac catheterization for fatigue, cyanosis and a loud systolic murmur over the left second inter-costal space anteriorly. Chest x-ray reveals right ventricular hypertrophy. The cardiac catheter shows a large atrial septal defect. The cardiac catheterization result which is most likely to predict problems separating from cardiopulmonary bypass is an elevated
A. pulmonary artery pressure
B. left ventricular end-diastolic pressure
C. pulmonary wedge pressure
D. pulmonary vascular resistance
E. right ventricular pressure

D


ASD with cyanosis suggests a right to left shunt present

In an anatomically normal heart, the output of the LV and RV are equal. Hence the amount of blood entering the pulmonary and systemic circulations is equal. Hence qp/qs ratio is 1:1

When there is a septal defect, blood will take the path of least resistance. Hence blood will now be preferentially ejected into the right atrium rather than the LV. Hence more blood enters the RV, and therefore pulmonary circulation. Hence qp/qs > 1. Often with severe ASDs, the ratio may be as high as 3:1

With time, increased pulmonary blood flow leads to pulmonary arteriolar hypertrophy. This increases pulmonary vascular resistance. Hence pulmonary artery pressures will begin to rise, and likewise RV pressures will rise also. The QP/QS ratio begines to decrease and will eventually become 1:1 as the right sided pressures rise.

Eventually Eisenmengers syndrome arises, and the heart is inoperable. Often the qp/qs ratio is less than 1, typically 0.7 or 0.8:1

ASD repair is undertaken surgically when the QP/QS ratio > 1.5

82. You are called to see a labouring 24 year old primigravida with pre¬eclampsia. She is convulsing. Following initial management, the best drug to prevent further convulsions is
A. phenytoin
B. diazepam
C. magnesium sulphate
D. carbamazepine
E. hydralazine

C


Chestnut:
“Magnesium sulfate is the preferred drug for the definitive treatment of seizures”

81. Paget’s disease of bone is LEAST likely to affect the
A. heart
B. respiratory system
C. renal system
D. neurological system
E. vertebral column

B


Stoelting:
Paget's disease of bone is characterized by excessive osteoblastic and osteoclastic activity, resulting in abnormally thick but weak bones. The cause is unknown but may reflect an excess of parathyroid hormone or a deficiency of calcitonin

Complications of Paget's disease involve:
­ bones (fractures and neoplastic degeneration)
­ joints (arthritis)
­ nervous system (nerve compression, paraplegia)
­ Hypercalcemia
­ Renal calculi may also occur

"Causes of high cardiac output include anemia, pregnancy, arteriovenous fistulas, severe hyperthyroidism, beriberi, and Paget's disease."

When calcification involves the cardiac structures, arrhythmia and heart block can result. There is a correlation between Paget's disease and calcific disease of the aortic valve. Peripheral vascular disease based on arterial calcification has been reported

No mention of resp complications with Paget’s

80. The correct ranking of fat/blood partition co-efficients, in order of increasing solubility in fat, for sevoflurane (S), isoflurane (I), desflurane (D) and nitrous oxide (N2O) is
A. N2O < D < S < I
B. D < N2O < S < I
C. D < N2O < I < S
D. N2O < D < I < S
E. N2O < S < D < I

D


Note blood/fat not blood/gas

Stoelting:
N20 2.3 < Des 27.2 < Iso 44.9 < Sevo 47.5

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

A


Stoelting:
"Anatomic closure of the foramen ovale occurs between 3 months and 1 year of age, although 20% to 30% of adults have probe-patent foramen ovales"
The rest seem pretty obvious

78. Left bundle branch block (LBBB) on the ECG is
A. commonly a normal variant
B. associated with a delay in atrio-ventricular conduction
C. demonstrated by a notched R wave in chest lead V1
D. associated with right axis deviation
E. a relative contra-indication to flotation of a pulmonary artery catheter

E

5% of IHD patients get RBBB on PAC insertion ∴ relative contraindication

77. All of the following are chiral compounds EXCEPT
A. bupivacaine
B. prilocaine
C. lignocaine
D. mepivacaine

C

76. Appropriate strategies for reducing intracranial pressure following an intracerebral haemorrhage during intracranial surgery, include the use of all of the following EXCEPT
A. a lumbar cerebrospinal fluid (CSF) drainage catheter
B. a propofol infusion
C. mannitol
D. hyperventilation
E. sodium nitroprusside

E

Probably wouldn’t put a lumbar drain in someone with raised ICP (risk of coning) but E is definitely false

