1
Q
f15B-1 Consider the following arterial blood gases. (Ref ranges in brackets) pH 7.28 PaCO2 36 Bicarbonate 18 mmol.l-1 (18-25) Base excess -7 mmol.l-1 (-4- +3) Na+ 142 mmol.l-1 (135-145) Cl- 112 mmol.l-1 (98-110)
These blood gases are consistent with
A. acute renal failure B. diabetic ketoacidosis C. ethylene glycol overdose D. intraoperative infusion of 6 litres of normal saline E. salicylate overdose
A
A. Acute renal failure (renal tubular acidosis)
? Could also be due to excessive administration of NaCl, although the chloride does not seem high enough to explain the acid-base derangement.
Partially compensated metabolic acidosis.
Anion gap = 142 - (112 + 18)
= 12
= normal
Causes of normal anion gap metabolic acidosis:
- excessive chloride administration
- loss of bicarb (e.g. from GIT or kidneys)
- renal tubular acidosis
2
Q
- What is the most sensitive monitor for detecting a venous air embolus during neuroanaesthesia?
A transoesophageal electrocardiography (yes - it said electro) B precordial Doppler C precordial stethoscope D capnography E something else wrong
A
B. Praecordial Doppler
3
Q
- A 34 year old primigravida collapses soon after delivery of her baby, the presumptive diagnosis is amniotic fluid embolus. Which ONE of the following supports this diagnosis?
A markedly raised serum tryptase B decreased C3-C4 levels C thrombocytosis D raised CRP E hyperfibrinogenemia
A
B. Decreased C3-4 levels
4
Q
RH30 You are performing a peribulbar block for eye surgery. You decide to add hyalase to your local anaesthetic mix. What is the recommended concentration for hyalase?
A 25 U/ml B 50 U/ml C 100 U/ml D 150 U/ml E 1500 U/ml
A
A. 25 IU/mL
A lot of variation in the quoted concentrations.
Efficacy demonstrated at concentrations as low as 15 units/mL (Schulenburg, BJA 2007: Hyaluronidase reduces local anaesthetic volumes for sub-Tenon’s anaesthesia).
5
Q
- (repeat PZ106) A 25 year old male presents for ECT at a free standing facility. He has a life threatening depressive illness that has not responded adequately to medication, however he is still taking tranylcypramine. The most appropriate course of action is
A cancel the procedure, cease tranylcypramine and perform the ECT in 2 weeks
B proceed with the ECT, but induce with midazolam and remifentanil
C proceed with the ECT, but pre treat with esmolol
D proceed with the ECT with caution, but with your usual drugs
E transfer the patient to a tertiary centre for their ECT
A
D. Proceed with the ECT with caution, but with your usual drugs
6
Q
- A patient has suffered a cardiac arrest. They are intubated but there is no IV access. Which drug can be given down the ETT?
A Amiodarone B Calcium C Lignocaine D Magnesium E Sodium bicarbonate
A
C. Lignocaine
ARC guideline 2010 - Adrenaline, lignocaine and atropine may be given via endotracheal tube, but other cardiac arrest drugs should NOT be given endotracheally as they may cause mucosal and alveolar damage.
7
Q
- (repeat SO19) A well 65 year old is having a total hip replacement under GA with sevo/nitrous/fentanyl. BP is 130/70 and stable. Before the surgeon commences reaming and cementing, the best thing to do is
A Induce hypotension B Raise BP with vasopressors C Turn off nitrous D Give steroids E Give heparin 5000u
A
C. Turn off nitrous
(N2O increases PVR)
CEACCP 2012 - Bone cement and the implications for anaesthesia:
‘Clinical reports and studies all demonstrate the presence of RV failure secondary to increased pulmonary artery pressure as the underlying cause of systemic hypotension and sudden cardiac arrest.’
8
Q
- Pt in ICU in their 20s is diagnosed with brain death. History is that of immunosuppression for a renal transplant but otherwise well. Patient has expressed a desire to be an organ donor. All these organs can be donated except
A Bone marrow B Heart C Lung D Liver E Transplanted kidney
A
A. Bone marrow
Increased rate of haematological malignancy with long-term immunosuppression.
Australian Bone Marrow Donor Registry:
Exclusion criteria:
- Personal or family history of Creutzfeldt-Jakob disease (CJD), Gerstmann-Straussler-Scheinker syndrome (GSS) or Fatal Familial Insomnia (FFI)
- Thalassemia major, sickle cell disease, Fanconi anaemia or haemophilia
- Previous recipient of an organ transplant or corneal or dura mater graft
- Previous recipient of injections of human growth hormone for short stature or human pituitary hormone for infertility prior to 1986
- Previous stroke or a heart attack
- Previous cancer of any kind excluding non melanoma skin cancer (BCC/SCC) or premalignant conditions such as cervical changes
- Previous IVDU
9
Q
- What is the IV loading dose of paracetamol for a 16kg child?
A 20mg/kg
A
15 mg/kg
…I think, although I can’t find a source.
10
Q
- PL35 Local anaesthetic systemic toxicity (LAST) Intralipid initial dose in mL/kg
A 0.5 B 1 C 1.5 D 2 E 5
A
C. 1.5 mL/kg (of Intralipid 20%)
11
Q
- 15B-29 MELD score includes INR, Creatinine and
A Albumin
B Bilirubin
C AST
D Fibrin
A
B. Bilirubin
12
Q
- Factor V Leiden homozygote. By how much is the risk of post-operative DVT increased?
A 2x B 5x C 10x D 20x E 50x
A
E. 50x
(from Circulation patient information page:)
Heterozygous factor V Leiden increases the risk of developing a first DVT by 5- to 7-fold.
Homozygous factor V Leiden increases the risk of developing clots to a greater degree, about 25- to 50-fold.
Wiki:
People who inherit two copies of the mutation (homozygous), one from each parent, may have up to 80 times the usual risk of developing this type of blood clot.
13
Q
- 15B-43 Kessel Blade has the blade coming off the handle at a degree of:
A 80 B 95 C 110 D 135 E 150
A
C. 110 degrees
LITFL
14
Q
- Surgery planned under brachial plexus block performed at axilla. Pain is felt on incision at the anterolateral right forearm. Which nerve has been insufficiently blocked?
A Radial B Ulnar C Median D Musculocutaneous E Median brachial cutaneous (also remembered as axillary)
A
D. Musculocutaneous
15
Q
- – 55M ICH, ventilated, paralysed, sedated, ICPs persistently 25mmg
A cool to
B give hypertonic saline
A
B. Give hypertonic saline
(but maintain serum osmolality
16
Q
- – Best method to prolong apnoeic oxygen saturation in obese patient:
A position head up
B place in sniffing position
C prone
D lateral
A
A. Position head up
17
Q
- – Neonate (born at 40 weeks, now 7 weeks old) why to reduce morphine infusion rate compared with older child
A Increased morphine crossing BBB
B Increased total body water/decreased fat
C Decreased enzymatic hepatic function
D Increased morphine-3-glucuronide (definitely M3G)
A
C. Decreased enzymatic hepatic function.
Sims and Johnson:
Immaturity of the blood-brain barrier was once thought to be responsible for apparent sensitivity of the neonate to drugs such as morphine, but it is now understood that pharmacokinetic differences are responsible.
(reduced protein binding with higher free morphine concentration; reduced clearance of morphine and its metabolites)
Ratio of M6G:M3G is also higher in neonates (4:10) compared to adults (1:10)
18
Q
- Motor evoked potentials are used to monitor spinal cord function in scoliosis surgery. Which drugs affect them the LEAST?
A. Non-depolarising muscle relaxants B. Nitrous oxide C. Opioids D. Propofol E. Volatiles
A
C. Opioids
(from table in WFSA review 2015:)
Fentanyl and remifentanil: no effect Ketamine: +/- Propofol, benzodiazepines: ++ Iso, sevo, barbiturates: +++ Nitrous: ++++
19
Q
- At initiation of laparoscopy/pneumoperitoneum which of the following cardiovascular parameters is LEAST likely to increase?
A. Cardiac Output B. Mean Arterial Pressure C. Heart rate D. Myocardial filling pressures E. Systemic Vascular Resistance
A
A. Cardiac output
Cardiac output may increase initially due to shunting of splanchnic blood into the central compartment, but after this CO will decrease due to restriction of venous return (from IVC compression) and elevated SVR.
