23.2 Flashcards

Question

The risk of developing postherpetic neuralgia may be reduced by treating acute herpes zoster (shingles) with A. Ibuprofen B. Gabapentin C. Aciclovir D. Amitriptyline E. Oxycodone

Answer 1

D. Amitriptyline Amitriptyline (used in low doses for 90 days from onset of the herpes zoster rash) reduces the incidence of postherpetic neuralgia N.B Antiviral agents started within 72 hours of onset of the herpes zoster rash accelerate the resolution of acute pain (U) (Level I) but **do not reduce** the incidence, severity and duration of postherpetic neuralgia UTD Both Gabapentinoids and TCAs are effective at TREATING postherpetic neuralgia. The former have lower risk of discontinuation due to adverse side effects. For moderate or severe pain, use gabapentinoids.

Answer 2

Idarucizumab (Praxbind) is a monoclonal antibody to dabigatran Dabigatran bleeding may be treated with: - idarucizumab - haemodialysis -PCC 25-50IU/kg - TXA will decrease fibrinolysis and has some effect - FFP also has some effect Humanized monoclonal antibody fragment (Fab) indicated in patients treated with dabigatran (Pradaxa) when reversal of the anticoagulant effects are needed for emergency surgery or urgent procedures, or in the event of life-threatening or uncontrolled bleeding - very high affinity for dabigatran (300x vs affinity for thrombin) - 5 g IV, provided as 2 separate vials each containing 2.5 g/50 mL (see Administration) - RE-VERSE-AD trial: undetectable levels <20ng/ml within minutes and for 24 hours - Limited data support administration of an additional 5 g depending on clinical situation Dosage Modifications Renal impairment: Renal impairment did not impact the reversal effect of idarucizumab; no dosage adjustment required Hepatic impairment: Dosing Considerations This indication is approved under accelerated approval based on a reduction in unbound dabigatran and normalization of coagulation parameters in healthy volunteers; continued approval for this indication may be contingent upon the results of an ongoing cohort case series study

Answer 3

c. Pharyngeal muscles Millers Anaesthesia: Reference artyicle from Millers: https://pubs.asahq.org/anesthesiology/article/92/4/977/710/The-Incidence-and-Mechanisms-of-Pharyngeal-and An adductor pollicis TOF ratio of 0.90 or less was associated with impaired pharyngeal function and airway protection, resulting in a four- to fivefold increase in the incidence of pharyngeal dysfunction causing misdirected swallowing. Moreover, pharyngeal function and airway protection may be impaired, even if the adductor pollicis muscle has recovered to a TOF ratio of more than 0.90.

Answer 4

C. Increased minute ventilation Cerebral blood flow Cardiac output Acid–base status Major haemorrhage Arterial inflow/venous outflow obstruction Oxygen content Haemoglobin concentration Haemoglobin saturation Pulmonary function Inspired oxygen concentration Inspired oxygen concentration

Answer 5

e Plasma esterases Remi = non-specific tissue and plasma esterases Esmolol = RBC esterases (not inhibited by cholinesterase inhibitors) Suxamethonium/mivacurium = plasma/pseudo/butyrylcholinesterase (same thing) Cisatracurium = Hoffman elimination (Atracurium =1/3 hoffman, 2/3 ester hydrolysis). "

Answer 6

D "Axilllary nodal dissection without lymphoedema: everything safe; NIBP, IAL, PIVC safe with lymphoedema – no absolute contraindication to using affected limb for monitoring and IV access - alternative site should be contemplated where practicable " "PG 18 (A) https://www.anzca.edu.au/resources/professional-documents/professional-document-appendix-topics/appendix-1-pg18(a).pdf"

Answer 7

C- Multifocal Atrial Tachycardia Cardioversion is contraindicated in MAT. Due to the multiple atrial foci, direct current (DC) cardioversion is not effective in restoring normal sinus rhythm and can precipitate more dangerous arrhythmias. - https://emedicine.medscape.com/article/155825-overview#a10 DCCV is indicated for 1. Any haemodynamically unstable narrow or wide QRS complex tachycardia 2. AF <48hrs 3. AF >48hrs with adequate anticoag/TOE to exclude thrombus 4. SVTs and monomorphic TVs not responding to trial of IV medical therapy DCCV is CONTRAindicated in: a. Digitalis toxicity and associated tachycardia b. AF >48hrs without adequate anticoagulation/TOE -BJAEducation 2017 https://academic.oup.com/bjaed/article/17/5/166/2669966 NB unlikely to synch in torsades but would still aim to

Answer 8

REPEAT 23.1 e. Obstructive w/ reduced FEV1 Mucous narrowing airways = obstructive Parenchymal damage = restrictive Obstructive PFP remains the most common pulmonary function pattern in adult CF and is associated with -decrease FEV1 & FVC/FEV1 For patients with CF, an obstructive pattern is generally seen, with a decrease in forced expiratory volume in 1 s (FEV1), and forced vital capacity (FVC) to FEV1 ratio. https://academic.oup.com/bjaed/article/11/6/204/263786 Can get mixed picture but ?at 20

Answer 9

A - GLP1 receptor agonist GLP1 agonists aka incretin mimetics (GLP1 is an endogenous incretin) - Slow gastric emptying - Inhibit glucagon release - Stimulate insulin production - Also reduce food intake

Answer 10

c) 2 minutes Optimal seizure duration somewhere between 10-120seconds. https://academic.oup.com/bjaed/article/10/6/192/299664 QLD health ECT guideline https://www.health.qld.gov.au/__data/assets/pdf_file/0028/444763/guideline-administration-electroconvulsive-therapy.pdf

Answer 11

a) case control https://www.cdc.gov/csels/dsepd/ss1978/lesson3/section5.html OR is measure of association between an exposure and an outcome. OR represents the odds an outcome will occur given a particular expsoure compare to the odds of the outcome occuring in absence of the exposure. Most commonly used in case control studies, can also be used in cross-sectional and cohort study designs (with some modification /assumptions) OR = 1 exposure does not affect odds of outcome OR >1 exposure assoicated with higher odds of outcome OR <1 exposure associated with lower odds of outcome"

Answer 12

C) 30 "ADULT: normal <5 mild 5 - < 15 moderate >/=15 - 30 severe >/= 30 Apnoea = breathing stop or reduce to 10% of normal levels for 10 secs Hypopnea (i.e. shallow breathing) = airflow decreases by more than 30% for 10 seconds AHI = total apnoea+hypopnoea / total no. of hours asleep"

Answer 13

c) 770mg Product info: Fresenius-Kabi When prolonged epidural blocks are used, either by continuous infusion or repeated bolus administration, the risks of reaching a toxic plasma concentration or inducing local neural injury must be considered. Cumulative doses of up to 800 mg ropivacaine for surgery and postoperative analgesiaadministered over 24 hours were well tolerated in adults, as were postoperative continuous epidural infusions at rates up to 28 mg/hour for 72 hours. product info: pfizer When prolonged blocks are used, either through continuous infusion or through repeated bolus administration, the risks of reaching a toxic plasma concentration or inducing local neural injury must be considered. Experience to date indicates that a cumulative dose of up to 770 mg ropivacaine hydrochloride administered over 24 hours is well tolerated in adults when used for postoperative pain management: i.e., 2016 mg. Caution should be exercised when administering ropivacaine for prolonged periods of time, e.g., > 70 hours in debilitated patients

Answer 14

d) Atropine Blue book 2019 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 catecholamines. - Dopamine/isoprenaline - effective - Norad/adrenaline, dobutamine - exaggerated effect due to ↑adrenoceptor density↑ - depends on intrinsic stores of catecholamines and degree of reinnervation - Phenylephrine/metaraminol (latter mostly direct) - effective but no reflex brady - Ephedrine - less effective (indirect mechanism > direct) digoxin - inotropy OK, but conduction effects at AV node absent (PSNS dennervation)"

Answer 15

d. cords "Roots - Interscalene Trunks - Superior trunk Divisions - Supraclav Cords - Infraclav Branches - Axillary https://teachmeanatomy.info/upper-limb/nerves/brachial-plexus/ "

Answer 16

c) 3b 1>90 2 60-89 3a 45-59 3b 30-44 4 15-29 5 < 15"

Answer 17

d) Hypotension The commonest presenting feature of perioperative anaphylaxis by far was hypotension (accounting for 46%), followed by bronchospasm/high airway pressure (18%), tachycardia (9.8%), flushing/non-urticarial rash 6.6% and cyanosis/oxygen desaturation (4.7%).