75. The most correct statement regarding a 70 kg male who has sustained third degree burns to all of his right arm and second degree burns to the anterior aspect of his trunk is that
A. he has burns to 21% of his body
B. he will require 2 to 4 ml of Hartmann’s solution per kilogram per percent burn in the first 8 hours after admission
C. a normal blood gas and chest X-ray on admission will be useful in excluding inhalational injury
D. prophylactic antibiotics and steroids are of proven benefit if he has suffered an inhalational injury
E. alkalinizing the urine will prevent renal damage if the burns were electrical

A


• Rule of nines: equates to 27% - ?close to 21%
• 2-4ml/kg/%BSA burnt in first 24 hours, half in first 8 hours after burn not after admission
• This is not how inhalational injury is exluded and can develop later
• "The use of many agents to treat inhalation injury has been described, but evidence of efficacy in humans from large studies is lacking. Steroids and prophylactic antibiotics are not indicated." (Anaesthesia and ICM 2008;9:9; 405)
• Rhabdomyolysis can occur with electrical burns. HCO3 to alkalinize urine can increase solubility of myoglobin, but will not prevent it with any surety

Addit. See oxford handbook anaesthesia – different system that gives 20.5%

74. Spinal anaesthesia in infants
A. often causes hypotension if the infant is awake
B. has a lower failure rate than in adults
C. eliminates the risk of postoperative apnoea
D. lasts for a longer time than in adults
E. may be performed at a higher spinal level than in adults

All incorrect
• Probably not
• Failure rate of 20% - higher than adults
• Proven to reduce risk of apneas – but not eliminate
• Shorter Duration - 20-60 minutes
• Spinal cord terminates more lower (L3), not higher

Wording changed next paper

73. Patients taking a selective serotonin reuptake inhibitor (SSRI) e.g. fluoxetine,
A. should NOT be given high doses of tramadol
B. can have their SSRI medication ceased without risk of withdrawal symptoms
C. will have potentiation of the effect of direct acting adrenergic agonists
D. are less sensitive to benzodiazepines than the general population
E. will have the majority of active drug cleared from the body within 36 hours following discontinuation

A


• Seems reasonable
• Obviously false
• MIMS: The antidepressant and antiobsessional action of fluoxetine is presumed to be linked to its inhibition of CNS neuronal uptake of serotonin. Studies at clinically relevant doses in humans have demonstrated that fluoxetine blocks the uptake of serotonin, but not of noradrenaline, into human platelets
• MIMS: "Benzodiazepines. The half-life of concurrently administered diazepam may be prolonged in some patients and coadministration of alprazolam may result in increased plasma alprazolam concentrations."
• Stoelting: 1 to 3 days for acute administration and 4 to 6 days for chronic administration

72. Propofol
A. is contra-indicated in all patients who give a history of egg allergy
B. requires a higher dose, when given slowly for induction of anaesthesia
C. may be diluted with 5% dextrose solution
D. causes no pain on injection if 20 mg of lignocaine is pre-mixed with 200mg prior to intravenous injection
E. has a metabolic half-life of 8 minutes

C


MIMSonline:
"Diprivan can be infused undiluted from plastic syringes, glass infusion bottles or Diprivan prefilled syringes. It can be diluted with Glucose 5% Intravenous Infusion BP only, and used from glass or PVC infusion bags/bottles."

71. 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

A


Miller:
"Not all postoperative visual loss is a result of direct orbital compression, however. Ischemic optic neuropathy (ION) seems to be a more frequent cause of postoperative visual loss than pressure causing occlusion of central retinal vessels

70. The pain of chronic herpetic neuralgia is best controlled by
A. ipsilateral stellate ganglionectomy
B. intrathecal alcohol injection
C. analgesic drugs
D. dorsal rhizotomy
E. topical capsaicin

C


ANZCA pain book:
• HZ-associated pain may be severe and early and effective treatment is essential. Multimodal analgesia, with regular paracetamol in addition to an opioid such as oxycodone or tramadol as required, has been recommended
• Oxycodone CR but not gabapentin was effective in significantly reducing the average worst pain during the first 14 days of HZ compared with placebo
• Evidence of benefit for sympathetic blockade in the treatment of HZ-associated pain was conflicting

69. Hyperosmolar non-ketotic coma
A. is relatively common in young diabetics
B. occurs in patients who have a history of diabetes in the majority cases
C. is more acute in presentation than diabetic ketoacidosis
D. is NOT associated with intracellular and intravascular dehydration
E. is associated with a decrease in serum sodium concentration

B

True, Typically middle aged to elderly type II diabetic patients, though 25% are undiagnosed diabetics

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

D


See article: A breathing circuit disconnection detected by
anesthetic agent monitoring, Canadian Journal of Anaesthesia
• Not if the disconnect is on the machine side
• Perhaps, depends how low is set. Only if the alarm is above 21%
• Not if the disconnect is distal the spirometer apparatus
• This would occur with disconnect
• Certainly not

