1
Q
During paediatric gas induction, the gas flow recommended by SPANZA for least environmental impact is:
a) 1L/min
b) 2L/min
c) 3L/min
d) 4L/min
e) 5L/min
A
Ans: 3L/min (0.15L/kg/min)
- 1 L/min: Well below the 0.15 L/kg guideline for most children—under-delivery of anesthetic, risk of inadequate induction or hypoxia.
- 2 L/min: Still falls short for an average-weight child around 13–14 kg or more. Many kids are heavier.
- 4 L/min: Excessive for environmental stewardship—it surpasses the minimum needed and produces needless gas waste.
- 5 L/min: Even more wasteful—far above the efficient threshold—and unnecessary per the SPA weight-based recommendation.
2
Q
The Mapleson circuit to best achieve normocarbia with mechanical ventilation is:
a) Mapleson A
b) Mapleson B
c) Mapleson C
d) Mapleson D
e) Mapleson E
A
Ans: Mapleson D
A - best for spontaneous ventilation
B, C - both crap
D, E, F - best for mechanical ventilation
https://epomedicine.com/medical-students/mapleson-breathing-circuit-made
3
Q
SQUIRE guidelines
a) Provide a framework for reporting new knowledge about healthcare improvement
b) How to conduct a systematic review
A
Ans: A) Quality improvement
SQUIRE → Quality Improvement
PRISMA → Systematic Reviews
CONSORT → Randomised Controlled Trials
STROBE → Observational studies
4
Q
What is the five number summary on a box and whisker plot?
A
Ans:
Minimum – the smallest observation (not counting outliers, if they’re shown separately).
First quartile (Q1) – the 25th percentile, below which 25% of the data lie.
Median (Q2) – the 50th percentile, the midpoint of the data.
Third quartile (Q3) – the 75th percentile, below which 75% of the data lie.
Maximum – the largest observation (again, excluding flagged outliers).
How it looks on the plot
The box spans from Q1 to Q3 (the interquartile range).
The line inside the box marks the median.
The whiskers extend to the minimum and maximum (unless outliers are plotted separately, in which case whiskers stop at the last non-outlier).
5
Q
Axis of ECG- left axis deviation (aVR was isoelectric, AVF negative, I positive)
a) -45 degrees
b) -75 degrees
c) +15 degrees
A
Ans: -45
AVF negative - must be between 0 and -180
I positive - must be between 0 and -90
AVR isoelectric - must be 90 degrees to -150 therefore answer is -60
(if the remembered leads are correct)
6
Q
What does a green colour on the laryngoscope blade mean
a) Reusable
b) Recyclable
c) Single use
d) Disposable
e) Fibreoptic light source
A
Ans: fibreoptic light source (in handle), lamp in the blade, electrical connection
versus black (?) handle which has light source in the blade not the handle.
The green colour coding on laryngoscope blades and handles is part of the ISO 7376 standard.
It does not indicate reuse/disposability — it tells you the type of light connector:
Green line/blade = Fibreoptic (FO) system → light is transmitted via fibreoptic bundle to the distal tip, with connection to an external light source (in modern blades, often LED).
Black line/blade = Conventional bulb system (light bulb in the blade itself).
Reusable vs single-use is a different labelling convention, typically written explicitly on packaging/blade (“Single Use Only” or manufacturer’s symbols).
7
Q
Arndt blocker attachment point for the breathing circuit (just a schematic drawing provided in the exam)
A
8
Q
Vivasight components (arrow to the red bit in the exam)
a) Flush port
b) Light source
c) Aspiration port
A
Flush port
9
Q
Semaglutide half life
a) 3 days
b) 7 days
c)14 days
A
6-7 days
From ANZCA clinical practice recommendation on periprocedural use of GLP-1/GIP receptor agonists
Exenatide 3.3-4 hours
Liraglutide 12.6-14.3 hours
Dulaglutide 4.7-5.5 days
Semaglutide 5.7-6.7 days
Tirzapatide 4.2-6.1 days
10
Q
Gastric USS image
a) Empty stomach
A
https://www.bjaed.org/article/S2058-5349%2819%2930047-2/fulltext
11
Q
Preoperative intravenous iron to treat anaemic before major abdominal surgery (PREVENTT) trial showed:
a) Reduced allogenic red cell transfusion
b) Reduced mortality
c) Reduced readmission rates within 30 days
d) Reduced infection rates
A
Ans: C) reduced readmission rates in 30 days
The PREVENTT (Preoperative Intravenous Iron to Treat Anemia before Major Abdominal Surgery) trial was a well‑designed, double‑blind, randomized controlled study comparing IV ferric carboxymaltose (1,000 mg) with placebo in anaemic patients scheduled for major abdominal surgery.
Published in the Lancet October 2020
Found that preoperative intravenous iron was not superior to placebo to reduce need for blood transfusion when administered to patients with anaemia 10-42 days before elective major abdominal surgery.
Readmissions to the hospital following surgery were significantly lower in the intravenous iron group in the first 8 weeks after the index operation.
12
Q
Compared to UFH, enoxaparin preferences:
a) Thrombin
b) Xa
A
B) Xa
Unfractionated heparin (UFH)
Binds to antithrombin (AT) → inhibits both Factor Xa and Thrombin (Factor IIa) equally well (anti-Xa : anti-IIa ratio ≈ 1:1).
Needs a longer chain length of heparin to bridge AT to thrombin — UFH has plenty of long chains.
Low molecular weight heparin (LMWH, e.g. enoxaparin)
Still works via AT, but because the chains are shorter, most molecules are too short to bind both AT and thrombin simultaneously.
Therefore, LMWH preferentially inhibits Factor Xa (anti-Xa : anti-IIa ratio ≈ 3–5:1).
Less effect on thrombin compared to UFH.
13
Q
Child on 15mcg/kg steroids, when to give hydrocortisone (stress dosing)
a) > 2 weeks
b) > 1 month
c) > 2 months
A
Stress dose if >15mg/m^2 daily for > 1 month
Stress dose is 2mg/kg hydrocortisone.
Iatrogenic adrenal suppression depends on dose, duration, and potency.
Hydrocortisone equivalence:
Prednisolone 1 mg ≈ Hydrocortisone 4 mg
A child on 15 mcg/kg/day prednisolone = 0.015 mg/kg/day.
In a 20 kg child → 0.3 mg/day pred. Equivalent to ~1.2 mg hydrocortisone/day.
This is a physiological dose (normal cortisol output is ~8–10 mg/m²/day hydrocortisone equivalent).
Thus, we’re talking about a child on replacement therapy, not supraphysiological “immunosuppressive” doses. The concern is duration of therapy → when is adrenal suppression likely?
Evidence / Guidelines (ANZCA, RCH Melbourne, SPANZA)
> 2 weeks of supraphysiological steroids is enough to risk HPA suppression.
If only physiological replacement → no stress dosing needed.
But the way this MCQ is written, they probably assume the child is on a “chronic course of steroids” and are testing the 2-week rule (a common exam trap).
14
Q
DCD - last acceptable organ
a) Lungs
b) Kidney
c) Liver
d) Pancreas
e) Heart
A
Ans: lungs (90 minutes)
Liver and pancreas - 30 minutes from withdrawal of support
Heart - 30 minutes from systolic <90
Kidneys - 60 minutes from systolic <50
Liver - 90 minutes from systolic <50
15
Q
DCD criteria, what doesn’t include
a) Immobility
b) Apnoea
c) Absent skin perfusion
d) Absence of circulation (no arterial pulsatility for 2 min)
Cannot recall other option, which was the answer (maybe absence of sedation?)
A
Ans: d
Should be absence of pulsatility for 5 minutes not 2 minutes.
Donatelife best practice guideline:
- Arterial blood pressure monitoring is recommended
- Absence of arterial pulsatility for 5 minutes is observed prior to confirmation of death
- Electrical asystole is not required, noting that electrical (ECG) activity may persist beyond circulatory arrest
- Death is confirmed by clinical examination (e.g. absence of spontaneous movement, breathing, heart sounds and central pulse)
- Post-mortem interventions that may restart the circulation should not be undertaken e.g. mechanical ventilation, chest compression
16
Q
Post herpetic neuralgia, feels like insects crawling across head, what is it?
a) Allodynia
b) Dysaesthesia
c) Formication
d) Pruritis
e) Hyperpathia
A
Ans: Formication
Dysaesthesia “spontaneous or evoked unpleasant abnormal sensations”
Hyperalgesia “increased response to a normally painful stimulus”
Allodynia “pain due to a stimulus that does not normally evoke pain such as light touch”
17
Q
What drug to avoid in congenital long QT
a) Propofol
b) Thiopentone
c) Ketamine
A
Ans: C) Ketamine
Uptodate:
= Droperidol, haloperidol, volatile, ondansetron, amiodarone. methadone
Propofol has least effect. Prop/remi TIVA is safe
“ketamine should be avoided because of its sympathomimetic effects”
Glyco and atropine can prolong QTc and precipitate torsades.
Thiopental can be used in patients with prolonged QT (prolongs the QTc but reduces TDP - transmural dispersion of depolarization)
Long QT syndrome | BJA Education | Oxford Academic (oup.com)
18
Q
Recurrent torsades treatment, acceptable
a) Flecainide
b) Lignocaine
c) Procainamide
d) Amiodarone
e) Sotalol
A
Ans: B) Lignocaine (dose is 1mg/kg bolus - ANZCOR)
- Overdrive pacing - Lignocaine decreases the QTc - Beta blockers - Isoprenaline
Uptodate:
- If baseline QTc is normal then less likely to respond to Mg and IV amiodarone may prevent recurrence.
“polymorphic VT” = without QT prolongation
“torsades” = a form of polymorphic VT with QT prolongation
19
Q
- Acceptable tryptase to diagnose anaphylaxis
a) (1.2 times normal) + 2
b) (1.8 times normal) + 2
c) Normal + 2
d) 10/mL
e) 15/mL
A
Ans: 2+ (1.2 x baseline)
Uptodate
20
Q
ANZAAG refractory anaphylaxis
a) Glucagon IV 10min
b) Glucagon IV 5 min
c) Glucagon IM 5 min
d) Glucagon IM 10 min
Other remembered “refractory anaphylaxis in someone on beta blocker”
a) Glucagon 1-2mg every 5 minutes until response
b) Once
c) Every 10 minutes
A
Ans: Glucagon 1-2mg every 5 minutes
21
Q
- Fem-fem VA ECMO, where is best representative of coronary PaO2?
A) Right radial
B) Either radial
C) Left radial
D) Pre-oxygenator
E) Post oxygenator
A
Ans: A) right radial
Right radial artery: samples blood from the innominate artery, which comes directly off the aortic arch and is perfused by whatever the LV ejects. → Best reflection of coronary and cerebral oxygen delivery.
Left radial artery: may also reflect LV output, but due to arch vessel anatomy, the right radial is preferred as the most reliable “surrogate” of coronary oxygenation.
Either radial: not correct — only the right gives the best correlation.
Pre-oxygenator blood: reflects patient’s venous return, not coronary perfusion.
Post-oxygenator blood: reflects ECMO circuit output, not what reaches coronaries.
22
Q
- Post op cognitive decline has an onset within:
A) Immediate post
B) Within one day, lasting one week
C) From ?3 weeks ?10 days post op for a year
D) From 1 month to 1 year
A
Ans: D
Delirium = 24-72hrs post-op
Immediate (minutes–hours after emergence).
