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57 Cards in this Set
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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 (N20) is A. N2O < D < S approximately = I B. N2O approximately = D < S < I C. N2O < S < D < I D. D < N2O < S < I E. D < N2O approximately = S < I |
A
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When viewing the central venous pressure trace
A. an accentuated "a" wave supports the diagnosis of atrial fibrillation B. a steeper than normal "x" descent supports the diagnosis of tricuspid regurgitation C. blunted "a" and "v" waves are associated with extensive right ventricular infarction D. flattened "x" and "y" descents are associated with pericardial constriction E. a monophasic pattern with obliteration of the "y" descent supports the diagnosis of cardiac tamponade |
E
• A – False. AF results in loss of a wave and x descent . • B – False. x descent impaired/obliterated as c wave will start to refill atria, and dominant c-v wave is characteristic. • C – False. RV infarction similar to a restrictive cardiomyopathy or pericardial constriction, including elevated mean pressure, prominent a and v waves, and steep x and y descents (an ‘M” or ‘W’ shape). • D – False. Prominent a and v waves, steep x and y descent (M or W shape). • E – True. CVP becomes monophasic with a single prominent x descent but an impaired y as early diastolic flow from RA to RV is impaired. In tamponade, the pericardial pressure is elevated throughout the cardiac cycle. Venous return is compromised in diastole, when cardiac volume and pericardial pressures are maximal → monophasic CVP. • a wave : This wave is due to the increased atrial(a) pressure during right atrial contraction. It correlates with the P wave on an ECG. • c wave : This wave is caused by a slight elevation of the tricuspid valve into the right atrium during early ventricular contraction (c). Correlates with the end of the QRS segment on an ECG. • x descent : This wave is probably caused by the downward movement of the ventricle during systolic contraction. (atrial rela(x)ation mid-systole) It occurs before the T wave on an ECG. • v wave : This wave arises from the pressure produced when the venous(v) filling of the right atrium comes up against a closed tricuspid valve. It occurs as the T wave is ending on an ECG. • y descent : This wave is produced by the tricuspid valve opening in diastole with blood flowing into the right ventricle. It occurs before the P wave on an ECG. |
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The most important factor in reducing peri-operative
morbidity in diabetic patients undergoing peripheral vascular surgery is A. tight control of blood sugar level in the peri-operative period B. frequent blood sugar level estimations C. the use of regional rather than general anaesthesia D. stabilisation of co-existing disease E. the use of an insulin infusion rather than a subcutaneous sliding scale regimen |
D
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Clinical features supporting the diagnosis of cardiac
tamponade include all of the following EXCEPT A. equal diastolic pressures of all heart chambers B. ST segment abnormalities C. increased venous pressure and cardiac output with fluid loading D. increased patient comfort in the sitting position E. impalpable apex beat and soft heart sounds |
C
A, B and E are definitely correct statement, and therefore NOT the answer. Not sure about C: agree with increased venous pressure but cardiac output may not increase if patient is already well filled. I think only increase in CO only if patient is hypovolaemic. D: True according to reference below, but is generally a feature of pericarditis. Reference: D. COLLINS. Aetiology and Management of Acute Cardiac Tamponade. (Critical Care and Resuscitation 2004; 6: 54-58) • ECG. This may reveal sinus tachycardia, low-voltage complexes and non-specific ST segment and T wave changes or ST segment elevation due to pericarditis. • The classical presentation of a cardiac tamponade is an elevated venous pressure, decreased systemic arterial pressure and a quiet heart • The patient is initially resuscitated with intravenous fluids to promote maximum filling of the heart. However, increasing the intravascular volume is usually only helpful in hypovolaemic patients as intravenous fluids in normovolaemic or hypervolaemic patients may only increase right-ventricular filling at the expense of the left ventricle and has had disappointing results in clinical trials. • The characteristic haemodynamic changes associated with cardiac tamponade include....equalisation of diastolic pressures (to within 3 - 4 mmHg) in the right atrium, right ventricle, pulmonary artery and left atrium • The major symptoms are often dyspnoea (the patient often is found leaning forward or sitting in the knee-chest position to relieve the breathlessness), fatigue and light-headedness |
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Following a retrobulbar block of the eye, brainstem spread
of the local anaesthetic would be suggested by A. an atonic pupil B. blindness in the blocked eye C. blindness in the contralateral eye D. difficulty in swallowing E. diplopia |
D
Clin Anaes p. 978: Brainstem anaes: violent shivering, CL amaurosis, eventual LOC, apnoea, hemiplegia/paraplegia, quadriplegia, hyper-reflexia. BLock of CNs 8-12 - deafness, vertigo, vagolysis, dysphagia, aphasia, loss of neck m power. Blindness is not from brainstem spread, but rather a sign of spread back to optic chiasm |
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To improve oxygenation in a patient intubated and
ventilated for a laparotomy you adjust the ventilator settings to apply 10 cm H20 of PEEP (positive end¬expiratory pressure). The patient's blood pressure falls from 130/80 to 90/50 mmHg. The addition of PEEP may result in a fall in blood pressure because PEEP causes A. decreased myocardial contractility B. decreased venous return C. increased left ventricular afterload D. increased left ventricular compliance E. increased right ventricular afterload |
B
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Serotonin syndrome has been associated with each of the
following medications EXCEPT A. chlorpromazine B. ondansetron C. pethidine D. phenelzine E. sumatriptan |
A
