21.2 Flashcards

Question

21.2 A 25-year-old male has continued post operative bleeding after an extraction of an impacted third molar tooth under a general anaesthetic. The patient mentions that his father bruises quite easily. His coagulation screen reveals: (Coagulation tests provided). The most likely diagnosis is His coagulation screen reveals: Prolonged APTT, Normal PT. a) Factor V Leiden b) Haemophilia A c) Haemophilia B d) Von willebrand disease

Answer 1

d) Von willebrand disease - autosomal dominant inheritance - may have normal or prolonged APTT, PT is normal *Haem A: X-linked recessive disorder; would expect prolonged aPTT, and normal PT *Haem B: X-linked recessive disorder; would expect normal aPTT and normal PT Up to date: Inheritance patterns — Most cases of VWD are transmitted as an autosomal dominant trait; this includes types 1 and 2B, and most types 2A and 2M. Baseline hemostasis assessment — Most patients will have a complete blood count (CBC) with platelet count and coagulation studies during the initial evaluation for excessive bleeding or bruising. ●Individuals with VWD generally have a normal CBC and a normal platelet count, with the exception of those with type 2B VWD, most of whom will have mild thrombocytopenia (eg, platelet count 100,000 to 140,000/microL). ●Individuals with VWD may have a normal or prolonged activated partial thromboplastin time (aPTT), depending on the degree of reduction of the factor VIII level. The prothrombin time (PT) is normal in VWD. Up to date: ●Hemophilia A – Inherited deficiency of factor VIII (factor 8 [F8]); an X-linked recessive disorder. ●Hemophilia B – Inherited deficiency of factor IX (factor 9 [F9]); also called Christmas disease; an X-linked recessive disorder. Laboratory findings — Hemophilia is characterized by a prolonged activated partial thromboplastin time (aPTT). However, the aPTT may be normal in individuals with milder factor deficiencies (eg, factor activity level >15 percent), especially in hemophilia B (factor IX deficiency), where even individuals with moderate disease may have a normal aPTT. In some individuals with hemophilia A, factor VIII levels may increase with stress, leading to a normalization of the aPTT or mis-categorization of factor levels and disease severity. In patients with hemophilia, the aPTT corrects in mixing studies, unless an inhibitor is present, which only applies to individuals who have received factor infusions or who have an autoantibody such as a lupus anticoagulant or an acquired factor inhibitor. Mixing studies that do not show correction of a prolonged aPTT suggest an alternative diagnosis such as an acquired factor inhibitor. The platelet count and prothrombin time (PT) are normal in hemophilia. Thrombocytopenia and/or prolonged PT suggest another diagnosis instead of (or in addition to) hemophilia. Measurement of the factor activity level (factor VIII in hemophilia A; factor IX in hemophilia B) shows a reduced level compared with controls (generally <40 percent). One exception is an individual with mild hemophilia A who undergoes testing when stressed or pregnant and has a falsely elevated factor level. If this is suspected, factor activity testing should be repeated under conditions of low stress. The plasma von Willebrand factor antigen (VWF:Ag) is normal in hemophilia. If VWF:Ag is reduced, this suggests the possibility of von Willebrand disease (VWD) rather than (or in addition to) hemophilia. Urinalysis is not done routinely, but if performed it may sometimes (but not always) show microscopic or macroscopic hematuria.

Answer 2

e) Muscular dystrophy - rhabdomyolysis risk if given to patients with Duchenne or Becker's muscular dystrophy - volatiles safe in all above, and also safe in patient's with myotonic dystrophy Malignant hyperthermia - high mortality uncoupling regulation of RyR1 to SR Duschenne muscular dystrophy - fatal rhabdo (hyperkalaemia) - MD: aspiration risk & poor resp function so risk fail extubation, avoid sux & volatiles > rhabdo & hyperkalaemia. Specifically for Myotonic dystrophy avoid triggers of myotonia (sux, neostigmine, hypothermia, diathermy) - MS: avoid pyrexia, GA safe, avoid sux, neuraxial likely safe (and advised for LSCS). - MG: relatively resistant to sux but sens to NDMB, caution with regional or neuraxial that compromises resp muscles. Avoid magnesium, steroid (unless stress dose) & drugs that prolong NMBA if used (lignocaine, aminoglycoside, CaChB). - ELS: sensitive to BOTH NDMB and sux. Same principles as MG. - GB: document neruo exam preop, avoid sux, use low dose roc (sens to NDMB), increase aspiration risk, HD instability (use an artline). "

Answer 3

d. 100 Normal is >30, but for major surgery the cutoff is 100 https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/10.1111/anae.13773"

Answer 4

Incidence of staphyloma

Answer 5

Adenosine (effect is exagerated) Denervated heart. Only drugs that act directly on the heart will be effective. Loss of predominant parasympathetic outflow - so SA node rate now 90-100. Preload dependent - frank starling mechanism. alpha and beta receptors remain intact but attenuated response to catechoamines. Dopamine/isoprenaline - effective Norad/adrenaline,dobutamine - exagerrated effect - depends on intrinsic stores of catehcolamines and degree of reinnervation metaraminol - effective but no reflex brady Pheynlephrine - effective ephedrine - less effective glyco/atropine - not effective No autonomic innervation of the heart -> lack of reflex bradycardia. Adenosine - exaggerated bradycardia - receptors present on heart b-blocker - effective - but caution with use as CO dependent on catechoamines digoxin - usually ineffective due to parasympathetic dennervation ANZCA blue book 2019 pg 69"

Answer 6

3 months is the minimum AHA Guidelines. ""we suggest that elective noncardiac surgery be deferred at least 6 months after a prior stroke, and possibly as long as 9 months to reduce the risk of perioperative stroke in patients undergoing noncardiac surgery."" https://www.ahajournals.org/doi/10.1161/CIR.0000000000000968 Consider delaying elective surgical cases for at least 9 months after a prior stroke (Level B-NR, Class IIa). SNACC 2020 https://journals.lww.com/jnsa/Fulltext/2020/07000/Perioperative_Care_of_Patients_at_High_Risk_for.6.aspx https://www.bjaed.org/article/S2058-5349(20)30123-2/fulltext"

Answer 7

e) LV hypertrophy ECHO FINDINGS intimal flap TYPING (type A): aortic regurgitation (acute dilatation of the aortic root, aortic leaflet prolapse, dissection flap prolapse, pre-existing disease, e.g. bicuspid valve) pericardial effusion and/or tamponade regional wall motion abnormality heralding coronary artery occlusion DOPPLER identifies true and false lumen detect aortic branch occlusion/ dissection (absent flow) Source LITFL

Answer 8

Honey (or sucralfate) - 10 mL every 10 minutes (maximum 6 times) while awaiting surgical retrieval Source QCH guidelines

Answer 9

d) Arrhythmia - caution if conduction disease however - used to relieve sympathetically mediated pain (abnormal connections between sympathetic and sensory nervous system) indications : CRPS head/UL, postherpetic neuralgia, CPSP, phantom limb, cluster/vascular headache, orofacial pain Hyperhydrosis Raynaud Scleroderma Meniere syndrome Intractable angina Refractory cardiac arrythmia Contraindication: recent MI, anticoagulation, glaucoma, contralateral nerve palsy, cardaic conduction block, severe emphysema https://www.ncbi.nlm.nih.gov/books/NBK507798/ "

Answer 10

"c.Stop volatile and calcium Duchenne muscular dystrophy -> rhabdomyolysis and hyperkalemia. Calcium for cardiac stabilization The only conditions shown to have a definite linkage with malignant hyperthermia (MH) are King–Denborough syndrome, central core disease, and Evans myopathy.7 Patients with other neuromuscular disorders have shown MH-type symptoms under general anaesthesia, but the link between these symptoms and true MH remains unclear. There is no association between DMD and MH; previously described ‘normothermic MH’ reports were almost certainly rhabdomyolysis https://academic.oup.com/bjaed/article/10/5/143/274799#3357763"

Answer 11

a) Spinal Controversy re spinal and MS - and limited data - current consensus is that spinal is also safe. Epidural more evidence to support that it is safe (PRIMS study) The MAB I think is to signify advanced MS (Really there isn’t heaps of evidence) Source World Fed Anaesthetists https://resources.wfsahq.org/wp-content/uploads/359_english.pdf

Answer 12

) Hypertension Talley & O'Connor CVS Exam: S3: Physiological in pregnancy; sign of LV failure; AR & MR S4: Never physiological, most often due to systemic hypertension Atrial gallop - stiff LV - hypertrophy or ischaemic ventricle Source CV phys 4th heart sound is a sign of a stiff ventricle. Needs to depend on effective atrial contraction (not heard in AF or MS/TS). Conditions that --> ventricular hypertrophy can cause 4th heart sound - left heart - HTN, AS, HOCM, previous MI (stiff heart) - right heart - pulmonary HTN, PS https://www.ncbi.nlm.nih.gov/books/NBK344/"

