Quick Phrases

Question 1

Describe your induction technique for a patient with severe aortic stenosis

Answer 1

My goals for this induction is to maintain preload, after load, and sinus rhythm.

I will achieve this by running a GA.
- Prior to induction, I will site art line, run fluid to maintain euvolaemia, and commence metaraminol infusion.

• I will use high dose fentanyl and a slow titrated, low-dose propofol infusion, in order to prevent hypotension, and blunt the sympathetic response to laryngoscopy. I will then give 100mg of rocuronium for intubation.

Question 2

You are called to ICU to intubate a morbidly obese, hypoxic patient. What are your priorities?

Answer 2

This is likely going to be a difficult airway.

My priorities are to
1) optimise oxygenation
2) prepare thoroughly for a difficult airway with safe rescue strategies.
3) minimising aspiration risk
4) ensure adequate resource for airway management in a remote location.

Question 3

How are you going to intubate a morbidly obese, hypoxic patient in ICU?

Answer 3

Preparation:
- Difficult airway trolley + experienced airway assistant.
- Ramp patient, then pre-oxygenate upright with NIV.
- Ensure adequate IV access, arterial line, and end-tidal monitoring.

Induction:
- Perform RSI with alfentnail, propofol, rocuronium, then lie patient flat.
- Intubate with videolaryngoscope as plan A, and confirm placement with EtCO2.

Question 4

How would you modify your induction for a patient with raised intracranial pressure?

Answer 4

My goals for this induction is to:
1) Maintain cerebral perfusion and oxygenation.
2) Prevent rise in ICP.
3) Acknowledge risk of aspiration.

Preparation:
- Temporise with mannitol and head up position.
- Ensure adequate IV access, arterial line, and infusions.

Induction:
- Slow uptitration of propofol and remifentanil, with metaraminol to maintain a MAP of 80 to 90.
- Once unresponsive, give 100mg rocuronium.
- Gentle laryngoscopy to secure airway.

Question 5

You have a patient with ongoing massive haemorrhage in theatre needing urgent anaesthesia. How would you induce this patient?

Answer 5

My goals are:
- Rapid onset anaesthesia.
- Maintain sympathetic drive and permission hypotension.
- Minimise risk of aspiration.

To achieve this, I will perform a GA with RSI.
- Ensure well working IV access and art line if time permits.
- Induce with 1mg/kg ketamine, 100mg rocuronium, apply cricoid, then secure the airway with a video laryngoscope and a size 8 ETT.

I will ensure that massive transfusion protocol is ongoing, and maintain SBP of 80-100 throughout.

Question 6

You are asked to anaesthetise a patient with severe pulmonary hypertension for an elective laparoscopic cholecystectomy. How would you approach induction?

Answer 6

My goals are:
1. Prevent further rise in PVR
2. Maintain perfusion and function of the right heart.

To achieve this, I will
- Ensure adequate IV access, arterial line, CVC prior to induction. Vasopressor and pulmonary vasodilators ready.
- Arrange for second anaesthetist with TOE expertise.
- Adequate pre-oxygenation for EtO2 of >0.9.
- I will perform a modified RSI with 2mg midaz, 300microg fentanyl, 40mg propofol, and 100mg rocuronium, and secure airway with a videolaryngoscope.

• Actively avoid hypoxia, hypercapnia, acidosis, and excessive sympathetic stimulation. Maintain MAP of 65 at all time.

Question 7

What vasopressor, inotropes, and pulmonary vasodilators will you use for a patient with severe pHTN?

Answer 7

Vasopressors:
- Noradrenaline at 1-10microg/min.
- Vasopressin at 1-3 units/hr

Pulmonary vasodilators:
- Inhaled NO at 20-50ppm.
- Milranone at 0.25microg/kg/min. Can also use nebulise dose at 5mg.

Inotropes
- Dobutamine 1-5 mic/kg/min

Question 8

You are asked to anaesthetise a child with active post-tonsillectomy bleeding for surgical control. What are your priorities?

Answer 8

My priorities are:
1) Volume resuscitation with crystalloid and blood products.
2) Rapidly secure the airway to minimise aspiration risk.
3) Prepare for difficult airway due to anatomical distortion and active bleeding.

Question 9

How will you induce this child with active post-tonsillectomy bleed?

Answer 9

I will achieve my priorities by:
- Team briefing on difficult airway plan, with adequate rescue management including a ENT surgeon on standby.
- Ensure adequate IV access and ongoing volume resuscitation.
- Prepare 2x functioning suctions, bottle of saline, adequate lighting, videolaryngoscope.