SVR and myocardial filling pressures definitely increase.
MAP usually increases (or stays the same).
HR usually increases, although vagal reflexes can occur from peritoneal stretch.
20
Q
- In order to use a 3 lead ECG setup to gain a CS5 view which of the following configurations would you use?
A. Lead I, RA lead below the clavicle, LA lead in the V5 position, LL at the hip
B. Lead I RA lead below the clavicle, LA lead at the hip LL in the V5 position
C Lead II RA lead below the clavicle, LA lead in the V5 position, LL at the hip
D Lead III RA lead below the clavicle, LA lead in the V5 position, LL at the hip
E Lead III RA lead below the clavicle, LA lead at the hip LL in the V5 position
A
A. Lead I; RA lead below the right clavicle, LA lead in the V5 position, LL lead at the hip
When a three-electrode ECG monitor is the only one available, it may be modified to allow approximation of stan- dard precordial lead positions. Lead I is selected, the positive exploring electrode (left arm) is located in the precordial V5 position, and the central negative electrode (right arm) may be placed in various positions on the thorax to achieve a central subclavicular (CS5), central manubrial (CM5), central chest (CC5), or central back (CB5) lead.
21
Q
110 – According to NAP4 what is the rate of failure for emergency cannula cricothyroidotomy?
A 10 B 20 C 40 D 60 E 80
A
D. 60%
There was a high failure rate of emergency cannula cricothyroidotomy, approximately 60%. There were numerous mechanisms of failure and the root cause was not determined; equipment, training, insertion technique and ventilation technique all led to failure.
In contrast a surgical technique for emergency surgical airway was almost universally successful. The technique of cannula cricothyroidotomy needs to be taught
and performed to the highest standards to maximise the chances of success, but the possibility that it is intrinsically inferior to a surgical technique should also be considered. Anaesthetists should be trained to perform a surgical airway.
22
Q
111 – Arndt bronchial blocker picture what is the straight port on the multi lumen connector for? (repeat)
A Connection of tracheal tube B Passage of nylon guide wire C Passage of fibreoptic D Passage of bronchial blocker E Connect circuit
A
C. Passage of fibreoptic bronchoscope
23
Q
- Which would be consistent with deep partial thickness burns?
(various combinations of whether painful or not, whether blanches or not, and how it looks +/- presence of blisters)
A Pain to deep pressure only, decreased capillary refill or doesn’t blanch?
B Blanches to pressure, very painful
C Painful to air, blanches to pressure with blisters?
D Painful to deep pressure, red and weeping/wet
E No pain, no CRT
A
A. Pain to deep pressure only, decreased capillary refill/doesn’t blanch
vicburns.org.au - deep partial thickness:
Involves epidermis and significant part of dermis, only deeper adnexal structures intact.
Blotchy red. May blister (large blisters which rupture within hours). No capillary refill/sluggish circulation.
Decreased sensation.
24
Q
- 50% burns in a patient weighing 70 kg, how much fluid to give in first 8 hours? (Repeat)
A 2.4 B 3.6 C 4.6 D 7L E 14L
A
Parkland:
4 x 70 x 50 = 14000 mL, 7000 mL in first 8 hours
…sounds like a lot
Modified Parkland probably more appropriate:
3 x 70 x 50 = 10500 mL, 5250 mL in first 8 hours
25
116. Patient with a large anterior mediastinal mass, develops hypoxia on induction, best management?
A Prone position
B Intubate and ventilate with IPPV
C Intubate and try to keep spontaneously breathing
D Deliver CPAP
A. Prone position
26
117 . Question about most common symptom associated with post-op neurological dysfunction
A Short term memory loss
B Agitation
C Hallucinations
D and E were less credible options I can't remember
A. Short term memory loss
CEACCP 2012: Cognitive decline after anaesthesia and critical care
Postoperative cognitive decline (POCD) can be defined as impairment of cognitive functions, including memory, learning, concentration, and speed of mental processing.
Affecting surgical patients in all age groups over the short term, POCD manifests days or weeks after surgery and shows faster resolution in younger populations, although it may be permanent. Usually expressed by patients as a new inability to complete once easily attainable tasks, symptoms include difficulty staying focused on a task, inability to multitask, difficulty finding words and recalling information recently acquired. In more severe cases, POCD can cause a catastrophic loss of cognitive function, with associated increased mortality, risk of prematurely leaving work, and dependence on social welfare.
27
118. Awareness incidence rate with GA under muscle relaxant from NAP5
```
A 1:1000
B 1:3000
C 1:8000
D 1:10,000
E 1:50,000
```
C. 1:8000
Discounting the Sedation cases, Unassessable and Unlikely reports, and the Statement Only cases (but including the Drug
Error and ICU cases) leaves 167 cases; yielding an incidence of patient reports of AAGA ~1: 17,000 (0.006%) general anaesthetics.
If drug swaps are excluded (as they are really examples of unintended paralysis rather than accidental awareness) this leaves 147 cases and an incidence of patient reports of 1:19,000 (0.005%). Both the number and the estimated incidence is remarkably close to the estimate from the Baseline Survey of 153 cases and ~1:15,000, respectively. The incidence using only Certain/probable and Possible reports is 1 in 20,000
There is a striking difference between the incidence of AAGA when no NMB is used (~ 1: 135,900) versus when an NMB is used (~1:8,200).
28
119. Propofol infusion syndrome involves all of the following except:
```
A Rhabdomyolysis
B Hepatomegaly
C Splenomegaly
D ST elevation
E Acidosis
```
C. Splenomegaly
(LITFL)
Propofol-related Infusion Syndrome is a life-threatening condition characterised by acute refractory bradycardia progressing to asystole and one or more of:
(1) metabolic acidosis
(2) rhabdomyolysis
(3) hyperlipidaemia
(4) enlarged or fatty liver
Investigations:
Bedside
- ECG: Brugada like pattern (coved type = convex-curved ST elevation in V1-V3), RBBB, arrhythmia, heart block
- blood gas: unexplained lactic acidosis; hyperkalaemia (if rhabdomyolysis or renal failure)
Laboratory
- lipids (lipaemic serum)
- UEC (renal failure)
- CK (rhabdomyolysis)
- propofol levels or chromatography (if available)
29
120 Pre-operative bowel prep:
```
A Reduces Mortality
B Reduces wound infection rates
C Reduces anastamotic leak rates
D Reduces re-operation rates
E Facilitates colonoscopy
```
E. Facilitates colonoscopy
CEACCP (2009) - Fast-track surgery and anaesthesia:
Bowel preparation is traditionally administered to all patients before colorectal surgery. However, a recent meta-analysis has demonstrated that, at least for segmental resections, bowel preparation may not be necessary and may increase the risk of septic complications and aggravate preoperative dehydration.
Australian Prescriber - Bowel preparation (2005):
Complete cleaning of the large bowel is essential for colonoscopy and radiological investigation of the colon (barium enema and more recently CT colonography). Bowel preparation has also traditionally been used prior to colonic surgery although the evidence for its benefit is scant.
30
124. AM51 How many vials of dantrolene should (according to guidelines from MH society) be kept at a remote hospital which has general anaesthesia services?
```
A 2
B 6
C 12
D 24
E 36
```
E. 36 (x 20 mg vials)
36 in remote locations, 24 in other places.
The following are the recommended contents of an MH Box:
Dantrolene
- 24 x 20 mg vials of Dantrolene
- Sterile water for injection (2000ml)clearly labelled as unsuitable for IV infusion
eg 250 ml bag from B/Braun or
100ml bottles of sterile water for parenteral injections (Pfizer)
- Drawing up needles (see above)
- 60 ml syringes 5-10
Include information on where to obtain additional dantrolene
Drugs
- 8.4% sodium bicarbonate (1mmol/ml)
- 50% dextrose 50 ml
- Lignocaine 1%
- Amiodarone 300mg
Cold Box in fridge
- 2 litres normal saline for IV use
- Actrapid insulin
Blood tubes for
- haematology, coagulation profile
- electrolytes, creatinine, urea, creatine kinase (CK)
- crossmatch
- blood gas syringes
Urine sample pot for myoglobin
Pathology forms (pre-written)
Task Cards (as described in the MH Resource kit instructions)
```
If space in your MH Box allows:
(otherwise, have instructions on where to find)
- Urinary catheter
- Urinary catheter and hourly urine bag
- Monitoring equipment
- Arterial line equipment
- Central line catheter
```
31
126. Pregnant patient, progressive dyspnoea. Which would most strongly warrant further investigation?
```
A soft 2/6 systolic ejection murmur
B elevated JVP
C third heart sound
D orthopnoea
E peripheral oedema at ankles
```
B. Elevated JVP
?orthopnoea
Mothers who develop incipient cardiac disease in late pregnancy are difficult to diagnose as symptoms are similar to the later stages of pregnancy i.e. shortness of breath, swollen ankles, fatigue, reduction in exercise capacity, murmurs, third heart sound and arrhythmias. Loud 4th heart sound, diastolic murmur, grade 3/6 systolic murmur, fixed splitting of second heart sound or opening snap should raise suspicion and appropriate investigations including ECG and echocardiography should be performed.