Acute confusional state, fluctuating attention, disorientation.
Delayed neurocognitive recovery
Within days–weeks post-op (up to 30 days).
Typically resolves within weeks.
Postoperative cognitive dysfunction (POCD) → now termed “postoperative neurocognitive disorder”
>30 days up to 12 months post-op.
Can be detected FROM 7 days after surgery
Subtle decline in memory, attention, executive function.
Diagnosed by neuropsychological testing, not bedside confusion screens.
Bluebook: “The time frame of onset of POCD remains undefined, but it can be detectable from 7 days after surgery… It is our belief that changes in cognition earlier than 7 days after surgery cannot be accurately tested and attributed to POCD.
BJA: The incidence of POCD in elderly patients at 1 week is 30%, at 3 months is 10–13% and at 1 yr is 1%”
23
Q
- Pre-eclampsia at 30 weeks with IUGR
A) Low CO, low SVR
B) Low CO, high SVR
C) High CO, low SVR
D) High CO, high SVR
A
B) Low CO, high SVR
Haemodynamics in preeclampsia (especially with IUGR)
Preeclampsia is driven by abnormal placentation → failure of spiral artery remodelling → high resistance uteroplacental circulation.
Leads to:
High afterload (↑ SVR)
Impaired ventricular filling, sometimes ↓ contractility → low or normal CO.
Subgroups exist:
“High output / low resistance” phenotype → more common with maternal features (hypertension, proteinuria, less IUGR).
“Low output / high resistance” phenotype → associated with early onset preeclampsia and IUGR (placental-driven).
24
Q
- Burns - expected physiological changes within the first 24 hours
A) High cardiac index
B) Increased PVR
C) Decreased SVR
D) High stroke volume
A
Ans: B) increased PVR
First 48 hours depressed myocardium, hypovolaemia (hypovolaemic shock)
- Increased Hct
- Increased PVR and SVR
- Decreased stroke volume
- Decreased cardiac index
- Decrease venous saturation
- Tachycardia
After 48 hours hypermetabolic state
- Decreased SVR, subclinical myocardial dysfunction
25
25. Which increases the risk of blood product related graft vs. host disease
A) Genetic variability between donor and recipient
B) Irradiated
C) Leukodepleted
D) Immunodeficiency
E) Transfusion of non-cellular product
Ans: D) Immunodeficiency
Pathophysiology recap
Caused by donor T-lymphocytes engrafting in the immunocompromised recipient and attacking host tissues.
Prevention: irradiation of cellular blood products (which inactivates T lymphocytes).
Leukodepletion is not sufficient (removes most WBCs but not all viable T-cells).
Plasma or non-cellular products (FFP, cryoprecipitate) do not cause GVHD, because they contain no viable lymphocytes.
26
26. When reconstituted, fibrinogen concentrate should be transfused within:
A) 30 min
B) 4h
C) 6hrs
Ans: 6hrs
Several answers depending on source.
Stable for 6 hours after reconstitution if kept between 20-25 degrees
^^ Australian PI is different to American PI. Australian PI states 6 hours.
LITFL - 6hrs
Fibryga - 24hrs
Riastap - 8 hrs
27
27. A man has this device put in because he isn't suitable for anticoagulation with AF. What is a WATCHMAN device / where is it?
A) Left atrial appendage
B) SVC
C) IVC
D) Right atrium
E) Ascending aorta
ANS: A) LAA
WATCHMAN device
A percutaneous left atrial appendage (LAA) occlusion device.
The LAA is the main site where thrombi form in non-valvular AF (~90% of cases).
By sealing off the LAA, the WATCHMAN prevents clot formation there, reducing stroke risk.
28
28. Aortic mechanical On-X valve has an inguinal hernia repair in 48 hours and INR is 1.5, what should you do?
A) Bridge with enoxaparin
B) Bridge with heparin
C) Cease warfarin
D) Cease aspirin
ANS: C
On-X valve is mechanical bileaflet valve with approval for low INR target 1.5-2.0.
The guidelines advise that patients with low thromboembolic risk, particularly those with On-X valves, may be safely managed without bridging if their INR is below 2.0 before surgery. However, if there are other thromboembolic risks (e.g., prior stroke, atrial fibrillation), bridging with heparin is advised. 2019 ACC guidelines
On-X have lower target INR 1.5-2: For mechanical On-X AVR and no thromboembolic risk factors: A lower INR of 1.5-2.0, starting 3 months after surgery with addition of aspirin (ASA) 75-100 mg daily (Class 2b).
2020 AHA guidelines
- low-mod bleeding risk procedure
- low-mod thromboembolic risk (in absence of additional risk factors??)
- On-X/cryolife product info suggests don't bridge https://www.heartvalvechoice.com/wp-content/uploads/2021/05/On-X-Valve-Patient-FAQs.pdf as does the NSW health guideline:
https://www.cec.health.nsw.gov.au/__data/assets/pdf_file/0006/458988/Guidelines-on-perioperative-management-of-anticoagulant-and-antiplatelet-agents.pdf
if there was some other risk factor in the stem, I would say bridge, and use UFH if CrCl <15ml/min
29
The transthoracic echo demonstrates:
Tricuspid regurgitation
30
30. TTE echo parasternal long axis which chamber?
- RV
RA
31
Non-inferiority trial (repeat, line crossed 0 and non-inferior line)
32
32. APRV ventilation
A) Spont breathing
B) Restrictive lung disease
C) Short bursts of high pressure to aid recruitment
D) Long expiratory for clearance of CO2
2023A repeat
Ans: A)
Inverse ratio, pressure-controlled mode: patient spends most of the cycle at a high continuous pressure (P high) to recruit alveoli and maintain oxygenation.
At regular intervals, there’s a brief “release” to a low pressure (P low) → this allows CO₂ elimination.
Patients are allowed (and encouraged) to breathe spontaneously throughout the cycle
Spontaneously breathing patient
Longer inspiratory times (prolonged high pressure maximises recruitment) = better oxygenation
brief releases at lower pressure facilitate CO2 clearance
Similar to constant recruitment method
33
33. Best TOE view for detecting myocardial ischaemia
A) Mid-oesophageal 4-chamber
B) Long axis
C) 2 chamber
D) Transgastric 2 chamber
D) transgastric 2 chamber
Myocardial ischaemia is detected by regional wall motion abnormalities (RWMA).
You want to see as many left ventricular (LV) wall segments as possible in one view.
ASE/SCA guidelines recommend the transgastric mid-short axis view as the most sensitive single view (shows all circumferential LV segments).
34
34. CXR with 3 lead pacemaker arrow pointing to:
A) LV
B) RV
C) Coronary sinus
35
35. Avulsed tooth, what fluid to place it in
A) Chlorhexidine
B) Saline
C) Balanced salt solution
D) Fresh bovine milk
E) Water
Ans: C)
International Association of Dental Traumatology (IADT) guidelines:
Best medium: Hank’s Balanced Salt Solution (HBSS), if available (rare outside hospitals/dental offices).
Practical recommendation: If HBSS not available, the best alternative is cold fresh milk.
Saline is “okay,” but doesn’t preserve periodontal ligament (PDL) cells as long as milk.
Milk vs saline:
Milk is closer to physiologic pH and osmolality, contains nutrients, and preserves viability for up to 6–24 h.
Saline is isotonic but has no nutrients → poorer long-term survival.
Chlorhexidine & water: both damaging to PDL cells.
So in exam context
If Balanced Salt Solution (HBSS) is listed → that is the scientifically best answer.
If HBSS is not an option, then the best practical answer is milk.
36
36. Pregnant MS (multiple sclerosis?) lady, cat 1 CS within 30 minutes, what method
A) Spinal
B) CSE
C) Epidural
D) GA
E) Methylpred then GA
Ans: GA if mitral stenosis, spinal if multiple sclerosis
GA
^top end article (if this means mitral stenosis)
- Cat 2 CSE intrathecal morphine in spinal and slowly titrated epidural
- Cat 1 then GA
If this means multiple sclerosis then just do a spinal if there is time
Avoid hyperthermia
It has been suggested in the past that neuraxial techniques, specifically spinal anaesthesia, may contribute to increasing relapses after delivery because the demyelinated spinal cord is exposed to neurotoxic local anaesthetic agents. However, the Pregnancy in Multiple Sclerosis study (PRIMS) found no correlation between the use of neuraxial techniques and relapses of MS in the postpartum period. Numerous subsequent reports support these findings.
37
37. Classic LMA cuff recommended maximum pressure
A) 30
B) 40
C) 50
D) 60
Ans: D)
60 cmH2O for both classic LMA as well as a Supreme
38
38. Narrow complex tachycardia ECG in young person post op PACU SBP 90 what treatment
A) Modified valsalva
B) Adenosine
C) DCCV
Ans: A) Modified Valsalva
Management of narrow complex tachycardia (SVT)
Stable SVT (good BP, no chest pain, no pulmonary oedema, no altered GCS):
Step 1: Vagal manoeuvres (best = modified Valsalva).
Step 2: IV adenosine.
Step 3: DCCV if refractory.
Unstable SVT (hypotension, chest pain, acute heart failure, altered GCS, shock):
Immediate synchronised DC cardioversion.
Pt right on cusp of "unstable, which is SBP < 90mmHg.
Given fit/well, likely can err on side of caution and go down the "stable pathway"
Valsava --> Adenosine 6mg, 12mg, 12mg.
39
39. Prilocaine Bier's block, which condition it shouldn't be used in
A) G6PD
B) Porphyria
Ans: A) G6PD deficiency - risk of methaemoglobinemia
Porphyria: Not specifically contraindicated; lidocaine and prilocaine are considered safe local anaesthetics in porphyria.
Absolute contraindications
Allergy to local anaesthetic (amide or ester, depending on drug used).
Severe peripheral vascular disease (risk of ischaemia and poor drug washout).
Sickle cell disease or trait (risk of sickling in ischaemic limb under tourniquet).
Infection at the site (risk of spreading infection into circulation).
Severe trauma or crush injury to the limb (compartment syndrome risk, poor distribution of LA).
Inability to use a tourniquet (e.g. burns, severe scarring, limb malformation).
Relative contraindications
G6PD deficiency → if using prilocaine (risk of methaemoglobinaemia).
Children → higher risk of tourniquet pain, cooperation issues, and LA toxicity.
Raynaud’s disease or severe vascular spasm syndromes → risk of ischaemia.
Extremes of age or frailty → poor tolerance of tourniquet pain.
Patients with poor cardiovascular reserve → in case of LA toxicity on tourniquet release.
40
40. Anaphylactic to MMR vaccine. What is contraindicated?
A. Gelofusine
B. Sulphonamides
Ans: A
Gelofusine and gelatin is associated with anaphylaxis to MMR
41
65yo M presented with confusion and hypoxia. CXR left chest whiteout and tracheal deviation
A) Left pleural effusion
B) Left pneumonia
C) Unilateral pulmonary oedema
D) Pneumonectomy
Left pleural effusion or pneumonectomy
Whiteout left lung.
Tracheal deviation present (but we need direction):
If deviation towards white side → collapse or pneumonectomy.
If deviation away from white side → pleural effusion.
The stem didn’t explicitly say which way, but in exams:
“Pleural effusion” is the classic cause of whiteout + deviation away.
“Pneumonectomy” would usually be hinted (scar, history of surgery).
Pneumonia/oedema → whiteout but typically no major tracheal deviation.