• Attempt pre-oxygenation with child upright. Induce with 3mg/kg propofol and 1mg/kg of sux. Cricoid on once child lied flat.
• Intubate with videolaryngoscope and an appropriately sized ETT. Limit amount of attempts and progress through pre-planned rescue techniques.

Question 10

What are the types of pacemaker?

Answer 10

Single chamber or dural chamber.

Uni-ventricle or biventricular.

Biventricular typically a cardiac resynchronising device

Question 11

Intralipid dose

Side effect of intralipid?

Answer 11

1.5ml/kg bolus
15ml/kg/hr
Second bolus after 5 mins, or double infusion rate.
Max 12ml/kg

Metabolic - fat overload syndrome, hyperglycaemia, hyperlipidaemia

Hepatic steatosis
Fat embolism, pulmonary HTN, ARDS

Question 12

Bundle for cerebral ischaemic protection?

Answer 12

• Supply: MAP 65, SpO2>95%, Hb >80 (100 in TBI), normoglycemia
• Demand: reduce CMRO2, adequate anaesthesia, antiepileptic, hypothermia, analgesia

Question 13

Bundle for spinal ischaemic protection

Answer 13

Optimise perfusion - MAP 90, Hb >100, avoid hypoxia and hypercapnia.

Reduce CSF pressure by lumbar drain to keep <10mmHg

Reduce demand - hypothermia

Early detection with lower limb neuro monitoring

Surgical - staged procedure, distal aortic perfusion, reduced duration of surgery

Question 14

Steps for crashing onto bypass

Answer 14

Incision, sternotomy, vessel exposure, heparinise 400u/kg ACT >480s, cannulate vessels, initiate CPB with perfusionist

Question 15

Considerations for coming off bypass

Answer 15

Airway confirm
B - check ventilation and oxygenation. Address high airway pressure
C - check epicardial pacing wires, TOE for contractility.
D - drugs (anti-arrhythmic, inotropes, vasopressors, anaesthetic agents), ensure adequately anaesthetised.

Protamine 1mg for 100u initial heparin dose. Reduce by 30%.

Electrolytes + BSL + Hb
Rewarming

Surgical - haemostats, de-airing.

Question 16

Complications of aortic dissection

Answer 16

Tamponade
Rupture
Ischaemia
Arrhythmia
Acute AR

Question 17

How would you anaesthetise a patient for pulmonary vein isolation for AF

Answer 17

Mode - GA
Method - TIVA to avoid PONV, groin haematolma
Monitoring - art line, TOE probe, transcutaneous pads
Drugs - heparin, ACT 350s
Well secured line and tube for long procedure in remote location.

Question 18

Surgical issues for pulmonary vein isolation

Answer 18

Long procedure.
Remote location.
Septal puncture.
Arrhythmia risk.
Anticipated complications - groin haematoma, tamponade, malignant arrhythmia.

Question 19

PACU calls for issues with hypotension post AF ablation - ddx?

Answer 19

Attend to patient.
Main Ddx - bleeding from groin, cardiac tamponade.

Must rule out - hypovolaemia, cardiac ischaemia, anaphylaxis.

Question 20

Approach to anaesthtising patients -

Answer 20

Preparation - equipment, drugs, personnel, specialised equipment.

Airway plan - A, B,C, D

Induction drugs

Question 21

How do you rapidly rule out any machine error causing high airway pressure?

Answer 21

bag ventilate the patient with AMBU

Question 21

Differentials for high airway pressure post induction.

Answer 21

Ddx include
Patient: bronchospasm, pneumothorax, anaphylaxis, aspiration

Machine: obstruction in circuit or HME

Tube: kink, sputum plug, endobronchial migration.

Question 22

What is auto-PEEP?

How can you measure this?

Answer 22

The positive pressure left within the alveolar at end of expiration, typically due to air trapping, and can lead to dynamic hyperinflation.

Measured by using an expiratory hold.
Measure PEEP - Set PEEP = intrinsic PEEP .

Question 23

How do you insert a double lumen tube?

Answer 23

I will pre oxygenate the patient and induce anaesthesia with muscle relaxation.

Then perform a direct laryngoscopy, and insert the DLT with the distal curvature anteriorly.

Once through cords, remove the stylet, and rotate counterclockwise 180 degrees

Advance tube until snug.

Inflate tracheal and bronchial cuffs, plus confirm position with fiberoptic scope.