Peripheral oedema and orthopnoea are common in pregnancy, and do not necessarily indicate cardiac disease.
3rd heart sound can be normal, especially in young people and especially in people with hyper dynamic circulations (represents rapid ventricular filling)
32
140. How before return to normal platelet function in chronic diclofenac use.
```
A 12hrs
B 1-2d
C 4d
D 7d
E 10d
```
? B. 1-2 days
Hard to find a definitive reference, but the one below would suggest 1-2 days is a good guess.
Schafer, J Clin Pharmacol 1995 - Effects of Nonsteroidal Antiinflammatory Drugs on Platelet Function and Systemic Hemostasis:
Unlike aspirin, the effect of nonaspirin NSAIDs on platelets is reversible. Because these drugs reversibly inhibit platelet cyclooxygenase, function of the enzyme is restored as the drugs are cleared from circulation. Therefore, normal platelet function returns more rapidly after discontinuation of NSAIDs with shorter half-lives.
A study comparing ten commercially available NSAIDs administered to healthy human volunteers demonstrated considerable variability in extent and duration of their inhibitory effects on ex vivo platelet aggregation. As predicted, a single oral dose of aspirin abolished the second wave of aggregation in response to ADP and epinephrine, and it produced a long-lasting effect that persisted for 5 to 8 days. Additionally, piroxicam, naproxen, diclofenac, and indomethacin blocked ADP- or epinephrine-induced second-wave aggregation, and the abnormality persisted 3 days after piroxicam was discontinued and 2 days after naproxen, diclofenac, and indomethacin were discontinued. Ibuprofen and diflunisal produced a weaker but definite effect, which normalized within 24 hours of ingestion.
33
141. How long after starting a unit of FFP does it have to be completed
```
A 2hrs
B 4
C 6
D 8
E 10hrs
```
B. 4 hours
| All blood component transfusions should be completed within 4 hours of starting
34
142. You arrive to a code blue for a 5 year old child 16kg in a shockable rhythm. CPR has commenced, he has had TWO shocks already. What is the next step:
```
A Adrenaline
B Amiodarone
C Iv fluid bolus
D Shock 50j
E Shock 100j
```
A. Adrenaline 10 mcg/kg
35
143. FAST scan includes
A Pelvis, pericardium, perihepatic, perisplenic
B Pelvis, pericardium, perihepatic, paracolic
C Lung, pericardium, perihepatic, perisplenic
D More combinations of above
A. Pelvis, pericardium, perihepatic, perisplenic
RUQ - Morison's pouch (between liver and R. kidney)
LUQ - between spleen an L. kidney
Suprapubic - between posterior bladder and vagina (Pouch of Douglas) or between bladder and rectum in males
Pericardium
36
144. You arrive in the emergency department to treat a man with an attempted hanging. He has a LMA in situ, it is easy to ventilate (or something like that) Sa 98% HR 120, BP 130/80 GCS 5 initially. What is the next single most important thing to do.
```
A Apply rigid collar with manual inline stabilisation
B Check subcutaneous emphysema
C Fibre optic examination of airway
D Lateral c-spine xray
E Remove LMA and intubate
```
A. Apply rigid collar with manual inline stabilisation
37
145. You are supplying oxygen from the variable flow meter on the wall at 6L/min. The tubing becomes obstructed. What is the pressure reached in the tubing
```
A 1atm (100kPa)
B 2atm (200kPa)
C 3atm (300kPa)
D 4atm (400kPa)
E 5atm (500kPa)
```
D. 4 atm (400 kPa)
38
146. The adverse event that leads to the most medico legal claims against anaesthetists is:
```
A Dental damage from airway management
B Eye injury
C Non-obstetric epidural complications
D Obstetric epidural complications
E Peripheral nerve injury
```
A. Dental damage from airway management
CEACCP (2006) - Injury during anaesthesia:
Oral injury occurs during 1 in 20 general anaesthetics (5%). Oral (especially dental) injury is the most frequent cause for complaint and litigation against anaesthetists.
Dental injury occurs during 1% of general anaesthetics. It is most commonly sustained during laryngoscopy and requires intervention in only 2% of cases. The teeth most likely to be injured are the upper incisors, most commonly in patients aged 50–70 yr.
39
147. 65 year old lady with osteoarthritis, for TKR in 2 weeks time. She has Fe deficiency anaemia, with Hb 105, Ferritin 30mcg/l. The best management would be:
A Oral Fe tablets until surgery
B Oral Multivitamin containing Fe until surgery
C IV Fe infusion
D Blood transfusion
E Check Hb on day of surgery and don't proceed if
C. IV iron infusion
Not enough time for oral iron to work.
See 'Intravenous Iron in Surgery and Obstetrics', blue book 2011.
40
148. What is the expected rise in platelets from one unit of pooled leucodepleted platelets in a 70kg patient?
```
A 10-20
B 21-40
C 40-60
D 60-80
E 80-100
```
B. 21-40
transfusion.com.au:
One unit (one standard adult dose) of Platelets Apheresis or Pooled Leucocyte Depleted would be expected to increase the platelet count of a 70 kg adult by 20–40 x 10^9 /L. The usual dose in an adult patient is 1 unit (apheresis) or 1 pool (pooled).
One unit of Platelets Paediatric Apheresis Leucocyte Depleted would be expected to increase the platelet count of an 18 kg child by 20 x 10^9 /L.
41
149. [Repeat] You are assessing a patient for intubation. MP3 and thyromental distance 6cm. Compared with MP, TMD is? (repeat)
Various combinations of mallampati being more/less sensitive and specific compared to thyromental distance
Thyromental distance is less sensitive but more specific for difficult intubation than Mallampati score.
42
150. You are about the anaesthetise a patient BMI 38 for bariatric surgery. Plan to give 1m/kg of sux. Compared with Ideal body weight, total body weight dosing results in:
```
A shorter onset, shorter duration
B shorter onset, similar duration
C shorter onset, longer duration
D similar onset, shorter duration
E similar onset, longer duration
```
E. Similar onset, longer duration (and better intubating conditions)
Lemmens, Anes Analg 2006 - The dose of succinylcholine in morbid obesity:
Optimal succinylcholine dosing for morbidly obese individuals (BMI > 4) was evaluated by randomized controlled trial with outcomes being onset of maximum neuromuscular blockade, intubating conditions, and duration of action of neuromuscular blockade. Groups received 1 mg/kg comparing dosing based on ideal body weight (IBW), lean body weight (LBW), or total body weight (TBW).
Results: Onset of neuromuscular blockade did not differ between groups. Intubating conditions* were significantly better in the group dosed by TBW. Duration of action of neuromuscular blockade differed between groups, TBW > LBW > IBW.
Ingrande, BJA 2010 - Dose adjustments of anaesthetics in the morbidly obese:
In MO subjects, the amount of pseudocholinesterase is increased. In addition, the amount of extracellular fluid is increased. As both of these factors determine the duration of action of succinylcholine, administration should be based on TBW. When compared with administration based on 1 mg kg−1 IBW or LBW, 1 mg kg−1 TBW administration results in a more profound block and better tracheal intubating conditions, with clinically insignificant postoperative myalgia.
43
X1 – man undergoing transcatheter aortic valve replacement, ECG shown with regular p waves approx. rate of 100, two broad QRS complexes with no relation to p waves. i.e. Complete heart block. What is the best way of managing this? (CPR was NOT an option)
```
A Atropine
B Transcutaneous pacing
C Adreline
D Isoprenaline
E Transvenous pacing
```
??