67. Postoperative cognitive dysfunction in the elderly
A. is less likely after regional anaesthesia with sedation than after general anaesthesia.
B. occurs immediately after surgery
C. persists for greater than one year in about 1% of patients
D. does NOT occur if optimum cerebral oxygenation and perfusion are maintained
E. resolves by three months following surgery in over 95% of patients

C


Miller:
- The reported incidence of postoperative cognitive dysfunction is 26% at 1 week and 10% at 3 months.
- Postoperative cognitive decline is reversible in most cases but may persist in approximately 1% of patients.
- Predictors of postoperative cognitive decline include age, low educational level, preoperative cognitive impairment, depression, and the specific surgical procedure.

66. A patient with pulmonary hypertension secondary to lung disease
presents for laparotomy. The anaesthetic technique LEAST likely to exacerbate the pulmonary hypertension is endotracheal intubation and
A. controlled ventilation with isoflurane, N2O and O2
B. spontaneous breathing with isoflurane and O2 / air
C. controlled ventilation with total intravenous anaesthesia and O2 / air
D. controlled ventilation with ketamine and O2 / air
E. controlled ventilation with high dose opioids, N2O and O2

C

65. When compared with non-specific nonsteroidal anti-inflammatory
drugs (NSAIDs), NSAIDs which are selective for the inducible cyclo-oxygenase-2 (Cox-2) enzyme,
A. induce significantly fewer cases of severe gastrointestinal bleeding with long-term use
B. have less inhibitory effects on platelet aggregation because they do NOT block platelet thromboxane production
C. are more protective of renal function
D. are effective in chronic musculoskeletal pain but NOT acute post-surgical pain
E. do NOT inhibit endothelial production of prostacyclin (PGI2)

B


Similar to Apr 2001 question
"Coxibs do not impair platelet function; this leads to reduced perioperative blood loss in comparison with non-selective NSAIDs"

64. Infusion of 1 litre of Hartmann's solution over 30 minutes in a healthy adult results in
A. hypercoagulability due to platelet activation
B. hypercoagulablity due to a fall in antithrombin III (ATIII) levels
C. hypocoagulablilty due to a fall in thrombin levels
D. hypocoagulablility due to a fall in platelet levels
E. no change in coagulation status

B


Are lactated Ringer's solution and normal saline solution equal with regard to coagulation? Boldt et al, Anesth Analg 2002 94(2) 378-84:
- Crystalloid hemodilution is associated with hypercoagulability in in vitro and in vivo studies
- Used either lactated Ringer’s solution or 0.9% saline solution for intravascular volume replacemen
- Fibrinogen and antithrombin III decreased similarly in both groups, most likely because of hemodilution
- Differences in TEG data from normal baseline were seen immediately after surgery and 5 h thereafter, indicating mild hypercoagulability

63. Cardiac arrest or severe bradycardia during spinal anaesthesia, in adults,
A. rarely occurs in young healthy patients
B. is often the result of hypoxaemia
C. is caused by vagal responses to decreased preload
D. should be treated by the prompt administration of atropine
E. is more common in vagotonic patients

C and E both right, however C removed following year so E must be correct answer


Cardiac Arrest During Spinal Anesthesia: Common Mechanisms and Strategies for Prevention, in Anesth Analg 2001;92:
• "Although many factors can contribute to cardiac arrest during spinal anesthesia, vagal responses to decreases in preload often play a key role. Patients with risk factors for bradycardia or overt vagal symptoms during spinal anesthesia appear to be at increased risk for cardiac arrest during spinal anesthesia."
• "Because a high degree of cardiac vagal activity can occur during spinal anesthesia , patients with strong resting vagal tone should be at increased risk for cardiac arrest during spinal anesthesia. The term “vagotonia” describes the clinical situation of resting bradycardia, atrioventricular block, or complete atrioventricular dissociation that is present in 7% of the population. In vagotonic patients asystole can occur when procedures that increase vagal activity are performed”

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

A


False Positive Rate = 1 - specificity
False Negative Rate = 1 - sensitivity

60. The incidence of post-anaesthetic sore throat can be reduced by the use of
A. smaller endotracheal tubes with cuffs that have a small area of contact with the tracheal mucosa
B. lubricants which contain local anaesthetic agents
C. uncuffed endotracheal tubes
D. smaller endotracheal tubes with cuffs that have a large area of contact with the tracheal mucosa
E. a dry endotracheal tube