Answer 18

D/ pbserve (Protocol at base of resource just above summary) 1 - stop injection 2 - keep catheter insitu initially (remove within 48hrs) 3 - maintain patency of arterial catheter (e.g. ?1mL/kg/hr saline) 4 - symptomatic relief - elevation, massage, passive mobilisation, analgesia, consider regional block 5 - calculate tissue ischaemia score (skin colour - cyanotic, CRT>3 sec, cold, sensory deficity - 1 point each) – if tissue iscaemia score 3 or 4 or high risk drug (benzo, penicillin, clindamycin, thiopental, phenytoin, diclofenac) --> consider heparin and d/w vascuar/IR + ensure follow up – if tissue ischaemia score 1 or 2 AND low risk drug --> monitor " https://www.anztadc.net/Publications/Images/ANZCA/Unintended%20Intraarterial%20injection%20WebAIRS%20news%20ANZCA%20Bulletin%20September%202019.pdf

Answer 19

a) Deepen with propofol and insert LMA Nasal continuous positive airway pressure (CPAP) is contraindicated after transsphenoidal surgery due to the risk of tension pneumocephalous. The level of consciousness, eye movements, visual fields, and acuity should be tested frequently and any deterioration discussed with the surgeon, and radiological investigation and/or re-exploration considered. https://academic.oup.com/bjaed/article/11/4/133/266875#3195876

Answer 20

New question Measures to avoid venous air embolism when inserting an internal jugular central venous catheter in an awake patient include all of the following EXCEPT c) Insert during inspiration Negative pressure generated by inspiration in an AWAKE patient https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5126790/ Measures to stop air embolus - Valsalva ↑ITP (helps prevent air from entering) - supine/head down (+ve venous P) - flush/infusion system stops air exposure - occlude catheter hubs at all times"

Answer 21

d) Pulmonary haemorrhage Rewording of 21.2 Question Won't increase in Myasthenia Gravis Causes of HIGH value include: Asthma Left-right intracardiac shunt polycythaemia Pulmonary haemorrhage Obesity - Dlco will increase but kco will not

Answer 22

b) 30mcg Moderate = 2mcg/kg Life threatening = 4-10mcg/kg file:///Users/jbjon/Downloads/Australian_and_New_Zealand_Anaesthetic_Allergy_Gro.pdf Draw up 1mg in 50ml = 20mcg/mL Grade 2 (mod) anaphylaxis = 2mcg/kg = 0.1ml/kg Grade 3 (life-threatening) = 4-10mcg/kg = 0.2-0.5ml/kg Cardiac arrest = 10mcg/kg IM adrenaline (1:1000): < 6yo = 150mcg = 0.15ml 6-12yo = 300mcg = 0.3mL "

Answer 23

Repeat 22.2 Serotonin syndrome Hyperreflexia differentiates Usually has hypertension and hyperthermia

Answer 24

Repeat SSRI Clonidine has limited efficacy ANZCA PG12 Background Paper ANZCA PERIOP CESSATION OF SMOKING GUIDELINE: "Effective pharmacotherapy options include nicotine replacement therapy, nicotine partial agonists such as varenicline (Champix), bupropion (Zyban), nortryptilline and clonidine" Up to Date Pharmacotherapy for Smoking Cessation in Adults - First-line pharmacotherapies for smoking cessation include nicotine replacement therapy (NRT), varenicline, and bupropion - Clonidine: despite promising initial studies, clonidine is now generally regarded as having limited efficacy for smoking cessation. - Selective serotonin reuptake inhibitors/anxiolytics – Selective serotonin reuptake inhibitors (SSRIs) and anxiolytic drugs generally have not been shown to be effective for smoking cessation

Answer 25

d) Vastus Lateralis Anteromedial: sartorius Lateral: vastus medialis Posterior: adductor longest and magnus

Answer 26

Repeat e) Ulnar nerve The cubital fossa is triangular in shape and consists of three borders, a roof, and a floor: Lateral border – medial border of the brachioradialis muscle. Medial border – lateral border of the pronator teres muscle. Superior border – horizontal line drawn between the epicondyles of the humerus. Roof – bicipital aponeurosis, fascia, subcutaneous fat and skin. Floor – brachialis (proximally) and supinator (distally). Contents: - radial nerve - biceps tendon - brachial artery - median 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"

Answer 27

REPEAT a) 5mmol bolus KCl https://www.anzcor.org/home/adult-advanced-life-support/guideline-11-5-medications-in-adult-cardiac-arrest/ Potassium is an electrolyte essential for membrane stability. Low serum potassium, especially in conjunction with digoxin therapy and hypomagnesaemia, may lead to life threatening ventricular arrhythmias. Consider administration for: Persistent VF due to documented or suspected hypokalaemia. [Class A; Expert consensus opinion] Adverse effects: Inappropriate or excessive use will produce hyperkalaemia with bradycardia, hypotension and possible asystole Extravasation may lead to tissue necrosis. Dosage: A bolus of 5 mmol of potassium chloride is given intravenously.

Answer 28

REPEAT c) Increased mortality Use of perioperative metoprolol was associated with: * Decreased rate of myocardial infarction * Decreased rate of revascularisation * Decreased rate of developing new atrial fibrillation * INCREASED rate of death * INCREASED rate of stroke * INCREASED rate of significant hypotension INCREASED rate of significant bradycardia

Answer 29

d) 48hrs Extrajunctional receptors are not found in normal active muscle but appear very rapidly whenever muscle activity has ended or after injury has been sustained. They can appear within 18 h of injury and an altered response to neuromuscu- lar blocking drugs can be detected within 24 h of the insult. They disappear when muscle activity returns to normal. BJA 2002 This up-regulation is not high enough to cause hyperkalemia with succinylcholine even at 24 – 48 h of immobilization/denervation https://citeseerx.ist.psu.edu/document?repid=rep1&type=pdf&doi=846b7ea4159b4dfa57bb12d77a91ec8d78927faf

Answer 30

REPEAT increased SVR EMSB handbook CO is reduced after Burn injury 2ry to: - myocardial depressant mediators - decreased blood volume - reduced venous return - increased pulmonary and systemic vascular resistance due to increased levels of catecholamines "Early CVS changes - shock phase first 24-48hrs -> mimics hypovolamic shock - low CO (halved): hypovolaemia, ↓SV, ↓CI, ↑HR. ↑SVR in response, ↑ADH, ↓BF to organs, ↑Hct - ↓oxygen delivery, (APO/bronchospasm/ARDS - particularly in inhalational injury), ↑PVR - resistance to NDMB Late CVS changes (hyperdynamic circulation 72-96hrs 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, ↓SVR, ↑CI - ↑VO2, ↑VCO2 - ↑↑nAChR (sux ↑↑↑K+)"

Answer 31

b) Stop antibiotics For adults with suspected sepsis or septic shock, we suggest AGAINST using procalcitonin plus clinical evaluation to decide when to start antimicrobials, as compared to clinical evaluation alone. Weak, very low quality of evidence For adults with an initial diagnosis of sepsis or septic shock and adequate source control where optimal duration of therapy is unclear, we suggest using procalcitonin AND clinical evaluation to decide when to discontinue antimicrobials over clinical evaluation alone. Weak, low quality of evidence

Answer 32

10mins PG18A Ventilation - continually monitored Oxygenation - adequate lighting for ax of colour of pt O2 analyser - alarm for low oxygen concentration Pulse ox - every pt under GA or sedation with variable pulse tone and low threshold alarm Ventilation - disconnection and failure alarm CO2 montior - for all pts under GA and immediately available for sedation ECG - available for all. Should be used for all undergoing general and major regional anaeshthesia as indicated. NIBP - available for every pt and range of cuff sizes available IABP - available BIS - available End tidal anaesthetic - all using volatiles Temp monitor - available each GA and used whenever warming device used Neuromuscular - used whenver extubating after using NDMB

Answer 33

b. Myaesthenia gravis or b. Cerebral palsy ED95 is 0.8mg/kg in a MG patient b. Cerebral palsy ->sux and volatiles are not contraindicated -> presence of extrajunctional receptors may cause hyperkalaemia a. Becker muscular dystrophy -> essentially milder Duchenne's (see duchenne response to Sux) b. Cerebral palsy -> Sux and volatiles not contraindicated -> reduced MAC requirement -> increased sensitivity to muscle relaxants c. Guillain Barre -> sux contraindicated due to risk of hyperkalaemia -> increased sensitivity to Non depolarising NB d. Frederich’s ataxia -> sux should be avoided due to risk of hyperkalaemia e. Duchenne muscular dystrophy -> sux and volatiles contraindicated due to rick of hyperkalaemia and rhabdomyolysis

Answer 34

REPEAT Increases NIRS , decreases peripheral spo2 SctO2 up, SpO2 down. ↑SctO2 from: ↑BF (↑[oxygenated blood] to previously underperfused) Dose-dependent relationship - note the time to peak/nadir SctO2/SpO2 was the same https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4384398/ https://www.bjaed.org/article/S2058-5349(22)00076-2/pdf - used in liver resection to estimate minimum liver volume required" Source: Korean Journal Anaesthesia https://www.researchgate.net/publication/274570990_Effects_of_intravenously_administered_indocyanine_green_on_near-infrared_cerebral_oximetry_and_pulse_oximetry_readings

Answer 35

C "https://www.bjanaesthesia.org.uk/article/S0007-0912(17)31007-3/fulltext#seccestitle40 Anteriorisation of alpha rhythm predominates when anaesthesia adequate for surgery Not clearly apparent just after loss of responsiveness Common with iso/sevo/propofol anaesthesia - usually alpha waves are ~10Hz in occipital regions when pt awake w/ eyes closed; these migrate to frontal regions under anaesthetic (or sleep) Difference between volatile and propofol anaesthesia: – in propofol theta power remains low regardless of concentration but iso/sevo anaesthesia theta power increases at surgical concentration of anaesthesia

Answer 36

REPEAT 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 37

Size 7.0 The Tube The endotracheal tube has a length and diameter. The endotracheal tubes size (“give me a 6.0 tube”) refers to its internal diameter in millimeters (mm). The ETT will typically list both the inner diameter and outer diameter on the tube (for example, a 6.0 endotracheal tube will list both the internal diameter, ID 6.0, and outer diameter, OD 8.8).