Question 24

Troubleshoot high airway pressure in a patient with DLT

Answer 24

I'd first temporise by giving 100% FIO2, disconnect from the ventilator to assess compliance manually, then rule out DLT obstruction or malposition using suction and bronchoscopy, while considering and ruling out lung pathologies such as bronchospasm, pneumothorax, or atelectasis.

Question 25

Troubleshoot hypoxia in DLT

Answer 25

I will temporise by giving 100% FiO2, disconnect from the ventilator to manually assess compliance, then rule out DLT obstruction or malposition by using suction and bronchoscopy. I will then pass an oxygen catheter down the operative lung, consider resuming two lung ventilation, and alert the surgeon if one-lung ventilation is no longer tolerated.

Question 26

A few useful thresholds of ROTEM in clinical practice?

Answer 26

FIBTEM MCF < 7mm -> hypofibrinogenaemia EXTEM CT > 80s -> delayed clot initiation -> FFP EXTEM MCF < 45 -> impaired clot strength, give platelets if FIBTEM normal LI30 <85% -> hyperfibrinolysis

Question 27

MH preparation

Answer 27

I would prepare for a trigger-free anaesthetic by avoiding all MH-triggering agents — specifically, volatile anaesthetics and succinylcholine. I would conduct a full flush and preparation of the anaesthetic machine: remove vapourisers, insert new circuits and soda lime, and flush the machine with high fresh gas flows (≥10 L/min) for at least 20 minutes, or use a clean, dedicated MH-safe machine if available. For induction and maintenance, I would use total intravenous anaesthesia with agents such as propofol and opioids. I’d use a non-depolarising muscle relaxant if needed. Monitoring includes temperature and end-tidal CO₂ trends, with dantrolene immediately available in the theatre."

Question 28

How to perform an audit

Answer 28

I would identify the topic, identify a suitable guideline, collect and analyse data, compare against existing protocol, implement change, reaudit for improvement

Question 29

Machine check

Answer 29

I would perform the check based on ANZCA PS31 guideline, which includes checking: - power supply - gas supply - breathing system - scavanging - leaks - suction and airway equipment - monitoring

Question 30

what is a physiologically difficult airway?

Answer 30

A physiologically difficult airway refers to a patient whose underlying cardiorespiratory condition increases the risk of decompensation during airway management, even if the anatomical airway appears normal.S

Question 31

steps of proning

Answer 31

Preparation - 5 people minimum, allow more if required. - team briefing prior. - Pre-oxygenate. Secure tube, lines. - Disconnect unneccesary infusions. Turn patient with arms tucked, face in foam, onto chest and pelvic support, or a specialised table like Jackson table. Once proned, systematically reassess airway, ventilation, haemodynamics, pressure area, and lines.

Question 32

Child with URTI - delay or proceed?

Answer 32

In a child with URTI risk of airway complications like bronchospasm and laryngospasm are increased, I will consider patient, anaesthetic and surgical issues. Patient - Presence of LRTI or systemic signs of infection. - history of chronic lung disease - Age <1 Surgical - Airway surgery. Anaesthetic - Experience of operator, and if paediatric anaesthetist immediately available. If proceeding, I'd optimise with pre-op bronchodilators, and choose bag mask ventilation or LMA to minimise airway irritation, but have a low threshold for conversation or cancellation.

Question 33

How to transcutaneously pace?

Answer 33

I would set pacemaker box to asynchronous mode at HR of 80, apply pads in an AP direction, 3 lead ECG set to pacer. Set initial current to 50mA and increase by increment of 10mA until electrical capture, then confirm presence of pulse. Then increase 10mA above the threshold.

Question 34

How do you initiate MTP?

Answer 34

I would activate MTP to notify blood bank and haematologist, and maintain constant communication with surgeons. I would initiate haemostatic transfusion by following the institutional guideline, with warming devices and a level 1 rapid infuser. I would monitor transfusion targets based on 30 minly ABG, coagulation profile and ROTEM. I would actively assess for prevent hypothermia, acidosis, hypocalcaemia, hyperkalaemia and transfusion reactions.

Question 35

What are the biochemical targets for MTP ?

Answer 35

Aim Hb > 100 if actively bleeding Plt > 50 INR and APTT 1.5x normal Fibrinogen 1.5 Ionised calcium > 1.1 Temp ≥35 pH ≥7.2 normal lactate

Question 36

How would you manage a trauma patient?