A


Anaesthesia, Volume 54, Issue 5, 1999. Pages: 444–453
smaller endotracheal tubes with cuffs that have a small area of contact with the tracheal mucosa - true: "In summary, the use of smaller tracheal tubes with cuffs that have a small area of contact with the tracheal mucosa will reduce the incidence of postoperative sore throat. Careful control of intracuff pressure may be beneficial even for short-term intubation, and consideration should be given to using either the anaesthetic gas mixture or saline to inflate the cuff. Lubricants containing local anaesthetic agents are not useful and may actually increase sore throat incidence"

59. A FALSE statement regarding natural latex rubber allergy is that
A. sensitivity of skin prick testing is greater than that of specific IgE antibody detection (RAST)
B. signs of Type I hypersensitivity are usually immediate
C. latex antibodies fall in time in a latex free environment
D. the risk factors of frequent exposure and atopy are additive
E. theatre latex aerogens are lowest in the morning

B


Latex allergy: an update from ANESTH ANALG 2003;96:1219–29:
- RAST tests are highly specific, but their sensitivity is low... (while) the skin-prick test was very sensitive and specific
- Latex proteins are absorbed slowly when the exposure is airborne, and symptoms usually develop approximately 30 min after exposure." (Hepner and Castells,)
- A recent follow-up study (72) on latex allergy in health care workers demonstrated that although the skin-prick test remained positive 2 yr after latex avoidance, latex specific IgE levels decreased in most patients
- The American Society of Anesthesiologists Task Force of Latex Sensitivity recommends that patients who are latex allergic have a surgical procedure performed as the first case in the morning, when the levels of latex aeroallergens are the smallest

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

C


Stoelting:
• Development of ventricular hypertrophy and increased compliance of the left atrium permit the accommodation of the regurgitant volume without a major increase in left atrial pressure. This allows patients to maintain cardiac output and remain free of pulmonary congestion and be asymptomatic for many years
• Mitral valve repair is preferred to mitral valve replacement because it restores valve competence, maintains the functional aspects of the mitral valve apparatus, and avoids insertion of a prosthesis. The mitral valve apparatus is very important in sustaining left ventricular function. The absence of the subvalvular apparatus causes distortion of the left ventricular contractile geometry and impairment of left ventricular ejection
• Survival may be prolonged if surgery is performed before the ejection fraction is less than 60% or before the left ventricle is unable to contract to an end-systolic dimension of 45 mm (normal < 40 mm).
• Although vasodilators are useful in the medical management of acute mitral regurgitation, there is no apparent benefit to long-term use of these drugs in asymptomatic patients with chronic mitral regurgitation
• S3 can be heard and recorded in healthy young adults. However, it is usually abnormal in patients over the age of 40 years, suggesting an enlarged ventricular chamber (uptodate)

56. Features of anaphylactoid reactions to anaesthetic drugs include
A. known but rare reactions to inhalational agents
B. a lower frequency of occurrence and severity following pre¬treatment with H1 and H2 receptor blockers
C. difficulty in establishing that a colloid plasma volume expander is the causative agent
D. rapid synthesis and release of histamine from basophil and mast cell membranes
E. lower morbidity in beta-blocked patients

B


• No reported cases of anaphylaxis to inhalational agents (Anesth and analg, Volume 97(5) November 2003 pp 1381-1395 Anaphylaxis During the Perioperative Period)
• There is evidence that H1 with or without H2 Rc blockers does reduce the frequency and severity of anaphylactoid reactions but not anaphylactic ("Strategies for the Prevention of Asthmatic,Anaphylactic and Anaphylactoid Reaction During the Administration of Anesthetics and/or Contrast Media" J Investig Allergol Clin Immunol. 2008;18(1):1-11)
• Is this talking about distinguishing difference between anaphylactic and anaphylactoid reactions?
• D and E wrong

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

A

i.e. the PE is forcing blood to areas of low V/Q ration and this increases shunt.

47. The LEAST effective means of preventing post-operative deep venous thrombosis (DVT) in elderly patients undergoing surgery for a fractured neck of femur is
A. low molecular weight heparin (LMWH) with no haematologic monitoring
B. unfractionated heparin adjusted to upper range normal aPTT
C. warfarin adjusted to an INR of 1.5 times normal
D. spinal anaesthesia

C


Towards evidence-based guidelines for the prevention of venous thromboembolism: systematic
reviews of mechanical methods, oral anticoagulation, dextran and regional anaesthesia as thromboprophylaxis:
• Mechanical methods reduce the DVT rate by 50%-66%
• Regional associated with a 50% reduction in DVT compared to GA
• Heparin cause a 66-75% reduction in DVT
• Oral anticoagulant, ‘very low intensity’ regimen (targeting INR <1.5): too few patients have been assessed in trials for conclusions to be drawn. In higher doses oral anticoagulants reduced the risk of DVT by about half