Answer 13

d) 4 - WFNS is 4 * alternatively her Fisher score is: grade 2 (diffuse thin (<1 mm) SAH, no clots; which estimates an incidence of symptomatic vasospasm of 25%)

Answer 14

Now no time frame

Answer 15

b) hypertension from splanchnic vasoconstriction below the level of the lesion ADR: - increased SNS below - increased PSNS above Hypertension (>25 mmHg increase) >40 mmHg increase or SBP > 150 is severe

Answer 16

-30 Left Axis Deviation LITFL

Answer 17

a) level of consciousness In any patient who is given an opioid, oversedation should be considered to indicate OIVI until proven otherwise, regardless of a patient’s respiratory rate or oxygen saturation levels. Source ANZCA PS 41

Answer 18

Left PCA 70% of stroke in anterior circulation (MCA (90%) > ICA, ACA) PCA stroke - occipital lobe - contralateral homonymous hemianopia , cortical blindness (if bilateral lesions) - medial temporal lobe - deficits in memory, behaviour alteration - thalamic infarct - contralateral sensory loss, aphasia (if dominant side involved), executive dysfunction, memory impairment, decreaed LOC ---- PRESERVED MOTOR ACA stroke - contalateral leg weakness (>arm weakness) and executive dysfunction MCA stroke - contralateral hemiparesis (variable involvement of face/UL/LL) and sensory loss in pattern similar to motor deficit - contralateral homonymous hemianopia - dysarthria - aphasia, aflexia, agraphia, aclaculia, apraxia (if dominant side) - neglet if not dominant side IN SUMMARY - if sensory loss and homonymous hemianopia without motor deficit - PCA https://www.strokenetworkseo.ca/sites/default/files/files/stroke_school_brockville_part_3.pdf"

Answer 19

assuming three chamber system and bottle D is the image on very right --> excess negative pressure In four chamber system extra chamber protects against suction failure https://derangedphysiology.com/main/required-reading/intensive-care-procedures/Chapter-262/underwater-seal-chest-drain-system

Answer 20

Codeine Source Appendix ANZCA PG 07 Avoid NSAID in mother of child with duct dependent cardiac lesion. Tramadol has been ok'd Tapentadol - current recommendation is to avoid due to lack of data Buprenorphine - NHS says it's ok https://www.anzca.edu.au/getattachment/d2c8053c-7e76-410e-93ce-3f9a56ffd881/PG07(A)-Guideline-on-pre-anaesthesia-consultation-and-patient-preparation-2017#page="

Answer 21

D 600 / (32-12) = 30 https://www.atsjournals.org/doi/full/10.1164/rccm.201102-0226pp shows auto peep and peep are additive

Answer 22

"e. ulnar nerve next least likley is radial nerve My Brother Throws Rad Parties (cub fossa contents medial to lat) median nerve, brachial artery (branches into radial and ulnar artery), tendon of biceps, radial nerve, posterior interosseous branch of radial N. https://radiopaedia.org/articles/contents-of-the-cubital-fossa-mnemonic#:~:text=A%20useful%20mnemonic%20to%20remember,My%20Brother%20Throws%20Rad%20Parties"repeat

Answer 23

"b. Propofol. Guidelines recommend Benzodiazepine/Propofol/Barbituates for seizure control. NYSORA/AAGBI 100% O2 + ETT if airway needs to be secured Intralipid for treatment of LAST - iniital bolus 1.5ml/kg over 1 min - start infusion of 15ml/kg/hr immediately after bolus - AFTER 5min can give another bolus (MAX 3 boluses including initial) if CVS not restored and double rate to 30ml/kg/hr - MAX cumulative dose of 12ml/kg https://anaesthetists.org/Portals/0/PDFs/Guidelines%20PDFs/New%20archived/Guideline_management_severe_local_anaesthetic_toxicity_v2_2010_archived.pdf?ver=2023-06-23-134115-697"

Answer 24

e) Reversible hypermetropia

Answer 25

c) comparisons of means between three groups in normally distributed data ANOVA (analysis of variance): comparisons of means between more than two groups or between several measurements in the same group is called analysis of variance and is frequently cited by the acronym ANOVA

Answer 26

c) 15mg factor of 0.3 Tapentadol 50 (x0.3)= OME 15 Oxycodone 10 (x1.5) = OME 15 Tramadol 75 (x 0.2) = OME 15 Hydromorphone 3 (x5) = OME 15 Buprenorphine 400 (x0.04) = OME 16 ANZCA opioid calculator

Answer 27

a) R1 side chain UP TO DATE: - sensitisation to R1 side chain in cephalosporins important in determining cross reactivity with penicillins.

Answer 28

"c) increased PVR Early CVS changs (max at 24hrs bost burns) - mimics hypovolamic shock - intravascular volume depletion, ^ SVR (by up to 200%), CO halved, ^ciruclationg vasopression - decreased oxygen delivery, ^ PVR - ^ Hct Late CVS changes (hyperdynamic circulation 2-5days post burn) - driven by catecholamine surge - ^ CO proportional to size of burn (part of hypermetabolic response, most commonly seen in patients with>40% burn) - ^HR, decreased SVR http://khcanaesthesia.com/onewebmedia/peri%20operative%20Mx%20BURNS.pdf "

Answer 29

"a. LUSCS - 40% seated craniotomy - 100%, LUSCS - 40%, Hip Arthroplasy - 30%, ACDF - 10% https://academic.oup.com/bjaed/article/2/2/53/306405"

Answer 30

pheochromatoma ICS contraindications 1) bowel contamination 2) haemoglobinopathies - sickle cell - fragile cells --> significant haemolysis 3) phaeochromcytoma - Vasoactive compounds may remain after washing. 4) temporarily stopped when substance not licensed for IV use is in surgical field - iodine, topical clotting agent, cement. Cancer not a contraindication - leukodepletion filters remove 99.9% of cancer cells from salvaged blood 2017 Blue book - pg 135"

Answer 31

remove the inner cannula BJA mx (from NAP4) If pt breathing - 1) Apply HF 2) Assess patency of trache - Remove speaking valve/inner cannula - suction - deflate cuff - if no improvement -> remove trache --> apply oxygen to face and stoma --> if patient apnoeic - BVM/SGA/airway adjuncts oral first than trache stoma --> intubate via mouth or stoma https://www.bjaed.org/article/S2058-5349(19)30125-8/fulltext#secsectitle0030"

Answer 32

albumin ALBUMIN AND PHOSPHATE the normal anion gap depends on serum phosphate and serum albumin the normal AG = 0.2 x [albumin] (g/L) + 1.5 x [phosphate] (mmol/L) albumin is the major unmeasured anion and contributes almost the whole of the value of the anion gap. every 1g/L decrease in albumin will decrease anion gap by 0.25 mmoles a normally high anion gap acidosis in a patient with hypoalbuminaemia may appear as a normal anion gap acidosis. this is particularly relevant in ICU patients where lower albumin levels are common Effects of albumin: Anion gap may be underesitmated in hypoalbuminaemia, because if albumin decreased by 1g/L then the anion gap decreases by 0.25 mmol To overcome the effects of the hypoalbuminaemia on the AG, the corrected AG can be used which is AG + (0.25 X (40-albumin) expressed in g/L

Answer 33

dopamine - least likely to cause pulmonary vasodilation (all the others do to my knowledge) - From UP TO DATE: > At low doses of 1 to 3 mcg/kg per min, dopamine acts primarily on dopamine-1 receptors to dilate the renal and mesenteric artery beds > At 3 to 10 mcg/kg per min (and perhaps also at lower doses), dopamine also stimulates beta-1 adrenergic receptors and increases cardiac output, predominantly by increasing stroke volume with variable effects on heart rate. > At medium-to-high doses, dopamine also stimulates alpha-adrenergic receptors, although a small study suggested that renal arterial vasodilation and improvement in cardiac output may persist as the dopamine dose is titrated up to 10 mcg/kg per min *clinically, the haemodynamic effects of dopamine demonstrate individual variability Dobutamine (inodilator): - selective β1-agonist that increases cardiac contractility and reduces pulmonary vascular and systemic vascular resistances Vasopressin: - vasopressin may have pulmonary vasodilatory effects in addition to a systemic vasoconstrictive effect Milrinone (inodilator): - the phosphodiesterase-3 inhibitors, milrinone and enxoimone, have positive inotropic effects combined with the capacity to reduce RV afterload (‘inodilators’) without significant chronotropic effect, but they can be associated with significant systemic hypotension