Answer 38

Repeat c. Anterior to erector spinae and posterior to transverse process 5th rib or B) at the tip of the transverse process Midpoint between T5-6 (Usual Incision T4-5, ICC T6)

Answer 39

NNT = 6 to 7 NNT=1/ARR. (Absolute Risk Reduction) ARR = 0.2-0.05 = 0.15 1/0.15 = 6.66 With respect to previous variation of this question: (base rate is 10%, experimental group is 8% (20% below 10%) therefore 100/ 2 = 50 or 1 divided by risk reduction population risk = 10/100 patients get PONV population risk + new antiemetic = 8/100 patients get PONV (8/100 as reduction by 20% with new drug) RR= 0.10-0.08=0.02 NNT= 1/RR =1/0.02 =50 https://bestpractice.bmj.com/info/us/toolkit/learn-ebm/how-to-calculate-risk/

Answer 40

a) Torsades 2ry to prolonged QT leading to R on T PETKOV

Answer 41

See combined deck for multiple Qs on lung ultrasound "A lines horizontal - may be normal or pneumothorax B lines vertical - can be interstitial fluid e.g. pulmonary oedema -> (After Hours, Batman is Vigilant) Pneumothorax features: - abscence of B lines & sliding (on highest point of anterior chest) - absence of lung pulse - presence of lung point

Answer 42

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 https://litfl.com/cryoprecipitate/ Fractionated plasma product consisting of Fibrinogen (Factor I), von Willebrand Factor, Factor VIII, and small amounts of Factor XIII and Fibronectin https://www.anzca.edu.au/getattachment/9ec71c61-8a66-4f81-b0f8-c87d65e36298/Australasian-Anaesthesia-2023

Answer 43

A. 30min All have cold perfusion as end point (but differ on withdrawal of life support vs sBP as the starting point) - heart - <30mins from sBP <90mmHg - liver and pancreas - <30mins from withdrawal of cardiorespiratory support - Kidney - Different between Aus and NZ. <60 mins from sBP<50mmHg (Aus). < 90 mins NZ - lungs - <90mins from sBP<50mmHg" 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 44

c. No need to bridge Dabigatran needs 5 days parenteral first See ETG recommendations https://www.ahajournals.org/doi/full/10.1161/JAHA.120.017559

Answer 45

a) C1-esterase inhibitor Treatment options: Plasma derived C1-esterase inhibitor = Berinert/Cinryze, Androgens = Danazol B2 Bradykinin Receptor antagonist = Icatibant FFP. Danazol (an androgen) is recommended as first line PROPHYLAXIS for planned procedures (need to give for 5-10 days prior and 2-5 days post) For emergency or high risk procedures C1 esterase inhibitor concentrate (Berinert or Cinryze) is recommended - give 1 hour before procedure - more effective than danazol but more expensive Berinert: - 20units/kg IV over 10 min - Symptoms usually stabilise in 30 mins - 2nd dose uncommon, but may be given 30mins to 2hrs after 1st dose Icatibant: - 30mg slow subcut infusion in abdominal area Due to the risk of precipitating laryngeal oedema, oropharyngeal procedures should usually involve general anaesthesia with endotracheal intubation Short answer: - if you have days before surgery increase danazole, if complex surgery increase danazole and give C1Inh - If you have acute emergency surgery give C1Inh Concentrate (Berinert/Cinryze) before and after - if you have an acute attack use C1Inh or Bradykinin antagonist (Icatibant) - If C1 Inh and Bradykinin antagonoist are not available then use FFP but this may worsen the attack due to the presence of C4 in the FFP - Has Cetirizine been misremembered instead of Cinryze as an option in this question? No it wasn't -> adrenaline, steroids, antihistamines have no role in treatment of HAE acute attack

Answer 46

Digoxin SGLT2 inhibitors (1st) ACEi (2nd), b-blocker (2nd), aldosterone antagonists (2nd?) have mortality benefits in HFrEF. Also, sacubitril with valsartan (aka Entresto), ivabradine, ACEI /ARB - LVEF <40% - reduce sodium reabsorption, reduce aldosterone, reduces remodelling - ARBs don't consistently reduce mortality! B-blocker (e.g. bisoprolol) - LVEF <40% - reduces SNS activity, antiarrythmic, reverses remodelling Aldosterone antagonist (e.g. spironolactone) - if symptomatic despite ACEI and b-blocker and LVEF <40% - weak diuretic, reduces effects of aldosterone Sacubitril with valsartan (neprolysin inhibitor + ARB) - LVEF <35% - in place of ACEI/ARB - causes vasodilation, reduces SNS activity, diuresis ISMN + hydralazine -> if no ARNi -> decreased M+M Vericiguat (Guanlyate cyclase inhibitor) - severe HF -> decr M+M"

Answer 47

distance below water is equal to -ve pressure generated when suction applied

Answer 48

b. FFP REPEAT recombinant ATIII concentrates or FFP (second line) >600IU/kg heparin = heparin resistance (if cannot achieve ACT >480s) - may be due to ATIII deficiency or ^protein binding of heparin - aquired defiiciency can be due to recent heparin administration 1) AT3 concentrate = treatment of choice (better than FFP); 1000u (1 amp) given (500-5000 units possible) 2) FFP - contains AT3 and cheaper but risks of transfusions (volume overload, lung injury, haemodilution) 3) Other possbile but limited experience - argatroban, bivalirudin - shorter acting, need to monitor using ecarin time

Answer 49

checked from 6hrs and up to 24hrs BJA 2007 Anaesthesia for thyroid and parathyroid surgery

Answer 50

A) Type 1 MI Not MINS as meets criteria for pre-existing definition of T1MI Clinical classification based on the assumed proximate cause of the MI: - Type 1 ○ MI caused by atherothrombotic coronary artery disease ○ And usually precipitated by atherosclerotic plaque disruption ( rupture or erosion) - Type 2 ○ MI consequent to a mismatch between oxygen supply and demand ○ Multiple potentional mechanisms: § Coronary dissection § Vasospasm § Emboli § Microvascular dysfunction § Increases in demand without underlying coronary artery disease - Type 3 ○ Patient with typical presentation of MI (ECG changes or VF) with unexpected death before blood samples for biomarkers could be drawn - Type 4a ○ MI associated with Percutaneous Coronary intervion (PCI) - Type 4b ○ Subcategory of PCI related MI related to stent/scaffold thrombosis - Type 5 CABG related MI

Answer 51

d) continue to avoid cognitive decline post-op Donepezil is in a class of medications called cholinesterase inhibitors. It improves mental function https://www.ukcpa-periophandbook.co.uk/medicine-monographs/donepezil donepezil = don't stop - Acetylcholinesterase inhibitor (prolongs sux, antagonises NDMB) - long half life 70hrs - effective washout will need it to be stopped for 3 weeks prior if sux will be used -- can cause phase 2 block - if non-depolarising neuromuscular blocker needed - neogstigmine may not be effective with reversal - use sugammadex OR cisatrcurium; Use neuromuscular monitoring stopping donepezil can --> decline in cognitive function that won't be regained. so need to decide carefully also ^ risk of delirium in dementia patients (59% vs 13% in controls) ^dementia risk doubles q5years aging"

Answer 52

a. Not safe or c. safe only in 1st trimester While relatively safe in early and mid pregnancy, NSAIDs can precipitate fetal cardiac and renal complications in late pregnancy, as well as interfere with fetal brain development and the production of amniotic fluid; they should be discontinued in gestational wk 32 APMSE

Answer 53

a) renal failure '...phosphate containing laxatives can lead to acute phosphate nephropathy' https://academic.oup.com/bjaed/article/16/9/305/1743822#35669023 - BJA Ed article Phosphate binds to calcium leading to crystal calcium phosphate deposition in tubules. Old repeat 2020 https://academic.oup.com/bjaed/article/16/9/305/1743822#35669023

Answer 54

c. Hypocalcaemia Laryngospasm is a rare, but serious and potentially lethal, complication of hypocalcemia in adults. In every adult presenting with acute dyspnea and stridor, the possibility of hypocalcemia should be considered. Hypocalcemia should be treated promptly.