Canadian Adverse Reaction Newsletter Volume 13, Number 3, July 2003 Table 1: Products that enhance serotonergic activity* Analgesics Codeine, fentanyl, meperidine, pentazocine Antidepressants MAOIs Moclobemide, phenelzine, tranylcypromine SSRIs Citalopram, fluoxetine, fluvoxamine, paroxetine, sertraline Tricyclic antidepressants Amitriptyline, clomipramine, desipramine, doxepin, imipramine, nortriptyline Other Bupropion, mirtazapine, nefazodone, trazodone, venlafaxine Antiparkinsonians Amantadine, bromocriptine, levodopa, selegiline Illicit drugs Cocaine, hallucinogenic amphetamines such as, but not limited to, MDMA ("ectasy"), LSD, mescaline Migraine therapy Dihydroergotamine, naratriptan, rizatriptan, sumatriptan, zolmitriptan Miscellaneous Brompheniramine, buspirone, carbamazepine, dextramphetamine, dextromethorphan, L-tryptophan, lithium, phentermine, reserpine, sibutramine, St. John's wort, tetrabenazine Note: Serotonin syndrome has also been reported with dextropropoxyphene, droperidol and metoclopramide,1 linezolid,4 and 5-HT3 antagonists (dolasetron, granisetron, ondansetron).7,8 There are reports of atypical antipsychotics (clozapine, olanzapine, risperidone) associated with serotonin syndrome when used in combination with serotonergic agents.1,9,12 |
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During transfusion of platelets a patient develops fever,
rigors and vomiting and becomes hypotensive and tachycardic. The most likely diagnosis is A. ABO incompatibility B. anaphylaxis C. bacterial contamination of the platelets D. leukocyte mediated transfusion reaction E. viral contamination of the platelets |
C
C is most likely, given that patient is too unwell for febrile nonhaemolytic transfusion reaction (which is common). Also platelet has higher incident of bacterial contamination due to storage in room temperature. http://www.manual.transfusion.com.au |
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The single best predictor of difficult intubation in a
morbidly obese patient is A. body weight B. history of snoring C. Mallampatti score D. neck circumference E. thyro-mental distance |
D
From Morbid Obesity and Tracheal Intubation (Anesth Analg 2002) • Factors looked at included: "height, weight, neck circumference, width of mouth opening, sternomental distance, thyromental distance and Mallampati score" • "Logistic regression identified neck circumference as the best single predictor of problematic intubation. Mallampati score inclusion did not further improve the model in our limited study with only 12 problematic intubations. In patients with a large neck, the view during direct laryngoscopy was poorer." |
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An adult male patient requires general anaesthesia. He
admits to long-standing substance abuse with central nervous system (CNS) stimulants. Compared with a patient who is not a substance abuser, he is likely to require an A. increased dose of induction agent and increased dose of opioid B. increased dose of induction agent and reduced dose of opioid C. increased dose of induction agent and unchanged dose of opioid D. unchanged dose of induction agent and increased dose of opioid E. unchanged dose of induction agent and unchanged dose of opioid |
E
According to pain book, 3ed 2010, no cross tolerance with opioid. No evidence for any difference in opioid requirement . As for induction dose: Anesth Analg 2006;103:203-206: "Acute amphetamine use dramatically increases anesthetic requirement and has been implicated in a case of severe intraoperative intracranial hypertension without postoperative sequelae. Chronic amphetamine use results in markedly diminished anesthetic requirement, which is thought to result from catecholamine depletion in the CNS, and has been implicated in a case of cardiac arrest during general anesthesia." |
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Investigation of a suspected anaphylactic reaction requires
measurement of tryptase levels. Correct statements regarding tryptase include each of the following EXCEPT A. 99% of body tryptase is in mast cells B. a concentration of greater than 20 ng.m1-1 suggests an anaphylactic reaction C. blood samples should be repeated 24 to 48 hours after the reaction D. maximum blood concentrations occur within 1 hour of the reaction E. tryptase concentrations rise after both anaphylactic and anaphylactoid reactions |
C
The CEACCP "anaphylaxis" article 2004 states that 1. Maximum concentrations occur rapidly within 1 hour 2. Increases in both anaphylaxis and anaphylactoid reactions 3. Approximately 99% of the body's total enzyme is located within the mast cell 4. A value >20ng/ml is more likely to indicate an IgE (hence anaphylaxis) response. 5. Samples should be taken at the following (3) times: immediately, at about 1 hour after reaction and about 6 hours or up to 24 hours after the reaction |
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When used for treatment of neuropathic pain, the dose of
gabapentin should be modified if the patient A. has impaired hepatic function B. has impaired renal function C. is also receiving amitriptyline D. is also receiving a proton-pump inhibitor E. is also receiving fentanyl transdermally |
B
Dosage adjustment in patients with compromised renal function or undergoing haemodialysis is recommended. - MIMS |
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The stellate ganglion lies
A. anterior to the anterior scalene muscle B. anterior to the dome of the pleura C. anterior to the thoracic duct D. at the level of the body of C6 E. posterior to the brachial plexus sheath |
A
Relations of stellate ganglion - Anaesthesia UK Website • Anterior : The structures anterior to the ganglion include the skin and subcutaneous tissue, the sternocleidomastoid and the carotid sheath. The dome of the lung lies anterior and inferior to the ganglion. • Medial : The prevertebral fascia, vertebral body of C7, oesophagus and thoracic duct lie medially. • Posterior: Structures posterior to the ganglion include the longus colli muscle, anterior scalene muscle, vertebral artery, brachial plexus sheath and neck of the first rib. |
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Concerning non-depolarising neuromuscular blockers,
A. cisatracurium is metabolised by the liver to laudanosine B. mivacurium has a half-life of approximately 10 minutes C. potentiation of neuromuscular blocking effect is seen with hyperkalaemia D. resistance to neuromuscular blockers may be seen in patients taking phenytoin or theophylline E. vecuronium is primarily excreted unchanged by the kidney |
D
• A - False. Cisatracurium undergoes spontaneous metabolism to produce laudanosine, not organ dependent • B - False. about 2 min • C - False. Hypokalaemia prolongs action, not hyperkalaemia • D - True. In Sasada and Smith under "Phenytoin" ... "it appears to increase the dose requirements of all of the non-depolarising relaxants (with the exception of atracurium) by 60-80%. No entry for Theophylline, but under "Aminophylline" says "in high concentrations, the drug will antagonise non-depolarising neuromuscular blockade caused by pancuronium or tubocurarine" • E - False. Vecuronium undergoes elimination also by the liver (ie non-exclusive elimination) |
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Isoflurane is administered in a hyperbaric chamber at 3