Answer 34

28 days Aprepitant PI: "Alternative or "back-up" measures of contraception should be used during treatment with this medicine and for one month following the last dose of this medicine." Pharmacokinetics: - aprepitant is a CYP3A4 inhibitor - caution is also advised with warfarin and phenytoin use

Answer 35

physical dependance BARASH: Physical dependence is a “physiologic state of adaptation to a specific psychoactive substance characterized by the emergence of a **withdrawal syndrome** during abstinence, which may be relieved in total or in part by re-administration of the substance.” Tolerance - predictable physiological decrease in effect of drug over time (more drug to achieve same effect Abuse - intentional use of opioid for non medical purose, such as euphoria or altering one's state of consciousness Addiction - pattern of continued use with experience of or demonstrated potential for harm. Pain book page 806"

Answer 36

"a. Sux - degraded by plasma cholineserase -- may result in prolonged paralysis Likely organophosphate poisoning. Covalent bonding with inactvation of acetylcholinesterase - cholinergic crisis - Long duration of effect + worsening side effects SLUDGE BBB - salivation, lacrimation, urination, diarrhoea, gastric emesis, bronchorroea, bronchospasm, bradycardia Nicotinic effects --> muscle fasiculations, weakness, parlysis --? similar to depolarising effects of sux Tx - atropine (20mcg/kg boluses) + pralidoxime (30mg IV than 8mg/kg/hr) (treats nicotinic effects) BZD for seizures activated charcoal if within 2hrs https://litfl.com/organophosphate-poisoning/"

Answer 37

sarcoid Only parenchymal lung disease in the bunch. DLCO usually preserved/high in asthma due to hyperinflation and ^pulmonary capillary blood volume Reduced DLCO with normal spiro - anaemia (mild decrease - pulmonary vascular disease - early ILD - valsalva manouvre Reduced DLCO with restriction on spiro - ILD - pneumonitis Reduced DLCO with obstruction on spiro - sarcoid - emphysema - CF - bronchiolitis – combined pulmonary fibrosis and emphysema - lymphagioleiomyomatosis Other - Carboxyhaemoglobin (COHb) - decreased DLCO - supplemental O2 - decreased DLCO

Answer 38

a) Less transfusion, same thrombosis Recent cochrane review ●A 2019 meta-analysis of randomized trials comparing preoperative administration of EPO versus placebo (32 trials; 4750 patients, mostly orthopedic and cardiac surgery) found reduced blood transfusions in the EPO groups. Decreased blood transfusions were seen in the entire population (RR 0.59, 95% CI 0.47-0.73; 28 trials), as well as the subgroups undergoing cardiac surgery (RR 0.55, 95% CI 0.47-0.73; nine trials) and major orthopedic surgery (RR 0.36, 95% CI 0.28-0.46; five trials). In addition, the EPO group had increased hemoglobin levels. There was no increase in the incidence of thromboembolic events with EPO.

Answer 39

"b) facial grimace 8 features found to be associated with successful awake extubation in children: eye opening, facial grimace, conjugate gaze, purposeful movement, movement other than coughing, end tidal <0.2% for sevo, Vt>5ml/kg, SpO2 >97%, positive laryngeal stimulation test https://pubs.asahq.org/anesthesiology/article/131/4/801/909/Assessment-of-Common-Criteria-for-Awake-Extubation https://www.bjaed.org/article/S2058-5349(21)00133-5/fulltext#:~:text=Eight%20features%20have%20been%20found,for%20desflurane)%2C%20Spo2 """

Answer 40

Warm ischaemia time: - Time from treatment withdrawal to the start of cold perfusion of the donated organs - Significance is the impact on graft function - Most important phase of WIT begins when the systolic BP is < 60mmHg - This includes the waiting period from the absence of circulation to the declaration of death and the time before initiating the flow of cold perfusate through the cannula Maximum WARM Ischaemia time - Heart 30 mins - Liver 30 mins - Pancreas 30 mins - Kidney 60 mins - Lungs 90 mins Maximum COLD Ischaemia time: - Heart = 4 hrs - Lungs = 6-8hrs - Liver/Pancreas = 12hrs (DBD)/6 hrs (DCD) - Kidneys = 18hrs (DBD)/ 12 hrs (DCD)

Answer 41

d) Gentamicin Drugs in the anaesthetic trolley that may unmask or worsen MG: - NMBs - gentamicin - beta blockers (metoprolol) - magnesium Anaesthetic drugs to be cautious with: - dexamethasone - antipsychotics - anticonvulsants - antibiotics (vancomycin, metronidazole)

Answer 42

TXA TXA for all patients with vWD. DDAVP for type 1 (relative deficiency) and 2a (qualitative problem). vWF and FVIII (Biostate) replacement for Type 2b and Type 3 (absolute deficiency). Platelets - second line option if ongoing bleeding https://www.uptodate.com/contents/von-willebrand-disease-vwd-treatment-of-major-bleeding-and-major-surgery#H3081086338 "

Answer 43

strained broth - high protein content NB orange juice is not considered clear fruit juice ANZCA PS07: "Clear fluids are regarded as water, carbohydrate rich fluids, specifically developed for perioperative use, pulp free fruit juice, clear cordial, black tea and coffee. It excludes fluids containing particulate matter, soluble fibre, milk-based drinks and jelly" NB clear fluids is not the same as clear fluid diet used in GLP1 fasting guidelines

Answer 44

outdated question "ANZCOR recommends: - target sBP >100mmHg - target SpO2 94-98% (avoid hypoxia and hyperoxia) - target normocarbia PaCO2 35-40mmHg - Monitor BSL - treat if >10mmol/L. Avoid hypglycaemia - Continue or consider starting an antiarrythmic for prevention of recurrent VF (eg. Lignocaine 2-4mg/min or amiodarone 0.6mg/kg/hr for 12-24hrs) - TTM 32-36deg . avoid hyperthermia - AGAINST routine seizure prophylaxis - should be started after first seizure - if STEMI or LBBB --> immediate PCI - reassessed for resuscitation related injuries - waith 72hrs after ROSC before prognosticating https://www.resus.org.nz/assets/Uploads/ANZCOR-Guideline-11.7-Jan16.pdf "

Answer 45

photosensitivity Gliolan (PI): - Aminolevulinic acid hydrochloride (ALA) - Natural precurore of haeme, metabolised into fluorescent prophyrins - The fluorescence in certain tissue targets for photodynamic diagnosis - Increased fluorescent porphyrin formation by malignant glioma tissue (i.e. GBM) - After excitation with blue light (λ=400‑410 nm), PPIX is strongly fluorescent (peak at λ=635 nm) and can be visualised after appropriate modifications to a standard neurosurgical microscope. - Avoid exposure of eyes and skin to light sources afterwards (photosensivity). Contraindications: - hypersensitivity - porphyria - pregnancy Precautions: - After administration of Gliolan, exposure of eyes and skin to strong light sources (e.g. operating illumination, direct sunlight or brightly focused indoor light) should be avoided for 24 hours. - Co-administration with other potentially phototoxic substances (e.g. tetracyclines, sulfonamides, fluoroquinolones, hypericin extracts) should be avoided - Within 24 hours after administration, other potentially hepatotoxic medicinal products should be avoided. - In patients with pre-existing cardiovascular disease, Gliolan should be used with caution since literature reports have shown decreased systolic and diastolic blood pressures, pulmonary artery systolic and diastolic pressure as well as pulmonary vascular resistance.