42
42. Post heart transplant recipient, expected sensitivity to:
A) Adenosine
B) Ephedrine - less effect
C) Atropine
D) Glycopyrrolate
Adenosine - use 1.5 mg or 3 mg
A) Adenosine ✅ Sensitivity is increased.
Because of denervation, there’s no vagal buffering. Adenosine has a more profound and prolonged AV nodal block in transplant patients.
Can cause prolonged asystole → must be given cautiously.
B) Ephedrine – less effect ✅ true statement but not the best answer here.
Reduced effect because the transplanted heart has no sympathetic nerve terminals.
C) Atropine ❌ No effect on HR (denervated heart).
D) Glycopyrrolate ❌ Same as atropine — little or no chronotropic effect.
43
43. What nerve does not innervate the breast/for breast surgery?
A) Long thoracic
B) Anterior intercostal
C) Posterior intercostal
D) Supraclavicular
Ans: long thoracic
A) Long thoracic ✅ not a sensory supply to the breast.
B) Anterior intercostal ❌ yes, contributes to sensory innervation.
C) Posterior intercostal ❌ contributes too, via lateral cutaneous branches.
D) Supraclavicular ❌ supplies upper portion of breast skin.
44
44. Post prem baby, having surgery. The minimum time before considered for day surgery is.
A) Postmenstrual age 54 weeks
B) 60 weeks
Ans) A - 54 weeks postmenstrual
Ex-preterm infants are at risk of apnoea, bradycardia, desaturation after GA.
Risk is highest in the first weeks after birth, and decreases with increasing postmenstrual age (PMA).
PMA = gestational age at birth + chronological age.
ANZCA PG29 - Healthy ex-premature infants who have reached a PMA of 60 weeks can be sent home with
standard discharge criteria.
The risk of postoperative apnoea did not fall to 1% or less until the infants reach a PMA of 54 weeks. In the ex-premature infant born at 32 weeks, the risk of apnoea did not fall to 1% or less until the
infants reach 56 weeks24 PMA. Apnoea in otherwise well ex-premature infants has been reported as late as 54 weeks postmenstrual age.
ANZCA PG29A - Ex-preterm infants at risk of postoperative apnoea should not be considered for same day discharge unless they are medically fit and have reached a postmenstrual age of
54 weeks.
45
45. Fontan woman, pregnant, what drug to avoid in labour?
A) Ergometrine
B) N2O
Ans) Ergometrine or carboprost - both increase PVRs
If giving oxytocin - give it slowly
Ergometrine
Potent vasoconstrictor → ↑ SVR, ↑ PVR, ↑ afterload.
Can cause acute pulmonary hypertension → catastrophic in Fontan.
Contraindicated.
Nitrous oxide (N₂O)
Can ↑ PVR slightly, but generally tolerated.
Avoid if patient has severe pulmonary hypertension, but not specifically contraindicated in all Fontan patients.
Note:
Oxytocin infusion = safe uterotonic in Fontan/PH.
Ergometrine, carboprost (PGF2α) = avoid (↑ PVR/SVR).
Misoprostol = safer alternative.
46
46. Dental surgery to bottom molar (38) with weird chin sensation post op. Which nerve damaged?
A) Lingual
B ) Mental
C) Inferior alveolar
D) Infratrochlear
ANS: B or C - likely C (mental nerve is the nerve supply but inferior alveolar is most likely to be damaged)
Inferior alveolar nerve (IAN) (branch of mandibular division, CN V3):
Runs in the mandibular canal.
Gives sensation to mandibular teeth.
Emerges at the mental foramen as the mental nerve → sensation to lower lip, chin, and gingiva.
Lingual nerve (also branch of V3):
Runs near the lingual plate of molar roots.
Provides sensation to anterior 2/3 tongue, lingual gingiva, floor of mouth.
Injury → tongue numbness, not chin.
Infratrochlear nerve:
Branch of nasociliary nerve (ophthalmic V1).
Supplies medial canthus of eye, nasal bridge → irrelevant here.
47
47. Child with status epilepticus, weight 20kg which is NOT a recommended treatment?
A) Midaz IM 3mg
B) Intranasal 6mg
C) Intraosseous 3mg
D) Buccal 6mg
E) IV 1.5mg
Ans: E
IM is 0.2mg/kg
Nasal is 0.3mg/kg
Buccal 0.3-0.5 mg/kg
IV 0.15mg/kg
IO 0.15mg/kg
48
48. Highest rate of mortality is BMI in category of:
A) <18.5
B) 18.5-24.9
C) 25-29.9
D) 30-34.9
E) 35-39.9
ANS: A)
Mortality higher in <18.5
Above BMI 40 is almost the same as <18.5, then BMI 50-60 is higher than in 18.5 group.
49
49. Major burns patient, pharmacologic effects in relation to non-depolarising NMBDs
Dose expected higher because of up-regulation of acetylcholine receptors
50
50. Class 2 obesity has an ASA score of:
A) 1
B) 2
C) 3
D) 4
Class 1 30-35
Class 2 35-40
Class 3 40+
ASA II for class II (and class I)
ASA III for class III
51
53. Obese patient, giving a dose of propofol for INDUCTION, what weight do you use?
A) LBW
B) IBW
C) ABW
D) TBW
LBW
- NMBD - lean (non-depol)
- Sux - total body weight
- Prop induction - lean
- Prop infusion - adjusted body weight
- Reversal - adjusted body weight
- Local anaesthetic - lean body weight
- All Abx TBW except gentamicin which is LBW
(SOBA)
52
54. Myasthenia gravis patients and NMBD:
A) Sensitive to non-depolarizing, resistant to depolarising…
B) Variants of above
Sensitive to non-depol (use a 1/10 - 1/5 dose)
Resistant to suxamethonium (2.5 times dose)
53
55. Magnesium 20mmol given intraop is NOT associated with
A) Reduced pain scores in PACU
B) Reduced PONV
C) Reduced MAC requirements
D) Prolonged neuromuscular blockade
E) Respiratory depression postop
Ans: B - ANZCA position statement no association with reduced PONV. No mention of respiratory depression.
Low-quality evidence related top periop Mg shows:
Statistically significant but small reduction in postop opioid requirements. No reduction in post op pain scores or PONV. (PS41)
APMSE 2020: IV magnesium as an adjunct to morphine analgesia has an opioid sparing effect and improves pain scores.
----
Magnesium’s proven effects:
Reduces postoperative pain scores.
Lowers opioid consumption → less PONV.
Reduces volatile anaesthetic requirements (MAC-sparing).
Potentiates non-depolarising muscle relaxants → can prolong NMB.
Respiratory depression:
Not listed as a recognised effect in ANZCA PS41 (2023 update).
Only occurs at toxic serum concentrations (e.g. > 4–5 mmol/L)
At clinical doses, magnesium actually reduces the risk of opioid-related respiratory depression by sparing opioids.
54
56. Severe hypokalaemia and cardiac arrest, ANZCOR recommends:
- 5mmol bolus IV
- 5mmol bolus IV over 5 mins
- 5mmol bolus IV over 10 mins
- 10mmol bolus IV over 5 mins
10mmol bolus IV over 10 mins
5mmol bolus IV
55
57. Child and laparotomy, 23kg, what fluid will you give for maintenance?
A) 45ml/hr 0.45% saline + 5% dextrose
B) 65ml/hr 0.45% saline + 5% dextrose
C) 65ml/hr 0.9% saline + 5% dextrose
D) 45ml/hr 0.9% saline + 2.5% dextrose
E) 45ml/hr 0.9% saline + 5% dextrose
Ans E) 45ml/hr 0.9% N/S + 5% dextrose
(2/3 maintenance for any patient that is sick)
Maintenance fluid = 4,2,1 rule (4mL/kg/hr for 1st 10kg, 2mL/kg/hr for 2nd 10kg, then 1mL/kg/hr after that; max 100mL/hr) = 65ml/hr
- in all unwell children (acute CNS/pulmonary conditions, post op & trauma) - 2/3 maintenaince rate due to ^ADH secretion (risk fluid overload/hyponatraemia)
https://www.rch.org.au/clinicalguide/guideline_index/intravenous_fluids/
56
58. Child with uncorrected TOF, having a tet spell. Management includes all except:
A) Prostaglandin
B) Sedation
C) Fluid bolus
D) Vasopressor
E) Beta blocker
ANS: A)
TOF:
- VSD
- Overriding aorta
- Pulmonary artery stenosis/atresia
- RV hypertrophy
Pathophysiology of a Tet spell
Triggered by ↓SVR or ↑PVR → worsens right-to-left shunting across VSD.
Child becomes cyanotic, hypoxic, tachypnoeic, irritable → spirals into acidosis, more PVR rise → vicious cycle.
Standard acute management
Positioning: Knee–chest → ↑SVR, ↓R→L shunt.
Sedation: Morphine or ketamine → decreases agitation and catecholamine-driven PVR rise.
Oxygen: Pulmonary vasodilator, reduces PVR.
Fluid bolus: Augments preload → improves RV output.
Vasopressors: Phenylephrine (pure α-agonist) → ↑SVR, reduces R→L shunt.
Beta-blocker (propranolol, esmolol) → relaxes infundibular spasm.
What about Prostaglandin E1?
Indication: To maintain ductus arteriosus patency in duct-dependent congenital heart disease.
57
59. Someone is on moclobemide, what drug is most likely to cause serotonin syndrome?
A) Pethidine
B) Tapentadol
C) Methadone
D) suxamethonium
E) Fentanyl
Pethidine --> precipitates serotonergic crisis.
A) Pethidine ✅ Classically notorious interaction with MAOIs → can cause severe serotonin syndrome.
B) Tapentadol → yes, risk, but less “classic” than pethidine.
C) Methadone → possible, but less commonly tested.
D) Suxamethonium ❌ no serotonergic effect.
E) Fentanyl ❌ possible case reports, but far lower risk.
58
52. Young man collapsed, ECG depicting brugada, what is the recommendation:
A) ICD
B) Flecainide
ANS A) ICD
Genetic sodium channelopathy (SCN5A mutation most common).
ECG: coved ST elevation in V1–V3 ± RBBB pattern.
Risk: sudden cardiac death from VF/VT, often in young men.
Precipitated by fever, sodium channel blockers, alcohol.
ICD = only proven therapy for prevention of sudden cardiac death in symptomatic patients (syncope, documented VT/VF, aborted cardiac arrest).
Flecainide is contraindicated — it’s a sodium channel blocker, can unmask or worsen.
59
60. Parkinsons patient on apomorphine infusion, what drug to given for nausea?
A) Cyclizine
B) Ondansetron
C) Droperidol
D) Metoclopramide
E) Prochlorperazine
ANS A) Cyclizine
Metoclopramide, prochlorperazine, droperidol ❌
All are dopamine antagonists → worsen Parkinsonian symptoms.
Contraindicated.
Ondansetron. Safe in Parkinson’s. Sometimes used, but can cause QT prolongation with apomorphine — caution.
Cyclizine (H₁ antagonist, anticholinergic) Frequently recommended alongside apomorphine to manage nausea. Safe, doesn’t worsen Parkinsonism.
60
61. Deep brain/vagal stimulator for refractory epilepsy, what can cause autostimulation?
A) Hypertension
B) Tachycardia
C) Bradycardia
D) Hypotension
E Hypothermia
F) Hyperthermia
ANS B) Tachycardia
Many epileptic seizures are preceded by tachycardia (ictal tachycardia).