46. Xenon concentration CANNOT be measured by
A. piezoelectric adsorption
B. infra-red absorption spectrometry
C. mass spectrometry
D. thermal conductivity
E. ultrasound techniques

B


Monoatomic particles don't absorb IR light

Current Opinion in Anaesthesiology Volume 13(4), August 2000, pp 443-447
“The measurement of xenon is difficult because it is diamagnetic and does not absorb infrared radiation. Its low reactivity precludes the use of specific fuel cell or electrode-type devices. Mass spectrometry works but is expensive. Physical properties such as its high thermal conductivity have also been used. Because of its density and atomic mass, xenon alters the speed of sound such that when an ultrasonic beam is passed through a sample, an estimation of the percentage of xenon can be made. A recent study [6] has demonstrated the accuracy of such a device, with a maximum difference between readings of 1.22% when compared with a reference method of laser refractometry”

45. Platelet concentrates used for transfusion
A. are pooled from several donors
B. require ABO typing
C. will help "turn-off" disseminated intravascular coagulation
D. are also a good source of cryoprecipitate
E. can be stored for 21 days

Multidonor platelets (i.e. ‘pooled’)
ABO and rhesus matching preferable but can be used without
Stored for 5 days at room temp



46. Xenon concentration CANNOT be measured by
A. piezoelectric adsorption
B. infra-red absorption spectrometry
C. mass spectrometry
D. thermal conductivity
E. ultrasound techniques

A


Multidonor platelets (i.e. ‘pooled’)
ABO and rhesus matching preferable but can be used without
Stored for 5 days at room temp

43. A low ejection fraction is MOST likely to be seen in a patient with
A. poor left ventricular (LV) systolic function
B. poor LV systolic function and severe mitral regurgitation
C. poor LV diastolic function
D. septic shock
E. a post myocardial infarct ventricular septal defect

A

MR leads to decreased ESV as blood regurgitating into atrium during systole. EF = (EDV-ESV)/EDV, therefore EF not decreased

42. The laryngeal mask when correctly inserted
A. may be safely used in a patient with latex allergy
B. lies with the sides facing the pyriform fossa
C. lies with the upper border under the base of the tongue
D. forms a seal around the laryngeal perimeter
E. has the black line on the tube always facing the lower lip of the patient

A


Though B,C & D also seem mostly correct
Product information:
 Latex free
 "When fully inserted using the recommended insertion technique, the distal tip of the LMA™ airway cuff reaches the distal end of the hypopharynx immediately above the oesophageal sphincter. Its sides face into the pyriform fossae and the upper border rests against the base of the tongue"
 lies with the upper border under the base of the tongue - almost true See above
 "In addition the LMA™ airway is contraindicated in patients with fixed decreased pulmonary compliance (e.g. patients with pulmonary fibrosis) because the LMA™ airway forms a lowpressure seal (approximately 20cm H2O) around the larynx."
 "The mask aperture must face posteriorly (Figure 8) and the black line on the airway tube should be oriented anteriorly toward the upper lip."

40. Tetra-iodothyronine (T4) is converted peripherally in the tissues to
A. equal quantities of tri-iodothyronine (T3) and reverse T3
B. mainly reverse T3 since this is the biologically active hormone
C. mainly T3
D. a greater proprtion of T3 during periods of surgical stress
E. equal quantities of di-iodothyronine (T2) and reverse T2

A


UpToDate:
"T4 is degraded at a rate of about 10 percent per day. Approximately 80 percent is deiodinated, 40 percent to form T3 and 40 percent to form rT3."

36. With regards to spinal anaesthesia
A. addition of intrathecal fentanyl does NOT enhance post-operative analgesia
B. intrathecal clonidine prolongs motor and sensory block
C. lignocaine is neurotoxic ONLY when the concentrations exceeds 2%
D. intrathecal clonidine does NOT cause sedation
E. intrathecal pethidine does NOT cause hypotension

B


"The Role of Intrathecal Drugs in the Treatment of Acute Pain". Anesthesia & Analgesia 2005; 101: S30-S43:
• Clonidine 75–225 mcg (average, 146 !g) added to spinal bupivacaine 13.75–15 mg prolonged sensory block from 2.5 to 3.7 h and motor block from 2.4 to 3.3 h (47)

35. In a patient with myasthenia gravis undergoing a laparotomy for large bowel obstruction, the need for post-operative ventilation is significantly increased by a
A. daily dose of pyridostigmine > 450mg
B. known history of resistance to suxamethonium
C. past history of prednisolone treatment > 10 mg.day-1
D. recent history of dysphagia
E. past history of thymectomy