Answer 46

cerebral oedema "a - Cerebral edema DKA is leading cause of morbidity and mortality in children with diabetes. Paediatric mortality mainly due to development of cerebral odema (60-90% of deaths) initially intracellular shrinkage due to high osmolality in plama from hyperglycaemia -- after treatment with insulin and fluid --> fluid shift back into cell --> cerebral oedema https://www.bjaed.org/article/S1743-1816(17)30291-3/pdf"

Answer 47

"a - tachycarida They are usually bradycardic CVS: hypotension, bradycardia, MV prolapse, impaired myocardial contractility, cardiomyopathy, ^ arrythmia (AV block. ST depression, TWI, QT prolongation) Resp: metabolic alkalosis, decreased lung compliance, aspiration pneumonia, PTX, pneumomediastinum Renal: proteinuria, reduced GFR, hypo - all electrolytes and renal stones GI: dental caries, periodontis, mallory-weiss tears, oesophgeal stricture, gastritis, delayed gastric emptying, risk of refeeding, fatty liver, hepatomegaly, cirrhosis, ^amylase, abnormal LFT, enlarged salivary gland Endocrine: delayed onset puberty, ^ cortisol/ GH, decreased glucose/insulin, impaired thermoregulation Immune: leucopenia, thrombocytopenia, haemolytic anaemia, poor wound healing Haem: bone marrow hypoplasia Neuro: decreased cognitive function, coma EEG abnromalities, seizures, neuropathy, ^pain threshold MSK: myalgia, myopathy, rhabdo, osteopenia, stress fracture https://academic.oup.com/bjaed/article/9/2/61/299563"

Answer 48

1 hour ASRA: 1 hour Although the occurrence of a bloody or difficult neuraxial needle placement may increase risk, there are no data to support mandatory cancellation of a case. Direct communication with the surgeon and a specific risk-benefit decision about proceeding in each case are warranted. Currently, insufficient data and experience are available to determine if the risk of neuraxial haematoma is increased when combining neuraxial techniques with the full anticoagulation of cardiac surgery. We suggest postoperative monitoring of neurologic function and selection of neuraxial solutions that minimise sensory and motor block to facilitate detection of new/progressive neurodeficits. NYSORA: Administration of intravenous heparin intraoperatively should be delayed for at least 1 hour after epidural placement; a delay before administration of subcutaneous heparin is not required. In cases of full heparinization for CPB, additional precautions include delaying surgery for 24 hours in the event of a traumatic tap, tightly controlling the heparin effect and reversal, and removing catheters when normal coagulation is restored.

Answer 49

a) Non-inferiority is not demonstrated Possible outcomes in a non-inferiority trial. In A (blue), non-inferiority is demonstrated. In B (green), non-inferiority is not demonstrated, and the trial is inconclusive. In C (red), the new treatment is inferior.

Answer 50

PCA e) Posterior cerebral ischaemia pupillary light reflex is preserved in cortical blindness Retinal detachment, or AION/PION will lose reflex Corneal abrasion = painful" UTD: Postoperative visual loss after anaesthesia for nonocular surgery Pupillary light reflexes* Unilateral central retinal artery occlusion, ischemic optic neuropathy, and retrobulbar hematoma result in a poor or absent pupillary response to light ("direct" response) with a normal response when light is directed to the other pupil ("indirect" response); this "relative afferent pupillary defect" is revealed when tested with the swinging flashlight maneuver; if these processes are bilateral, there will be poor or absent direct pupillary responses and a relative afferent pupillary defect only if asymmetric. Mid-dilated and nonreactive pupils are consistent with acute angle-closure glaucoma, while sluggish to fixed and dilated pupils are seen with glycine-induced visual loss. Pupillary light reflexes are normal in cases of corneal abrasion, cerebral or cortical visual loss, and in cases of PRES. Examination of pupils is discussed more fully separately.

Answer 51

a) Vertebral orange = vertebral blue = basilar purple = PCA red arrows = AICA yellow = pontine arteries Circle of Willis:

Answer 52

c) Junctional rhythm Up to date: Anaesthesia for elective eye surgery Oculocardiac reflex manifestations — Manifestations of the oculocardiac reflex commonly occur when pressure is applied to extraocular muscles. These include bradycardia (a decrease of 10 to 20 percent in the basal heart rate), junctional rhythms, hypotension, and, rarely, asystole. This reflex can occur during injection of local anesthesia or during the surgical procedure itself. Management includes stopping the stimulus (eg, release of traction or manipulation of the extraocular muscles). If this is ineffective, an anticholinergic medication (eg, atropine or glycopyrrolate) is administered. The risk of inducing this reflex may be reduced by an effective regional anesthetic block or general anesthesia with adequate depth.

Answer 53

midazolam - Opioids, benzodiazepines and pregabalin may also be used to alleviate symptoms. (blue book 2019) Postoperative agitation due to akathisia may be misinterpreted as delirium. This may be mistakenly treated with haloperidol (a dopamine antagonist), exacerbating the akathisia and agitation45. Benzodiazepines should be used as treatment for akathisia instead7. Perioperative treatment of symptoms If RLS symptoms occur perioperatively, patients should be allowed to walk or move their legs in bed as soon as possible. If prolonged bed rest is required, the frequency of RLS medications may be increased to three times a day. If oral intake is feasible, a patient’s usual oral medication may be given. Levodopa (a dopamine agonist) may be administered by nasogastric tube. Alternatively, parenteral apomorphine or a rotigotine patch may be used. Apomorphine (1 milligram) may be injected subcutaneously on an hourly basis. Nausea is a common side effect so it may need to be given with an antiemetic. Rotigotine patches may be used every 24 hours. Opioids, benzodiazepines and pregabalin may also be used to alleviate symptoms. Patients should be proactively investigated and treated for iron deficiency, targeting ferritin level greater than 300 micrograms/ litre in adults, and 50 micrograms/litre in children.

Answer 54

a) No increased risk of surgical wound infection - Now, the Perioperative Administration of Dexamethasone and Infection Trial (PADDI), led by Professor Tomás Corcoran, Director of Research in the Department of Anaesthesia and Pain Medicine, Royal Perth Hospital has found that administering a low-dose of dexamethasone during anaesthesia for surgical operations does not increase the risk of surgical wound infections. Slight increase in BSLs. NO change in SSI large pragmatic, international, non-inferiority trial - 8880 adult patients elective non cardiac surgery - Dex 8mg vs Placebo - excluded - diabetic pts with HbA1c >9%, procedure associated with primary infection, time critical surgery - primary outcome SSI within 30days post op - non inferiority margin 2% - tertial outcome - BSL (difference between pre-op and max BSL POD2) - 1.2mmol/L higher in Dex compared to Placebo https://www.nejm.org/doi/full/10.1056/NEJMoa2028982"

Answer 55

"d - IE ratios - no evidence Consensus recommendations 2019 : - Vt 6-8ml/kg IBW - PEEP at least 5cmH20 and individualised - 30deg headup if possible - FiO2 lowest possible (aim SpO2 >94%) - alveolar recruitment manouvres beneficial - machine better than bag - minimise PEEP lost between transitioning - lowest effective pressure for shortest effective time Hyperoxia - ^ oxidateive stress, peripheral and coronary vascular vasoconstrictuion, decrease CO, ^ resoption atelectasis, ^postop pulmonary complications, masking effect of O2 therapy --> delayed diagnosis of gas-exchange impairment. https://www.bjanaesthesia.org/article/S0007-0912(19)30647-6/fulltext"

Answer 56

"c) pneumthorax in M-mode normal - sand on the beach PTX - statosphere/barcode sign Haemothorax - pleural effusion + echogenic material = haematocrit sign Interstitial oedema - b lines pneumonia - bronchograms - looks like liver https://www.pocus101.com/lung-ultrasound-made-easy-step-by-step-guide/#Lung_Ultrasound_Signs_and_Findings https://www.melbourneus.com/pneumothorax/ "

Answer 57

"b - Adductor canal. Opthalmic blocks> Addutor canal. Adductor canal specifically for lower limb blocks - Unknown cause Rare complication Myotoxicity after regional anaesthesia defined as: occurance of symptoms related to muscle damage, including muscle paralysis/wekaness, occurence of dipolpia/ptosis/hypertropia and hypotropia after catarcht surgery, enzymatic changes indicateive of muscle damage (such as elevated CK) Myotoxic damage appeared to occur independent of needle size and LA concentration. https://www.bjanaesthesia.org/article/S0007-0912(18)30572-5/pdf"

Answer 58

A suprascap https://www.orthobullets.com/shoulder-and-elbow/3062/scapular-winging stabilisation of scap by long thoracic, spinal accessory nerve, dorsal scapular nerve

Answer 59

No answer provided. ?encephalitis These are all complications of dural puncture. Up to date: Post dural puncture headache

Answer 60

hypoxia "a - Hypoxia Factors that ^ free peak plasma concentration ^ LAST - low AAG (neonateds, pregnant) --> ^ free - decreased elimination or ^ suscpetibility (renal/liver/cardiac failure) - acidosis, hypercarbia, hypoxia - carnitine deficiency ^ risk for cardiac toxicity (especially with bupivacaine) https://www.uptodate.com/contents/local-anesthetic-systemic-toxicity?search=local%20anesthetic%20systemic%20toxicity&source=search_result&selectedTitle=1~55&usage_type=default&display_rank=1#H3971070218" NYSORA: LAST There is a greater likelihood for LA systemic toxicity in petite patients (small muscle mass), those at the extremes of age, and patients with preexisting heart disease or carnitine deficiency. Roughly half the cases of LAST are atypical, with no seizures (other CNS symptoms), only CV toxicity or delayed onset. The incidence of toxicity increases with injections near richly vascular areas. It is highest with paravertebral injections, followed by upper and lower extremity PNBs. Prevention of LAST-related morbidity requires optimizing a complete system for regional anesthesia: patient selection, nerve block choice, drug and dose, complete monitoring and use of USGRA when possible, and preparing for LAST by having a kit available and practicing with simulation. Prevention also includes raising awareness and educating our non-anesthesiology colleagues about proper use of LAs and risks, including management of LAST.