Answer 36

I would acknowledge the context, attend to assess patient, call for help, assume team leader and allocate roles appropriately. I would assess the patient based on the EMST principles. This means getting a quick handover from the first responders, perform a C-ABC assessment.

Question 37

At what age is the testing for MH suitable?

Answer 37

Minimum weight limit is 30 kg and 10 years old. ( for muscle biopsy) Patients can have genetic testing without age limits.

Question 38

Principles of managing foreign body removal in paeds

Answer 38

- Maintain spontaneous ventilation - Adequate topicalisation to facilitate insertion of suspension laryngoscopy and rigid bronchoscopy. - Rapid onset anaesthesia and limit time to surgical instrumentation. - Planned rescue airways, and maintain constant communication with surgeon.

Question 39

Symptoms of severe pre-eclampsia

Answer 39

Sustained BP > 160/110 Proteinuria >5g / 24hrs Oligouria Pulmonary oedema Abnormal liver enzymes with pain Platelets <100 Cerebral complications: seizures, headache, visual disturbance

Question 40

Treatment options for BP in pre-eclampsia

Answer 40

Methyldopa 250mg BD then uptitrate Labetalol 200mg BD, up to 800mg TDS IV labetalol 20-40mg boluses, then 1mg/min Nifedipine 20mg PO Hydralazine 5mg IV Epidural SNP

Question 41

Dose of magnesium infusion

Answer 41

loading dose of 4g over 15mins, infusion at 1g/hr, continue to 24 hours post-partum Check Mg level every 6 hours, aim for 2-4 mmol/l Can rebolus 2g in eclampsia

Question 42

What are the elements of consent

Answer 42

Ensure decision-making capacity Decision is voluntary Disclosure of information, including indication, process, risks and alternatives. Patient to provide explicit consent, ideally in writing, and documented.

Question 43

How do you determine if one has capacity?

Answer 43

They must demonstrate: - understanding of information - Retaining info - Able to weigh the risks and benefits - Communicate a choice.

Question 44

management for emergency hysterectomy

Answer 44

Quick assessment for ROSC and improvement in haemodynamics. Neonate team to care for newborn. Active third stage management. Urgent transfer to theatre for wound closure. Decision on extubation.

Question 45

How will you transfer this patient.

Answer 45

I would ensure: - Appropriate escort team including an anaesthetic nurse and technician. - Adequate monitoring equipment --> This means standard continuous monitoring equipment, transport ventilator, portable suction, infusion pumps, 2x oxygen tanks. - Adequate emergency drugs --> propofol, muscle relaxant, vasopressors. - Mapped out route and receiving team at destination notified.

Question 46

Difficult airway management approaching CICO scenario

Answer 46

In the event of a difficult airway, I would follow the DAS guideline, which emphasises - Maintaining oxygenation. - Limiting number of airway attempts. - Having a clear plan with defined stop points. I would go through my - Plan A max three attempts at laryngoscopy - Plan B of SAD insertion - Plan C of mask ventilation - Plan D of FONA.

Question 47

How is APGAR score done?

Answer 47

Rapid assessment of the newborn at 1 and 5 mins after birth. Five domains, each scoring 0-2 for a total of 10. - Appearance - Pulse - Grimace - Activity - Respiration Score of 7-10 is normal

Question 48

When and how to perform neonatal CPR?

Answer 48

Prioritise - Ensure open airway - Provision of PEEP - Maintenance of normothermia - Progress through ALS based on HR cut off of 100 and at 60. Ensure open airway Chest compression at 3:1 ratio IV adrenaline at 10mic/kg

Question 49

How would you assess someone's sepsis?

Answer 49

I would assess for sepsis using combination of clinical signs and scoring system. I look for evidence of organ dysfunction, such as altered conscious state, reduced urine output, hypotension, tachypnoea, along side markers like lactate WCC and renal function.

Question 50

How would you assess the response of sepsis after 1L of fluid?

Answer 50

I would assess vital signs to look for improvement in the haemodynamics, and evaluate perfusion to vital organs, such as improvement in conscious state, urine output, cap refill and lactate trend.

Question 51

What's the qSOFA score and what does it represent?

Answer 51

qSOFA score (1 point each) on GCS < 15, RR ≥22, SBP ≤100 Score of ≥2 = increased risk of mortality and prolonged ICU stay.

Question 52

What's in a SOFA score?

Answer 52

6 organ system evaluation (Resp, coat, liver, cardiovascular, CNS, renal) Higher score = higher mortality risk.