Some modern VNS devices (with closed-loop technology) detect sudden HR rises as a proxy for seizure onset.
This can then trigger extra stimulation in an attempt to abort the seizure.
61
62. The most consistent risk factor for postoperative vomiting in children is
A) Age 3 years or older
B) Pre-pubertal Female
C) Intraop opioids
D) Nitrous oxide
E) Strabismus surgery
E) Strabismus (or age >3)
- If consistent = E, if most common/frequency related then A.
Uptodate:
- Preop:
○ Age >/= 3
○ History of PONV/POV
○ Hx motion sickness
○ FHx PONV/POV
○ Post puberty females
- Intraop:
○ Surgery:
§ Strabismus, adenotonsillectomy, otoplasty, surgery >30 min
○ Volatile anaesthetics
- Postop:
Long acting opioids
N2O depends on duration (ENIGMA 2): NNH 9 if >2hr procedure, 128 if <1hr procedure
62
63. Which muscle does not elevate the larynx?
A) Sternohyoid
B) Glenohyroid
C) Thyrohyoid
D) Myelohyoid
Sternothyroid --> depresses the larynx
Sternohyoid, omohyoid --> indirect depressor
Thyrohyoid --> elevates the larynx
Myelohyoid, stylehyoid, geniohyoid --> indirect elevators of the larynx
Suprahyoid muscles (elevate hyoid & larynx):
Mylohyoid
Geniohyoid
Stylohyoid
Digastric
Infrahyoid muscles (“strap muscles”, mostly depress larynx):
Sternohyoid → depresses hyoid
Omohyoid → depresses hyoid
Sternothyroid → depresses thyroid cartilage
Thyrohyoid → brings thyroid cartilage towards hyoid (effectively elevates larynx relative to hyoid)
63
64. What is not a good indicator for neonate being ready for extubation?
A) Grimace
B) RR>16
C) conjugate gaze
D) TV >5ml/kg
E) Eye opening
Ans B) RR>16
Criteria for awake extubation:
- Conjugate gaze
- Facial grimace
- Eye opening
- Purposeful movement
- TV>5ml/kg
Deep extubation:
- No cough /confirm deep anaesthesia (cuff deflation)
- Adequate TV
Normal ventilatory pattern
64
65. What nerve is not related to the trigeminal?
A) Auriculotemporal
B) Supratrochlear
C) Infratrochlear
D) Greater auricular
E) Lingual
Infraorbital
Ans D) Greater auricular
Branches & relations of the trigeminal nerve (CN V)
Ophthalmic division (V1):
Supratrochlear
Infratrochlear
Maxillary division (V2):
Infraorbital
Mandibular division (V3):
Auriculotemporal
Lingual
65
66. Right homonomous hemianopia and right hemisensory loss - affected region
A) Left posterior cerebral
B) Left anterior cerebral
C) Superior cerebellar
D) Left anterior inferior cerebellar
Symptoms of posterior cerebral artery stroke include contralateral homonymous hemianopia (due to occipital infarction), hemisensory loss (due to thalamic infarction) and hemi-body pain (usually burning in nature and due to thalamic infarction) 3. If bilateral, often there is reduced visual-motor coordination 3. It is generally considered that sensory loss and hemianopia unilaterally without paralysis, is diagnostic of PCA territory stroke 4.
66
67. What is not a features of TURP syndrome?
- Hyperglycinaemia
- Hyponatraemia
- Hypervolaemia
- Hypokalaemia
- Hypo-osmolar
Alternate options:
- Hyperglycinaemia
- Hyponatraemia
- Hypervolaemia
- Hypoglycaemia
Ans: Hypokalaemia, hypogylcaemia
Worrying signs = Hyponatraemia (<120mmol), Hyperkalaemia (>6mmol), hypo-osmolarity, high glycine.
- hyponatraemia (dilutional effect of a large volume of absorbed irrigation fluid, but later due to natriuresis)
- iso-osmolar (or mildly hypo-osmolar)
- increased osmolar gap from absorbed glycine
- hyperglycinaemia (up to 20 mM; normal is 0.15-0.3mmol/L)
- hyperserinaemia (major metabolite of glycine)
- hyperammonaemia (due to deamination of glycine and serine)
- hyperoxaluria and hypocalcaemia (glycine is metabolised to glycoxylic acid and oxalic acid, the latter forms calclium oxalate crystals in the urinary tracts and may contribute to renal failure)
- metabolic acidosis
- haemodilution and haemolysis
67
68. Equation for pulse pressure variation
A) 100x PPmax-PPmin / PPmean
B) 100 x PPmax-PPmin/ PPmin
C) Other
B) 100 x (ppmax-Ppmin)/Ppmean
PPV >13% (on controlled ventilation, sinus rhythm) --> suggests patient is fluid responsive.
Not valid if arrythmia, spontaneous breathing, low tidal volume (<8ml/kg), open chest
68
69. Oxygen pulse in CPET is surrogate for
A) Stroke volume
B) Anaerobic threshold
A) SV
Oxygen pulse = VO2/HR
- Amount of oxygen consumed per heart beat.
VO2 = HR x SV x (CaO2 - CVO2)
VO2/HR = SV x (CaO2 - CVO2)
So oxygen pulse reflects SV and arteriovenous O2 difference.
CaO2-CVO2 often not change much, therefore ~SV.
69
70. What increases DLCO?
A) Pulmonary haemorrhage
B) Pulmonary hypertension
C) COPD
A) Pulmonary haemorrhage
Pulmonary haemorrhage -> extra Hb in alveolar space -> CO uptake artifically increases DLCO
Pulm HTN -> decrease capillary blood volume -> decrease DLCO
COPD esp emphysema -> destruction of alveolar walls -> decrease SA -> decrease DLCO (asthma can incrase DLCO due to increase pulm blood volume)
70
71. What is an acceptable reason to defer #NOF?
A) K+ 2.7
B) HR 110, atrial fibrillation
C) Hb 86
D) Na 126
E) Clopidogrel taken within 3 days
K 2.7
Reasons to defer
* Haemoglobin < 80 g.l−1
* Plasma sodium concentration < 120 or > 150 mmol.l−1 and potassium concentration < 2.8 or > 6.0 mmol−1
* Uncontrolled diabetes
* Uncontrolled or acute onset left ventricular failure.
* Correctable cardiac arrhythmia with a ventricular rate > 120.min−1
* Chest infection with sepsis
Reversible coagulopathy
71
72. Image of ROTEM, EXTEM "in this bleeding patient" what to give (shows hyperfibrinolysis)
A) Plt
B) Fibrinogen
C) TXA
Wine glass shape --> hyperfibrinolysis, give TXA
72
73. V5 lead position for an ECG?
A) Mid clavicular line 5th IC space
B) Mid clavicular line 4th IC space
C) Anterior axillary line 5th IC space
D) Anterior axillary line 4th IC space
Anterior axillary line 5th IC space
Chest lead (precordial) positions
V1: 4th intercostal space (ICS), right sternal edge
V2: 4th ICS, left sternal edge
V3: midway between V2 and V4
V4: 5th ICS, mid-clavicular lineV5: same horizontal level as V4 (5th ICS), anterior axillary line
V6: same horizontal level as V4, mid-axillary line
73
74. What is the most sensitive predictor of 30 day mortality and MACE?
A) DASI score 55
B) AT<11
C) proBNP >300
D) 6MWT< 400
E) VO2 <11
C) ProBNP
VISION study (Devereaux et al., JAMA 2012; Anesthesiology 2017) → Pre-op BNP/NT-proBNP is the most sensitive and consistent predictor of 30-day death and non-fatal MI after major non-cardiac surgery.
CPET variables (AT, VO₂) are useful for peri-op planning but not as sensitive as BNP for hard endpoints like MACE.
METs trial:
- Subjective assesssment of functional capacity if poor predictor
- DASI improved prediction
- ProBNP independently predicted both 30-day and 1-year mortality or MI
74
75. VO2 max and DASI questionnaire relationship. Score of 40 on DASI equals what VO2?
A) 20L/min or ml/kg/min
B) 30
C) 40
D) 50
Other: DASI 48 = 48 VO2 max?
B) 30
Predicted VO2 max = 0.43 x DASI +9.8 i.e. 0.4 x DASI +10
DASI 34 = 7 METS
DASI 10 = ~4 METS
To simplify it you can make it 40/2 + 10 = 30
If divide that by 3.5 you get METS -> 8.5 METS
75
76. Drug that will not raise pulmonary vascular resistance at low doses?
A) Dopamine
B) Vasopressin
C) Noradrenaline
D) Milrinone
E) Dobutamine
OR Which is most likely to cause pulmonary hypertension?
A) Dopamine
B) Dobutamine
C) Vasopressin
D) Milrinone
E) Prostacycline
ANS: Likely D - milrinone (will not raise PVR).
Likely A - dopamine for most likely to cause
- Vasopressin also attenuates pulmonary hypertension
Uptodate:
Pulmonary vasoconstriction --> phenylephrine, adrenaline,
Milrinone and dobutamine inodilators. Milrinone also reduces PVR.
76
77. Sepsis guidelines, which measure is NOT recommended to assess fluid status?
A) Urine output
B) Passive leg raise response
C) PPV
D) Response to fluid bolus
E) Echocardiogram
Ans: A) Urine output
Urine output is an end-organ perfusion marker, not a reliable or dynamic measure of fluid responsiveness.
CVP is also a static marker.
For adults with sepsis or septic shock, we suggest using dynamic measures to guide fluid resuscitation, over physical examination or static parameters alone
Weak recommendation, very low-quality evidence
Remarks
Dynamic parameters include response to a passive leg raise or a fluid bolus, using stroke volume (SV), stroke volume variation (SVV), pulse pressure variation (PPV), or echocardiography, where available.
77
78. Newborn at 1 minute, sats 75%, grimacing, pulse 120, RR 40, what do you do?
- Observe
- CPAP
- Intubate
CPR
A) Observe
HR >100 → no chest compressions, no PPV required.
RR 40, HR normal, grimacing = breathing spontaneously and perfusing adequately.
SpO₂ appropriate for 1 min of life.
Management at this point: supportive observation (dry, warm, clear airway, monitor)
NRP target saturations (pre-ductal, right hand):
1 min: 60–65%
2 min: 65–70%
3 min: 70–75%
4 min: 75–80%
5 min: 80–85%
10 min: 85–95%
78
79. Patient has arrested day 10 post cardiac surgery, what do you NOT do:
A) Give adrenaline 1mg
B) Give amiodarone
C) 3 sequential shocks
D) Atropine 3mg
E) 1L fluid bolus
A) Give adrenaline
CALS protocol 10 days is the cutoff - borderline question
Avoid routine 1 mg adrenaline IV boluses.
Reason: in the postcardiotomy setting, the problem is often surgical/mechanical (tamponade, graft occlusion, massive bleeding) or refractory VF/VT.
Giving large-dose adrenaline can increase myocardial oxygen demand, worsen ischaemia, impair graft flow, and make defibrillation less effective. If vasoactive support is needed, use small doses of adrenaline (10–100 mcg), noradrenaline, vasopressin, or pacing, depending on the cause.
B) Amiodarone
For refractory VF/VT, amiodarone is recommended and safe
C) 3 sequential shocks
If VF/VT occurs within 10 days of surgery, up to 3 sequential shocks are recommended before chest compressions (to minimise sternal disruption and because re-entry arrhythmias often revert with shocks alone).
D) Atropine 3 mg
Used in severe bradycardia/asystole. Still appropriate in this context.