B. Transcutaneous pacing (initially)
E. Transvenous pacing (as soon as feasible)
(Probably transcutaneous pacing initially until transvenous pacing can be established - will have arterial sheaths in for TAVI but nothing in femoral vein)
44
X2 - A patient presents for THR with a febrile illness, but wishes to proceed despite the risks. You can justify your decision to defer the case based on:
```
A Automony
B Beneficence
C Non-maleficence
D Paternalism
E Utilitarianism
```
C. Non-maleficence
45
X3 - You collect ropivacaine levels post-operatively. This type of data is:
```
A Continuous
B Numerical
C Ordinal
D Nominal
E Categorical
```
A. Continuous
46
X4 - Randomised controlled trial means:
A Patients randomly allocated to treatment groups
B Patients randomly allocated to treatment or placebo
C Patients allocated systematically
D Neither the patient nor the investigator knows which group the patient is in
E ?
B. Patients randomly allocated to treatment or placebo
| best of the remembered options
47
X5 - Clinical phase III trial means:
```
A dose finding
B In patients WITHOUT the disease
C Randomised controlled trial in patients
D Post marketing study
E ?
```
C. Randomised controlled trial in patients
australianclinicaltrials.gov.au
Phase I - assessing safety (small number of people, 20-80)
Phase II - assessing efficacy and further evaluation of safety (several hundred people)
Phase III - assessing efficacy versus current standard of care (hundreds to thousands of subjects). Also used to monitor for adverse effects.
Phase IV - post-marketing surveillance studies; designed to monitor the effectiveness of the approved intervention in the general population and to collect information about any adverse effects associated with widespread use over longer periods of time
48
X6 - Cancer patient on subcutaneous morphine, 70mg in 24 hours. Converting this to an oral dose of long acting morphine. What is a reasonable starting dose?
```
A 35mg bd
B 70mg bd
C 100mg bd
D 150mg bd
E 200mg bd
```
B. 70 mg bd
Subcut to oral, multiply by 2-3 --> 140-210 mg in 24 h.
Always err on the lower side when rotating opioids or changing routes - can always have breakthrough if needed.
49
X7 - Neurosurgery in the sitting position. What is the most sensitive way to detect venous air embolism?
```
A Praecordial doppler
B PA Catheter
C TOE
D ET CO2
E ?
```
C. TOE
LITFL:
Intraoperative monitoring:
- ETN2: sudden increase in ET nitrogen
- ETCO2: increased dead space -> sudden fall in ETCO2
- ECG: tachyarrhythmias, AV block, right heart strain, T wave changes, ST changes
- CVP: increase in CVP
- PAC: increase in PCWP
- TOE: bubbles seen on TOE (most sensitive monitoring device for VAE, can detect 0.02 ml/kg of air administered by bolus injection)
- Precordial Doppler: bubbles heard (most sensitive noninvasive monitor for VAE, can detect 0.25 ml of air)
- Transcranial Doppler ultrasound (highly sensitive, in patients with PFO)
- Fall in SpO2 (late sign)
50
X8 (repeat) - Bowel surgery. What is the best way to assess fluid status.
A. Arterial pressure variation.
I don't recall the rest.
A. Arterial pressure variation
51
X9 RFTs – No clinical stem, just RFTs with FEV normal, FVC normal, FEV/FVC ratio 89%, DLCO 44%, RV and TLC both 80-90%
I remember this not mentioning pulmonary haemorrhage; and TLC or RV were 98%
```
A Asthma
B COPD
C Pulmonary haemorrhage
D Pulmonary fibrosis
E Pulmonary arterial hypertension
```
E. Pulmonary arterial hypertension
Decreased DLCO:
- Interstitial lung disease
- Emphysema
- Pulmonary hypertension
- Anaemia
- Cardiac insufficiency
- Pulmonary thromboembolism
- Hypothermia
- Hypothyroidism
Increased DLCO:
- Exercise
- High altitude
- Polycythaemia
- Left to right cardiac shunt
- Pulmonary haemorrhage
- Asthma
- Morbid obesity
- Hyperthyroidism
52
X10 Modified from previous - CS5 – what are the lead arrangements and lead examined. No information about what you are looking for (ie region or rhythm vs. ischaemia)
A. RA at R subclavian, LA at V5, LL at L hip, lead I
B. RA at R subclavian, LA at hip, LL at V5, lead I
C. RA at R subclavian, LA at V5, LL at L hip lead II
D. RA at R subclavian, LA at left hip, LL at V5 lead III
E. RA at R subclavian, LA at V5, LL at L hip, lead III
A. RA below R. clavicle, LA at V5, LL at L. hip; select lead I on the monitor
53
X12 You arrive at the delivery of a term neonate with resuscitation in progress. At 2 minutes, saturations are 70%, child is breathing, has been dried and is warm. A HR was also given which was more than 60. What do you do?
A Observe
B Mask ventilation
C 100% oxygen
D ?
A. Observe
Targeted (pre-ductal) SpO2 after birth:
- 1 min: 60-70%
- 2 mins: 65-85%
- 3 mins: 70-90%
- 4 mins: 75-90%
- 5 mins: 80-90%
- 10 mins: 85-90%
If term, breathing or crying spontaneously and good tone, observe.
If not breathing, or inadequate breathing (gasping, apnoea, irregular), or HR
54
X13 65 male patient in ICU with severe, overwhelming sepsis, Hb 75G/L, INR 1.5, SvO2 70%. What product do you give?
```
A Nothing
B 1 unit red cells
C 1 unit red cells and PTx
D 1 unit red cells and FFP
E 2 bags FFP
```
A. Nothing
55
X14 - Picture of 1st rib – what is the structure that attaches to the shaded area:
```
A Scalenus medius
B Saclenus anterior
C SCM
D Parietal pleura
E Articular surface with clavicle
```
(it was scalenus medius, picture lifted from Gray's/wikipedia)
A. Scalenus medius
56
X15 The Australian Resuscitation Council guidelines indicate precordial thump may be appropriate for
A monitored pulseless VF
B monitored pulseless VT
C witness onset asystole due to AV conductance disturbance
D unwitnessed cardiac arrest
E witnessed but unmonitored cardiac arrest
B. Witnessed, monitored pulseless VT
The precordial thump may be considered for patients with monitored, pulseless ventricular tachycardia if a defibrillator is not immediately available. [Class B; LOE IV]
The precordial thump is relatively ineffective for ventricular fibrillation, and it is no longer recommended for this rhythm.
There is insufficient evidence to recommend for or against the use of the precordial thump for witnessed onset of asystole caused by AV-conduction disturbance.
The precordial thump should not be used for unwitnessed cardiac arrest.
A precordial thump should not be used in patients with a recent sternotomy (eg. for coronary artery grafts or valve replacement), or recent chest trauma.
57
X16 - 85 F for fracture hip, otherwise well, normal ECG day prior, electrolytes normal. Otherwise well other than now in AF with HR 110-145, BP 130/80 what do you do:
```
A Amiodarone
B DC Cardioversion post induction GA
C Digoxin
D Metoprolol
E Anticoagulate
```
D. Metoprolol (as long as no signs of cardiac failure) to control rate
otherwise amiodarone
could also cardiovert, given documentation of normal ECG the day prior, although would sedate (e.g. fent/midaz) rather than induce general anaesthesia.
58
X17 How many weeks of anticoagulation prior to elective DCR per AHA/ACC
```
A 1 week
B 2 weeks
C 3 weeks
D 4 weeks
E 5 weeks
```
C. 3 weeks
For patients with AF or atrial flutter of 48 hours’ duration or longer, or when the duration of AF is unknown, anticoagulation with warfarin (INR 2.0 to 3.0) is recommended for at least 3 weeks before and 4 weeks after cardioversion, regardless of the CHA2DS2-VASc score and the method (electrical or pharmacological) used to restore sinus rhythm. (Level of Evidence: B)
For patients with AF or atrial flutter of more than 48 hours’ duration or unknown duration that requires immediate cardioversion for hemodynamic instability, anticoagulation should be initiated as soon as possible and continued for at least 4 weeks after cardioversion unless contraindicated. (Level of Evidence: C)
59
X18 Child for elective procedure, maternal GREAT-grandfather had MH. What is the most reassuring that he doesn’t have MH
A Exposure to halothane age 2 without incident
B Maternal grandfather negative IVCT
C Mother negative genetic test
D No other reports in family despite multiple exposure
E Normal serum CK
B. Maternal grandfather negative IVCT (as long as this is the great grandfather's son)
60
X19 Child with periodic breathing, fever, rash
Various combinations of metabolic and respiratory acidosis and alkalosis
??