Answer 55

c) falsly low SpO2 Effects of hihg dose hydroxycobalamin: - red urine - thrombocytosis - leukopenia

Answer 56

b) 0.28 Given it's already the recommended FGF -> increasing flow won't increase FiO2 Fixed orifices to deliver fixed oxygen supply - entrains more air if flow rate is higher - constant FiO2 regardless of RR and flow pattern - if flow rate < recommended amount for specific Venturi mask -> mask won't deliver stated FiO2 - if flow rate > rate recommended -> FiO2 won't continue to increase" https://geekymedics.com/oxygen-delivery-devices/"

Answer 57

D> Myocardial ischaemia An inverted U wave may represent myocardial ischemia (and especially appears to have a high positive predictive accuracy for left anterior descending coronary artery disease[7] ) or left ventricular volume overload. ^Wikipedia -------- U-wave inversion is abnormal (in leads with upright T waves) A negative U wave is highly specific for the presence of heart disease Common causes of inverted U waves Coronary artery disease Hypertension Valvular heart disease Congenital heart disease Cardiomyopathy Hyperthyroidism In patients presenting with chest pain, inverted U waves: Are a very specific sign of myocardial ischaemia May be the earliest marker of unstable angina and evolving myocardial infarction Have been shown to predict a ≥ 75% stenosis of the LAD / LMCA and the presence of left ventricular dysfunction ^LITFL: https://litfl.com/u-wave-ecg-library/

Answer 58

D) Mitral Stenosis (Rheumatic, moderate to severe) DOAC use is contraindicated in certain clinical conditions, notably, in patients who have a mechanical heart valve and those with rheumatic mitral stenosis. Moderate to severe renal impairment or significant hepatic disease is also a contraindication to DOAC treatment Bioprosthetic valves are less thrombogenic thus DOAC use is acceptable. https://www.ahajournals.org/doi/epdf/10.1161/JAHA.120.017559 C/I - Mechanical valves - moderate to severe (rheumatic) mitral stenosis - pregnancy / breastfeeding (can use clexane) - moderate-severe renal disease - CYP3A4/P-glycoprotein inducers: carbamazepine, phenytoin DOACs cf. warfarin: better prevention thromboembolism, lower risk major bleeding (incl. ICH) (although ^risk GI bleed) Relative CI to DOACs- significant hepatic disease, GI bleeds (note aspirin not useful)"

Answer 59

8mg/hr Guidelines for mx of glucocorticoids during the perioperative period for patients with adrenal insufficiency https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/10.1111/anae.14963 "Dex:pred:hydrocort conversion 4:25:100 8:50:200 CSection/surgery: 100mg IV at induction, then 8mg/hr IV infusion; 6-8mg dexamethasone IV will suffice for 24hrs (as alternative) CSection: normal morning dose, then 100mg bolus IV just before anaesthesia. Postpartum for both: double PO glucocorticoid for 48hrs (or use 50mg q6h hydrocort until E+D) If pt unwell (e.g. hypotensive, drowsy, peripherally shut down, IV/IM hydrocortisone 100mg STAT) https://rightdecisions.scot.nhs.uk/maternity-gynaecology-guidelines/maternity/antenatal-general/adrenal-crisis-avoidance-in-pregnant-women-at-risk-520/ 2020 AAGBI Periop steroid guidelines: "

Answer 60

b) O2 consumption when sitting One metabolic equivalent (MET) is defined as the amount of oxygen consumed while sitting at rest and is equal to 3.5 ml O2 per kg body weight x min.

Answer 61

C:3 (Pt is GCS 14 E4V4M6, with motor deficit) The WFNS scale: Grade 1: GCS 15, no motor deficit. Grade 2: GCS 13-14 without deficit Grade 3: GCS 13-14 with focal neurological deficit Grade 4: GCS 7-12, with or without deficit. Grade 5: GCS <7 , with or without deficit. (BJA Education, Deranged Physiology)

Answer 62

e) Liver transplantation - Oxygen therapy for symptom relief - Liver transplant provides long term survival benefit - All other therapies tried but no conclusive evidence of benefit/nil are FDA approved Hepatopulmonary Syndrome Article https://www.ncbi.nlm.nih.gov/books/NBK562169/ Hepatopulmonary syndrome (BJA) - Prevalence up to 20% (end stage liver disease) - Characterised by: disordered pulmonary capillary vasodilation and VQ mismatch - Present with hypoxia, ortheodeoxia (decrease in PaO2 when standing) - Diagnosis w/bubble echocardiography - Risk factor for early post-transplant mortality - If transplant successful, will resolve over time

Answer 63

a) neostigmine infusion Consider this Ogilve's Syndrome Psuedo-obstruction. If > 9cm dilation, would need surgical management. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3168359/#!po=17.5000 Ogilvie syndrome - colonic pseudo-obstruction (i.e. obstruction w/o mechanical cause): needs >9cm colon for dx - MUST exclude toxic megacolon/mechanical obstruction '>3, 6, 9 ' rule. Bowel is dilated -> consider obstruction or paralytic ileus small bowel >/=3cm, large bowel >/=6cm (and appendix) caecum >/=9cm (>12cm -> ^ risk of perforation) Sx: abdo distension, pain, vomiting, fever, constipation/diarrhoe"

Answer 64

d) Ibuprofen 400mg - Ibuprofen (because of the single oral dose statement) APMSE 5th edition Acute pain after third molar extraction is the most extensively studied model for testing postoperative analgesics in single-dose investigations. Nonselective NSAIDs or coxibs are recommended as “first-line” analgesics following third molar extraction (Derry 2011 Level I, 155 RCTs, n=16,104), however paracetamol is also safe and effective with a dose of 1,000 mg providing better pain relief than lower doses (Weil 2007 Level I [Cochrane], 21 RCTs, n=1,968). The best available evidence suggests the use of NSAIDs either with or without paracetamol is effective and well-tolerated (Moore 2018 Level I, 5 SRs, n unspecified). Nonselective NSAIDs are more effective than paracetamol or codeine (either alone or in combination) (Ahmad 1997 Level I, 33 RCTs, n=5,171). Ibuprofen (200–512 mg) specifically is superior to paracetamol (600–1,000 mg) in this setting and combining these two drugs improves analgesia further (Bailey 2014 Level I [Cochrane], 7 RCTs, n=2,241) Coxibs are of similar efficacy to nsNSAIDs in acute postoperative dental pain. Single-dose celecoxib 200 mg is less effective than ibuprofen 400 mg; while celecoxib 400 mg provided similar analgesia to ibuprofen 400 mg with increased time to rescue analgesia following dental surgery . In a comparison of PO celecoxib (400 mg, then 200 mg every 12 h), ibuprofen (400 mg every 8 h) and tramadol (100 mg PO every 8 h), celecoxib was the most effective analgesic

Answer 65

d 60cm H2O

Answer 66

e. peak of R wave https://derangedphysiology.com/main/required-reading/cardiothoracic-intensive-care/Chapter%20634/normal-iabp-waveform https://litfl.com/intra-aortic-balloon-pump-trouble-shooting/ With ECG trigger - Balloon inflates with onset of diastole = peak/middle of t wave -> ↑coronary perfusion - Balloon deflates at onset of LV systole = peak of R wave -> ↓afterload ∴↑stroke volume

Answer 67

e) hypothermia Prader Willi - severe hyptonia, hyperphagia, risks of morbid obesity, learning and behavioural difficulties, severe psychiatric problems, short stature due to GH deficiency, incomplete pubertal development, decreased bone density, cardiac conduction defect, convulsions Temperature instability may be exacerbated under anesthesia. Other causes of temperature instability, including infection or hypothyroidism, should be ruled out. https://www.openanesthesia.org/keywords/prader-willi-syndrome/?search_term=prader%20w Stoelting: Prader-Willi syndrome is a rare genetic disorder characterized by hypothalamic-pituitary abnormalities with severe hypotonia during the neonatal period and during the first two years of life, hyperphagia with a risk of morbid obesity during infancy and adulthood, learning difficulties and behavioural problems or severe psychiatric problems. The disease affects 1/25,000 births.