Answer 61

CO2 Laser danger is proportional to penetration. Penetration inversely proportional to the laser wavelength. CO2 laser has very little penetration (~ 10micrometres), as it has a wavelength of 10 600nm. Helium-Neon laser also has very little penetration. Nd:YAG is the most powerful, with a penetration of 2-6mm, as it has a wavelength of 1064nm.

Answer 62

"d) less maternal bradycardia - nil pt required anticholinergic so clinical significance unclear no difference in N/V norad non inferior to phenyl in terms of acid base profiles and APGAR at 1min and 5mins https://www.bjanaesthesia.org.uk/article/S0007-0912(20)30442-6/fulltext https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/full/10.1111/anae.14976"

Answer 63

pancreatic fistula -> should cause NAGMA HAGMA: Lactate Toxins Ketones Renal failure NAGMA Chloride Addison's, adrenal insuffiency, acetazolamide GI loss (pancreatic fistula) Extra: RTA Anion gap: - Anion Gap = Na+ – (Cl- + HCO3-) - The Anion Gap (AG) is a derived variable primarily used for the evaluation of metabolic acidosis to determine the presence of unmeasured anions - The normal anion gap is assumed to be 12, and the normal HCO3 is assumed to be 24 Delta ratio: - can check delta ratio in the presence of a high anion gap metabolic acidosis (HAGMA) to determine if it is a ‘pure’ HAGMA or if there is coexistant normal anion gap metabolic acidosis (NAGMA) or metabolic alkalosis.

Answer 64

a) Bleeding ECMO complications: - patient complications: bleeding & coagulopathy most common - mechanical complications: access insufficiency common Blue book 2017 VV ecmo for respiratory support VA ecmo for CVS support Pt complications Bleeding (5-79%) > thrombosis, neurolgical catstrophe, infection (45%), differential hypoxia (VA ecmo) - often seen following return of some native cardiac function --> blood from ECMO circuit being directed into distal aorta preferetially pefuse lower body and blood from LV preferentially perfuse coroary/cerberal circulation --> so if poor pulmonary gas exchange, oxygenation may be inadequate (so need multiple SpO2 monitoring --> Right arm (supplied by brachiocephalic trunk which also supplies carotid) ANZCA blue book 2017 pg 63 https://www.anzca.edu.au/resources/college-publications/australasian-anaesthesia-(the-blue-book)/blue-book-2017-(1)"

Answer 65

a) CO2 "b - CO2 - black ribbon – works by taking away oxygen element of fire triangle - won't cause damage to electrical equipment so best for areas in server/data rooms, electrical machinery, offices C - dry chemical (white ribbon) can also be used - 2 types - ABE and BE (for different categories of fire) https://www.fireextinguisheronline.com.au/blog/post/types-of-fire-extinguisher-in-australia-all-you-need-to-know Fire triad - oxidiser - oxygen or N2O - ignition source - 'spark' - laser, diathermy, electical devices, defib, drills, fibreoptic light, buildup of static/fautly equipment or power sockets - fuel - substance that stores potential energy that may be released as heat energ y - bedding, surgical materials, alcohol prep solutions https://academic.oup.com/bjaed/article/15/2/78/248435 "

Answer 66

"a. PEA 50% / Asystole 28% /Unknown 11% / VF 6 % / VT 5% ROSC 74% Survival to discharge 40.7% https://pubmed.ncbi.nlm.nih.gov/30170022/"

Answer 67

b"4 - Superior / Anteromedial / Lateral / Posterior. A PA LM Seed Makes Another Little Palm (R Side) ASIA ALPS (L side) " Right lung: RUL: APA RML: LM RLL: SMALP Left lung: LUL: ASIA (S&I form the lingular lobe) LLL: ALPS Subsegments (total of 42) Left: 10 + 10 Right: 6 + 4 + 12

Answer 68

e) Decreased SVR - increased CO, increased SBP and decreased DBP with widened PP High CO state (+/- failure -- LVEF does not ^ appropriately during exercise suggesting presence of cardiomyopathy) - ^CO state due to ^ peripheral oxygen needs and ^ cardiac contractility - increased HR, contractiliity, sBP (widened pulse pressure), pulmnoary artery pressure, myocardial oxygen https://www.uptodate.com/contents/cardiovascular-effects-of-hyperthyroidism?search=cardiovascular%20effects%20of%20hyperthryod&topicRef=7833&source=see_link in HYPOthryoid - opposite occurs - decreased CO - decreased contractility, HR, diastolic relaxation (so decreased compliance and diastolic filling), peripheral tissue oxygen utilisation - blunted response to catecholamine mediated ^ in inotropy - ^ SVR, ^Qtc" UP TO DATE: Cardiovascular effects of hyperthyroidism: - Thyroid hormone has important effects on cardiac muscle, the peripheral circulation, and the sympathetic nervous system that alter cardiovascular hemodynamics in a predictable way in patients with hyperthyroidism. - The main changes are : ●Increases in heart rate, cardiac contractility, systolic and mean pulmonary artery pressure, cardiac output, diastolic relaxation, and myocardial oxygen consumption ●Reductions in systemic vascular resistance and diastolic pressure

Answer 69

"a - bile acids needed for absorption of Vit K obstetric cholestasis occurs in late 2nd and early 3rd trimester of pregnancy. Aetiology unclear. - manifests as increased pruritis, increased serum bile acids and LFT, high PT (due to Vit K deficiency) - associated with ^ still birth, RDS, mec, fetal asphyxiation (serum bile acids > 40microm/L - Tx: ursodeoxycholic acid - 300BD up to 300mg TDS (Max dose 21mg/kg/day) -- if refractory - rifampin, cholestyramine, S-adenosyl-L-methonine https://www.ncbi.nlm.nih.gov/books/NBK551503/"

Answer 70

c) Lowest FiO2 possible aim sats 88-92% if hypoxic Bleomycin Bleomycin is a particularly important chemotherapy drug for the anaesthetist to be aware of. Bleomycin is often used to treat germ cell tumours and Hodgkin's disease in a curative setting. The major limitation of bleomycin therapy is the potential for subacute pulmonary damage that can progress to life-threatening pulmonary fibrosis. Pulmonary toxicity occurs in 6–10% patients and can be fatal. Exposure to high-inspired concentration oxygen therapy, even for short periods, as experienced during anaesthesia, is often implicated in causing rapidly progressive pulmonary toxicity in patients previously treated with bleomycin. These claims have been considered controversial by some, but it is the authors' recommendation that any patient previously exposed to bleomycin therapy should be treated as high risk, and summary guidance regarding oxygen therapy is shown:

Answer 71

b) Diaphragm

Answer 72

c) Cease clopidogrel for 5 days, continue aspirin - prostatic surgery, the risk of major bleeding may be greater than the risk of stent thrombosis - For clopidogrel, we stop five days before surgery - Clopidogrel, if stopped, should be restarted with a loading dose of 300 mg as soon as possible after surgery, perhaps later in the day if postoperative bleeding has stopped. Some experts recommend a higher loading dose of 600 mg to decrease time to effectiveness in the higher-risk postoperative setting - suggest that surgery be performed in centers with 24-hour interventional cardiology coverage UP TO DATE: Noncardiac surgery after PCI Nonemergency noncardiac surgery — For patients who have undergone previous stenting with either BMS or DES and who will need cessation of one or both antiplatelet agents, we prefer to defer planned nonemergency, nonurgent noncardiac surgery until at least six months after stent implantation. The risks of noncardiac surgery before six months are increased after both BMS and DES. For patients whose surgery requires cessation of one or both antiplatelet agents and cannot wait six months, and where the risks of delaying surgery outweigh the benefits, our recommended minimal duration of DAPT is four to six weeks, depending on the urgency of surgery and risk of thrombotic complication. This is based in part on evidence suggesting that the increased risk of MI and cardiac death is highest within the first month after stent placement and no clear difference in risk between BMS and DES. Although we prefer to wait at least six weeks when possible, in patients for whom earlier surgery is in their best interest after weighing risks and benefits, we sometimes refer patients as early as four weeks after stent placement. The proinflammatory and prothrombotic risks of surgery may increase the baseline risk of stent thrombosis even in the presence of DAPT and regardless of stent type during this early period after stenting. We believe this risk to be higher prior to the minimum duration of DAPT recommended above, but the final decision to continue or discontinue antiplatelet therapy in the perioperative period should be made only after an informed discussion among the surgeon, managing cardiologist (and other health care providers), and patient has taken place. In many cases, DAPT can be continued in the perioperative period, although for some surgeries, such as neurosurgery, posterior eye surgery, or prostatic surgery, the risk of major bleeding may be greater than the risk of stent thrombosis. In these patients who undergo noncardiac surgery before the recommended minimum duration of DAPT, a platelet P2Y12 receptor blocker should be discontinued for as brief a period as possible. Aspirin should be continued through the perioperative period, since the risk of stent thrombosis is further increased with the cessation of both aspirin and clopidogrel and surgery can usually be safely performed on aspirin. The rationale to continue aspirin comes in part from the POISE-2 trial (PCI subgroup analysis), which is discussed separately. However, as many neurosurgical patients, for whom bleeding might be life threatening or lead to severe adverse outcomes, were not enrolled in POISE-2, the optimal strategy is not known. ●Minor surgical and dental procedures usually do not require cessation of antiplatelet therapy. ●With regard to stopping P2Y12 inhibitor prior to noncardiac surgery, we generally follow recommendations found in the manufacturer's package insert for each drug. - For clopidogrel, we stop five days before surgery; that is, the last dose is taken on the sixth day before surgery. - For prasugrel, we stop seven days before surgery. - For ticagrelor, we stop three to five days before surgery. - Some experts are willing to recommend shorter discontinuation periods for procedures less likely to be associated with major bleeding. ●Clopidogrel, if stopped, should be restarted with a loading dose of 300 mg as soon as possible after surgery, perhaps later in the day if postoperative bleeding has stopped. Some experts recommend a higher loading dose of 600 mg to decrease time to effectiveness in the higher-risk postoperative setting. ●We suggest that surgery be performed in centers with 24-hour interventional cardiology coverage

Answer 73

a) Midazolam 0.15mg/kg 1st line: Midazolam IV/IO/IM --> 0.15mg/kg 2nd line: Midazolam IV/IO/IM --> 0.15mg/kg 3rd line: Keppra 40mg/kg (max 3g) 4th line: Phenytoin 20mg/kg or phenobarbitone 5th line: Intubation and deep sedation with midazolam, propofol +/- phenobarbitone

Answer 74

c) Alcohol 70% - only suitable for short-term cannulation (<24 hours)

Answer 75

c) 0.7 75% is normal cutoff for DLCO Obstructive disease - FEV1/FVC < 0.7 Mild FEV1 >/=80% Mod 55-80%% Severe 30-50% Very severe < 30% https://www.uptodate.com/contents/image?imageKey=PULM%2F61983"

Answer 76

d) LBW LBW - propofol induction, thieopentone, fentanyl, alfentanil, morphine, non-depolarising NMBD, paracetamol, LA ABW - Propofol maintenaince, neostigmine, sugammadex, antibiotics https://www.sobauk.co.uk/_files/ugd/373d41_eebe369c3c6b4021bff6f3da059aa796.pdf"

Answer 77

d) WPW Type B pattern LITFL: ECG features of WPW in sinus rhythm -> PR interval < 120ms -> Delta wave: slurring slow rise of initial portion of the QRS -> QRS prolongation > 110ms -> Discordant ST-segment and T-wave changes (i.e. in the opposite direction to the major component of the QRS complex) -> Pseudo-infarction pattern in up to 70% of patients — due to negatively deflected delta waves in inferior/anterior leads (“pseudo-Q waves”), or prominent R waves in V1-3 (mimicking posterior infarction Can be left-sided (Type A) or right-sided (Type B), and ECG features will vary depending on this: Left-sided AP: produces a positive delta wave in all precordial leads, with R/S > 1 in V1. (Dominant R Wave in V1) Sometimes referred to as a type A WPW pattern Right-sided AP: produces a negative delta wave in leads V1 and V2. Sometimes referred to as a type B WPW pattern Tachyarrhythmias in WPW There are only two main forms of tachyarrhythmias that occur in patients with WPW 1. Atrial fibrillation or flutter. -> Due to direct conduction from atria to ventricles via an AP, bypassing the AV node 2. Atrioventricular re-entry tachycardia (AVRT). -> Due to formation of a re-entry circuit involving the AP Breakdown of Type A example: - Sinus rhythm with a very short PR interval (< 120 ms) - Broad QRS complexes with a slurred upstroke to the QRS complex — the delta wave - Dominant R wave in V1 suggests a left-sided AP, and is sometimes referred to as “Type A” WPW - Tall R waves and inverted T waves in V1-3 mimicking right ventricular hypertrophy (RVH) — these changes are due to WPW and do not indicate underlying RVH - Negative delta wave in aVL simulating the Q waves of lateral infarction — this is referred to as the “pseudo-infarction” pattern

Answer 78

b - alcoholic liver - albumin would suggest chronic picture ALP > 3 x ALT suggest cholestasis picture ^ALT and ^AST suggest hepatocellular injury - >10x upper limit suggest acute severe insult - hepatitis or hypoxia - mildly elevate suggest infection, alcohol, fatty liver or medication AST high - S = shit faced cholestatic picture = ^ GGT and ^ ALP Elevated AST: ALT = 1 --> associated with ischaemia (CCF, ischaemic necrosis, hepatitis) AST: ALT >2.5 --> alcoholic hepatitis, AST: ALT <1 --> high rise in ALT specific for hepatocellular damage - paracetamol OD with hepatocellular necrosis, viral hipatitis, ischaemic necrosis, toxic hepatitis ^ALP - primarily associated with cholestasis and malignant hepatic inflitration (marker of rapid bone turnover and extensive bone mets) ^GGT - sensitive to alcohol ingetsion, marker of hepatocellular damage but non-specific, sharpest rise associated with biliary and hepatic obstruction https://litfl.com/liver-function-tests/ https://www.racgp.org.au/getattachment/36d1c5e0-9c1d-43fc-a8a0-b323e3ed8fbe/Liver-function-tests.aspx

Answer 79

d) Trigger for initiating CICO Rescue is SpO2 <90% - According to the Vortex Approach the trigger for initiating CICO Rescue is the inability to confirm adequate alveolar oxygen delivery following best efforts at all three upper airway lifelines. Trigger for Initiating CICO Rescue VORTEX APPROACH The trigger for initiating CICO Rescue is the inability to confirm adequate alveolar oxygen delivery following best efforts at all three upper airway lifelines. Note that this trigger is independent of the oxygen saturations since, even in the unusual situation where the oxygen saturations remain high following best efforts at all three lifelines, the inability to confirm alveolar oxygen delivery means that eventual desaturation is inevitable. Rather than being a deterrent to its performance, recognition of the need for CICO Rescue while the oxygen saturations remain high should be viewed as advantageous – providing increased time to perform this confronting procedure in a more controlled manner, thereby increasing the chance of success. Conversely, a critically low oxygen saturation is not in itself a trigger to initiate CICO Rescue if best efforts at all three lifelines have not yet been completed. While legitimate opportunities to enter the Green Zone in a timely fashion via the familiar upper airway lifelines remain, these should be given priority, as they are more likely to be successful than resorting to an unfamiliar and more traumatic technique. Oxygen saturations are therefore not a relevant consideration in deciding the trigger for CICO Rescue – this is always “the inability to confirm adequate alveolar oxygen delivery following best efforts at all three upper airway lifelines”. They are, however, a relevant consideration in making the context dependent decision of what constitutes a best effort at each lifeline in a particular situation. This is because the oxygen saturations impact on how much time it is reasonable to invest in optimising each of the upper airway lifelines before declaring a best effort. When the oxygen saturations are critically low it might be reasonable to have only one attempt at each lifeline before declaring a best effort, even though this means leaving some potential optimisation interventions untried. This is because the incremental benefit of repeated attempts to optimise a lifeline that has already failed is typically low relative to untried alternative lifelines. Thus the time expended on such low yield interventions cannot be justified when the patient is already critically hypoxaemic and alternatives (including CICO Rescue) with a substantially higher likelihood of success remain.