atmospheres absolute pressure using a variable bypass vaporizer. At a given dial setting and constant fresh gas flow, vapour will be produced at A. the indicated vapour concentration B. three times the indicated vapour concentration C. one third the partial pressure obtained at 1 atmosphere D. the same partial pressure as is obtained at 1 atmosphere E. three times the partial pressure obtained at 1 atmosphere |
D
Saturated vapour pressure is unchanged, therefore partial pressure of volatile is unchanged. The vapour concentration will be one-third of that indicated |
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Publication Bias is that
A. researchers with a strong track record are more likely to get research published B. studies with positive results are more likely to be published C. studies with negative results are more likely to be published D. studies on important clinical questions are more likely to be published E. the prestige of the journal will affect readers' perception of the quality of the study |
B
Myles and Gin. p.34 "Publication bias -- where negative studies are less likely to be submitted, or accepted, for publication" |
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An 8-year-old boy, weighing 25 kg, is undergoing a
laparotomy for excision of an hepatic tumour. A blood gas sample taken during the procedure shows a haemoglobin level of 65 g.1-1. Assuming no further blood loss, what volume of packed red blood cells will raise the haemoglobin to 90 g.1-1? A. 100 ml B. 150 ml C. 250 ml D. 350 ml E. 450 ml |
C
Similar to previous question: 4ml/kg of packed cells will increase Hb by 10g/L So 100ml will increase Hb by 10 Therefore 250ml will increase Hb by 25 |
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Which of the following statements regarding Marfan's
syndrome is FALSE? A. aortic valve involvement results in significant aortic stenosis B. cardiovascular manifestations are due to cystic medial necrosis C. catastrophic aneurysm and/or dissection of the aortic and pulmonary arteries may occur D. iliac artery aneurysm is an associated feature E. mitral valve disease with prolapse is more common than in the general population |
A
- A: aortic root dilatation causes aortic regurgitation not stenosis - B: Cystic medial necrosis is the hallmark histologic change associated with dissection in those with Marfan syndrome - C: True - D: Lots of case reports of this - E: Mitral regurgitation due to mitral valve prolapse is a common abnormality |
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Which one of the following is most likely to be associated
with a high mixed venous oxygen saturation (Sv02)? A. acute myocardial infarction B. acute pulmonary embolism C. cardiac tamponade D. sepsis E. severe liver disease |
D
Oh’s ICU “a raised SvO2 (>75%) will imply low demand, eg. Hypothermia, or a cellular utilisation problem, easily explained in cyanide poisoning when the oxidative phosphorylation mechanism is inhibited, but much more difficult to rationalise when it is seen (commonly) in sepsis” Although apparently it can occur in severe liver disease also |
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Severe hypotension associated with tumour handling in a
patient undergoing liver resection for carcinoid tumour is best treated with A. angiotensin B. aprotinin C. metaraminol D. noradrenaline infusion E. octreotide |
E
Stoelting “the occurrence of intraoperative carcinoid crisis manifesting as bronchospasm or hypotension is treated with IV octreotide 100-200 mcg” |
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Regarding patients aged 65 years or older with recurrent
atrial fibrillation (AF) A. amiodarone and digoxin have similar efficacy in restoring sinus rhythm B. patients who have been reverted to sinus rhythm should still remain on warfarin therapy C. patients who remain in atrial fibrillation with heart rates less than 80 beats per minute do NOT require long term warfarin therapy D. peri-operative therapy with a beta-blocker will commonly lead to restoration of sinus rhythm E. restoration of sinus rhythm with electrical DC cardioversion improves long-term survival in comparison to controlling heart rate alone |
B
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You are commencing general anaesthesia for a 2-year-old
child to allow biopsy of an anterior mediastinal mass. A pre-operative CT scan demonstrated compression of the lower trachea and the carina by the mass. During inhalational induction, the child desaturates to 70% due to airway compression by the mass. You should A. apply continuous positive airway pressure (CPAP) via facemask B. arrange urgent median sternotomy C. intubate the patient and allow spontaneous ventilation D. intubate the patient and provide positive pressure ventilation E. place the patient in the prone position |
E
This answer appears to be E as this will relieve any obstruction caused by the mass. Placing an ETT will not help as the obstruction in beyond the carina. A median sternotomy will take time if surgeons not already scrubbed and prepped. One of the classical teachings with anterior mediastinal masses is that despite appropriate CPAP, intubation, ventilation the cardiorespiratory collapse is not improved. Often made worse by paralysis (NMBD's). The below reference seems to agree. Miller says: "The operating room team should retain the capability of changing the patient's position rapidly to the lateral or prone position" |
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With respect to gastric volumes and fasting in children,
A. casein-predominant milks empty faster than whey¬predominant milks B. children have a higher incidence of aspiration than adults C. solids rely on first order kinetics for gastric emptying but liquids follow zero order kinetics D. the rate of gastric emptying is NOT related to the energy content of the meal E. unlimited clear fluid ingestion 2 hours before surgery does NOT affect volume, but does affect the pH of stomach contents |
B
A. False for second half • Human milk and whey predominant formula empty faster than casein predominant formular and cow's milk. B. TRUE • Paediatric aspiration is slightly more common than in adults (1 per 1200–2600 compared to 1 per 2000–3000 in adults) C. False • Solids follow zero order (linear decay) kinetics and liquids first order (exponentail decay), in regards to stomach emptying. D. False. It is: Solutions that are hypertonic, contain acid, fat, or certain amino acids all retard gastric emptying. High lipid and/ or caloric content (glucose) slows the emptying of solids from the stomach (Stoelting Pharm & Phys p839) E. False • Clear fluids up to 2 hrs preop do not increase gastric volume or significantly change gastric pH (there may be an increase in pH with clear fluids up to 2 hrs) |
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An 80 year-old man is undergoing bilateral orchidectomy.