Answer 68

e) decreased afterload https://academic.oup.com/bjaed/article/13/6/208/246828#2904603 Aortic cross-clamping and physiological considerations Clamp application increases the afterload of the heart and a sudden increase in arterial pressure proximal to the clamp; this can be attenuated with vasodilators [e.g. glyceryl trinitrate (GTN), sodium nitroprusside], opioids, or deepening of anaesthesia. These measures may also allow fluid loading in preparation for clamp release; however, the effect of vasoactive drugs is unpredictable; they may change haemodynamics without improving cardiac output and tissue perfusion due to blood redistribution.10 Increased afterload and left ventricular end-diastolic volume both increase myocardial contractility and oxygen demand. This increase in myocardial oxygen demand is usually met by an increase in coronary blood flow and oxygen supply, but can cause myocardial ischaemia. After aortic cross-clamp release, peripheral vascular resistance decreases by 70–80%, causing a decrease in arterial pressure. Hypotension can also be caused by blood sequestration in the lower half of the body, ischaemia–reperfusion injury, and the washout of anaerobic metabolites causing metabolic (lactic) acidosis. This can cause direct myocardial suppression and profound peripheral vasodilatation. Coronary blood flow and left ventricular end-diastolic volume also decrease (almost 50% from pre-clamp levels) after clamp release. Strategies to manage hypotension after aortic cross-clamp release include gradual release of the clamp, volume loading, vasoconstrictors, or positive inotropic drugs (e.g. ephedrine, meteraminol, phenylephrine, epinephrine, and norepinephrine). It is important to be aware that vasoactive drugs should only be used after adequate volume repletion.10 Management of aortic cross-clamp application and release requires excellent communication with the surgeon in order to anticipate and manage the physiological effects. Bacterial translocation: hypoxic insult immeidately after clamping -> visceral/mesenteric ischaemia -> ↑intestinal permeability -> ↑bacterial translocation https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4698535/ Abdo compartment syndrome - POSTOP and can be due to capillary leak, ischaemia-reperfusion injury and massive transfusion - but not due to clamp itself ARF - 5-13% risk, due to decreased RBF (can cause renal tubular necrosis) and reperfusion injury. ^risk with cross clamp>30mins (and particularly supra-renal) https://applications.emro.who.int/imemrf/Esculapio/Esculapio_2014_10_3_114_117.pdf"

Answer 69

Most likely answer will be related to hypophosphataemia Refeeding syndrome is a constellation of biochemical abnormalities which occurs when normal intake is resumed after a period of starvation. Its characteristic features are **low levels of phosphate, potassium, magnesium and sodium**. Its major complications include **cardiac arrhythmias, heart failure (due to hypophosphataemia), muscle weakness, rhabdomyolysis, seizures and an altered sensorium.** The major risk factors are calorie malnutrition of any cause, alcohol or drug use, low BMI (18-16) and starvation for 5-10 days. Pathophysiology With the restoration of glucose as a substrate, insulin levels rise and cause cellular uptake of these ions. **Depletion of adenosine triphosphate (ATP) and 2,3-diphosphoglyceric acid (2,3-DPG)** results in **tissue hypoxia** and **failure of cellular energy metabolism.** This may manifest as **cardiac and respiratory failure**, with **paraesthesiae** and **seizures** also reported. Thiamine deficiency may also play a part. - Exogenous sources of phosphate are inadequate to supplement the daily phosphate requirements - Intracellular phosphate stores are used to synthesise ATP (using protein and fat as fuel) - Homeostatic mechanisms maintain serum concentrations of these ions at the expense of intracellular stores Reference: https://derangedphysiology.com/main/required-reading/endocrinology-metabolism-and-nutrition/Chapter%20315/refeeding-syndrome "

Answer 70

"d) 60mins Calcium (if ecg changes) - onset <3mins, duration - 30mins (wont affect K level itself but to stabilise cardiac membrane) Insulin/dextrose - onset 15mins, peak 60mins, duration 2-3hrs Salbutamol - onset 30 mins, peak 120mins duration 2-3hrs Bicarb (in acidosis) - onset 30-60mins, duration 2-3hrs Resonium - onset 60mins (PR) and 4hrs (PO), duration variable

Answer 71

c) Staphyloma https://eyewiki.aao.org/Ocular_Anesthesia#cite_note-:2-3 **Contraindications** **Absolute** Confirmed allergy to a necessary anesthetic, and nystagmus. Other contraindications are just those of the particular surgery that is to be performed. **Relative** Long eye (in the anterior to posterior axis, evidenced by high myopia), staphyloma (abnormal protrusion at a weak spot in the wall of the eye), enophthalmos (posteriorly or deep set eyes), and extended surgery duration are relative contraindications to retrobulbar and peribulbar anesthesia. In an uncooperative patient, patients deemed to be unable to follow commands during surgery, children and those with uncontrollable neurological movements, general anesthesia may be considered.

Answer 72

700ml 50% of blood volume in 3 hours S Blaine. BJAE Paediatric massive transfusion. https://www.bjaed.org/article/S2058-5349(17)30099-9/fulltext Children- (pRBC) transfusion i.e. replacement of: >1 blood volume in 24hours OR >50% TBV in <3-4hours OR >10% TBV over 10 minutes (OR 40mL/kg blood) Adults - replacement of >1 blood volume in 24hours OR >50% blood volume in 4hrs 10mL/kg pRBC increases Hb 20g/L; 1 unit pRBC ~300mL

Answer 73

Now we just crack on hoping that their Hb/electrolytes/LV function has been optimised within 36hrs https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/10.1111/anae.15291 The 2011 guidelines list seven ‘acceptable’ reasons for delaying surgery: 1 Haemoglobin < 80 g.l−1 2 Plasma sodium concentration < 120 or > 150 mmol.l−1 and potassium concentration < 2.8 or > 6.0 mmol−1 3 Uncontrolled diabetes 4 Uncontrolled or acute onset left ventricular failure. 5 Correctable cardiac arrhythmia with a ventricular rate > 120.min−1 6 Chest infection with sepsis 7 Reversible coagulopathy Rather than cancelling surgery on the day of operation in reaction to one of the seven abnormalities listed, the Working Party considers that 36 h (or less) provides sufficient time for the proactive involvement of anaesthetists in correcting medical obstacles to surgery. In the (rare) event of cancellation for medical reasons, patients should be kept under 12-hourly assessment by anaesthetic teams "HIP ATTACK RCT 2020: accelerated surgery (<6hrs post diagnosis) vs standard care (median time 24hrs from dx) - no differences in mortality or major complications (e.g. MI/CVA/VTE/sepsis/pneumonia/bleeding) - no harm to pts - signficant ↓in postop delerium, LoS and better mobilisation; note no recommendations due to increased costs of expediting surg ECHO - don't delay (unlikely to treat anyway); invasive monitoring intraop +/- ICU postop 2020 UPDATE - target Hb>90 for frailer patients or ~100 for patients with hx of IHD or who are symptomatic POD1 (fatigue/dizziness -> failure to mobilise) from anaemia (KPI = day 0 or day 1 mobilisation); as opposed to ALL pts in 2011. Anticipate 25g/L drop in Hb periop

Answer 74

All muscles in the anterior compartment of the arm are innervated by the musculocutaneous nerve. - biceps brachii: forearm flexion and supination. Accessory shoulder flexor - coracobrachialis: shoulder flexion, arm adduction. - Brachialis: forearm flexion The musculocutaneous nerve innervates skin on the anterolateral side of the forearm.

Answer 75

b) crescendo TIA symptoms https://academic.oup.com/bja/article/99/1/119/269458 Symptomatic Ideally, patients presenting with a suspected TIA should have undergone investigation and, if appropriate, surgery within 2 weeks of presentation. crescendo TIA symptoms (variable definitions: 2 TIAs within 24hrs, or 3 within 3 days. Also read 2+ in 1 week) – all others are suggesting to defer CEA Highest risk of recurrent stroke from symptomatic ICA plaque is within first 2 weeks from initial event with risk remaining high for 6 weeks. - CEA within 2 week symptom onset: NNT 5. NNT = 125 if >2 weeks or if CVA - symptomatic stenosis 50-99% (i.e. TIA or stroke) - Can be deferred if large stroke area (risk of cerebral oedema), contalateral carotid occlusion, haemodynamic instability, contralateral laryngeal palsy" (Tandem lesion, or tandem occlusion, is a term used in cerebrovascular imaging and intervention to refer to the simultaneous presence of high-grade stenosis or occlusion of the cervical internal carotid artery and thromboembolic occlusion of the intracranial terminal internal carotid artery) Asymptomatic High-grade carotid stenosis was evaluated in three high-quality randomized controlled trials performed from the late 1980s through the early 2000s. These were the VA trial [47], ACAS [48], and ACST [49]. In a meta-analysis of these three trials, including 5268 subjects with a mean follow-up of 3.3 years per subject, CEA was associated with a 2.9 percent risk of perioperative stroke or death. CEA reduced the risk of any stroke, but the benefit was small with an overall absolute risk reduction of approximately one percent per year [50]; the corresponding NNT to prevent one stroke at three years was approximately 33. The outcome of any stroke or death was not significantly lower with CEA compared with medical therapy alone (20.5 versus 22.6 percent, relative risk [RR] 0.92, 95% CI 0.83-1.02). UTD suggests - <69% stenosis medical mx >70 - 99% medically stable and life expectancy at least 5yrs consider medical verse surgical mx. Some will only operate if >80-99% stenosis https://www.uptodate.com/contents/management-of-asymptomatic-extracranial-carotid-atherosclerotic-disease?sectionName=Carotid%20endarterectomy&search=carotid%20endarterectomy%20indications&topicRef=8193&anchor=H2&source=see_link#H1585579663

Answer 76

b) Central retinal occlusion Complications of HBOT: - claustrophobia - hypoglycaemia - middle ear barotruama - sinus squeeze - seizure (secondary to oxygen toxicity) - progressive myopia (typically reverses completely in days to weeks) - cataracts with very long exposure - cumulative pulmnoary oxygen toxicity - pulmonary barotrauma +/- air embolism - worsens CCF in pts with severe disease due to reduced HR (incr vagal tone from hyperbaric pressures) and systemic vasoconstriction Blue book 2019 pg 55 Absolute CI: - untreated pneumothorax (↑↑pleural air on decompression) - premature infants -> blindness risk - Bleomycin (O2 -> interstitial pneumonitis -> pulmonary fibrosis) - Cisplatin (↑cytotoxicity impedes wound healing) - disulfiram (Antabuse) Relative: pregnancy, asthma, COPD, URTI, thoracic surg, seizures, fevers, optic neuritis"