Answer 80

"a - Not in the same structures. Bleeding from hepatic vein cannot be controlled using a pringle maouver Pringle manoeuvre = temporary inflow occlusion - Xclam hepatodudenal ligament (hepatic artery, portal vein, common bile duct) -- > Decreased VR and ^SVR --> haemodynamic instability https://www.bjaed.org/article/S2058-5349(22)00076-2/fulltext "

Answer 81

d) The pooled data from all of the studies Forest plots or blobbograms are used in order to show graphically the studies which have been included in the meta-analysis. They demonstrate the differences between studies and provide an estimate of the overall result. ================== The effect of one study on the overall conclusion Graphically the studies which have been included in a meta-analysis. They demonstrate the differences between studies and provide an estimate of the overall result * the width of the lines represents 95% confidence interval * Squares = point estimate of the difference between study groups. Size of square proportional to weighting of study (main determinant = sample size) * Diamond at bottom = pooled data from all studies * X axis = relative benefit * Y axis = line of no effect "

Answer 82

a) Amputation Top 10 Rank order: 1. Amputation 30-85% 2. Thoracotomy 5-67% 3. Mastectomy 11-57% 4. Inguinal hernia repair 0-63% 5. Sternotomy 28-56% 6. Cholecystectomy 3-56% 7. Knee arthroplasty 19-43% 8. Breast Augmentation 13-38% 9. Vasectomy 0-37% 10. Radical prostatectomy 35%

Answer 83

a) Greater occipital e - greater occipital nerve SGLT - 1. Supraclavicular Nerve (C3/4) 2. Great Auricular Nerve (C2/3) 3. Lesser Occipital Nerve (C2) 4. Transverse Cervical Nerve (C2/3) - Also Anterior

Answer 84

d) 10 minutes or 20min https://journals.sagepub.com/doi/10.1177/0310057X20937710 states 20min one of those shit questions that depends on your source. Morgan & Mikhail's (chapter 36: anaesthesia for ophthalmic surgery): " Succinylcholine increases IOP by 5-10mmHg for 5-10 minutes". - due to prolonged contracture of the EOM BARASH: Succinylcholine increases IOP 7 to 10 mmHg reaching a peak pressure 1 to 2 minutes after IV administration and returns to the baseline in 5 to 7 minutes. This increase may be attenuated by pretreatment with anesthetics, although none completely eliminates the increase in IOP. In the presence of a lacerated globe, this increase in IOP may increase the extrusion of intraocular contents although greater increases in IOP may occur during crying and coughing. Yao & Artusio's: - also quotes same information: increases IOP 7 to 10mmHg, returning to baseline in 5 - 7 minutes. Stoelting's: Intraoccular pressure peaks at 2-4 minutes after administration and returns to normal by 6 minutes

Answer 85

b electrical alterans Physical findings in Tamponade: - A number of findings may be present on physical examination, depending upon the type and severity of cardiac tamponade - None of the findings alone are highly sensitive or specific for the diagnosis. Beck's triad 1. Low arterial blood pressure 2. Dilated neck veins 3. Muffled heart sounds - Are present in only a minority of cases of acute cardiac tamponade. Physical findings of sinus tachycardia and the absence of frank hypotension may indicate significant hemodynamic compromise from cardiac tamponade and serve as an indication for immediate pericardiocentesis. In contrast, Kussmaul sign (the absence of an inspiratory decline in jugular venous pressure) is not usually seen in cardiac tamponade. Tachycardia and hypotension - Sinus tachycardia is seen in almost all patients, in an attempt to maintain cardiac output - Hypotension is somewhat more variably present - One exception is when the underlying disease is associated with bradycardia, as with a pericardial effusion and subacute cardiac tamponade associated with hypothyroidism. - Tachycardia also may not be seen in patients with early cardiac tamponade even though they have signs of a hemodynamically significant effusion, such as an elevated jugular venous pressure. Elevated jugular venous pressure - The JVP is almost always elevated in cardiac tamponade and may be associated with venous distension in the forehead and scalp. - CVP wave form: ->x descent is preserved ->y descent is attenuated or absent (due to the limited or absent late diastolic filling of the ventricle) Pulsus paradoxus -defined as: abnormally large decrease in systolic blood pressure (>10 mmHg) on inspiration - common finding in moderate to severe cardiac tamponade and is the direct consequence of ventricular interdependence. - not all patients with cardiac tamponade have pulsus paradoxus (eg, those with chronic hypertension leading to elevated ventricular diastolic pressures or those with a co-existent atrial septal defect). Pericardial rub — A pericardial rub may be heard in patients with cardiac tamponade due to inflammatory pericarditis. Electrocardiography - ECG in cardiac tamponade typically shows sinus tachycardia and may also show low voltage. - If pericarditis is present, the ECG findings typical of that disorder are also seen. - Electrical alternans is characterized by beat-to-beat alterations in the QRS complex and, in some cases, other electrocardiographic waves that reflect the swinging of the heart in the pericardial fluid. - Electrical alternans is relatively specific but not very sensitive for cardiac tamponade; rarely, this phenomenon is seen with very large pericardial effusions alone. Diagnosis: Clinical diagnosis is usually suspected based on the history and physical examination findings, which may include: ●Chest pain ●Syncope or presyncope ●Dyspnea and tachypnea ●Hypotension ●Tachycardia ●Peripheral edema ●Elevated jugular venous pressure ●Pulsus paradoxus Presence of a pericardial effusion on echocardiography with evidence of cardiac chamber collapse, flow variation, or dilation of the inferior vena cava is consistent with, and highly suggestive of, cardiac tamponade. However, the diagnosis of cardiac tamponade can only be confirmed by the hemodynamic and clinical response to pericardial fluid drainage.

Answer 86

a) Amiodarone 150mg over 30minutes, then 1mg/min for 6 hours UP TO DATE: Arrhythmias in COPD For patients with atrial fibrillation and COPD, we suggest using verapamil or diltiazem rather than metoprolol in patients who require ventricular rate control (Grade 2C). Metoprolol is reserved for patients who do not respond to the calcium channel blockers and do not have uncontrolled bronchoconstriction. For those with an accessory pathway or heart failure, amiodarone or digoxin may be preferred as outlined in the table (table 3).

Answer 87

b) 2 - if male CHA2DS2-VASc score ≥2 to be recommended chronic OAC (Grade 1A). - if female CHA2DS2-VASc score ≥3 to be recommended chronic OAC (Grade 1A). * non-sex risk factor also holds bearing: - For patients with CHA2DS2-VASc score of 1 in males and 2 in females based on age 65 to 74 years, we recommend chronic OAC (Grade 1A). Up to date: Our approach to deciding whether to prescribe anticoagulant therapy for patients with AF (excluding those with rheumatic mitral stenosis that is severe or clinically significant [mitral valve area ≤1.5 cm2], a bioprosthetic valve [surgical or bioprosthetic] within the first three to six months after implantation, or a mechanical heart valve) is as follows: *For a CHA2DS2-VASc score ≥2 in males or ≥3 in females, we recommend chronic OAC (Grade 1A). *For a CHA2DS2-VASc score of 1 in males and 2 in females: -For patients with CHA2DS2-VASc score of 1 in males and 2 in females based on age 65 to 74 years, we recommend chronic OAC (Grade 1A). Age 65 to 74 years is a stronger risk factor than the other factors conferring one CHA2DS2-VASc score point. -For patients with other risk factors, the decision to anticoagulate is based upon the specific nonsex risk factor and the burden of AF. For patients with very low burden of AF (eg, AF that is well documented as limited to an isolated episode that may have been due to a reversible cause such as recent surgery, heavy alcohol ingestion, or sleep deprivation), it may be reasonable to forgo chronic OAC and institute close surveillance for recurrent AF, although it may not be possible to reliably estimate AF burden from surveying symptoms or infrequent monitoring. The frequency and duration of AF episodes vary widely over time, and episodes are often asymptomatic. *For patients with a CHA2DS2-VASc of 0 in males or 1 in females, we suggest against OAC (Grade 2C). Patient values and preferences may impact the decision. For example, a patient who is particularly stroke averse and is not at increased risk for bleeding may reasonably choose anticoagulation, particularly if the patient is a candidate for treatment with a direct oral anticoagulant (DOAC). 2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline

Answer 88

e) Low resistance

Answer 89

b) Pulmonary hypertension Up to date: Overview of pulmonary function testing in adults Diffusing capacity — Measurement of the single-breath diffusing capacity for carbon monoxide (DLCO; also known as transfer factor or TLCO) is quick, safe, and useful in the evaluation of restrictive and obstructive lung disease, as well as pulmonary vascular disease. The technique and interpretation are discussed separately. In the setting of restrictive disease, the diffusing capacity helps distinguish between intrinsic lung disease, in which DLCO is usually reduced, and other causes of restriction, in which DLCO is usually normal. In the setting of obstructive disease, the DLCO helps distinguish between emphysema, in which it is usually reduced, and other causes of chronic airway obstruction, like asthma or chronic bronchitis, where it is usually normal. The DLCO is also used in the assessment of pulmonary vascular disease (eg, thromboembolic disease, pulmonary hypertension), which typically causes a reduction in DLCO in the absence of significant restriction or obstruction

Answer 90

a) face, legs, activity, cry, consolability

Answer 91

"d) Knee extension weakness Femoral Nerve motor function = leg flexion at hip, leg extension at knee. Obturator Nerve motor function = adduction of thigh. Sciatic N - innervates post compartment of thigh and indirectly entiere lower leg and foot (tibial N and common fibular N) " BJA: Perioperative peripheral nerve injuries https://academic.oup.com/bjaed/article/12/1/38/260058 Lower limb peripheral nerve injuries Sciatic nerve injury (L4–S3) Mechanism of injury Stretch, compression, ischaemia, and direct damage are the primary mechanisms. The lithotomy, frog leg, and sitting positions have been implicated in perioperative injury to this nerve (hyperflexion of the hip, abduction, and extension of the leg causes stretching). Regional anaesthetic techniques and hip arthroplasty may also cause injury. A higher incidence is seen in men aged 45–55 yr and in patients suffering with diabetes mellitus. The common peroneal component is usually affected, as this is more superficial compared with the tibial component. Clinical presentation Injury manifests as paralysis of the hamstring muscles and all the muscles below the knee leading to weak knee flexion and foot drop. All sensation below the knee except the medial aspect of the leg and foot is impaired.