61
X20 Ankle bock what supplies plantar foot
```
A deep peroneal
B posterior tibial
C superficial peroneal
D sural
E saphenous
```
B. Tibial nerve (via medial and lateral plantar nerves)
62
X21 Interscalene block – what is most likely to be missed
A Medial cutaneous nerve of forearm
B Radial nerve
C Median nerve
D Axillary nerve
A. Medial cutaneous nerve of forearm
63
X22 Pregnant woman, 33 weeks, thyroid storm for an urgent caesarean section, already been treated with steroid. What next?
```
A Carbimazole
B Esmolol
C IV magnesium
D Propothyiouracil
E Potassium Iodide
```
B. Esmolol
(LITFL)
Thyroid storm = life threatening exacerbation of hyperthyroid state with 1 or more organ dysfunction
Clinical features:
- may occur 6-24 hours post surgery
- fever
- sweating
- HR >140/min
- coma
- nausea and vomiting
- diarrhoea
Management:
Supportive
- IVF (glucose)
- cooling
- paracetamol (no NSAIDS or asprin -> displaces thyroxine from proteins)
- propanolol increments (1mg IV) or esmolol boluses -> infusion (50-100mcg/kg/min)
Specific
- hydrocortisone 200mg IV QID (adrenal insufficiency + decreases T4 release and conversion)
- propylthiouracil (1g load PO -> 250mg QID to inhibit thyroid hormone release and decrease peripheral conversion from T4-T3)
- after blockade by propylthiouracil give sodium iodide or potassium iodide or Lugol’s iodine
64
X23 65 year old, 3 days postop, hypoxia, VQ scan shows non-segmental, matched perfusion and ventilation defects.
```
A Asthma
B Emphysema
C PE
D Atelectasis
E Pulmonary infarction
(I remember pneumonia being an option)
```
B. Emphysema
E. Pulmonary infarction
A matched V/Q scan in patients with a pulmonary embolism, may result from lung consolidation induced by a pulmonary infarction, localized edema, or hemorrhage
Matched ventilation perfusion defects generally = low probability for PE (unless there is associated infarction/haemorrhage - see above)
Patients with asthma rarely have perfusion defects (but may have ventilation defects)
Atelectasis and pneumonia tend to cause VQ mismatch
In patients with early or mild COPD, the perfusion scan may be normal or near normal. As lung parenchymal destruction progresses, it characteristically produces matched non-segmental ventilation-perfusion defects. Perfusion defects may also result from bullae themselves or by their compression of adjacent lung tissue. Large apical bullae may considerably decrease perfusion in the upper lung zones. Among patients with extensive obstructive airway disease, when the perfusion abnormalities exactly match the ventilation defects on the single breath image, the incidence of PE has been shown to be low (4%), regardless of the pattern identified on washout images. A mismatch pattern with the single breath view, even if partial, was associated with a much higher incidence of PE (50%) [1].
65
X24 TTE with apical 5 chamber view with marker on valve in LVOT. What is this?
```
A Aortic valve
B
C
D
E
```
A. Aortic valve
66
X25 TOE transgastric short axis view of LV. Label on anterior wall. What coronary territory is it?
```
A LCx
B LAD
C
D RCA
E ?
```
B. LAD
67
X26 45 year old man with left lung cancer. Otherwise well and CT shows no metastasis. FEV1 2.3 L and FVC 3.4 L. Do you?
A Proceed with either pneumonectomy or lobectomy
B Lobectomy only
C Assess split function (Refer for V/Q scanning)
D Formal cardiopulmonary exercise testing
E ?TTE -- (I do not recall TTE as an option but I do remember an option to decline both).
D. Formal CPET
Three legged stool of assessment:
- Lung mechanics (want ppoFEV1 > 40% pred)
- Parenchymal function (want ppoDLCO > 40% pred)
- Cardiopulmonary reserve (want VO2max > 15 mL/kg/min)
For lobectomy, need to know pre-op FEV1 as % predicted.
you can then calculate ppoFEV1
= pre-op FEV1 % x (1 - fraction of functional lung tissue removed)
--> left lung = 20/42, right lung = 22/42
If ppoFEV1 > 40%, low risk of complications
68
X27: You are called to the cardiac catheter lab to assist when a 55-year-old man with unstable angina becomes restless during difficult placement of a right coronary artery stent. When you arrive he is conscious and responding to voice. He is sweating with a pulse of 60 beats per minute in sinus rhythm, blood pressure measured from arterial catheter of 80/50 mmHg and Sp02 of 97%. The arterial pressure wave has an exaggerated fall with inspiration. The most appropriate next clinical intervention would be to
Not sure about all these options below, but some (definitely echo) were there and stem was the same
A. administer atropine
B. commence an adrenalin infusion
C. perform a quick transthoracic echocardiograph
D. sedate and intubate
E. transfer to operating theatre immediately
C. Perform a quick TTE (to exclude/diagnose tamponade)
...then probably start an adrenaline infusion
69
X28 Innervation of the hard palate. Pretty sure this was a repeat.
A: Nasopalatine and greater palatine
B: Labial and ...
A. Nasopalatine and greater palatine
Sensory nerves of the palate are branches of the maxillary nerve, which branch from the pterygopalatine ganglion.
• Greater palatine nerve supplies gingiva, mucous membrane and glands of most of hard palate.
• Nasopalatine nerve supplies mucous membrane of anterior part of hard palate.
• Lesser palatine nerve supplies soft palate
70
X29 Lithotomy position for laparoscopy. What is not a risk factor for compartment syndrome lower leg?
```
A) obesity
B) male gender
C) lithotomy stirrups
D) PHx hypertension
E) intraoperative hypotension
```
D. PHx hypertension
Karmaniolou, West Indian Medical Journal (2010) - Compartment syndrome as a complication of the lithotomy position
In lithotomy, both venous drainage and arterial supply are impaired, due to compression of the femoral and popliteal vessels at the hip and knee respectively.
Risk factors:
- Decreased perfusion pressure of the compartment (perfusion pressure = MAP - compartment pressure - normally 10-12 mmHg)
- Intraoperative hypotension and hypothermia
- Lithotomy + Trendelenburg
- Prolonged procedure
- Use of stirrups
- Graduated compression stockings
- Male sex
- Obesity
- PVD
71
X30: You are called to review a patient in recovery who is short of breath after resection of a lung SCC. He is weak, cannot flex hips or lift arms. He was given atracurium (35mg) which was reversed 90 minutes ago. This is most consistent with:
```
A Eaton lambert
B Myasthenia gravis
C Steroid induced myopathy
D Limb girdle muscular dystrophy
E Myotonic dystrophy
```
A. Eaton Lambert
Lambert-Eaton myasthenic syndrome (LEMS) is a rare presynaptic disorder of neuromuscular transmission in which quantal release of acetylcholine (ACh) is impaired, causing a unique set of clinical characteristics, which include proximal muscle weakness, depressed tendon reflexes, posttetanic potentiation, and autonomic changes. The initial presentation can be similar to that of myasthenia gravis (MG), but the progressions of the 2 diseases have some important differences.
LEMS disrupts the normally reliable neurotransmission at the neuromuscular junction (NMJ). This disruption is thought to result from an autoantibody-mediated removal of a subset of the P/Q-type Ca2+ channels involved with neurotransmitter release.
In 40% of patients with LEMS, cancer is present when the weakness begins or is found later. This is usually a small cell lung cancer (SCLC), although LEMS has also been associated with non-SCLC, lymphosarcoma, malignant thymoma, or carcinoma of the breast, stomach, colon, prostate, bladder, kidney, or gallbladder.
Clinical manifestations frequently precede cancer identification. In most cases, the cancer is discovered within the first 2 years after onset of LEMS and, in virtually all cases, within 4 years.
72
X31: According to ANZCA professional standards, a LEVEL 2 machine check includes:
A: Ensuring that there are no leaks both when the vaporisers are being used and when they are not being used.