Answer 77

c) Vasopressin - =/↓ PVR Dobutamine: ↓SVR (β2)/PVR https://www.bjaed.org/action/showPdf?pii=S2058-5349%2821%2900031-7 - 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 78

d) cease 2 weeks before or e) stop 2 weeks before, start moclobemide and omit Moclobemide day of surgery Probably won't be making any major drug changes without the prescribing doctors OK. But acknowledging withdrawal risk +/- risk to mental health e) is also a reasonable option. Tranylcypromine, sold under the brand name Parnate among others, is a monoamine oxidase inhibitor. More specifically, tranylcypromine acts as nonselective and irreversible inhibitor of the enzyme monoamine oxidase. In the elective setting, there is some debate regarding the management of patients on MAOI. Although the risks associated with anaesthesia in those taking this group of drugs are significant, abrupt withdrawal may precipitate serious psychiatric relapse. Traditionally, irreversible MAOIs have been stopped 2 weeks before operation; however, omitting the dose of moclobemide on the day of surgery is acceptable. It has been suggested that in the elective situation, patients could be switched from an irreversible MAOI to moclobemide to avoid a prolonged period of discontinuation.

Answer 79

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 https://www.merck.com/product/usa/pi_circulars/e/emend/emend_pi.pdf https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5809356/ Works as a centrally acting NK1 receptor antagonist by blocking actions of Substance P - also ↑activity of dexamethasone & ondansetron (in chemo)"

Answer 80

d. Stop volatile, calcium ?Duchenne muscular dystrophy? This patient most likely has Anaesthesia Induced Rhabdomyolysis (AIR) given the peaked Twaves and slow rise in ETCO2 Calcium dose: 50mg/kg calcium gluc, or 20mg/kg of calcium chloride Duchenne muscular dystrophy (presents earlier 2-3yo than Becker 5-15yo) -> AIR rhabdomyolysis -> hyperkalemia (avoid sux/volatiles). Calcium for cardiac stabilization - prior uneventful volatile does NOT mean future ones safe https://academic.oup.com/bjaed/article/10/5/143/274799#3357763 In absence of precise diagnosis, undiagnosed neuromucular disease should not have elective surgery/anaesthesia (unless for diagnosis), as specific dx so important in risk assessment and anaes mx

Answer 81

b) 2 ATM or c) 1-4ATM https://academic.oup.com/bjaed/article/7/1/2/509371 **A typical parameter-set for HFJV via a subglottic catheter is DP, 2 atm; f, 150 min−1; Fio2, 1.0; I-time, 50%. ** Driving pressure 1-2 atm (250-500ml/s) RR 8-10 Automated jet ventilator – typical starting jet pressure for an adult is 1.5 bar (~1.5 atm). Manual jet ventilators deliver up to 3.5-4 bar.

Answer 82

a) Iron transfusion Iron infusion (ferric carboxymaltose) – can cause renal wasting of phosphate resulting in severe hypophosphataemia Vitamin D deficiency and hyperparathyroidism can also cause hypophosphataemia. Vitamin D deficiency would result in low calcium whereas hyperparathyroidism would result in hypercalcaemia. Fanconi syndrome: rare defect of proximal tubule leading to decreased reabsorption -> results in hypokalaemia, hypophosphataemia, hyperchloraemic metabolic acidosis. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6689119/

Answer 83

e) Deep anaesthesia ↑ POD and no change in mortality/serious complications (e.g. MI, sepsis) - Inclusion criteria: age>60, ASA 3/4, >2hr duration of surgery, hospital stay>2days - volatile only (NO TIVA/N2O/ketamine) - delirium assessed for 5 days - light anaesthesia prevented 1 in 10 cases of POD (i.e. lower incidence of poor cognitive screen scores at 1 year) Study reviewed by research FANZCA who thinks powered sufficiently and reasonable level of evidence. substudy = https://www.bjanaesthesia.org/article/S0007-0912(21)00493-1/fulltext

Answer 84

a) Tamponade Oesophageal fistula more likely in left atrial ablation Cardiac tamponade occurs ~1%. Can usually be managed with reversal of anticoagulation and percutaneous drainage. Vascular complications most common followed by tamponade. https://www.ahajournals.org/doi/10.1161/circep.113.000768 https://academic.oup.com/bjaed/article/12/5/230/289246#3659733

Answer 85

b) 1 or more RF Risk factors - female (MC), age<50, post-op opioids, hx PONV, non-smoker recommendation from new consensus guideline - 2 forms of prophylaxis for patients with 1-2 risk factors and 3-4 for more risk factors Fourth consensus guidelines Cochrane meta-analysis – NK1 receptor antagonist most effective prevention (aprepitant 40mg PO pre induction)."

Answer 86

"c) plasma metanephrines Traditional biochemical diagnosis of phaeochromocytomas relied upon 24 h collections of urinary catecholamines and vanillylmandelic acid (24 h due to diurnal variation in levels), and also blood sampling for plasma catecholamines. The short half-life of plasma catecholamines makes it difficult to differentiate pathological over-production from a transient stress response to venesection. Modern techniques measure levels of metanephrine and normetanephrine which are breakdown products of epinephrine and norepinephrine, respectively (Fig. 1). Sampling of these can be performed from either urine or plasma and there is no agreement over which is superior. Plasma tests are slightly more sensitive and more convenient to collect, while urine tests have a greater specificity. Both modern and traditional methods have numerous potential causes of false-positive results, including recent exercise, venous sampling in the sitting position, dietary factors, renal impairment, and many common medications. Examples of these medications include: * norepinephrine re-uptake inhibitors (amitriptyline, olanzapine, venlafaxine), * adrenergic receptor blockers (atenolol, phenoxybenzamine), * monoamine oxidase inhibitors (moclobemide, phenelzine), * recreational drugs (cocaine, amphetamine, caffeine), * sympathomimetics (salbutamol, terbutaline), * others (paracetamol). Phaeo - adrenal medulla tumor that secretes catecholamines HTN present in 90%, paroxysmal in 30-50% of cases; + palpitations, sweating (classic triad). Also Paraganglioma - neuro endocrine tumor for extra-medulla paraganglia - some produce catecholamine (Mx same) ## Footnote https://www1.racgp.org.au/ajgp/2021/january-february/adrenal-disease-an-update

Answer 87

C. Wedge PAC and insert bronchial blocker according to legend cardiac anaesthetist --> see explanation below LITFL: Pulmonary haemorrhage after PAOP measurement Specific therapy - Lay the patient ruptured side down - withdraw pulmonary catheter 2-3 cm with balloon down then refloat PAC with balloon inflated to occlude pulmonary artery (to try to tamponade bleeding) --> this is wedging (options D and E don't specify to withdraw and inflate balloon) -stop antiplatelet agents and anticoagulants give reversal agents: — protamine for heparin — platelets for anti-platelet agents - give blood products as indicated by FBC, coags and clinical state - interventions — angiogram or bronchoscopy to isolate pulmonary vessel involved — if bleeding doesn’t settle will require lobectomy As the pt is already intubated probably easier/safer just to chuck down a BB rather than do a tube exchange for a DLT

Answer 88

Alprostadil (PGE1) From Paediatric BASIC on CHD: - Resuscitation of an infant or newborn in shock should follow a standard approach regardless of the aetiology. - Any patient with a duct dependent lesion either for pulmonary blood flow, or systemic output, will require PGE1. The problem is that whether or not a duct dependent lesion is present is unclear in most cases. If CHD has been diagnosed antenatally, PGE1 should be started. - The cyanosed neonate presenting with severe cyanosis (O2 <75) and/or in extremis should be started on PGE1; the assumption being that the duct has closed and needs to be reopened. https://www.bjaed.org/article/S2058-5349%2818%2930062-3/fulltext - suggests 10ml/kg boluses for collapsed neonate - Possible adverse effects of prostaglandin infusions include apnoeic periods, hyperthermia, and hypotension. Usually start slow and increase but in collapse and CHD suspected start higher (20-200ng/kg/min) - Aim to balance ciruclation by A increasing pulmonary vascular resistance or decreasing systemic vascular resistance.