E) 1L fluid bolus
Hypovolaemia and tamponade are common reversible causes after cardiac surgery. Giving fluids empirically is reasonable and recommended early.
79
80. Diagnosis for TRALI not based on:
A) Hypoxaemia
B) Onset within 6 hours of transfusion
C) PCWP high (??or low based on which remembered answer)
D) Bilateral infiltrates on CXR
E) Raised BNP (may be an alternative answer)
ANS C) PCWP high or E) Raised BNP
CLINICAL FEATURES
* dyspnoea
* hypoxia
* fever
* hypotension or hypertension
DIAGNOSIS
* acute onset ALI(within 6 hours of a transfusion)
* hypoxia (PaO2/FiO2 <= 300mmHg regardless of PEEP or SpO2)
* bilateral pulmonary infiltrates
not cardiogenic in origin pr left atrial hypertension (PAWP < 18mmHg)
BNP and PCWP are not elevated in TRALI (they would be in TACO – transfusion-associated circulatory overload).
80
Diagnosis of HITS based on 4Ts score, which are:
A) Thrombocytopaenia
B) Timing of plt drop
C) History of thrombus
D) Other cause thrombocytopaenia
E) Plt serotonin release assay
MDCalc: --> diagnostic probability score 4 Ts
Thrombocytopaenia (A) – how much the platelets have dropped (e.g. >50% fall = 2 points).
Timing (B) – typically 5–10 days after heparin start, or <1 day if prior heparin in last 30 days.
Thrombosis (C) – new thrombosis, skin necrosis, anaphylactoid reaction = 2 points.
oTher cause (D) – if no alternative cause is likely, 2 points.
Plt serotonin release assay --> diagnostic of HIT
81
IABP trace, green arrow pointing to unassisted diastolic pressure
82
To confirm ETT, need ETCO2 more than how much from baseline?
A) 7.5mmhg
B) Other number
As per Chrimes paper
7.5mmHg
83
Third heart sound due to:
A) health person less than 40y
B) HTN
C) Mitral prolapse
Ans: A) Healthy persion <40 yo
Talley and O'Connor:
- 3rd heart sound sounds like "Kentucky'
- Diastolic sound heard best with the bell
- Normal to hear in states of states of increased cardiac output
○ Pregnancy, thyrotoxicosis, some children
The third heart sound (S₃) is a low-pitched, early diastolic sound just after S₂, produced by rapid passive ventricular filling.
It occurs when the ventricle is compliant and fills quickly – which is normal in children, young adults, and pregnant women.
After age 40, it’s usually pathological, indicating volume overload (heart failure, MR, AR, high-output states).
Why the others are wrong:
B) Hypertension
Chronic HTN leads to a stiff, non-compliant ventricle (LVH).
This produces an S₄ (atrial kick against stiff ventricle), not S₃.
C) Mitral valve prolapse
Classic finding = mid-systolic click ± late systolic murmur.
Not associated with an S₃.
84
Patient presents for a trans-urethral resection of the prostate (TURP). He had a single drug-eluting coronary stent for angina pectoris inserted six months ago and is taking clopidogrel and aspirin. The most appropriate preoperative management of his medications is to
A) Cease clopidogrel for 5 days
B) Cease clopidogrel for 10 days
C) Continue both
D) Cease clopidogrel for 7 days and aspirin for 20 days
Ans A) Cease for 5-7 days - Flow chart from AHA 2024
Modern guidelines (ESC, AHA, ANZCA periop) recommend at least 6 months of dual antiplatelet therapy (DAPT) after elective DES insertion for stable ischaemic heart disease.
Beyond 6 months, if bleeding risk is high, clopidogrel can be stopped and aspirin continued.
Clopidogrel pharmacology
Platelet inhibition is irreversible; new platelets must be generated.
Half-life ≈ 8 hours, but clinically relevant effect lasts 7 days.
Standard pre-op guidance = cease 5–7 days before high-risk surgery.
85
Painless visual loss, with preserved pupilliary reflex
A) AION
B) PION
C) Vertebrobasilar (?stroke)
D) Corneal abrasion
E) Cerebral infarct
Ans E) Cerebral infarct.
AION → optic disc swelling, RAPD, loss of pupillary reflex.
PION → retrobulbar optic nerve infarct, also RAPD, no pupillary reflex preservation.
Vertebrobasilar stroke → may cause visual symptoms, but usually not isolated painless monocular visual loss with preserved reflex.
Corneal abrasion → painful, tearing, photophobia, not painless.
Won't be preserved reflex in AION or PION
86
Woman complaining of persistent shortness of breath 3 days post prolonged knee operation. v/q scan showing patchy, non segmental areas of equal non ventilation and perfusion. Cause
A) PE
B) Pulm infarct
C) COPD
D) Atelectasis
ANS: D) Atelectasis
PE: classically shows mismatched, segmental perfusion defects → ↓perfusion but preserved ventilation.
Pulmonary infarct: essentially a complication of PE → also produces wedge-shaped, mismatched perfusion defect.
COPD: can produce matched defects, but tends to be diffuse/chronic and usually described as “heterogeneous ventilation with matched perfusion defects,” not an acute peri-op finding.
Atelectasis: collapse of alveoli → both ventilation and perfusion ↓ in the same regions due to hypoxic pulmonary vasoconstriction → gives matched defects (equal ↓ ventilation and ↓ perfusion).
87
What is the half life of a 100u/kg heparin dose?
A) 30mins
B) 1 hour
C) 2 hours
D) 3 hours
E) 4 hours
Ans: B) 1 hour
Cleared by both rapid, saturable reticuloendothelial system uptake and slower renal clearance.
Hence:
Low doses (25 U/kg) → half-life ≈ 30 min.
Moderate doses (100 U/kg) → half-life ≈ 60 min (1 hour).
Higher doses (400 U/kg) → half-life ≈ 150 min (2.5 hours).
Reference: BJA Education 2016;16(7):242–248; Goodman & Gilman’s Pharmacology.
88
What does not innervate the knee?
- Posterior cutaneous nerve of the thigh
- Obturator nerve
- Peroneal nerve
- Tibial nerve
Other options from other remembered document:
- Common peroneal
- Tibial
- Saphenous
- Obturator
Posterior cutaneous nerve of the thigh
Ans: A) posterior cutaenous nerve of the thigh
The knee has a rich articular nerve supply, following Hilton’s law (joints are innervated by branches of the nerves that supply the muscles moving them).
Femoral nerve → via branches from vastus medialis, lateralis, intermedius, rectus femoris.
Obturator nerve → posterior division contributes to posterior capsule.
Sciatic nerve branches:
Tibial nerve → posterior capsule and cruciates.
Common peroneal (fibular) nerve → lateral capsule and anterolateral joint.
Posterior cutaneous nerve of the thigh → purely sensory to skin of posterior thigh; does not supply the knee joint.
Obturator nerve → yes, contributes posterior articular branches.
Peroneal nerve → yes, supplies lateral knee capsule.
Tibial nerve → yes, supplies posterior and intra-articular structures.
89
What DOESN’T the sciatic nerve do?
A) Foot plantar flexion
B) Toe extension
C) Knee flexion
D) Knee extension
Ans D) knee extension
Origin: L4–S3.
Splits into:
Tibial nerve → posterior leg compartment (plantarflexion, toe flexion, inversion, intrinsic foot muscles).
Common peroneal (fibular) nerve → anterior/lateral leg (dorsiflexion, toe extension, eversion).
Also gives motor branches in thigh:
Hamstrings → knee flexion.
90
What nerve is not potentially damaged by insertion of supraglottic airway?
A) Facial
B) Trigeminal
C) Glossopharyngeal
D) Vagus
E) Lingual
Ans A) Facial nerve
Branches of the trigeminal, glossopharyngeal, vagus and the hypoglossal nerve may all be injured.
Order of most common:
- lingual
- RLN
- hypoglossal
- glossopharyngeal
- inferior alveolar
- infraorbital
Lingual nerve (branch of V3, trigeminal)
Most common → paraesthesia of anterior 2/3 tongue, taste disturbance.
Glossopharyngeal nerve (CN IX)
Can be compressed by cuff in oropharynx → loss of sensation posterior tongue, dysphagia.
Vagus nerve (CN X)
Branches affected:
Recurrent laryngeal nerve → hoarseness, vocal cord palsy.
Superior laryngeal nerve → impaired pitch control.
Hypoglossal nerve (CN XII)
Sometimes reported → tongue weakness.
91
Somatic innervation in the second stage of labour includes the following nerves EXCEPT
A) Genitofemoral nerve
B) Posterior cutaneous nerve of the thigh
C) Inferior gluteal nerve
D) Pudendal nerve
Ans C) inferior gluteal nerve - → motor to gluteus maximus. No perineal or genital sensory contribution.
First stage:
Pain from uterine contractions and cervical dilatation.
Visceral afferents travel with sympathetic nerves → T10–L1 (hypogastric plexus).
Second stage:
Pain from distension of vagina, pelvic floor, perineum.
Somatic innervation via pudendal nerve (S2–4) and contributions from perineal branches of posterior femoral cutaneous and ilioinguinal/genitofemoral nerves.
Nerves involved in second stage (somatic)
Pudendal nerve (S2–S4) → perineum, pelvic floor, vulva.
Posterior cutaneous nerve of thigh (S2–S3) → perineal branches contribute to posterior perineum.
Genitofemoral nerve (L1–L2) → genital branch supplies mons pubis and anterior labia.
92
Dental extraction 3rd molar, now numbness over lower chin, which nerve has been damaged?
A) Inferior alveolar
B) Mental
C) Infraorbital
Ans: A) inferior alveolar nerve
The inferior alveolar nerve is a branch of V3, located close to 3rd molar nerve). The mental nerve is terminal branch but would not be injured directly.
Depends on wording of question. The nerve that supplies region affected is mental. but most likely to be damaged in inferior alveolar.
If lower incisors -> mental nerve
93
Cryoprecipitate does NOT contain
A) Factor IX
B) Factor XIII
C) Fibronectin
D) Von Willebrand Factor
Ans A) Factor IX
Contents of Cryoprecipitate
Fibrinogen (high concentration)
Factor VIII
Factor XIII
Von Willebrand Factor (vWF)
Fibronectin
94
Tibial fracture, Posterior tibial nerve injury, which compartment
- Superficial posterior
- Deep posterior
- Anterior
Other remembered: what compartment? Pain, toe flexion, plantar sensory loss.
- Deep posterior
- Superficial posterior
- Anteral
- Lateral
Medial
Ans: Deep posterior
Anterior: deep peroneal nerve, anterior tibial artery, tibialis anterior, EHL, EDL.
Lateral: superficial peroneal nerve, fibularis longus & brevis.
Superficial posterior: gastrocnemius, soleus, plantaris; innervated by branches of tibial nerve, but the nerve itself runs deeper.
Deep posterior: tibial nerve proper, tibialis posterior, FDL, FHL.
95
Hyalase increases the following:
A) Speed of muscle akinesis
B) Chemosis
C) Rate of allergic reactions
Ans A) Speed of muscle akinesis
Mechanism
Hyaluronidase hydrolyses hyaluronic acid in connective tissue → increases tissue permeability and spread of local anaesthetic.
Clinical effects
Faster onset of akinesia and anaesthesia (because the LA spreads more readily).
Reduced chemosis & orbital pressure (better LA distribution, less fluid pooling).