D


Miller:
Post-op ventilation is especially important in cases involving:
• myasthenia gravis of more than 6 years duration
• chronic obstructive lung disease
• daily pyridostigmine requirement of 750 mg in association with significant bulbar weakness
• vital capacity of less than 40 mL/kg

32. Specific treatment of abnormal bleeding due to hypo-fibrinogenaemia is administration of
A. whole blood
B. cryoprecipitate
C. epsilon-aminocaproic acid
D. fibrin
E. packed cells

B

31. This sidestream capnograph tracing during mechanical ventilation using a circle absorber system is NOT consistent with

A. a stuck open expiratory valve
B. a stuck open inspiratory valve
C. exhaustion of soda-lime
D. a leak in the inspiratory limb on the patient side of the inspiratory valve
E. a leak in the inspiratory limb on the ventilator side of the inspiratory valve

E


Capnograph shows CO2 rising during inspiration consistent with re-breathing
• A: If the expiratory valve is stuck open, during inhalation, CO2 containing gas will be entrained from the expiratory limb
• B: During expiration, gas will pass into the inspiratory and the expiratory limbs of the circuit. During the next breath the inhaled gass will contain CO2
• C: Presumably possible
• D: Same reasoning as for inspiratory valve stuck open
• E: Leaks that occur on the ventilator side of the one way valves shouldn't cause rebreathing of CO2

30. Advantages of local anaesthesia for middle ear surgery compared with general anaesthesia do NOT include
A. avoidance of problems with middle ear pressure
B. a drier surgical field
C. ability to monitor facial nerve integrity
D. ability to monitor hearing
E. substantial reduction in post-operative nausea and vomiting

C


- middle ear pressure: are they referring to N20?
- Miller’s
 A head-up position to reduce venous pressure and bleeding is often successful. A smooth, balanced anesthetic with adequate analgesia (remifentanil infusion) avoids tachycardia and hypertension, and optimal ventilation avoids hypercapnia. Induced hypotension requires a careful assessment of the risks and benefits, and should not be performed on patients with preexisting cardiovascular compromise.
 ? easier to control these variable with GA
- Miller’s:
 Facial nerve monitoring is used during middle ear, mastoid, and inner ear procedures to identify the facial nerve and reduce the incidence of iatrogenic facial nerve injury
 When the nerve is stimulated, electrodes attached to the face detect nerve activity, and the monitor signals
 Neuromuscular blockade would certainly prevent monitoring, though don’t need to paralyse, could use remifentantl for example
- Would definitely be able to monitor hearing with LA
High rate of PONV with middle ear surgery, likely to be less without

29. According to current legal recommendations in Australia regarding the obtaining of consent for anaesthesia
A. it is reasonable to withhold risk information from the very anxious patient
B. it is adequate to use the standard of risk disclosure set by a responsible body of medical opinion
C. only risks which would be considered significant by a reasonable person need to be discussed
D. significant risks with a likelihood of less than 1% may need to be discussed

D

If an extremely unlikely risk is of concern to the patient it does need to be discussed - as per Rogers v Whittaker

28. The second cervical nerve root
A. passes between the transverse process of the axis (C2) and C3, to emerge and divide into anterior and posterior primary rami
B. contributes fibres through the anterior primary ramus which go on to form the greater occipital nerve
C. can be blocked near the occipital artery at the nuchal line
D. can be blocked 1 cm caudad to the mastoid process and 1 cm posterior to the line joining the tip of the mastoid to the anterior tubercle of C6

D


Anatomy for Anaesthetist
• A false: It passes between C1 and C2.
• B false: the greater occipital nerve is formed by the posterior ramus of C2
• C unsure: "The nerve (?C2/?Greater occipital) is blocked by injecting local anaesthetic just medial to the occipital artery at a point one-third of the distance between the greater occipital prominence and the mastoid process."
• D true: "Blockade of the deep cervical plexus is achieved by depositing small (3–5 ml) volumes of local anaesthetic near the transverse processes of the 2nd, 3rd and 4th cervical vertebrae (C2–4). With the patient in the supine position and the head turned away from the side to be blocked, the mastoid process and the transverse process of C6 (at the level of the cricoid cartilage, the most prominent of the cervical transverse processes) are identified, and a line is drawn between them. The roots of the cervical plexus lie beneath this line. The transverse process of C2 is 1.5–2.0 cm distal to the tip of the mastoid process, that of C4 is approximately midway between the clavicle and the mastoid process, that of C3 lies midway between the transverse processes of C2 and 4"

27. Complications of coeliac plexus block include
A. hypertension
B. failure of erection
C. constipation
D. paraplegia
E. dysaesthesia along L3-4

D


Clinical Anaesthesia:
"The most common complication is postural hypotension, which is largely due to blockade of the lumbar sympathetic chain. Intravascular injection into the vena cava is more likely to produce a severe systematic reaction than accidental intraaortic injection. Other less common complications include pneumothorax, retroperitoneal hemorrhage, injury to the kidneys or pancreas, sexual dysfunction, or, rarely, paraplegia (due to injury of a lumbar artery of Adamkiewicz)."