Answer 89

a. Decreased mortality Death in bleeding trauma patients Early administration of TXA safely reduced the risk of death in bleeding trauma patients and is highly cost-effective. Treatment beyond 3 hours of injury is unlikely to be effective. - Reduced death due to bleeding x 0.85 - Equivocal blood transfusion - Equivocal thromboembolism ARR 1.5% (NNT 68) - https://www.thebottomline.org.uk/summaries/icm/crash-2/

Answer 90

c) T6 LITFL: https://litfl.com/trauma-spinal-injury/ **Neurogenic shock** is classically characterised by hypotension, bradycardia and peripheral vasodilatation. Neurogenic shock is due to loss of sympathetic vascular tone and happens only after a significant proportion of the sympathetic nervous system has been damaged – as may occur with lesions at the T6 level or higher. **Spinal shock** is not a true form of shock. It refers to the flaccid areflexia that may occur after spinal cord injury, and may last hours to weeks. It may be thought of as ‘concussion’ of the spinal cord and resolves as soft tissue swelling improves. Priapism may be present. "b) T5 https://docs.google.com/document/d/1uvuCJkvV3v53ViT0M1SXJUr9TSYraYm44W3dkhcw9Fc/edit?usp=sharing Summary SCI mx 4 phases: phase 1 - areflexia days 0-1 phase 2 - initial reflex return days 1-3 phase 3 - early hyperreflexia days 4-28 phase 4 - later hyperreflexia 1-12mth

Answer 91

C. 3 - 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 92

d) Dexamethasone The ECG shows LONG QT https://litfl.com/qt-interval-ecg-library/

Answer 93

b) 3rd nerve palsy https://derangedphysiology.com/main/required-reading/neurology-and-neurosurgery/Chapter%204631/lesions-oculomotor-nerve-cn-iii This is the "down and out" eye syndrome. It is characterised by ptosis, a down-and-out pupil, mydriasis, absent light reflex with intact consensual constriction of the opposite eye, and failure of accommodation. Classically, this is the lesion which develops during uncal herneation, due to an ipsilateral cerebral injury. Causes of unilateral CN III lesions: - Uncal herneation: Pressure from herniating uncus on nerve - Fracture involving ipsilateral cavernous sinus - Cavernous sinus thrombosis (ipsilateral) - Aneurysm (ipsilateral) - Midbrain lesion (see Question 26.2 from the second paper of 2011) Causes of bilateral CN III lesions: - Cavernous sinus thrombosis - Aneurysm - Contralateral brainstem lesion (midbrain) Exclusion of a 4th nerve lesion - Tilt the head to the same side as the lesion - The affected eye will intort if the fourth nerve is intact.

Answer 94

c) Larger bolus lower infusion rate https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/10.1111/anae.13345 https://journals.lww.com/anesthesia-analgesia/fulltext/2014/06000/a_general_purpose_pharmacokinetic_model_for.12.aspx Eleveld Effect site - bolus 2.33mg/kg and infusion of 76.5ml/hr (for 70kg male with opioid Ce 4.0) Eleveld plasma - bolus 0.36mg/kg, infusion 102ml/hr Schnider effect - bolus 1.01mg/kg, infusion 90.6ml/hr Marsh plasma - bolus 1mg/kg, infusion 103ml/hr

Answer 95

d) Von willebrand disease - autosomal dominant inheritance - may have normal or prolonged APTT, PT is normal - haemophilia A/B canNOT have been passed down from father to son (as father passes on Y chromosome) and Haemophilia A/B is X-linked. - APTT prolonged. Normal PLT/bleeding time/PT. Factor 8 low in Haem A. Factor 9 low in Haem B Factor 11 low in Haem C vWD (type 1 quantitative, type 2 qualitiative, type 3 complete absence; note vWF is carrier for VIII) - normal or prolonged APTT - normal or reduced PLT - normal or prolonged bleeding time - 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. 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.

Answer 96

All People Kick My Cat Atm> PSI > KPA > mmHg > cmH2O 1ATM = 14.69 PSI = 101.325 kPa = 760mmHg = 1033 cmH20

Answer 97

Metabolic acidosis Anion gap = (Na + K) - (Cl + HCO3); <12 w/o K, <16 w/ K included MUDPILES = HAGMA Methanol/EtOH Uraemia DKA (or ketoacidosis) Pyroglutamic acidosis Iron (OD) Lactic acidosis Ethylene glyclol Salicylates NAGMA = PANDA RUSH Pancreatic secretion loss Acetazolamide Normal saline intoxication (hyperchloraemic MA) Diarrhoea Aldosterone antagonists/Addison's (insufficient cortisol/aldosterone = adrenal insufficiency; aldosterone secretes H+ in distal tubule) Renal tubular acidosis Ureteric diversion Small bowel fistula Hyperalimentation (TPN)

Answer 98

c. Hypercarbia Single-lung ventilation leads to a **right-to-left intrapulmonary shunt** as the nondependent lung continues to undergo perfusion with no ventilation, leading to a widened alveolar-to-arterial (A-a) oxygen gradient, which may contribute further to **hypoxemia**. Factors leading to decreased blood flow to the ventilated lung also lead to hypoxemia. Such factors include: Low Fio2 leads to **hypoxic pulmonary vasoconstriction** in the dependent ventilated lung High mean airway pressures in the dependent ventilated lung Vasoconstrictor agents Intrinsic PEEP The lateral decubitus position under anesthesia: Under anesthesia, there is a decrease in functional residual capacity. The upper lobe moves under anesthesia to a more favorable portion of the compliance curve versus the lower lung, which lies now on a less favorable portion of the compliance curve. Neuromuscular blockade contributes to abdominal contents pressing against the dependent hemidiaphragm, thereby restricting ventilation. Open non-dependent lung leads to variation in compliance and thus **worsens ventilation-perfusion (V/Q) mismatch** - thereby leading to hypoxemia. **Carbon dioxide elimination is usually unaffected **in using single-lung ventilation with adequate maintenance of minute ventilation. Both lungs may be affected independently by single-lung ventilation. The ventilated-dependent lung is prone to ventilator-induced lung injury due to higher tidal volumes used. The nondependent nonventilated lung is prone to injury by surgical trauma and ischemia-reperfusion injuries. Considering these physiological changes in single-lung ventilation is vital to safely performing the anesthetic technique and airway management. Reference: StatPearls Single-Lung Ventilation https://www.ncbi.nlm.nih.gov/books/NBK538314/"

Answer 99

a) commence TIVA (if high flow O2 is option that would be next) Immediate management as per MHANZ (probably the ones they want us to use) Give dantrolene as priority (2.5mg/kg TBW) - 20mg/vial; 1 amp w/ 60mL H2O Stop trigger 1. declare emergency and if possible stop surgery 2.Turn off Volatile and hyperventilate with high flows (15L/min) of 100% O2 Do not waste time changing circuit or anaesthetic machine 3. Start non triggering anaestethetic 4. Give dantrolene 5. Simultaneously treat life threatening effects https://malignanthyperthermia.org.au/malignant-hyperthermia-resource-kit https://anaesthetists.org/Portals/0/PDFs/Guidelines%20PDFs/Guideline%20Malignant%20hyperthermia%202020.pdf?ver=2021-01-13-144236-793 as per guidelines are different: As per anaesthetic crisis manual 1. Call for help, communicate and delegate 2. Stop any volatile and remove vaporiser 3. Allocated task cards 4. Give dantrolene 5. Hyperventilate with 100% high flow oxygen 6. Use activated charcoal filters on both limbs 7. Maintain anaesthesia with TIVA 8. Insert IAL +/- CVC 9. Actively cool if temperature > 38.5 10. Treat associated hyperkalaemia, acidosis, arrhythmias Hyperk - CaCl 10% 10ml, Insulin 10u / 50mL 50% dextrose - 10mL Hyperthermia - cool if T>38.5, IV saline 4deg, surface cooling (ice), peritoneal lavage if open already Acidosis - hyperventilate (normocapnoea), consider sodium bicarb 0.5mmol/kg IV to aim pH >7.2 Arrythmia - lignoacaine 1-2mg/kg, amiodarone 2-3mg/kg over 15mins Additonal monitoring - core temp, IAL, UO aim >2ml/kg/hr, CVL, urgent bloods - ABG/FBC/U+E/CK/ COAG Charcoal filter- may assist in reducing volatile load Once stabilised -monitor for at least 24hrs in ICU - recurrence may occur -> more dantrolene

Answer 100

b) Subclinical Hyperthyoirdism Subclinical hyperthyroidism: low TSH, normal T3 + T4 (probably secondary to over treatment with thyroxine) Clinical hyperthyroidism: low TSH, high T3, high/normal T4 Subclinical hypothyroidism: high TSH, normal T3 + T4 Clinical hypothyroidism: high TSH, low/normal T3, i T4 Amiodarone: high/normal TSH, low T3 (2o to inhibition of pituitary T4 to T3 conversion) Sick euthyroid: low TSH, low T3 Hypophysectomy (central hypothyroidism): low/normal TSH/T3/T4 Compliant on thyroxine: normal TSH, high/normal T3, low T4 Non-compliant w thyroxine (pt taking several tabs prior to Dr’s appointment): high TSH, normal T4

Answer 101

B. 20% 25% (a few studies have higher ranges but typically around 20-25%) https://doi.org/10.1192/bjp.bp.115.165498 Oral - 20% Subling - 30% IN - 40-50% IM - 93%