Possible increased risk of allergic reaction, particularly if bovine-derived hyaluronidase is used.
96
Use of methylene blue rather than patent blue
A) Reduced rate of anaphylaxis
B) More expensive
C) Easier to see sentinel nodes
D) Reduced O2 saturations
Ans A) reduced rate of anaphylaxis
Fourth most common cause of anaphylaxis in NAP6
The use of methylene blue in the UK has largely been superseded by Patent Blue because of concerns about the adequacy of lymphatic uptake and fat necrosis at the injection site.
- Methylene blue is less expensive
- Methylene blue has a lower rate of anaphylaxis
Easier to see sentinel nodes with patent blue
Patent blue V
Widely used for sentinel lymph node biopsy.
Significant risk of anaphylaxis (up to 2%).
Can also cause skin tattooing.
Methylene blue
Much lower rate of anaphylaxis compared with patent blue.
Readily available, cheap.
Does not reduce SpO₂
Some reports suggest less vivid staining of sentinel nodes compared with patent blue, but still acceptable.
97
Best method to reduce post ERCP pancreatitis?
A. Rectal indomethacin
B. Gentamicin
C. Creon post op
D. Preop smoking cessation
Ans A) rectal NSAID (indomethacin or diclofenac)
Strongest proven intervention
Rectal NSAIDs (indomethacin or diclofenac, 100 mg)
Given immediately before or after ERCP.
Substantial reduction in incidence and severity of PEP.
Now standard of care in high-risk and even average-risk patients.
Other adjuncts (secondary measures)
Prophylactic pancreatic duct stent:
Effective in high-risk cases (difficult cannulation, sphincter of Oddi dysfunction).
More technically demanding, not universal.
Aggressive periprocedural IV hydration with Ringer’s lactate:
Some evidence of reduced PEP.
Avoiding high-risk techniques (e.g. pancreatic duct injection, excessive cannulation attempts).
Not effective / not recommended
Routine use of nitroglycerin, somatostatin analogues, or corticosteroids.
Antibiotics do not reduce PEP risk.
98
Epipen dose compared to normal 1:1000 IM adrenaline dose in adult anaphylaxis?
A. Higher dose
B. Same dose lower volume
C. Same dose and normal volume
D. Same dose higher volume
E. Lower dose same concentration
Ans: E) lower dose same concn
IM adrenaline 0.5mg IM (1:1000) in 0.5ml
Epipen 300mcg in 0.3mL (1:1000, 1mg/ml)
Anapen 500mcg in 0.3mL
99
How to clean laryngoscope handle?
A. Soap and water
B. sterilisation
C. Disinfection
D. clean and sterilise
E. clean and disinfect
PG28 Infection control
- Handle clean with soap and water (non-critical)
Critical - penetrates mucosa (blade)
Semi-critical - contact with intact mucous membranes
Laryngoscope blade → contacts mucous membranes → classified as a semi-critical device → must be cleaned AND sterilised (or high-level disinfected).
Laryngoscope handle → usually only contacts the provider’s hands (not mucous membranes). Classified as a non-critical device → requires cleaning and low/intermediate-level disinfection.
100
What additive prolongs block best?
A. Clonidine
B. Dexamethasone
C. Bicarbonate
D. Adrenaline
ANS: B. Dexamethasone
Clonidine (α2-agonist):
Prolongs sensory and motor block.
Side effects: hypotension, sedation, bradycardia.
Less effective than dexamethasone.
Dexamethasone (corticosteroid):
Strongest and most consistent evidence for prolonging peripheral nerve blocks.
Extends block duration by several hours (especially perineural use; IV also effective but slightly less so).
Mechanism: unclear; thought to reduce local perineural inflammation, alter nociceptive fibre activity.
Bicarbonate:
Alkalinises solution, speeds onset (not duration).
Adrenaline:
Vasoconstriction → reduces systemic absorption → modest prolongation.
Effect less than dexamethasone.
Also provides intravascular marker for test dose.
101
What is not acceptable for ARDS? /What is not a suggested management of ARDS?
A. Recruitment manoeuvres
B. Proning
C. High PEEP
D. Neuromuscular blockade
E. Negative fluid balance
ANS: A. recruitment manoeuvres
Proning
* Strong evidence (PROSEVA trial, NEJM 2013).
* Mortality benefit when used early and for ≥16 h/day. ✅ Acceptable.
High PEEP strategies
Used to improve oxygenation, especially in moderate–severe ARDS.
Supported by ARDSNet protocols. ✅ Acceptable.
Neuromuscular blockade
Short course (≤48 h, cisatracurium) in severe ARDS can improve oxygenation and ventilator synchrony.
ACURASYS trial suggested mortality benefit; ROSE trial less convincing, but still acceptable practice. ✅ Acceptable.
Negative fluid balance
Conservative fluid management after initial resuscitation improves oxygenation and ventilator-free days (FACTT trial).
Not harmful, widely recommended. ✅ Acceptable.
Recruitment manoeuvres
Once promoted, but recent large RCT (ART trial, NEJM 2017) showed ↑ mortality and barotrauma with aggressive recruitment manoeuvres.
Now not recommended as routine therapy in ARDS. ❌ Not acceptable.
102
The recommended skin preparation for a neuraxial:
A. 0.5% chlorhex/ 70% alcohol.
B. 2% cholhex/ alcohol
c. 70% alcohol
D. Iodine
E. Chlorhexidine gluconate
ANS: 0.5% chlorhex/ 70% alcohol.
A. 0.5% chlorhex / 70% alcohol — accepted option
B. 2% chlorhex / alcohol — higher concentration; some concern about neurotoxicity with 2% for neuraxial use.
C. 70% alcohol — less effective than chlorhexidine + alcohol combination.
D. Iodine — OK alternative if chlorhexidine is contraindicated, but not the preferred in many guidelines.
E. Chlorhexidine gluconate (without specifying concentration or alcohol) — incomplete; concentration/alcohol component matters.
103
Expected blood volume in pregnant lady
A. 60 ml/kg
B. 70 ml/kg
C. 80 ml/kg
D. 90 ml/kg
E. 100 ml/kg
ANS: 100ml/kg
Total blood volume increase: about 30–50% above baseline.
Plasma volume: increases by ~40–50%.
Red cell mass: increases by ~20–30% (greater if iron supplementation is adequate).
Leads to physiological anaemia of pregnancy (haemodilution).
104
What is the 4th pacemaker letter meaning
A. chamber sensed
B. Chamber paced
C. Rate modulation
D. Multi chamber pacing
ANS: Rate modulation
Breakdown of the positions:
1st letter – Chamber paced (A = atrium, V = ventricle, D = dual).
2nd letter – Chamber sensed.
3rd letter – Response to sensing (I = inhibited, T = triggered, D = dual).
4th letter – Rate modulation (R = rate responsive).
5th letter – Multisite pacing (e.g. CRT devices).
105
Time for reversal of therapeutic dabigatran after administration of Idarucizumab 5 g is
A. 5mins
B. 15mins
C. 30mins
ANS: 5 mins (maximum)
Dose: 5 g IV (given as two 2.5 g boluses no more than 15 min apart).
Onset: Immediate, with complete reversal of anticoagulant effect within minutes.
Clinical studies (RE-VERSE AD trial) showed normalisation of dilute thrombin time and ecarin clotting time within 5–15 minutes in almost all patient
106
The accompanying image is obtained while doing an ultrasound guided erector spinae plane block at the level of the transverse process of the fourth thoracic vertebra. The muscle marked by the arrow is the
- Trapezius
- Rhomboid
- Deltoid
Erector spinae
Rhomboid
"TRE"- trap, rhomboid, erector spinae
107
Max dose topicalisation airway in mg/kg
A. 7
B. 9
C. 11
Ans: 9mg/kg
Intravenous / infiltration / nerve block:
Without adrenaline: 3–5 mg/kg
With adrenaline: 7 mg/kg
Topical application (airway, mucosa):
Absorption is less predictable, but the accepted ceiling is 9 mg/kg (some texts quote up to 8–9 mg/kg as safe).
Beyond this, risk of systemic toxicity (seizures, arrhythmias) rises.
108
BD morphine, bowel obstruction, showing signs of withdrawal. What is this?
A. opioid dependence
B. Physical dependence
C. Tolerance
D. Opioid use disorder
Ans: Physical dependence
Opioid dependence (older term, often misused):
Historically used broadly, but in modern usage should be avoided unless you mean opioid use disorder.
Physical dependence:
A physiological state where abrupt cessation or an antagonist → withdrawal syndrome.
This can occur in anyone on chronic opioids, even if used appropriately (e.g. for cancer pain).
Tolerance:
Diminished effect over time → need higher doses for same analgesia.
Not the same as withdrawal.
Opioid use disorder (DSM-5):
A pathological pattern of opioid use leading to clinically significant impairment/distress (craving, compulsive use, loss of control, continued use despite harm).
Not the same as simple physical dependence.
109
NAP 5 - cardiac anaesthesia awareness
A.1/8000
B. 1/700
C. 1:19,000
D. 1:1600
1/8000 (answer)
GA LSCS = 1/670
Overall GA = 1/19,000
GA no muscle relaxant = 1/130,000
110
NAP7 - most common cause perioperative arrest
A. Major haemorrhage
B. Anaphylaxis
C. Airway issues
Ans: major haemorrhage (17%)
bradyarrhythmia 9%
cardiac ischaemia 7%
111
DDAVP not used for:
A. nocturnal enuresis
B. Haemophillia B
C. Von Wil disease 2A
D. Uraemic bleeding
E. Central diabetes insipidus
Ans: Haemophilia B
How DDAVP works
Synthetic analogue of vasopressin (V₂-selective).
Increases release of von Willebrand factor (vWF) and factor VIII from endothelial stores.
Also increases water reabsorption in renal collecting ducts.
Clinical uses
Central diabetes insipidus → ↓ urine output via V₂ action.Nocturnal enuresis → ↓ nocturnal urine production.
Mild haemophilia A (factor VIII deficiency) → raises factor VIII.
vWD type 1 and some type 2 (esp. 2A) → raises vWF.
Uraemic bleeding → improves platelet function.
Not useful in
Haemophilia B (factor IX deficiency) → DDAVP does not increase factor IX levels.
112
Noradrenaline has tissued into skin from peripheral cannula, most appropriate first step is:
A. remove cannula
B. Flush with saline
C. Heparin?
D. Hyalase?
E. Cold compress
F. Subcut phentolamine
Ans: subcut phentolamine
- Stop infusion
- Do not remove IV line
- Elevate limb if possible, do not apply pressure
- Do not flush the line
- Attempt aspiration of remaining drug from IV line with small syringe
- Do not use ice/cold compress (causes further vasoconstriction)
See below reference, phentolamine and hyaluronidase mentioned.
We are going with phentolamine as answer.
113
What is not associated with POTS (postural orthostatic tachycardia syndrome)?
A. COVID-19
B. Hypermobility disorder
C. Normal resting LV function
D. ECG changes
Ans: ECG changes
Definition: Sustained HR increase ≥30 bpm (≥40 bpm if <20 y/o) within 10 min of standing, without orthostatic hypotension.
Typical patient: Young women, often with overlapping syndromes.
Pathophysiology: Dysautonomia, hypovolaemia, hyperadrenergic states, small fibre neuropathy.
Associations
COVID-19 → clear association, especially post-acute COVID (“long COVID”) triggering dysautonomia.