You have administered spinal anaesthesia using heavy bupivacaine with the patient in the sitting position. The minimum adequate block for this procedure can be presumed when you can demonstrate a loss of skin sensation at the A. symphysis pubis B. midpoint between the symphysis pubis and the umbilicus C. umbilicus D. xiphisternum E. nipple |
C
Need block to T9/10 (OHA pg 641) = umbilicus • Xiphisternum = T6 • Nipple = T4 • Midway between pubis & umbilicus = T11/12 • Pubis = L1 |
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A 33-year-old chronically spinally injured patient becomes
hypertensive and sweaty during general anaesthesia for urinary sphincterotomy. His level of spinal cord injury is T4 and it is complete. You consider the diagnosis of autonomic hyperreflexia. Autonomic hyperreflexia A. could have been prevented by performing subarachnoid anaesthesia B. is unlikely with a T4 level lesion C. should be treated by administration of a beta-blocker D. should be treated by administration of an opioid analgesic E. will resolve once the surgical stimulus ceases |
A
A - True • "Spinal anaesthesia...can reliably prevent autonomic dysreflexia and spasm"...Anaesthesia for Patients with Chronic Spinal Cord Injury; CEACCP 2001 B - False • "Increased sensitivity of sympathetic reflexes in patients with spinal cord injury above T5/6” Yentis 3rd Ed p51 C – False • "Nifedipine (10mg SL) or GTN (SL or TD) or alpha-blockers are all used in first-line therapy" CEACCP D - False E - False (?) • 'Management of an episode of autonomic dysreflexia should always begin with removal of the precipitating stimulus, if known. This alone may be sufficient and blood pressure often returns to baseline levels immediately.'...'Anaesthesia for chronic spinal cord lesions' Hambly, P. R., Martin, B Anaesthesia Volume 53(3) March 1998 pp 273-289 |
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A morbidly obese 140kg, 40-year-old male is scheduled for
cholecystectomy. He has no history of cardiac disease. His ideal body weight is 70kg. Compared to his resting cardiac output at ideal body weight, his resting cardiac output at his weight of 140 kg would be A. decreased by 20% or more B. decreased by 10% C. unchanged D. increased by 10% E. increased by 20% or more |
E
Not completely clear, though: • Stoelting suggest CO increases 0.1L/min per kg fat • BJA article suggests 20-30ml/min per kg of fat, Volume 85, Number 1 Pp. 91-108 |
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Following a VT (ventricular tachycardia) arrest, a 1-year-old
girl has received two DC shocks, then one dose of adrenaline 100 micrograms, followed by a further DC shock. The next step in her treatment should be A. adrenaline 100 micrograms B. adrenaline 1000 micrograms C. amiodarone 50 milligrams D. DC shock 20 J E. DC shock 40 J |
C
As per resus guidelines - Amiodarone should be given after the 3rd shock |
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Which of the following statements regarding infection
control is FALSE? A. devices to be used in the upper airway that may cause bleeding must remain sterile until used B. provided there is an adequate filter between the patient and the breathing circuit, the circuit can be re-used for subsequent patients on an operating list C. when performing central neural blockade, the anaesthetist must adopt a full aseptic technique D. when performing central venous cannulation, the anaesthetist must adopt a full aseptic technique E. when performing vascular cannulation, the anaesthetist must wash hands and should wear gloves |
A
ANZCA PS Document 28 3.1 INVASIVE PROCEDURES 3.2.2 Devices to be sited in the upper airway Devices passing through the mouth or nose will become contaminated in the upper airway. Endotracheal tubes, nasal and pharyngeal airways should be kept sterile until used. Reusable face masks must be thoroughly decontaminated and then undergo disinfection prior to each use. Items to be placed in the upper airway which may cause bleeding e.g. laryngoscope blades and temperature probes, must be disinfected before reuse. It is not ordinarily necessary to package these items separately while they await their next use. Where the manufacturer advises that a particular piece of equipment is to be sterilised before use, e.g. the laryngeal mask, that advice is to be followed. Laryngoscope handles should be decontaminated between uses. There should be separation of unused items and soiled items during use. |
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Pneumoperitoneum for laparoscopy is commonly associated
with an INCREASE in each of the following EXCEPT A. arterial pressure B. inotropic state C. secretion of vasopressin D. systemic vascular resistance E. venous resistance |
B
According to Miller inotropy is decreased, vasopressin is increased |
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Regarding non-obstetric abdominal laparoscopic surgery
during the second trimester of pregnancy A. carbon dioxide pneumoperitoneum induces foetal acidosis B. fetal heart rate is depressed if maternal intra¬abdominal pressure reaches 12 mmHg C. mechanical ventilation during general anaesthesia should be used to maintain a maternal arterial PaCO2 of 40 mmHg D. premature labour is a common complication unless prophylactic tocolytics are used E. the risk of miscarriage or premature labour is NOT increased |
A
A true B IAP of 12 would increase SVR and MAP, so I don’t think it will affect foetus C ?less than this D true for all surgery with advanced gestational age (predispose to premature labour). Laparoscopic is meant to have reduced incidence, but not proven. E true if intra-abdominal pressure <20mmHg |
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A healthy female patient is undergoing a laparoscopic
sterilisation under a relaxant based general anaesthetic. Which of the following monitors does NOT have to be in continuous use? A. capnograph B. electrocardiogram C. oximeter D. oxygen analyser E. ventilator disconnect alarm |
B