Answer 102

a) propofol https://academic.oup.com/bjaed/article/12/3/128/258959#3092690 Unsafe: thiopentone, ketamine, sevoflurane, oxycodone, diclofenac, ephedrine, erythromycine Undetermined: ropivacaine, vasopressin, metarminol, dexamethasone, etomidate Safe: Propofol, desflurane, N2O, midaz (low-dose) lignocaine, bupivacaine, all NMBs, fentanyl family, morphine, tramadol, other NSAIDs, benzos, phenyl/Ad/NAd, uterotonics, TXA. Porphyria - probably the disease behind the myths of vampires (make sure to drop this in your medical viva) --> sensitive to sunlight, gum recessiong (fangs), urine is red so they are obviously drinking blood, garlic can cause an attack due to its sulfur content... I digress - group of disease where there is an enzyme defect in the synthesis of haem --> accumlation of precursors that are oxidised into porphyrins - can have porphyric crises -- attacks most frequent in women in 3rd - 4th decades. Precipitated by drugs, stress, infection, alcohol, menstruation, pregnancy, starvation, dehydration --- symptoms: abdo pain, vomiting, motor/sensory neuropathy, autonomic dysfunction, CN palsies, mental distrubances, convulsions, pyrexia Before anaesthetic, particularly neuraxial: careful neurological assessment - peripheral neuropathy - autonomic instability; -> + hypovolaemia + neuraxial = circulatory collapse (note regional ok) - active disease = ^risk acute crises Oxford handbook pg 202"

Answer 103

https://litfl.com/ecg-axis-interpretation/

Answer 104

"c) sinus tachy with widened QRS; cocaine also TCA overdose - toxicity develops 30mins post overdose, peaks 2-6hrs post. - 4 receptors antagonsim invovled - central and peripheral Ach receptors, alpha adrenergic receptors, norad and serotonin reuptake, fast sodium channels in myocardial cells - anticholinergic symptoms - agitation, restless, delirium, mydriasis (big pupils), warm skin, tachycardia, ileus, urinary retention (SLUDGE) - CVS toxicity - tachycardia, arrythmia, HTN, Hypotension (due to alpha blockade), broad complex tachy but can also develop bradycardia pre arrest) - CNS toxcicity - delirium, agitation, sedation, seizures, coma (often precedes CVS signs) - metabolic acidosis https://litfl.com/another-tca-overdose/"

Answer 105

c) pelvic splanchnic -> visceral not somatic nerve other option is inferior gluteal (motor, no sensory)

Answer 106

a. PECS I (PECS II Covers SA and will extend to the sternum)

Answer 107

REPEAT a) 30 min If the anaesthesia machine requires electrical power for normal operation, a backup power supply must be a part of the machine and permit normal operation for at least 30 minutes after a mains power supply failure. An alarm must be activated at the time of the mains failure and the state of the reserve power supply must be indicated while it is in use. https://www.anzca.edu.au/getattachment/f05e02ec-2023-4c50-b57f-9549ea0c4183/PS54(A)-Position-statement-on-the-minimum-safety-requirements-for-anaesthesia-machines-and-workstations-for-clinical-practice-2021#page=

Answer 108

e) Propofol https://www.bjanaesthesia.org/article/S0007-0912(20)30547-X/pdf

Answer 109

d) Dopamine Dobutamine (β1 and β2), dopexamine (DA1, some β2) and low-dose dopamine (DA1 and DA2, β1 and β2, α1 in high dose) all have vasodilatory effects on the splanchnic circulation, and have been shown to improve markers of perfusion. For many years, low-dose infusions of dopamine were used as a prophylactic and therapy for acute renal failure, using the logic that DA1- and DA2-mediated vasodilation in renal and splanchnic beds would be protective. https://pubmed.ncbi.nlm.nih.gov/12794401/

Answer 110

REPEAT e. Oxygen consumption/min divided by HR VO2/HR: oxygen consumption divided by HR, known as the ‘oxygen pulse’ (ml beat–1) https://www.bjaed.org/article/S2058-5349(19)30021-6/fulltext The objective of CPET is to determine functional capacity in an individual. Deficiencies in CPET-derived variables—specifically: 1. ventilatory anaerobic threshold (AT) 2. peak O2 consumption (VO2peak) 3. ventilatory efficiency for carbon dioxide (VE/VCO2) —are associated with poor postoperative outcomes (mortality, morbidity, admission to intensive care, and length of hospital stay) after intra-abdominal surgery. 7. Does the oxygen pulse increase with exercise? The oxygen pulse is the VO2 divided by HR, and represents the product of the stroke volume and the arterial-venous oxygen difference. It can be seen in panel 2 and can be viewed as a surrogate for stroke volume, and as such should increase at the start of exercise before slowly reaching a plateau at its highest predicted value.

Answer 111

C. two vertebrae below carina https://academic.oup.com/bja/article-abstract/115/2/252/323905?redirectedFrom=fulltext

Answer 112

Answers could also possibly be COPD, Acute stroke or Neonates c) Bleomycin toxicity 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.2 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.3 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 in Table 4. Summary guidance—oxygen therapy for patients who have received bleomycin > Patients have a life-long risk of bleomycin-induced lung injury > Oxygen therapy should be avoided if at all possible > Clinical procedures (and leisure activities) involving a high should be avoided If a patient is hypoxic > O2 therapy should be minimized to maintain O2 saturation of 88–92% > High oxygen concentrations should be used with extreme caution for immediate life-saving indications only (to maintain O2 saturation of 88–92%)

Answer 113

90mg PO morphine Oral Tapentadol 25mg = 8mg Oral Morphine Oral Oxycodone 5mg = 8mg Oral Morphine Oral Tramadol 25mg = Oral Morphine 5mg Oral Hydromorphone 4mg = Oral Morphine 20mg S/L Buprenorphine 200mcg = 8mg Oral Morphine IV Oxycodone 5mg = Oral Morphine 15mg IV Morphine 5mg = Oral Morphine 15mg IV Hydromorphone 1mg = Oral Morphine 15mg

Answer 114

midazolam (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. - Opioids, benzodiazepines and pregabalin may also be used to alleviate symptoms. 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 115

New question. a) 30 day mortality Postoperative myocardial injury was associated with an increased risk of death. Twenty-seven of the 315 patients (8.6%; 95% CI, 6.0–12.2%) with myocardial injury died within 30 days compared with 29 of the 1312 patients (2.2%; 95% CI, 1.5–3.2%) with normal troponin I levels (P<0.01) Reference: Myocardial Injury After Noncardiac Surgery and its Association With Short-Term Mortality (Circulation 2013)

Answer 116

REPEAT f) Increased SVR IAP<10mmHg - ↑ VR/CO (from splanchnic/GI cirulcation) IAP 10-20mmHg (MC) - ↓VR/CO, ↑SVR (also ↑catecholamines), <->or ↑BP IAP>20mmHg - ↓↓ VR/CO --> ↓ BP (starts to impede VR seriously) https://academic.oup.com/bjaed/article/4/4/107/308013 2004 Resp: ↓ FRC, ↑AWR + ↓compliance. Barotrauma risk"

Answer 117

d) diplopia Bilateral visual loss associated with insufficiency to posterior circulation so: parieto-occipital ischaemia, signs of stroke, visual agnosia, ophthalmoplegia or diplopia.

Answer 118

a) VVI with intermittent failure to capture contentious question There are regular pacing spikes, but no regular broad QRS (i.e. capture). The pacing spikes are not happening in a repolarising segment, therefore this does not explain why there is no ventricular response.

Answer 119

b) Diuretics Grade 1: moderate hypoxia (Spo2<94%) or hypotension [fall in systolic blood pressure (SBP) >20%]. Grade 2: severe hypoxia (Spo2<88%) or hypotension (fall in SBP >40%) or unexpected loss of consciousness. Grade 3: cardiovascular collapse requiring CPR. Patient Risk factors: 1. old age 2. poor pre-existing physical reserve 3. impaired cardiopulmonary function -> NYHA 3 or 4 4. pre-existing pulmonary htn 5. Male Sex 6. Diuretics 7. ASA grade 3 or 4 8. osteoporosis 9. bony metastases 10. concomitant hip fractures (particularly pathological and intertrochanteric) (latter due to abnormal vascular channels through which marrow contents can enter the circulation) Surgical Risk factors 1. patients with previously un-instrumented femoral canal > revision surgery 2. Use of long-stem femoral component Anaesthetic Risk reduction: - discussion between surgeons and anaesthetists over uncemented vs. cemented based on patient Hx particularly if lon-stem prosthesis, femoral fracture or patients with cardiorespiratory disease - no clear evidence regarding the impact of anaesthetic technique - increase inspired O2 considered in all patients at time of cementation - avoid intravascular volume depletion - Higher level of haemodynamic monitoring in high risk patients Factors NOT predictive of severe BCIS include: Arteriosclerosis Angina pectoris Congestive heart failure Beta-blockers Angiotensin-converting enzyme inhibitors.

Answer 120

repeat 23.1 c) 20mmHg Intra-abdominal hypertension is defined as a sustained intra-abdominal pressure of >12 mm Hg, and abdominal compartment syndrome occurs at a pressure >20 mm Hg in association with new organ dysfunction. Intra-abdominal hypertension is graded as follows: Grade 1=12–15 mm Hg; Grade 2=16–20 mm Hg; Grade 3=21–25 mm Hg; and Grade 4 >25 mm Hg.

23.2 Flashcards

(146 cards)