B: Checking the breathing circuit if it has been changed
C: Checking the inspiratory and expiratory valves
D: Checking the (?external) scavenging system
E: Checking the reserve oxygen cylinder is adequately filled for its intended purpose
??
All of the above
Level 2 check (before each list):
• Service label
• High pressure system
• Low pressure system (check for leaks, check volatile cassettes, oxygen failure warning system, flow controls)
• Ventilator (incl. disconnection and high pressure alarm)
• Emergency ventilation system
• Scavenging
• IV and LA administration devices (power supply/battery life, occlusion pressure alarms)
• Other apparatus (airway equipment, suction, gas analysis devices, monitoring equipment, IV infusion devices, humidifiers, filters)
• Final check (make sure vaporisers are turned off and breathing system is purged with air or oxygen)
• Documentation
73
X36: [Repeat]. Obese patient day 1 post-op. On morphine PCA. Febrile. "Slightly" drowsy. SpO2 88%. In addition to increasing oxygen what do you do?
CXR, antibiotics (for HAP), physiotherapy, optimise analgesia (maximise non-opioid analgesia, assess ongoing need for/dosing of opioid treatment based on risk-benefit assessment), HDU review.
74
X37: [Repeat]. Rate of CO2 rise with apnoea in normal adult. BUT there was an option for 3.5mmHg/min (and NO OPTION for 3mmHg/min of 4mmHg/min)
3-4 mmHg/min
Cook, BJA (1998) - Changes in blood-gas tensions during apnoeic oxygenation in paediatric patients:
The rate of increase in arterial carbon dioxide tension in adults is 3-4 mmHg/min.
75
X38: Which is least likely to have a difficult airway?
```
A: Apert syndrome
B: Downs syndrome
C: Treacher Collins syndrome
D: Hurler
E: ?
```
?? All are associated with difficult airway management
If had to pick one, Down syndrome --> laryngoscopy is generally straightforward, despite tendency to obstruct during face mask ventilation
Apert syndrome
- Mid-face hypoplasia with narrow nasopharyngeal passages and variable degree of choanal stenosis
- Direct laryngoscopy view can worsen after mid-face advancement surgery which is commonly carried out for cosmetic reasons
- High arched palate, which is often covered with excessive soft tissue
- Fused cervical vertebrae in 2/3 of patients
- Narrow trachea (secondary to fused tracheal rings)
- Face mask ventilation is especially difficult
- Changes progress with age
Down syndrome
- Macroglossia (relative to midface hypoplasia)
- Micrognathia
- Sublottic stenosis in 10% (acquired) - often require smaller ETT than predicted for age
- High incidence of OSA
- Frequent RTIs
Treacher Collins
- Micrognathia
- Cleft palate
- Microstomia
- Hypoplastic zygoma
- Funnel-shaped larynx
- Airway worsen with growth
Hurler
- The most severe form of mucopolysaccharidosis
- Coarse facies, macocephaly
- Micrognathia and macroglossia
- Decreased mobility of Cx spine and tMJ
- Atlantoaxial instability with subluxation common
- Tracheal narrowing
- Airway Mx becomes more difficult as pt gets older
76
f15B-x40 An ICU patient is intubated and ventilated post some kind of abdominal surgery. NGT in situ with ongoing high output. Currently on CSL 60mL/hr. ABG: pH 7.66, HCO3 35 mmol/l, Cl- 78, pCO2 32. What to do to improve acid base status? (I can't remember the specific options but they were various combinations of the following: )
A. minute ventilation -?keep same/?reduce
B. keep current IV fluids/ keep CSL but increase rate/ change to NS
C. Start PPI
D. Start acetazolamide
Change to normal saline, and decrease minute ventilation slightly.
Kerry Brandis emphasises 'must give chloride':
Chloride administration is essential for correction of chloride-depletion metabolic alkalosis and the alkalosis can be corrected with chloride even if volume depletion persists. Because of electroneutrality requirements it is not possible to give chloride alone, so 'giving chloride' is equivalent to 'giving saline' in most cases. (One exception to this is giving a dilute HCl infusion -see below)
Volume administration will not correct the alkalosis unless the administered fluid contains chloride. This is not difficult though as all available ECF replacement fluids contain chloride so administering these IV fluids to correct the volume deficiency must necessarily replenish chloride.
Maintenance IV fluids (eg 5% dextrose) are poor at replenishing IV volume and contain little or no chloride; they are not useful for this correction and should not be used.
Mineralocorticoid excess causes renal potassium wasting. This can maintain a metabolic alkalosis even in the absence of chloride depletion.
Rarely, it may be advantageous to institute treatments (eg HCl infusion; acetazolamide) that can return the bicarbonate level to normal more quickly. These are not routine components of management, and should not deflect attention from correcting the primary cause and from correcting a chloride deficiency, but may be useful for occasional patients with 'resistant' metabolic alkalosis managed in an Intensive Care Unit.
Proton pump inhibitors (eg omeprezole) have been successfully used to decrease gastric acid loss and prevent or ameliorate metabolic alkalosis.
Correction of metabolic alkalosis - summary:
- Correct cause if possible (eg correct pyloric obstruction, cease diuretics)
- Correct the deficiency which is impairing renal bicarbonate excretion (i.e. give chloride, water and K+)
- Expand ECF Volume with N/saline (and KCl if K+ deficiency)
- Rarely ancillary measures such as HCl infusion, acetazolamide (one or two doses only), oral lysine hydrochloride
- Supportive measures (eg give O2 in view of hypoventilation; appropriate monitoring and observation)
- Avoid hyperventilation as this worsens the alkalaemia
77
f15B-x41: When to send tryptase after suspected anaphylaxis:
```
A. 1 hr
B. 4 hrs
C. ?
D. ?
E. 24 hrs
```
CEACCP:
As soon as possible after initial resuscitation, then at 1-2 hours, then any time after 24 hours (to get baseline level).
Australian and New Zealand Anaesthetic Allergy group say check at 1, 4 and > 24 hours
78
X42: [Repeat] Patient unstable with PE after joint replacement (tachycardic and hypotensive), already heparinised.
```
A: Thrombolysis
B: Referral for thrombectomy
C: Supportive care including fluids and inotropes
D:
E:
```
B. Referral for thrombectomy (if interpose and fluids don't work)
Thrombolysis relatively contraindicated in the post-op period.
79
X43: [Repeat] What does this TEG show? (hyperfibrinolysis)
Hyperfibrinolysis
80
X44: [Repeat] Prothrombinex is relatively contraindicated in a bleeding patient with:
```
A: A past history of HITS
B:
C:
D:
E:
```
A. Past history of HITS
| Prothrombinex contains heparin
81
X45: Subtenon is relatively contraindicated in:
```
A: Long axial length
B: Previous scleral band which remains in situ
C: Inferonasal pterygium
D:
E:
```
B. Previous scleral band which remains in situ (prevents access to the posterior pole)
C. Inferonasal pterygium (excessive bleeding)
Probably B is the best answer, as you can always alter your entry point slightly to avoid the pterygium.
82
X50: [repeat] On CPB. MAP drops very low after first dose cardioplegia. Mixed venous sats 80%. What to do?
```
A: Metaraminol
B: Start an adrenaline infusion
C: Give fluid
D: Change pump flow rates
E:
```
A. Metaraminol
83
X51: According to the current (2010) ARC ALS guidelines, what is the correct dose for the first three shocks of a shockable rhythm?
```
A: Biphasic 50, 100, 150
B: Biphasic 100, 150, 200
C: Biphasic 100, 200, 200
D: Monophasic 120, 240, 360
E: Monophasic 360, 360, 360.
```
E. Monophasic 360, 360, 360
...Although nearly all defibrillators these days give biphasic shocks --> 200/200/200
Recommended Energy Levels:
Monophasic: the energy level for adults should be set at maximum (usually 360 Joules) for all shocks. [Class A; LOE III-2]
Biphasic waveforms: the default energy level for adults should be set at 200J for all shocks.
Other energy levels may be used providing there is relevant clinical data for a specific defibrillator that suggests that an alternative energy level provides adequate shock success (eg. Usually greater than 90%). [Class A; LOE II]
For second and subsequent biphasic shocks energy levels should be at least equivalent and higher energy levels may be considered if available. [Class B; LOE II]
84
X52: What is not a sign of damage to a part of the sympathetic system? [In the context of surgery where something sympathetic related could be damaged]
```
A: Blepharoptosis
B: Exopthalmos
C: Facial flushing
D: Miosis
E:
```
B. Exophthalmos
| blepharoptosis = droopy eyelid, i.e. ptosis
85
X53: Providing sedation for endoscopy. What must you have?