ANZCA PS18 3. MONITORING EQUIPMENT In general, monitoring equipment aids the clinical assessment of a patient and the following equipment should be available for use on every patient undergoing anaesthesia. However, depending on the type of anaesthesia, some of these monitors are mandatory (please refer to those specific monitors). When the monitors are in use on a patient, the alarms (visual and audible) must be enabled and appropriate (refer section 1.5). The audible component of the alarm system must be able to be heard by the practitioner respsonsible for the anaesthesia. When any of the monitors of physiological function are in use during anaesthesia, regular recordings should be documented in the anaesthesia record. 3.1 Oxygen Analyser A device incorporating an audible signal to warn of low oxygen concentrations, correctly fitted in the breathing system, must be in continuous operation for every patient when an anaesthesia breathing system is in use. 3.2 Breathing System Disconnection or Ventilator Failure Alarm When an automatic ventilator is in use, a monitor capable of warning promptly of a breathing system disconnection or ventilator failure must be in continuous operation. This must be automatically activated. 3.3 Pulse Oximeter Pulse oximetry provides evidence of the level of oxygen saturation of the haemoglobin of arterial blood at the site of application and may identify arterial pulsation. A pulse oximeter must be in use for every patient undergoing general anaesthesia or sedation. When this particular monitor is in use, the variable pulse tone as well as the low threshold alarm shall be appropriately set and audible to the practitioner responsible for the anaesthesia. 3.4 Electrocardiograph Equipment to monitor and continually display the electrocardiograph must be available for every anaesthetised patient. There should be a 5-lead option available for every patient. 3.5 Intermittent Non-Invasive Blood Pressure Monitor Equipment to provide intermittent non-invasive blood pressure monitoring must be available for every patient undergoing anaesthesia. A variety of cuff sizes must be available. 3.6 Continuous Invasive Blood Pressure Monitor Equipment to provide continuous invasive blood pressure monitoring should be available. In most cases, this refers to a monitor connected via a transducer to an intra-arterial line. 3.7 Carbon Dioxide Monitor A monitor of the carbon dioxide level in inhaled and exhaled gases must be in use for every patient undergoing general anaesthesia. 3.8 Volatile Anaesthetic Agent Concentration Monitor Equipment to monitor the concentration of inhalational anaesthetics must be in use for every patient undergoing general anaesthesia from an anaesthesia delivery system where volatile anaesthetic agents are available. Automatic agent identification should be available on new monitors. 3.9 Temperature Monitor Equipment to monitor “core” temperature continuously must be available for every patient undergoing general anaesthesia. 3.10 Neuromuscular Function Monitor Equipment to monitor neuromuscular function must be available for every patient in whom neuromuscular blockade has been induced. 3.11 Monitor of Anaesthetic Effect on the Brain When clinically indicated, equipment to monitor the anaesthetic effect on the brain should be available for use on patients at high risk of awareness during general anaesthesia. 3.12 Other Equipment When clinically indicated, equipment to monitor other physiological variables (e.g. the electroencephalogram, central venous pressure, transoesophageal echocardiogram, cardiac output monitor or respiratory mechanics) should be available. |
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A 65-year-old male presents with acute aortic regurgitation
due to ascending aortic dissection. He is in pulmonary oedema. He has a blood pressure of 160/80 and a pulse rate of 100 per minute. While awaiting surgery, the most appropriate therapy would be A. aortic balloon counter pulsation (IABP) B. beta-blockade C. dobutamine D. dopamine E. sodium nitroprusside |
E
Though potentially C ACC/AHA 2006 Guidelines “Nitro- prusside, and possibly inotropic agents such as dopamine or dobutamine to augment forward flow and reduce LV end- diastolic pressure, may be helpful to manage the patient temporarily before operation. Intra-aortic balloon counterpul- sation is contraindicated. Although beta blockers are often used in treating aortic dissection, these agents should be used very cautiously, if at all, in the setting of acute AR because they will block the compensatory tachycardia.” |
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Which one of the following statements concerning tramadol
is FALSE? A. it has an active metabolite B. it inhibits serotonin and noradrenaline reuptake C. it is LESS likely (at normal doses) to cause respiratory depression than other opioid agonists D. it is metabolised in the liver and excreted by the kidneys E. it structurally resembles codeine |
E
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A term baby with a congenital diaphragmatic hernia is
initially stable, requiring only increased ambient oxygen to maintain Sa02 > 95%, however he develops increasing respiratory distress. Your approach to intubation should be A. awake intubation B. gaseous induction with CPAP (continuous positive airway pressure) C. mask hyperventilation prior to intubation D. rapid sequence induction E. trial of nitric oxide before intubation |
A
Miller pg 2396: "Anesthesia management of patients with diaphragmatic hernia includes the following: an awake intubation without bag and mask ventilation prevents overdistention of the stomach and herniation across the midline" |
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A 6-year-old child is referred via the orthopaedic clinic for
closed reduction under general anaesthesia of a forearm fracture, sustained 2 days earlier. He is an asthmatic, usually well controlled, but has a current upper respiratory tract infection. He is on salbutamol 2 puffs twice a day, and on auscultation his chest is clear. He is adequately fasted and can proceed to theatre immediately. The best choice for airway management of this child is A. endotracheal intubation and controlled ventilation B. endotracheal intubation and spontaneous ventilation C. facemask and spontaneous ventilation D. laryngeal mask airway and spontaneous ventilation E. ProsealTM laryngeal mask airway and spontaneous ventilation |
C
Ideally aim not to instrument the airway in a patient with asthma and an URTI. Should be a short procedure, and there is no increased aspiration risk |
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Acute compartment syndrome in the lower limb
A. can be reliably detected by loss of peripheral pulses B. does NOT occur after open fractures of the tibia C. is a contraindication to regional anaesthesia D. is often associated with pain on passive stretching of the affected compartment E. occurs more commonly in patient over 35 years of age |
D
Acute compartment syndrome of the leg. Editorial BMJ 2002;325:557–8 “The essential clinical feature of compartment syndrome in conscious patients is severe pain out of proportion to the injury, aggravated by passive muscle stretch. Sensory loss in the distribution of the nerves traversing the affected compartments may be a useful early sign. The diagnosis may be difficult in the presence of impaired consciousness, in children, and in patients with regional nerve blocks” |
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Naltrexone
A. given as a single usual dose, blocks the pharmacological effects of opioids for approximately 8 hours B. has minimal hepatotoxic effects, even at high doses C. is a mixed opioid agonist/ antagonist D. is predominantly metabolised in the kidney E. is used in the treatment of alcohol dependency |
E