Hypermobility disorders (Ehlers–Danlos, joint hypermobility syndrome) → strongly associated, due to abnormal connective tissue and vascular compliance.
Normal resting LV function → yes, cardiac structure is normal; POTS is not due to cardiomyopathy or systolic dysfunction.
114
Pregnancy highest risk
A. bicuspid valve with dilated aortic root
B. HOCM with hypertrophied septum
C. Severe MR
D. PDA
Ans: Biscuspid valve with dilated aortic root
Bicuspid valve with dilated aortic root
Major concern = risk of aortic dissection/rupture, especially if aortic root >4.5–5.0 cm.
Pregnancy increases blood volume and cardiac output, and hormonal changes weaken aortic wall connective tissue → highest risk scenario.
Classified as WHO risk class IV if significantly dilated — pregnancy contraindicated.
HOCM (hypertrophic obstructive cardiomyopathy)
Risk of arrhythmias, obstruction, maternal cardiac events.
Usually WHO class II–III; can often tolerate pregnancy with close monitoring.
Severe MR (mitral regurgitation)
Chronic MR often well tolerated in pregnancy because reduced SVR decreases regurgitant fraction.
WHO class II generally.
Patent ductus arteriosus (PDA)
If small and uncomplicated, usually well tolerated.
Risk increases only if pulmonary hypertension develops.
115
Aortic dissection, which is NOT a bad sign
A. RWMA
B. Right dilated ventricle
C. Dilated aortic root
D. AR
Ans: Right dilated ventricle
A) Regional wall motion abnormality (RWMA)
Bad sign → means coronary malperfusion, most often RCA, leading to infarction. Strongly linked with mortality.
B) Right ventricular dilatation
This is not a classic feature of aortic dissection.
RV dilatation suggests pulmonary embolism or pulmonary hypertension, but is not a recognised poor prognostic marker for dissection.
C) Dilated aortic root
Important risk factor for developing dissection (esp. bicuspid valve, Marfan, connective tissue disease).
Once dissection has happened, a dilated root predisposes to aortic regurgitation and rupture — so it is a bad prognostic sign.
D) Aortic regurgitation (AR)
Definitely a bad sign → causes acute LV failure, pulmonary oedema, cardiogenic shock.
NB: pericardial effusion most high risk - present of pericardial effusion in an ascending aorta dissectioon is an indicator of poor prognosis and suggests supture of the false lumen in the pericardium.
116
PFT in dude, detect nitric oxide >70ppm number ppm. Meaning
A. Smoker
B. COPD
C. Exacerbation of asthma
Ans: exacerbation of asthma
Fractional exhaled nitric oxide - helps to diagnose asthma
Measures amount of nitric oxide exhaled from a breath
Produced by cells involved in inflammatory process
* Marker of airway eosinophilic inflammation.
* High levels = eosinophilic asthma / Th2-driven inflammation.
Adults:
<25 ppb → low
25–50 ppb → intermediate
50 ppb → high (eosinophilic inflammation very likely)
Children:
<20 ppb low; >35 ppb high
Smoking inhibits NO -> decrease FeNO
COPD increase FeNO but not as much as asthma
117
118. Compared to a continuous infusion, PCEA does NOT reduce
A. Incidence instrumental delivery
B. Incidence of C-section rates
C. Clinical workload
D. Motor weakness
Ans: Incidence of C-section rates
Epidural does NOT affect c/s rate (with either type of epidural, compared to those without)
ANZCA blue book 2021 pg 195
PCEA vs continuous epidural infusion:
- Decreased motor blockade
- decreased total LA consumption
- decreased workload
- similar obstetric outcomes and analgesia
Assoc/ decrease in instrumental deliveries in nulliparous females with intermittent bolus with no difference in C-section rate
Lower concentration LA decreased rate of instrumental delivery (w/ less motor blockade & improved fetal outcomes) with similar levels of analgesia
Blue book article Harriet Wood
118
119. A 70-year-old man undergoes a stress echocardiogram as part of his preoperative preparation before a total hip replacement. If he has clinically significant coronary artery disease, the earliest indicator during his test is most likely to be
A. ECG changes
B. RWMA
C. diastolic dysfunction
D. Angina
E. Hypotension
Ans: C. diastolic dysfunction
- unless C isnt an option, then B
Metabolic alterations -> inducible changes of perfusion -> diastolic dysfunction -> RWMA-> ischaemic ECG changes -> angina
Diastolic dysfunction (impaired relaxation) → earliest change.
Regional wall motion abnormalities (RWMA) → detected by echo, precede ECG or symptoms.
ECG changes (ST depression/elevation, T-wave changes).
Angina (pain) → subjective, comes later.
Hypotension, haemodynamic instability → very late, ominous sign.
119
Return to practice
A. 2 weeks for every year of absence
B. 4 weeks for every year of absence
C. 6 weeks for every year of absence
D. 8 weeks for every year of absence
Ans: B - 4 weeks for every year of absence
"the total duration of a formal return to practice program will be determined by the learning needs analysis. The starting point for calculating the total duration is one month per year of absence from anaesthesia practice."
120
CPET Borg’s scale, what is it for?
A. VO2 max
B. oxygen consumption
C. Lactate threshold
D. Subjective effort
E. CO2 production
Ans: D - Rating of perceived exertion
12 on Borg scale corresponds to 60%
'Very hard' = 16 = 80% VO2 max
Scale is from 6-20
Borg’s Scale
A subjective rating of perceived exertion (RPE).
Scale typically runs 6–20, designed so that multiplying by 10 ≈ heart rate at that effort (e.g. 13 → HR ~130).
Patient points to the number that corresponds to how hard they feel they are working.
Used to correlate symptoms with physiological measurements (VO₂, VCO₂, workload).
Option analysis
A. VO₂ max → objectively measured via gas exchange, not by Borg.
B. Oxygen consumption → measured directly with spirometry during CPET, not Borg.
C. Lactate threshold → inferred from ventilatory equivalents / gas analysis, not Borg.
D. Subjective effort → ✅ exactly what Borg scale measures.
E. CO₂ production → measured objectively during CPET.
121
ANZCOR recommendations on minimum time from cardiac arrest to post arrest prognostication?
A. 12 hr
B. 24 hours
C. 48hr
D. 72 hrs
E. 96hrs
C. 72 hours
CT within 48 hours also mentioned by anzcor
122
Spinal, 3ml, patient supine and horizontal, hyperbaric qualities vs normal bupivacaine
A. Lesser block height, shorted duration of action
B. Lesser block height, longer DOA
C. Greater block height, shorter DOA
D. Greater block height, longer DOA
E. No difference in block height, longer DOA
Ans: C - Greater block height, shorter duration
Baricity recap
Isobaric solution = same density as CSF. Spread depends mainly on dose/volume and patient characteristics, not position.
Hyperbaric solution = heavier than CSF (e.g. bupivacaine + dextrose). Spread depends on gravity + patient position.
In this scenario
3 ml hyperbaric bupivacaine given with patient supine, horizontal (flat).
Compared to plain/isobaric bupivacaine:
Spread: Hyperbaric solution will sink in CSF; in supine, it gravitates to dependent thoracic kyphosis → produces a higher block height.
Duration: Addition of dextrose doesn’t shorten LA pharmacokinetics. If anything, block duration is similar or slightly shorter than isobaric (but not longer).
123
Epilepsy surgery, some sort brain monitoring and which drugs affect it the least
A. Remifentanil
B. Ketamine
C. Sevoflurane
Ans: A - Remifentanil
BZDs should not be given - suppress EEG.
Ketamine - non-specific activation
Sevo- non-specific dose-dependent activation
Opioids, metohexital increase IEAs (stimulate seizure), alfentanil often used to stimulate IEA
https://www.bjaed.org/article/S2058-5349(19)30123-4/fulltext
124
Giving indocyanine green
a) Increases NIRS, Decreased peripheral saturations
b) decrease NIRS, decrease peripheral
c) no change NIRS, decrease peripheral
d) increases NIRS AND periph
e) decrease NIRS, increases peripheral
Ans: Increases NIRS but decreased peripheral sats
ICG = a dye used for cardiac output, hepatic function, retinal angiography.
Peak absorption: ~805 nm.
NIRS (cerebral oximetry) and pulse oximetry (SpO₂) both use light in the near-infrared range (~660 and 940 nm).
Because of spectral overlap, ICG transiently affects readings:
NIRS: falsely ↑ readings (due to strong absorption, misinterpreted as higher HbO₂).
Pulse oximetry (SpO₂): falsely ↓ readings (SpO₂ under-reads after ICG injection).
125
Accuracy of pulse ox, which does NOT affect
A. Anaemia
B. AF
C. Carboxyhaemoglobin
D. Poor peripheral perfusion
Ans: Anaemia
MetHb - brings sats towards 85%
CarboxyHb - falsely high reading
Carboxyhaemoglobin → absorbs at 660 nm, read as oxyhaemoglobin → SpO₂ falsely high.
Anaemia → the absolute Hb doesn’t affect the ratio measurement, but severe anaemia (low signal, poor perfusion) can reduce accuracy in practice. Still, classic teaching: anaemia alone does not affect SpO₂ accuracy if perfusion is adequate.
Atrial fibrillation (AF) → irregular pulse can reduce plethysmograph quality, but oximeter still works (averaging may fluctuate, but not systematically inaccurate).
Poor peripheral perfusion (shock, hypothermia, vasoconstriction) → poor signal, unreliable reading
126
Best post-op analgesia after wisdom tooth removal
A. Ibuprofen
B. Celexocib
C. Tramadol
D. Paracetamol
Ans: Ibuprofen 400mg better than celecoxib 200mg, but celecoxib 400mg and ibuprofen 200mg is equivalent but celecoxib has a longer time to rescue.
However APMSE scientific evidence says similar efficacy between non-selective NSAIDs and celexocib
NSAIDs (ibuprofen, diclofenac) are the most effective single agents — they target prostaglandin-mediated inflammatory pain from surgical trauma in bone and gingiva.
Paracetamol is helpful but weaker on its own; best in combination with NSAIDs.
Tramadol (weak opioid + monoaminergic) is less effective than NSAIDs for this type of pain, with more side effects (nausea, sedation).
Celecoxib (selective COX-2 inhibitor) can be effective, but not superior to non-selective NSAIDs like ibuprofen in this context, and is not first-line.
127
What is NOT a feature of thyroid storm?
A. Jaundice
B. Bronchospasm
C. Seizures
Ans: Bronchospasm
Clinical features of thyroid storm
Cardiovascular: tachycardia, AF, high-output heart failure, shock.
CNS: agitation, delirium, psychosis, seizures, coma.
GI/hepatic: nausea, vomiting, diarrhoea, abdominal pain, jaundice (can occur due to hepatic dysfunction and congestive hepatopathy).
Other: hyperthermia, sweating, goitre, ophthalmopathy.
128
Expected physiological change in hyperthyroidism:
A. Decreased diastolic relaxation
B. reduced SVR
C. Decreased PVR
D. Increased diastolic BP
Ans: Reduced SVR
Key haemodynamic changes in hyperthyroidism
Cardiac output: ↑ (due to ↑ heart rate, ↑ contractility, ↑ blood volume).
Systemic vascular resistance (SVR): ↓ (thyroid hormones → peripheral vasodilation).
Pulse pressure: widened (↑ systolic BP, ↓ diastolic BP).
Diastolic relaxation: actually enhanced, not decreased — thyroid hormone accelerates myocardial relaxation (↑ SERCA activity, faster Ca²⁺ reuptake).