Answer 92

d. G6PD - contraindicated (don't use prilocaine) Indications: methemoglobinemia (symptomatic or asymptomatic with >20% MetHb, or >10% if risk factors such as anaemia or ischemic heart disease); vasoplegic shock post cardiopulmonary bypass; hepatopulmonary syndrome, septic shock. Other uses have included use as an antimalarial agent, anti-cancer treatment, treatment of ifosfamide neurotoxicity, as a dye/stain (e.g. test for aspiration), priapism, CN toxicity Contraindications: G6PD deficiency (lack of NADPH prevents methylene blue from working and may lead to haemolysis); renal impairment; methaemoglobin reductase deficiency; nitrite-induced methaemoglobinaemia due to cyanide poisoning; hypersensitivity ADE: anaphylaxis, trigger serotonin syndrome, intereferes SpO2, non-speicifc symptoms."

Answer 93

d) Reduced RR BJA: HFNP oxygen therapy https://www.bjanaesthesia.org/article/S0007-0912(17)53999-9/fulltext - reduced RR - increased MV - reduced WOB, reduced Vd, reduced AWR - provides CPAP 3-7 cmH20 (mouth closed)

Answer 94

e) Protamine The interpretation of this graph is not especially laborious. The cardinal abnormality is the massively prolonged CT and CF of the INTEM graph, which suggests that something has killed the intrinsic pathway of the clotting cascade. The CT returns to normal in the HEPTEM graph, which is essentially just an INTEM test with adde heparinase. The presence of heparinase seems to have reversed all of the coagulopathy - the CFT, alpha-angle and MCF have all returned to normal. Therefore, this patient has no coagulation problems other than the heparin. https://derangedphysiology.com/main/required-reading/haematology-and-oncology/Chapter 1.2.0.1/intepretation-abnormal-rotem-data

Answer 95

b) Factor VII Redcross: Cryoprecipitate contains most of the following found in fresh frozen plasma: 1. factor VIII 2. fibrinogen 3. factor XIII 4. von Willebrand factor 5. fibronectin Prothrombinex-VF® is a lyophilised concentrate of human coagulation factors it contains: Factors: II IX X small amount of factor VII. Also contains: plasma proteins (human) Antithrombin III (human) Heparin sodium (porcine) Sodium Phosphate Citrate Chloride

Answer 96

d) 7500mls Compared with the blood volume (65 to 70 mL/kg) in nonpregnant women, the blood volume in pregnant women at term is increased to 100 mL/kg

Answer 97

c) Genitofemoral

Answer 98

b) Suprahyoid Extrinsic Muscles of the larynx: 1. Sternothyroid muscle 2. Thyrohyoid muscle 3. Inferior constrictor of the pahrynx Indirect elevators of the larynx: 1. Mylohyoid 2. Stylohyoid 3. geniohyoid Indirect depressors of the larynx: 1. Sternohyoid 2. Omohyoid Intrinsic Muscles of the larynx: 1. Posterior Cricoarytenoid 2. Lateral Cricoarytenoid 3. Interarytenoid 4. Thyroarytenoid 5. Vocalis 6. Cricothyroid actions of intrinsic laryngeal muscles 1. Abductor of the cords: posterior cricoarytenoids 2. Adductors of the cords: lateral cricoarytenoids, interarytenoids 3. Sphincter to the vestibule: aryepiglottics (interarytenoid), thyroepiglotics 4. Tension regulators of the cords: Cricothyroids (tensors), Thyroarytenoids (relaxors), Vocales (fine adjustment)

Answer 99

d) Knee extension weakness - most correct based on answers remembered - this is femoral innervation Superficial peroneal nerve injury (L4–5 S1–2) Mechanism of injury Lithotomy and the lateral position are the common risk factors as the nerve is potentially compressed at the fibular head. Length of time in lithotomy has not been associated with an increased risk of developing a PPNI. Clinical presentation There is loss of dorsiflexion and eversion of the foot (equinovarus deformity). Sensory manifestations are described along the anterolateral border of the leg and the dorsum of the digits except those supplied by saphenous and sural nerves. Orthobullets: Common peroneal nerve - superficial & deep branches Deep peroneal - motor: extensor digitorum longus, extensor hallucis longus (dorsiflexion) - sensory: 1st dorsal webspace Superficial peroneal - motor: peroneus longus and brevis (eversion) - sensory: dorsum foot (except for 1st dorsal webspace & 5th toe) Lower limb peripheral nerve injuries Sciatic nerve injury (L4–S3) Mechanism of injury Stretch, compression, ischaemia, and direct damage are the primary mechanisms. The lithotomy, frog leg, and sitting positions have been implicated in perioperative injury to this nerve (hyperflexion of the hip, abduction, and extension of the leg causes stretching). Regional anaesthetic techniques and hip arthroplasty may also cause injury. A higher incidence is seen in men aged 45–55 yr and in patients suffering with diabetes mellitus. The common peroneal component is usually affected, as this is more superficial compared with the tibial component. Clinical presentation Injury manifests as paralysis of the hamstring muscles and all the muscles below the knee leading to weak knee flexion and foot drop. All sensation below the knee except the medial aspect of the leg and foot is impaired.

Answer 100

B - weakness in thumb abduction (APB) Muscles weak in C8-T1 radiculopathy but intact in ulnar neuropathy 1. flexor pollicis brevis 2. abductor pollicis brevis 3. opponens pollicis 4. lateral lumbricals AbOF the Law may be useful—the abductor (Ab) and flexor (F) pollicis brevis, opponens pollicis (O), and lateral lumbricals (Law) are “above the law” that intrinsic hand muscles are ulnar-innervated

Answer 101

D) Age Can Grandma Functionally Support Medication Nutrition Mood Continence Self i.e. C (cognition) G (general health) F (functional independence) S (social support) M (medication use) N (nutritional status) M (mood, presence of mental illness) C (continence) S (self reported performance)

Answer 102

d. Ferritin ANZCA blue book: ACD caused primarily by inflammation Mechanism: 1. Iron - Inflammation reduces Iron availabilty as a protective mechanism whereby Iron is sequestered and stored in macrophages to limit availability to microbial pathogens - Hepcidin expression is increased, this prevents the release of Iron by reticuloendothelial system resulting in "functional iron deficiency" with reduced tissue availability of iron, despite apparently normal total body iron stores. (hence increased Ferritin) 2. Response to erythropoietin - mechanism not clear suspect blunting of response to erythropoietin 3. Therapeutic agents chemotherapies that impair bone marrow response to erythropoiesis 65% of patients with lung and gynae cancer treated with platinum based drug develop anaemia RCPA advice on interpretation of Soluble Transferrin Receptor: Soluble transferrin receptor levels in plasma are elevated if there is increased iron demand due to Iron deficiency, increased erythropoiesis (eg, Haemolysis) or dyserythropoiesis (eg, Megaloblastic anaemia), regardless of other, coexistent states. Thus, it can be used to demonstrate iron deficiency in patients who also have an acute phase response and it can distinguish Iron deficiency from the Anaemia of chronic disease. Patients with an acute phase response have reduced plasma iron and transferrin with elevation of Ferritin, making these usual indicators unreliable.

Answer 103

Dilated RA and RV

Answer 104

NIM tube: Neural Integrity Monitor Electromyogram Tracheal Tube

Answer 105

d) >6 Medical emissions of N2O account for <4% of all emissions of N2O, the majority originating from microbial action on nitrogenous fertilizers

21.2 Flashcards

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