• A: False. "Clinical studies indicate that Revia (Naltrexone) 50 mg will block the pharmacological effects of 25 mg of intravenously administered heroin for periods as long as 24 hours. Other data suggest that doubling the dose of Revia provides blockade for 48 hours, and tripling the dose of Revia provides blockade for about 72 hours." Mims Online. • B: False. "Naltrexone has the capacity to cause hepatocellular injury when given in excessive doses. Naltrexone is contraindicated in acute hepatitis or liver failure, and its use in patients with active liver disease must be carefully considered in light of its hepatotoxic effects." Naltrexone Product Information. • C: False. "Revia is a pure opioid antagonist. It markedly attenuates or completely blocks, reversibly, the subjective effects of all opioids." Mims Online. • D: False. "Naltrexone is metabolised mainly to 6β-naltrexol by the liver enzyme dihydrodiol dehydrogenase." Wikipedia. • E: True. "Uses/Indications: Alcohol dependence (within treatment program); adjunctive therapy in maintenance of former opioid dependent patients." and "The mechanism of action of Revia in alcoholism is not understood; however, involvement of the endogenous opioid system is suggested by preclinical data." Mims Online. |
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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 |
B
Anaesthesia for telescopic procedures in the thorax British Journal of Anaesthesia 1998; 80: 223–234 Table 1 Major complications of mediastinoscopy: (by kind permission of J. L. Benumof) Haemorrhage Pneumothorax Recurrent laryngeal nerve injury Air embolism Compression of vessels a. Aorta → reflex bradycardia b. Innominate artery ( R brachiocephalic trunk) c. Right carotid → hemiparesis d. Right subclavian → loss of right radial pulse Compression of trachea Infection, tumour spread |
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Which of the following statements regarding the use of
epidurally administered adjuvant drugs with epidural analgesia for acute postoperative pain is FALSE? A. adrenaline added to the local anaesthetic improves thoracic epidural analgesia B. clonidine added to epidural opioids improves analgesia C. clonidine prolongs the effects of epidural local anaesthetics D. ketamine added to opioid based epidural analgesia improves analgesia E. neostigmine combined with an epidural opioid reduces the dose of opioid required |
B
A: True - in thoracic epidural infusions used after surgery the addition of adrenaline improved analgesia B: False - no evidence that clonidine will improve a block, only prolong it. C: True - clonidine prolongs the analgesic effect of epidural LA D: True - combination of ketamine for epidural analgesia improves pain relief E: True - epidural neostigmine combined with an opioid reduces the dose of epidural opioid that is required From Acute Pain Manual: 2nd ed (2005) Pg 80: “Whilst the addition of clonidine prolongs the effect, regarding efficacy the AP Book says Evidence that the addition of clonidine to an epidural ... is more effective than clonidine or the opioid alone is weak and inconsistent (Level 1). So B is false - (note that quality and duration of block are different things)” |
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Regarding chemotherapy agents,
A. azathioprine is a cholinesterase inhibitor and may interact with suxamethonium B. bleomycin may have an idiosyncratic (i.e. not dose related) association with progressive respiratory fibrosis C. cyclophosphamide has NO known interactions with neuromuscular blocking agents D. high cumulative doses of doxorubicin are associated with cardiomyopathy E. nonsteroidal anti-inflammatory drugs (NSAIDs) do NOT interact with methotrexate |
D
• A – False. • B – False. Has dose-related pulmonary toxicity. Stoelting p 564 • C – False. Cyclophosphamide is a cholinesterase inhibitor • D – True. Stoelting p 563 • E – False. Methotrexate is associated with renal toxicity, and so are NSAIDS – they worsen renal function when used together |
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A 40-year-old caucasian male presents to the pre-operative
assessment clinic 2 days prior to his elective laparoscopic cholecystectomy. He has had no recent symptoms from his cholelithiasis. His body mass index (BMI) is 29 kg.m-2 and he has a 12-month history of type 2 diabetes. He drinks approximately 40 grams of alcohol per week and has been taking amoxicillin with clavulanic acid for 7 days for a respiratory tract infection, which has now resolved. Routine pre-operative liver function tests (LFTs) are as shown (normal ranges in brackets) Gamma GT: 322 IU.1-1 (10-70) Alk Phos: 3161U.1' (50-130) ALT: 30 IU.1-1 (<45) AST: 25 IU.1-1 (<40) Bilirubin: 10 mmo1.1-1 (<20) Albumin: 39 g.1-1 (35-50) Full blood count and coagulation studies are normal. The most appropriate management relating to these LFTs would be to A. assume the abnormalities are reversible and drug related and proceed with surgery B. postpone his surgery until a hepatobiliary ultrasound can be performed C. proceed with surgery but administer peri-operative thiamine D. reconsider the indication for surgery because the patient has early cirrhosis and is at increased risk of peri-operative complications E. screen for viral hepatitis serology before surgery |
B
Obstructive LFT pattern – pre-op ERCP may be indicated |
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Regarding the normal term infant
A. foetal haemoglobin (HbF) comprises approximately one-third the total haemoglobin at birth and falls to negligible levels by 3 months of age B. foetal haemoglobin (HbF) comprises approximately 70% of the total haemoglobin at birth and falls to negligible levels by 6 months of age C. haemoglobin level below 90g.1-1 at 9-12 weeks (physiological anaemia) is common and does NOT require investigation D. normal haemoglobin at birth should be greater than 200 g.1-1, unless there has been delay in umbilical cord clamping E. total blood volume is approximately 70 ml.kg-1 body weight |
B
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Which of the following statements regarding transient
neurological syndrome (TNS) following spinal anaesthesia is FALSE? A. it is more common in patients placed in the lithotomy position B. it is more common following lignocaine C. it is unlikely to be due to neurotoxicity D. it may progress to cauda equina syndrome E. it resolves within 72 hours in the majority of patients |
D