26. Each of the following drugs increases lower oesophageal sphincter tone EXCEPT
A. metoclopramide
B. domperidone
C. prochlorperazine
D. cyclizine
E. atropine

E


Straight forward – increased parasympathetic tone
Power and Kam:
• Increase LOS tone: Metoclopramide, anti-cholinesterases, alpha agonists, histamine, sux
Decrease LOS tone: anti-muscarinic agents (atropine), dopamine, ethanol, opioids, ganglion blockers and beta adrenergic agents

25. A five-year-old child presents with headache, morning vomiting and double vision for three weeks. On examination nystagmus is present when the eyes are turned to either side. The most likely diagnosis is
A. tuberculous meningitis
B. craniopharyngioma
C. aseptic meningitis
D. posterior fossa tumour
E. acoustic neuroma

D

23. 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

C


Not clear with this one
Old data suggested Hep B was more common, though far from “the majority of cases”
23% have chronic hepatitis, 51% have chronic active hepatitis
Hep B hepatitis shouldn’t make you Hep C antigen positive

22. Supine hypotension during late pregnancy is associated with
A. a rise in the systemic vascular resistance
B. a rise in the cardiopulmonary blood volume
C. increased heart rate
D. stable stroke volume
E. a rise in the cardiac index

A


American Journal of Obstetrics & Gynaecology 2002: 187; 1634-4
“Supine Hypotension Syndrone is defined as a 15-30 mmHg reduction in systolic BP with a sustained elevation in HR of > 20 bpm”

UpToDate - Maternal Cardiovascular and Haemodynamic Adaptations to Pregnancy/Supine Hypotensive Syndrome:
"The reduction in preload can result in maternal hypotension, usually within 3 to 10 minutes, associated with one or more signs and symptoms of reflex autonomic activation and/or reduced cardiac output. The earliest sign of developing supine hypotension is an increase in maternal heart rate and a decrease in pulse pressure indicating significantly reduced venous return”

However, in this 1996 review American Journal of Obstetrics & Gynecology. 175(4):867-872, Oct 1996:
"In 1953 Howard et al. [1] described bradycardia, syncope, and a sudden drop in blood pressure, in supine third-trimester gravid women. This clinical scenario, known as the "supine hypotensive syndrome," occurs in approximately 8% of women in late pregnancy”

Bezold-jarich Reflex

19. A 68 yr old patient with chronic renal failure is scheduled to have a peritoneal dialysis catheter inserted. Her bleeding time is 11 min (N 3 to 5 min) and platelet count is 110 x 109.l-1. Preoperatively she should be
A. given 2 units fresh frozen plasma
B. given 1-desamino-8-d-arginine vasopressin (DDAVP) 0.3 microg.kg-1 intravenously
C. given 2 units of platelets
D. cancelled and taken off salicylates for 1 week
E. accepted for surgery without any further treatment

B


Presumably referring to uraemic platelet dysfunction

RACP Manual:
• “This test is largely obsolete and rarely indicated. It has been replaced in most circumstances by more reproducible and less invasive tests”
• Reference Interval - <9 minutes
• “The bleeding time should not be used as a 'screening test' for inherited or acquired bleeding disorders as it has very low sensitivity and specificity”
• “Although it may be abnormal in von Willebrand’s disease, inherited disorders of platelet function, uraemia, myeloproliferative disorders and after aspirin and NSAID use, its ability to predict surgical bleeding and/or the need for therapeutic cover in these situations is very limited”

Stoelting:
“Most patients with severe uremia have a prolonged bleeding time in excess of 30 minutes. This condition is corrected by hemodialysis. It may also relate to the patient's anemia since the bleeding time shortens with either transfusion or erythropoietin therapy. For acute bleeding episodes, DDAVP therapy can improve platelet function transiently. Infusion of conjugated estrogens (0.6 mg/kg per day) for 5 days will also shorten the bleeding time”

Leaning towards B rather than E as this has been the practice I’ve seen and doesn’t make sense to wait and see if they bleed
According to Clara: patietns with urea >20 get ddavp prior to renal biopsy or CVC

18. The skin of the anterolateral part of the gluteal region, between the iliac crest and the greater trochanter, is supplied by the
A. ilioinguinal nerve
B. genito-femoral nerve
C. superior gluteal nerve
D. subcostal nerve
E. lateral cutaneous nerve of thigh