```
A: Anaesthetic machine
B: Suxamethonium
C: Mechanical ventilator
D: Defibrillator
E: Laryngoscope
```
All of the above
Laryngoscope is the only one that is actually on PS09
86
X54: [repeat] Suspected AFE. What would be supportive [various lab tests provided, which I believe were the same as in the past].
A. ?
Reduced C3 and C4
87
f15B-x55: Abdominal compartment syndrome is diagnosed (in an appropriate context for it) when intra-abdominal pressures are consistently greater than
```
A: 12mmHg
B: 20mmHg
C: 24mmHg
D:
E:
```
12 mmHg
Wiki:
- Definition of abdominal compartment syndrome = IAP > 12 mmHg
- IAP > 20 associated with organ failure
emedicine:
In an excellent group of articles, Burch et al developed a grading system. Patients with higher-grade abdominal compartment syndrome have end-organ damage, which is evidenced by splenic hypercarbia and elevated lactate levels, even if they appear clinically stable. The following grading system has become accepted if IAH is present:
Grade I: 10-15 cm H 2 O
Grade II: 15-25 cm H 2 O
Grade III: 25-35 cm H 2 O
Grade IV, greater than 35 cm H 2 O
End-organ damage has been observed with IAP as low as 10 cm H2 O, and multiple studies have found damage at values ranging from 20-40 cm H2 O. Disparity exists because abdominal compartment syndrome never occurs as an isolated event.
Cheatham et al found abdominal perfusion pressure (APP) to be a much better predictor of end-organ injury than lactate, pH, urine output, or base deficit. The APP is equal to the mean arterial pressure minus the IAP.
88
X66: [repeat] Patient with respiratory failure, low PaO2/FiO2 ratio, cardiac index of 1.7, PCWP of 25. Which mode of ECMO would be most appropriate?
```
A: VA
B: VV
C: AV
D:
E:
```
A. VA
3 types:
- Veno-venous (VV)
- Veno-arterial (VA)
- Arterio-venous (AV)
The first 2 require an external pump, whereas AV is powered by the body's cardiac output (pt must have a CI of at least 2.5 L/min/m2.
Veno-venous ECMO is designed to provide gas exchange, while veno-arterial ECMO provides both gas exchange and haemodynamic support.
AV-ECMO allows a small amount of oxygenation, but predominantly CO2 removal.
89
X67: [repeat] When to stop dabigatran (for non valvular AF) in a patient with normal renal function prior to THR planned to be done under spinal?
```
A: 7 days
B: 3 days
C: 3 days, bridge with clexane
D:
E: Continue until day of surgery
```
...of the options listed:
B. 3 days
CrCl > 80 --> 48 h
CrCl 50-80 --> 72 h
CrCl 30-50 --> 96 h
90
X67: [repeat] AAI pacing post CABG. Looked like second degree (wenckebach) block
...Wenckebach
91
X68: What do you expect to happen if you put a magnet over an AICD?
A: Turn off antitachycardia feature, no change to pacing
B: Turn defib off, asynchronous pacing
C: Turn defib off, no change to pacing (or, continue synchronous pacing)
D: No change to defib, asynchronous pacing
E:
C. Turn defib off, no change to pacing
Stone, BJA (2011) - Perioperative management of patients with cardiac implantable electronic devices:
Even when the ICD has been deactivated by a magnet, pacemaker function of an ICD is not affected. thus, in a patient with an ICD, the magnet response will always be to deactivate the ICD and the pacing behaviour will not change to an asynchronous mode.
92
X69: Young patient, recently diagnosed with phaeochromocytoma. Not on any medications. Presents to ED tachycardic (~140) with SBP 220, sweaty, blurred vision, headache. Best initial treatment:
```
A: Phenoxybenzamine
B: Phentolamine
C: Esmolol
D: GTN
E:
```
B. Phentolamine
Needs long-term control with phenoxybenzamine but the oral preparation takes too long to work (half life 24 h) and the patient needs acute blood pressure control to avoid acute LVF/haemorrhagic stroke.
If IV phenoxybenzamine is available (apparently it is, although I have never seen this and they def wouldn't have it in ED), this would be a reasonable alternatively (acts in 1 hour, lasts 3-4 days)
93
X70: Pathognomonic for post dural puncture headache:
```
A: Worse on standing
B: Occipital area only
C:
D:
E:
```
A. Worse on standing
94
X71: Technique to minimise absorption of irrigation fluid during TURP:
A: Fluid no more than 60cm above the patient
B: Use NS rather than glycine
C: Use laser
D: Limited resection of gland only if gland > 200g
E: Limiting the amount of fluid to only 1L
A. Fluid no more than 60 cm above the patient
If the question was 'technique to minimise the risk of TURP syndrome', best answer would be to use laser.
CEACCP (2009) - Anaesthesia for TURP:
The height of the bag should be kept as low as possible to achieve adequate flow of fluid. 70 cm is usually satisfactory...
Open prostatectomy may carry fewer complications, if the prostate is very large (> 100 g)...
Newer techniques of prostatic resection use different types of energy (heat, laser, ultrasound, microwave) to vaporise prostatic tissue and coagulate surrounding blood vessels. These techniques are reported to cause less haemorrhage than conventional TURP, but specimens for histology cannot be obtained. Since diathermy is not used, normal saline may be used as the irrigating solution, minimising the risk of the TURP syndrome.
95
X72: What is the GCS. Opens eyes to voice. Responds "purposefully" to pain (not specified if localises or withdraws) Speaks, but confused.
E3 V4 M5
= 12
LITFL describes localising as 'purposeful movement':
Localises to pain (Purposeful movements towards painful stimuli; e.g., hand crosses mid-line and gets above clavicle when supra-orbital pressure applied)
96
X73: Recent case with LMA. Now has hoarse voice. Nasendoscopy shows one vocal cord in the paramedian position. What is the site of injury?
```
A: Lingual n.;
B: Vagus n.;
C: Superior laryngeal n.;
D: Recurrent laryngeal n.
E:
```
D. Recurrent laryngeal nerve.
One vocal cord in the paramedic position = unilateral vocal cord paralysis.
External branch of superior laryngeal nerve supplies cricothyroid muscle.
Recurrent laryngeal nerve supplies all other intrinsic muscles of the larynx.
Chan, Laryngoscope (2005) - Vocal cord paralysis after laryngeal mask airway ventilation:
As the LMA has increased in popularity, however, so has the incidence of LMA-related complications. Cases of mucosal trauma, hematoma, tongue cyanosis, arytenoid dislocation, and lingual, hypoglossal, and recurrent laryngeal nerve paralyses have been documented in various anesthesia journals.
Endo, Am J Otolaryngol (2007) - Bilateral vocal cord paralysis caused by laryngeal mask airway
We report a case of bilateral vocal cord palsy temporarily observed after using the LMA, which required urgent tracheotomy. Severe swelling of the arytenoid suggested that bilateral recurrent laryngeal nerve palsy was caused by prolonged compression on the pyriform fossa. One month later, vocal cord movements were fully recovered. It should be noted that bilateral vocal cord palsy is a possible complication associated with use of the LMA.
97
```
X73: What is the smallest ETT that can be railroaded over an aintree catheter?
A: 5.5
B: 6.0
C: 6.5
D: 7.0
E:
```
D. 7.0
98
X74: SAH, all associated with poor prognosis except:
```
A: Pulmonary oedema
B: Stunned myocardium
C: Fever
D: Delayed cerebral ischaemia
E:
```
??
All are associated with poor prognosis
Stunned myocardium if you had to pick one.
99
X75: Most common cause of foot drop after prolonged labour:
A: Lumbosacral plexus compression by fetal head/forceps
B: Common peroneal nerve injury due to lithotomy position
C:
D:
E:
A. Lumbosacral plexus compression by fetal head/forceps
100
X76: In an adult, the spinal cord ends at the caudal end of which vertebral body?