A. - True – Lithotomy worse than prone B. – True – is more likely with Lignocaine, mostly with 2-5% C. – True – pain in the back, buttocks, and thighs mirrors the distribution of nerve damage in cauda equina syndrome sufficiently to support the theory that the nerves are indeed irritated by a noxious intrathecal injection D. – False – Cauda Equina Syndrome from from neurotoxicity with 5% Lignociane E. – True – most resolve within 3 days, rarely persist after a week TRANSIENT NEUROLOGIC SYNDROME • Transient Radicular Irritation • not associated with any detectable neurologic deficit • pain in the back, buttocks, and thighs mirrors the distribution of nerve damage in cauda equina syndrome sufficiently to support the theory that the nerves are indeed irritated by a noxious intrathecal injection. • Symptoms in 12 to 24 hrs - most often resolve in 3 days, and rarely persist beyond a week. • In addition to the use of intrathecal lidocaine, cofactors that contribute to the occurrence of TNS include the lithotomy position, positioning for knee arthroscopy, and outpatient status • No effect – LA concentration, the presence of glucose, Adr, and technique-related factors such as the size or type of needle do not alter the incidence of TNS. • risk factors for cauda equina syndrome and transient neurologic syndrome similar • Occurred after 2% as well as 5% lidocaine - bupivacaine is relatively blameless (near zero incidence) • Parturients may be at lower risk than other surgical patients |
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Possible mechanisms of postoperative visual loss include
each of the following EXCEPT A. atherosclerosis causing decreased blood flow to the optic nerve B. fluid overload C. isovolaemic haemodilution D. posturally induced raised venous pressure E. variations in the number of posterior ciliary arteries |
C
Postoperative ischaemic optic neuropathy" (Anes Analg 1995 (80)1018-29 ), CEACCP 2006 "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. The cause-and-effect relationships associated with ION are uncertain, but low arterial pressure, low hematocrit, and lengthy surgical procedures are statistically associated with the phenomenon." (Miller Ch 63) |
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Which of the following statements regarding patients with
ankylosing spondylitis is FALSE? A. amyloid renal infiltration is rarely seen B. cardiac complications occur in less than 10% of cases C. normochromic anaemia occurs in over 85% of cases D. sacroileitis is an early sign of presentation E. uveitis is the most common extra-articular manifestation |
C
eMedicine • A. True - Amyloidosis is a rare complication of long-standing disease and can lead to renal failure • B. TRUE - <5% according to Yentis, Cardiac involvement is 3.5(15yrs)-10%(30yrs) • C. FALSE- certainly occurs, but not sure of rate - 85% seems high. "a normochromic, normocytic anaemia is present in 15% of patients with ankylosing spondylitis" • D. True - is a feature; usually first presenting sign • E. True- Anterior uveitis is the most common extra-articular manifestation of the disease and affects approximately 20% of patients |
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Regarding spinal cord blood supply, the
A. anterior spinal artery arises from the posterior inferior cerebellar arteries B. anterior spinal artery supplies 50% of the spinal cord, while the 2 posterior spinal arteries supply 25% each C. largest radicular artery is usually in the lumbar region D. posterior spinal arteries are only supplied by radicular arteries E. upper cervical segment of the spinal cord receives most of its blood flow from the vertebral arteries |
E
• A – False – ant. Spinal artery formed from 2 branches of vertebral arteries • B – False - ant supplies 2/3, posterior 1/6 each • C – False - Largest (most important) radicular branch – Artery of Adamkiewicz from T1 and lower thoracic/upper lumbar level. • D – False – post. Spinal arteries arise from vertebral arteries • E – True – in neck ant 2/3 cord supplied by vertebral aretery and posterior 1/3 from PICA |
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In acute coronary syndromes with ST elevation on ECG
A. aspirin should be administered only after reperfusion strategies have commenced B. patients can wait up to 24 hours from onset of ischaemic symptoms before implementation of a reperfusion strategy C. patients should have elevated cardiac enzymes before proceeding to reperfusion strategies D. patients undergoing reperfusion strategies should have aspirin or clopidogrel but NOT both E. percutaneous coronary intervention is preferable to fibrinolytic therapy |
E
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A young woman with type 1 von Willebrand disease
presents for a dilatation and curettage. She is a Jehovah's Witness. You consider administering intravenous desmopressin in an attempt to reduce haemorrhage. Which of the following statements regarding desmopressin is FALSE? A. it is a synthetic substance and is acceptable to Jehovah's Witnesses B. it is likely to reduce haemorrhage in this patient C. it should be given 30 minutes prior to surgery as an infusion D. its duration of effect is approximately 5 days E. the intravenous dose is 0.3 mcg.kg-1 |
D
• A. – True – DDAVP is synthetic • B – True – reduces bleeding in vWD by increases FVIII and vW Factor levels by 2-4 times • C – True - give 30- 60 mins per-op as iv infusion • D – False - The duration of drug effect is 8 to 20 hours, with much individual variation – MIMS Online • E - True – true statement. dose |
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Regarding the use of epidurals for post-operative analgesia,
A. epidural analgesia following bowel surgery may increase the risk of anastomotic leakage B. epidurals have similar analgesic efficacy to intravenous PCA (patient controlled analgesia) with morphine C. studies show the overall failure rate of epidurals to be less than 2% D. the incidence of pulmonary infections with epidural local anaesthetics is LESS than that with parenteral opioids E. the incidence of significant epidural haematoma is NOT affected by concomitant anti-thrombotic therapy |
D
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When optimising patients for surgery using goal-directed
therapy, which of the following parameters is LEAST useful? A. blood pressure B. cardiac index C. oxygen saturation of blood aspirated from a central venous catheter D. oxygen saturation of blood aspirated from the distal port of a pulmonary artery catheter E. stroke volume variability |
E
Early Goal-Directed Therapy in Severe Sepsis and Septic Shock Revisited: Concepts, Controversies, and Contemporary Findings (Chest 2006) Early Goal-Directed Therapy (EGDT) : CVP, MAP, SvO2 (either central or mixed venous). |
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The best indicator of adequacy of fluid resuscitation in the
trauma patient is A. arterial pH B. blood pressure C. core temperature D. pulse rate E. serum lactate level |
E
Fluid management for trauma; where are we now? CEACCP 2006 “After definitive control of haemorrhage, the emphasis of resuscitation shifts to the restoration of normal tissue perfusion. The phenomenon of ‘occult hypoperfusion’ has been used to describe patients (specially young patients) who reach the ICU with normal vital signs, but persistently elevated serum lactate.7 These patients are hypovolaemic owing to under-resuscitation, but supporting their blood pressure on the basis of profound vasoconstriction. If not promptly recognized, this situation creates the potential for sustained shock, organ system failure and death. When receiving such a patient, it is imperative that the ICU practitioner examines the patient’s arterial blood gas and serum lactate concentration for any evidence of persisting anaerobic metabolism. If present, the patient should be aggressively fluid resuscitated until the lactate concentration has cleared to normal” |