Pulmonary vascular resistance (PVR): generally unchanged.
Diastolic BP: tends to fall (so it does not increase).
129
Somatic pain in the second stage of labour is NOT transmitted via the
A Pudendal
B Ilioinguinal
C Genitofemoral (L1/2)
D Inferior gluteal
E Posterior cutaneous nerve of thigh
Ans: Inferior gluteal (L5-S2)
First stage → visceral pain from uterine contractions and cervical dilatation.
Transmitted via sympathetic afferents (T10–L1).
Second stage → somatic pain from stretching of vagina, pelvic floor, perineum.
Transmitted via:
Pudendal nerve (S2–S4) – main supply to perineum.
Posterior cutaneous nerve of thigh (S2–S3) – perineal branches to posterior perineum.
Ilioinguinal nerve (L1) – anterior perineum/labia.
Genitofemoral nerve (L1–L2) – mons pubis, labia majora.
130
Which drug NOT to give with cocaine toxicity?
A. phentolamine
B. Metoprolol
C. GTN
D. Propofol bolus
Ans: Metoprolol
Giving B blockade may lead to reduced myocardial contractility and HR in the setting of unopposed alpha effects (peripheral vasoconstriction etc.) --> failure
131
SGLT-2i use for diabetes, what do they NOT cause?
A. Glycosuria
B. Reduced eGFR
C. Euglycaemic ketosis
D.Hypoglycaemia
Ans: D - Hypoglycaemia
* Can cause hypoglycaemia if used in combination with insulin or sulfonylurea
* As monotherapy do not cause hypoglycaemia
However they definitely DON'T reduce eGFR as they are used to prevent progression of chronic kidney disease? RACGP - Sodium glucose cotransporter 2 inhibitors for chronic kidney disease
A. Glycosuria → Yes, mechanism of action.
B. Reduced eGFR → True. They cause an initial small dip in eGFR (afferent arteriole vasoconstriction) but long-term renoprotection.
C. Euglycaemic ketoacidosis → Recognised adverse effect (rare but important).
D. Hypoglycaemia → Not a direct effect, because they don’t stimulate insulin. Hypoglycaemia risk is low unless combined with insulin or sulfonylurea
132
Buprenorphine patch stopped, when will plasma levels drop by 50%
A. 12 hours
B. 24 hours
C. 48 hours
D.72 hours
Ans: A - 12hrs
Norspan product info
“After removal of a NORSPAN patch buprenorphine concentrations initially decline at a rate of approximately 50% in 12 hours. Thereafter, mean elimination half-lives have been reported to be between 30 and 45 hours.”
133
Autonomic dysreflexia is more likely seen in spinal lesions at the level of:
A. T5 incomplete injury
B. T5 complete injury
C. T10 incomplete injury
D. T10 complete injury
T5 complete injury
134
5 kPa is approximately equivalent to
A. 37 mmHg
B. 45 mmHg
Ans: A - 37 mmHg
Conversion factor
1 kPa = 7.50062 mmHg
135
Baby swallows battery, what to give:
A. mild
B. bicarb
C. sucralfate
D. chewing gum
E. activated charcoal
Ans: Sucralfate (or honey)
Key pathophysiology
Button battery lodged in the oesophagus can cause alkaline burns and liquefaction necrosis within 2 hours.
The mechanism: hydrolysis at the negative pole → generation of hydroxide ions → caustic injury.
Immediate management = urgent endoscopic removal if in oesophagus.
While waiting, some adjuncts can neutralise the alkali and reduce tissue damage.
Evidence-based adjuncts
Honey (in children >12 months) or sucralfate suspension:
Both can coat the mucosa and neutralise hydroxide ions.
Shown to reduce depth of oesophageal injury in animal studies and human case series.
Recommended by NASPGHAN/ESPGHAN guidelines (2019).
Activated charcoal: not useful (does not neutralise alkali, interferes with endoscopy).
Bicarbonate: wrong direction (would worsen alkali).
Chewing gum: no role.
Milk: previously used historically, but not effective/recommended.
136
Risk of AFE is highest in:
A. Caesarean
B. Induction of labour
C. Labour augmented by oxytocin infusion
Ans B - Induction of labour.
Age>35, multiple pregnancy, induction of labour all associated
UKOSS study (Knight et al., BJOG 2010;117:1417–25) — the largest population-based study of AFE risk factors:
Induction of labour: OR ~2.9 (significant risk factor).
Caesarean section: OR ~3.86 (even stronger risk factor).
Instrumental delivery: also increased risk.
Advanced maternal age, multiple pregnancy, placenta praevia/abruption: also associated.
Other registries (US, Australia, Japan):
Consistently show both induction and operative delivery increase risk.
But operative delivery (esp. caesarean) usually carries the highest odds ratio.
https://www.npeu.ox.ac.uk/research/projects/97-ukoss-afe
137
You have induced a patient (I forget this part) and ten minutes later- reduced air entry left side, sats 85%, hypotensive. Lung USS on the left side shows no sliding and a lung point sign.
A. Left needle decompression 2nd IC space
B. Left chest drain insertion
C. Left finger thoracostomy
D. Pull the ETT back 2cm
E. Get a CXR
Ans: C- left finger thoracostomy
A. Left needle decompression 2nd ICS → acceptable immediate management.
B. Left chest drain insertion → definitive, but too slow in peri-arrest unstable situation (you need immediate decompression first).
C. Left finger thoracostomy → best in an intubated/anaesthetised patient; faster and more reliable than needle.
D. Pull the ETT back 2 cm → not appropriate; USS showed lung point = pneumothorax, not endobronchial intubation.
E. Get a CXR → inappropriate; unstable patient, don’t delay.
138
Compared with open mechanical aortic valve repair, TAVI has:
A. Reduced mean gradient
B. Reduced vascular injury
C. Reduced arrhythmia
D. Reduced paravalvular leaks
Alternative options:
- Paravalvular leak
- Reintervention rates
- Vascular complications
- Heart block
- Transvalvular gradient
Ans: reduced mean gradient
TAVI disadvantages (higher risk than SAVR):
Paravalvular leak → more common in TAVI.
Reintervention rates → higher long-term in TAVI (valve durability less than mechanical or surgical bioprosthesis).
Vascular complications → more common in TAVI (large-bore femoral access).
Heart block / pacemaker requirement → more common in TAVI (valve compresses conduction tissue).
TAVI advantages (lower risk than SAVR):
New-onset atrial fibrillation → lower in TAVI.
Bleeding and transfusion requirement → lower in TAVI.
Transvalvular gradient → lower or similar with TAVI, because self-expanding prostheses often achieve larger effective orifice area.
Consider choosing reduced arrhytmias/AF if reduced mean gradient is not an option
https://www.ahajournals.org/doi/10.1161/CIRCINTERVENTIONS.115.003326?doi=10.1161/CIRCINTERVENTIONS.115.003326
139
The number of segments in the left lower lobe of the lung is:
A. 3
B. 4
C. 2
Ans: 4
Bronchopulmonary segments of the lungs
Right lung (10 segments total):
Upper lobe: apical, posterior, anterior (3)
Middle lobe: lateral, medial (2)
Lower lobe: superior, medial basal, anterior basal, lateral basal, posterior basal (5)
Left lung (8–10 segments, depending on source):
Upper lobe: apicoposterior, anterior, superior lingular, inferior lingular (4)
Lower lobe: superior, anteromedial basal, lateral basal, posterior basal (4)
(In some texts the anteromedial basal is split into anterior + medial basal = 5, but usually counted as 4.)
140
Current ANZCA recommendations for a child 7 months old fasting prior to surgery are:
A Clear fluids one hour, breast milk 3 hours
B Clear fluids two hours, breast milk 3 hours
C Clear fluids one hour, breast milk 4 hours
D. clear fluids two hours, breast milk 4 hours
Ans: Clear fluids 1 hour, breast milk 3 hours
From ANZCA’s Pre-anaesthesia consultation BP 2024 guidance:
For infants < 6 months, breast milk is permitted up to 3 hours pre-anaesthesia.
Clear fluids allowed until 1 hour prior to anaesthesia in paediatric patients (in many centres).
These are minimum fasting times — practice acknowledges risk balancing, reducing unnecessary prolonged fasting.
So summarised for a child ~7 months old (which is >6 months):
Clear fluids: up to 1 hour pre-op
Breast milk: likely same as infants, but some guidelines extend breast milk 3 hours pre-op for children under 6 months, but for those ≥6 months, breast milk rules may adjust. But in ANZCA / RCH guidelines, breast milk up to 3 hours appears consistent.
141
In relation to ECHO, TAPSE refers to:
A. Right ventricular contraction
B. Tricuspid valve something
Ans: A
TAPSE = Tricuspid Annular Plane Systolic Excursion
Measured on echo using M-mode at the lateral tricuspid annulus.
It tracks the longitudinal displacement of the tricuspid annulus towards the RV apex during systole.
Surrogate for RV longitudinal systolic function.
Used to estimate RV ejection fraction
TAPSE < 17 mm indicates RV systolic dysfunction (ASE guidelines).
Quick and reproducible, but only measures longitudinal contraction, not radial/overall RV performance.
142
143. EPO given perioperatively
A. decreased transfusion and increased thrombosis risk
B. decreased transfusion and decreased thrombosis risk
C. same transfusion, decreased thrombosis
D. decreased transfusion, similar thrombosis risk
Ans: A - decreased transfusion and increased thrombosis risk
Erythropoietin (EPO) perioperatively
Use: given preoperatively (often with iron) to increase red cell mass in patients at risk of transfusion (e.g. cardiac, orthopaedic, Jehovah’s Witness).
Effect on transfusion: multiple RCTs and meta-analyses show EPO reduces allogeneic blood transfusion requirements.
Effect on thrombosis risk:
Concern: EPO increases Hb and haematocrit → increased viscosity → possible ↑ thrombosis risk.
Meta-analyses show small but significant increased risk of thromboembolic events in surgical patients (esp. when Hb targets are high).
Example: Cochrane Review 2020, Erythropoiesis‐stimulating agents for preoperative anaemia — found decreased transfusion but increased risk of venous thrombosis.
143
Which statement is true regarding Dabigatran and clotting tests? :
A) Dabigatran has no effect on PT/INR.
B) Dabigatran primarily affects PT/INR, causing prolonged results.
C) aPTT is the best test to monitor Dabigatran.
D) Dabigatran prolongs aPTT and is best monitored with dilute thrombin time (dTT).
E) Dabigatran does not require laboratory monitoring.
Ans: D - Dabigtran prolongs aPTT and is best monitored with dilute thrombin time (dTT)
PT/INR:
Minimal effect. Not reliable for dabigatran monitoring.
So A is broadly true, but incomplete — PT/INR may be slightly prolonged, but not useful clinically.
APTT:
Prolonged in a dose-dependent but non-linear fashion.
A normal APTT → likely minimal dabigatran present, but not quantitative.
So C is incorrect — aPTT is not the best monitoring test.
Thrombin Time (TT):
Extremely sensitive — any dabigatran prolongs it.
Normal TT excludes clinically relevant drug effect.
Dilute thrombin time (dTT) = best quantitative test in practice.
Specialised tests: dTT (Hemoclot), or ecarin clotting time (ECT) are the true quantitative assays.
Routine monitoring: Dabigatran does not require routine lab monitoring, but tests are used in emergencies (bleeding, urgent surgery).
ANZCA part 2
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