D


Anatomy for Anaesthetists:
“The 12th thoracic (subcostal) nerve runs along the lower border of the 12th rib below the subcostal vessels, passes behind the lateral arcuate ligament to run in front of quadratus lumborum behind the kidney and colon. The nerve then passes between transversus abdominis and internal oblique and then has a course and distribution which are similar to the lower intercostal nerves. However, there is one point of difference: the lateral cutaneous branch of the 12th nerve descends without branching to supply the skin over the lateral aspect of the buttock"

17. A patient with a head injury who has eye opening to speech, no verbal
responses and withdrawal motor responses would have a Glasgow Coma Scale score of
A. 4
B. 5
C. 6
D. 7
E. 8

E


E3V1M4

14. A 30 year old female with a three month history of dyspnoea and dry cough has the following lung function tests
Actual Predicted
Forced expiratory
volume in one second (L) 1.4 2.84
Vital capacity (L) 1.51 3.30
FEV1/VC 93% 86%
Carbon monoxide diffusing
capacity (ml.mmHg-1.min-1) 8.4 25.7
The most likely diagnosis is

A. alpha-1 anti-trypsin deficiency
B. asthma
C. bronchiectasis
D. sarcoidosis
E. chronic bronchitis

D

Restrictive pattern with a reduced DLCO

13. When a new diagnostic test is evaluated in a group of subjects in whom the diagnosis is known, the following results are obtained
Disease known Disease known
to be present to be absent
Test result positive 50 20
Test result negative x 80
If a subject from this population tests positive, the probability of having the disease is approximately
A. 0.8
B. 0.7
C. 0.6
D. 0.5
E. cannot be calculated because 'x' is unknown

B


PPV = TP/(TP + FP)
PPV = 50/(50+20)
PPV = 0.7

10. Causes of inverted P waves in Lead II of the electrocardiogram include
A. transposed lower limb leads
B. junctional rhythm
C. hypothermia
D. left axis deviation
E. inferior myocardial infarction

B

i.e. retrograde conduction from a junction pacemaker source

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

D

Fisher's Exact Test: 2x2 with small sample size <50, non parametric

8. The development of a pleural effusion would be an unusual complication of
A. streptococcal pneumonia
B. staphylococcal pneumonia
C. mycoplasma pneumonia
D. pneumococcal pneumonia
E. none of the above

E


Respiratory guidelines:
"In community-acquired pneumonia with pleural infection, the most common organisms are Streptococcus pneumoniae and the Streptococcus anginosus/milleri group, with Staphylococcus species accounting for 10% or less of infections. For empirical antibiotic treatment of an empyema complicating community-acquired pneumonia possibly due to other organisms, including Mycoplasma pneumoniae and Legionella species, see Community-acquired pneumonia. In all cases antibiotic regimens should be adjusted according to subsequent results from the pleural fluid sample."

Harrison’s
“<20% of mycoplasma develop effusions”

Conflict on wiki but there seems to be multiple sources quoting 20% rate of effusions with mycoplasma, so this doesn’t seem like an ‘unusual’ complication

7. The use of epidural opioids for analgesia after caesarean section is NOT associated with
A. respiratory depression
B. activation of herpetic lesions
C. facial pruritis
D. a higher incidence of nausea and vomiting than occurs with other techniques of administration
E. an increased incidence of urinary retention

D


Stoelting (pharm) side effects of neuraxial opioids:
- pruritis : esp face, neck and upper thorax
- urinary retention
- viral reactivation
- N+V
- Sedation
- CNS excitation
- Neonotal morbidity
- Sexual dysfunction
- Ocular dysfunction
- GI dysfunction
- Thermoregulatory dysfunction
- Water retention

Cant find any direct reference for this but overall discussion seems to lean to this

4. In a patient who has had an arterial embolism in a limb
A. it is important to keep the affected limb warm
B. heparin should NOT be given
C. surgery will almost certainly be required if the muscles of the limb are paralysed
D. surgery should be deferred, whenever possible, for at LEAST twenty four hours
E. it is important to localise the embolus precisely so that the arteriotomy can be performed directly over it

C


CEACCP – limb revascularization (section on acute ischaemia):
“if sensory loss or muscle weakness is present, blood flow must be restored within 6 h to decrease the possibility of limb loss”

“Heparin in anticoagulant doses may be administered but usually surgical embolectomy followed by arteriography with or without intrathrombus thrombolysis, angioplasty, stenting or bypass grafting is required”

3. C-reactive protein
A. is a reliable marker of metastatic breast cancer
B. is a chronic phase protein produced in the lungs
C. is usually increased dramatically in response to infection
D. is found only in the cerebrospinal fluid (CSF)
E. decreases in response to tissue trauma

C