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A 50-year-old female patient presents with a 12 hour
history of feeling unwell and is found to fulfil the criteria for Systemic Inflammatory Response Syndrome. Her blood pressure is 80/45 mmHg, her pulse rate is 90 beats.min-1 and her central venous pressure is 12 mmHg. The hypotension is most appropriately managed with A. adrenaline B. dobutamine C. dopamine D. ephedrine E. noradrenaline |
E
NEJM Volume 345 : 1368-1377 Nov 8, 2001 Number 19 Early Goal Directed Therapy in the Treatment of Severe Sepsis and Septic Shock Refers to concept of early goal directed therapy, where 1 – filling until CVP 8-12 mmHg 2 – maintain 65 < MAP < 90 with either vasopressors or vasodilators à this is where this patient is at 3 – measure ScVO2 – if < 70%, measure Hct, if Hct < 30%, then transfuse 4 – if ScVO2 still < 70%, then start dobutamine |
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An 85-year-old woman requires an emergency repair of an
obstructed inguinal hernia. She has recently suffered a pulmonary embolus and is taking warfarin. You elect to perform an inguinal field block. Which of the following nerves does NOT need to be blocked? A. iliohypogastric B. ilioinguinal C. ilioinguinal of the contralateral side D. femoral E. subcostal |
D
OHA p1096: Inguinal field block : iliohypogastric, ilioinguinal and genitofemoral nerves plus branches from overlapping intercostal nerves supply the inguinal region. |
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A 4 year old boy (D) presents for insertion of grommets. His
maternal great-grandfather (A) is known to have had an episode of malignant hyperthermia (MH). Which of the following is the strongest evidence that the boy is NOT susceptible to MH? A. the boy was exposed to halothane at age 2 years with no sequelae B. the boy has recently been shown to have a normal serum creatinine kinase C. the boy's grandfather (B) has had a negative muscle-contracture test for MH D. the boy's mother (C) has had negative molecular genetic testing for MH E. there have been NO other episodes of MH in the family despite exposure to known triggers on multiple occasions |
C
A – false. previous exposure to GA does not rule out susceptibility to developing MH B – false. low sensitivity test C – true. The most sensitive test for MH that we have, and the value of the test lies in ruling out MH susceptibility D – false. genetic testing has low sensitivity, only about 25%, due to large number of mutations in the RYR-1 gene responsible for most cases of MH. Sensitivity should improve as more mutations identified. Yao p 1097 E – false. |
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The LEAST desirable position for the tip of a central venous
catheter which has been inserted into the left internal jugular vein is A. mid-way along the left brachiocephalic vein B. at the junction of the left brachiocephalic vein and the superior vena cava (SVC) C. in the SVC at the level of the carina D. at the junction of the SVC and the right atrium E. in the right atrium |
B
Zone A represents the lower SVC and upper RA. In this zone CVCs placed from the left side are likely to lie parallel to the vessel walls. However, a part of this zone lies within the RA and therefore within the pericardial reflection. This may represent a necessary compromise for left-sided CVCs to ensure they lie parallel to the vessel wall. Zone B represents the area around the junction of the left and right innominate veins and the upper SVC. This is a suitable area for CVCs placed from the right side, however left-sided CVCs will enter this area at a steep angle and are at risk of abutting the lateral wall of the SVC and should ideally be advanced into zone A. Zone C represents the left innominate vein proximal to the SVC. CVCs in zone C are probably suitable for short-term fluid therapy and CVP monitoring, but not for inotrope infusions or long-term use. |
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Which of the following statements regarding anaphylactic
and anaphylactoid reactions is FALSE? A. cross-sensitivity between latex and bananas, chestnuts and avocado has been reported B. cross-sensitivity of cephalosporins with penicillin is about 8% C. gelatin solutions used for resuscitation can worsen any reaction D. reactions to neuromuscular blocking agents are more common in females E. vecuronium is more likely to cause an anaphylactoid rather than an anaphylactic reaction |
E
Anaphylaxis, CEACCP 2004 • A "There is a recognized cross-reactivity between latex sensitivity and certain foods, especially bananas, chestnuts and avocado." • B. "Penicillins are most frequently implicated in hypersensitivity reactions. The incidence of cross-reactivity with cephalosporins is about 8%." However, I’m sure this is now considered fase • C. "Fluids used for resuscitation after anaphylaxis may themselves cause histamine release and worsen any reaction. The risk is greatest with gelatin solutions." • D. "This could explain why anaphylaxis to neuromuscular blocking agents is five to ten times more common in females." • E. "Steroid-based compounds (vecuronium and pancuronium) cause anaphylactic reactions, whereas benzylisoquinoliniums (mivacurium and atracurium) tend to cause anaphylactoid reactions." |
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You are asked to see a 60-year-old male 2 days following a
cervical laminectomy because he has 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 a 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 muscle E. weakness of the first dorsal interosseous muscle |
D
• A - False (supplied by ulnar (C7, C8, T1)). • B - False (C6/C7 dermatome à not useful). • C - False (not useful - all interosseous muscles innervated by ulnar). • D - True (this muscle is innervated by the MEDIAN Nerve (C5,C6,C7,C8,T1) - if ulnar nerve injury was the cause this muscle would be preserved, if C8/T1 root was injured this muscle will be affected). • E=False (innervated by ulnar). Mnemonic: A good way to remember what muscles are in the thenar eminence is "OAF"; oafs have big thenar eminences. 'O' = opponens, 'A' = abductor, 'F' = flexor. There is only one opponens. The other two muscles each have a long partner and thus are called "brevis." Meat-LOAF: the "M" in the word "Meat" helps you remember that the LOAF muscles of the hand are innervated by the Median Nerve ABOF (pronounced "above") the Law muscles. The law states muscles of the hand are supplied by ulnar nerve. However, ABOF the Law muscles are supplied by MEDIAN nerve. 'AB' = abductor, 'O' = Opponens, 'F' = Flexor, Law 'L' = Lateral Lumbricals |