```
A: L1
B: L2
C: T12
D: S2
E:
```
A. L1
Wiki:
The spinal cord begins at the occipital bone and extends down to the space between the first and second lumbar vertebrae
101
X77: You are trialling a new drug for hypertension in one group of patients and comparing it to placebo (given to another group). In three months time you will measure the blood pressure and want to compare the two groups. Which test would be most appropriate?
```
A: Chi squared
B: Fishers exact test
C: Student's t-test
D: Mann-whitney U test
E: Bland Altman test
```
D. Mann-Whitney U test (if you are simply comparing the two groups at 3 months)
Numerical (continuous) data, 2 independent groups, data likely to be non-parametric (right skewed)
--> Wilcoxon rank sum (Mann-Whitney U test)
If you are comparing the post-treatment BPs against the pre-treatment BPs in one of the groups, you would use Wilcoxon signed rank (for paired data)
Chi square and Fishers exact tests used for categorical data
Student's t test used for symmetrical (parametric) data
Bland Altman used to describe the relationship between two measurement techniques when data are numerical (usually one measurement technique compared against an accepted standard technique)
102
X78: In tetralogy of fallot, the degree of cyanosis is associated with:
```
A: The size of the VSD
B: The position of the VSD
C: The degree of RV outflow obstruction
D:
E:
```
C. The degree of RVOT obstruction
emedicine:
The natural history of untreated tetralogy of Fallot includes the following:
- The degree of cyanosis is related to the severity of right ventricular (RV) outflow tract obstruction (RVOTO)
- Infants with acyanotic tetralogy of Fallot gradually become cyanotic
- Patients who are already cyanotic become more cyanotic than before as a result of worsening infundibular stenosis and polycythemia
- Polycythemia develops secondary to cyanosis
- A relative state of iron deficiency (ie, hypochromia) may develop; patients require monitoring for this condition
- Hypoxic spells may develop in infants
- Growth retardation may be present if cyanosis is severe
- Brain abscess and stroke can occur but are rare
- Subacute bacterial endocarditis is occasionally a complication
- Aortic regurgitation may develop in some patients, particularly those with severe tetralogy of Fallot
- Coagulopathy is a late complication of a long-standing cyanosis
103
X79 Best method (or most accurate) assessment of fluid status
A: Arterial pulse contour analysis
B: BP + HR
C:?
D: EJECTION fraction of ventricle via TOE
E: Pulmonary capillary wedge pressure
A. Arterial pulse contour analysis
104
X80 Best way to reduce chance of auto-PEEP occurring is to increase
```
A: Expiratory time
B: Insiratory time
C; Respiratory rate
D: ?
E: Amount of positive pressure ventilation
```
A. Expiratory time
105
X81 One bag of pooled platelets will increase platelet count by
```
A: 10-20
B: 20-40
C: etc
D: ?
E: ?
```
B. 20-40
106
X82 Patient given prophylactic 8mg Ondansetron + 4mg Dexamethasone and feeling nautious in recovery. Best next treatment is
```
A: Cyclizine 50mg
B: ?
C: Metoclopramide 10mg
D: Droperidol 0.625mg
E: ?
```
D. Droperidol 0.625 mg
| or cyclizine, but greater body of evidence for droperidol
107
X88 Risk of blood transfusion reaction with group specific ABO + Rh matching, but not cross matched
```
A:
B:
C:
D: 98.?
E: 99.8
```
Brandis:
- ABO compatible blood (99.4% safe)
- ABO and Rh compatible (99.8% safe)
- ABO and Rh compatible + negative antibody screen (99.94% safe)
- ABO and Rh compatible + negative antibody screen + negative Coombs test (99.95% safe)
108
X89 Sux left out of fridge for 1 week. How much has its efficacy reduced
```
A: 2%
B: 5%
C:10%
D: ?
E: ?
```
A. 2%
109
X92 Which of the following features are associated with chronic pain?
```
A: Increasing patient age
B: Low level of anxiety about surgery
C: Minor pain post-op
D: Care not to damage intercostal nerves
E: Performance of a paravertebral block
```
?? None of the options are associated with the development of chronic pain
APM Scientific Evidence 4th ed (2015):
Risk factors for chronic post surgical pain
Pre-op factors:
- Pain, moderate to severe, lasting > 1 month
- Repeat surgery
- Psychological vulnerability (e.g. catastrophising)
- Pre-op anxiety
- Female gender (adults)
- Younger age (adults)
- Workers' comp
- Genetic predisposition
- Inefficient DNIC
Intra-op factors:
- Surgical approach with risk of nerve damage
- Avoidance of nitrous oxide anaesthesia
Post-op factors:
- Pain (acute, moderate to severe)
- Radiation therapy to area
- Neurotoxic chemotherapy
- Depression
- Psychological vulnerability
- Neuroticism
- Anxiety
110
X93 FEV1 3.3, (predicted 4.3), Left sided cancer
A: Proceed with pneumonectomy and lobectomy
B: Proceed with lobectomy only, not for pneumonectomy
C: Not for surgery
D: Send for cardio-pulmonary testing
E: Send for VQ scan.
D. Send for cardiopulmonary testing
Preop FEV1 = 76% predicted (3.3/4.3)
ppoFEV1 = 76% x (1 - [20/42])
= 40% (for left pneumonectomy)
Borderline in terms of risk stratification, so would be useful to know about parenchymal function (DLCO) and cardiopulmonary reserve (CPET).
Would probably be fine for lobectomy, but don't think you can say 'not for pneumonectomy' based on this information.
111
x98 Class I equipment, active wire touching casing. What happens when electricity / power supply is switched on
```
A: Nothing
B: Fuse will blow
C: ?
D: ?
E: RCD will go off immediately
```
B. Fuse will blow
rch biomedical engineering - electrical safety:
Class I equipment is fitted with a three core mains cable containing a protective earth wire. Exposed metal parts on class I equipment are connected to this earth wire.
Should a fault develop inside the equipment and the exposed metal comes into contact with the mains, the earthing conductor will conduct the fault current to ground. Regular testing procedures ensure that earthing conductors are intact, as the integrity of the earth wire is of vital importance.
CEACCP (2003) - Electrical safety in the operating theatre:
...If a fault occurs which allows the live supply to come into contact with an accessible part, current flows down the earth wire. This new circuit has a lower resistance, resulting in an increased current which melts the protective fuses and breaks the circuit, removing the source of potential electrocution. In addition to the fuse in the mains socket, Class I equipment should have fuses at the equipment end of the mains supply lead, in both the live and neutral conductors so that this protection is operative even if the equipment is connected to an incorrectly wired socket outlet.
112
x99 Risk of bone cement implantation syndrome increased with
```
A: Increasing age
B: Male gender
C: ?
D: ?
E: Previous exposure to cement
```
? A. Increasing age
CEACCP (2012) - Bone cement and the implications for anaesthesia:
Risk factors for the development of BCIS
Patient factors:
- ASA III-IV
- Pre-existing pulmonary hypertension
- Significant cardiac disease
- Osteoporosis
Surgical factors:
- Pathological facture
- Intertrochanteric fracture
- Long-stem arthroplasty
113
x101 Risk of anaphylaxis recurring post-rocuronium anaphylaxis is greatest with
```
A: Cisatracurium
B: Atracurium
C: Vecuronium
D: Pancuronium
E: Unknown due to variable cross-sensitivity
```
C. Vecuronium
(slightly higher with sux if this was an option)
Sadleir, BJA (2013) - Anaphylaxis to neuromuscular blocking drugs: incidence and cross-reactivity in Western Australia from 2002 to 2011:
Patients diagnosed with NMBD anaphylaxis most frequently cross-reacted with succinylcholine. This was followed by rocuronium, vecuronium, and pancuronium. Benzylisoquinoliniums cross-reacted less frequently.
Cross-reactivity rates specific for roc anaphylaxis:
- Sux (44%)
- Vec (40%)
- Atrac (20%)
- Panc (19%)
- Cisatrac (5%)
114
X103 You have a fire emanating from your anaesthetic machine. The most appropriate treatment is:
```
A. fire blanket
B. CO2 extinguisher
C. wet chemical extinguisher
D. ?
E. ?
```
A. Fire blanket
CEACCP (2014) - Environmental emergencies in theatre and critical care areas: power failure, fire, and explosion
Water, CO2, foam and wet chemical extinguishers should not be used on fires involving flammable gases (i.e. anaesthetic machines).
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