Study deck (25.2, 24, 23, 22, 21) Flashcards

Question

22.2 The piece of airway equipment shown is a a. bullard laryngoscope b. CMAC video stylet c. lightwand d. flexible bougie

Answer 1

CMAC video stylet bullard laryngoscope - looks rigid torture device with a fibreoptic source lightwand - literally a light on a stylet for blind intubation Flexible bougie - the one Adrian showed me

Answer 2

Tracheal stenosis ?post lung transplant - looks like obstructive pattern - degree of bronchial strictures, stenosis) - bronchial stenoses in lung transplant -> biconcave loop

Answer 3

d. Use lower frequency probe low frequency/curvilinear probe low-frequency transducer used to scan deeper structures, however at expense of reduced image resolution Conduction velocity = frequency x wavelength ↑Frequency (=↓ wavelength) -> ↑resolution but ↓tissue penetration (from ↑attenuation)

Answer 4

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

Answer 5

b. Myaesthenia gravis In contrast to other neuromuscular disorders, succinylcholine may be used in myasthenia gravis. The required dose may need to be increased by up to two-fold, as those with the disease show a relative resistance to the drug. Sux is not recommended in patients with neuromuscular disease due to: 1. presence of extrajunctional receptors and risk of hyperkalaemia and rhabodmyolysis 2. fasiculations causing temperomandibular muscle spasm preventing intubation | ED95 is 0.8mg/kg in a MG patient

Answer 6

d) 4 - WFNS is 4 * alternatively her Fisher score is: grade 2 (diffuse thin (<1 mm) SAH, no clots; which estimates an incidence of symptomatic vasospasm of 25%) Note the new modified Fischer scale. G0 No SAH or IVH (0%) G1 Focal or diffuse thin SAH but no IVH (6-24%) G2 Focal or diffuse thin SAH with IVH (15-33%) G3 Thick SAH no IVH (33-35%) G4 Thicc SAH with IVH (34-40%) The main differences between the Fisher scale and modified Fisher scale are: 1) Fisher scale, no SAH is grade 1, but 0 in modified Fisher scale 2) Fisher scale, thin SAH & no IVH is grade 2, but 1 in modified Fisher scale 3) Fisher scale, thick SAH with no IVH is grade 3 and the same 3 in modified Fisher scale 4) Fisher scale, any IVH is grade 4, irrespective of the presence of SAH but in modified Fisher scale it is either 2 if thin or no SAH, or grade 4 if thick SAH | GCS 7-12

Answer 7

b) 100 Brain trauma foundation Level III recommendation. To decrease mortality and improve outcomes: Maintain SBP at >100mmHg for patients 50 - 69 Maintain SBP at >110 for patients 15 - 49 Maintain SBP at >110 for patients 70 or older

Answer 8

Anaemia Causes of inaccuracies: - nail polish - Indocyanin green - AF - Methaemoglobin etc

Answer 9

Ans: B) AS - particularly with bicsupid valve is more prevalent than HOCM and presents in this age group MOST COMMON unknown 39% aha has a table of prevalence for syncope arrhythmias and vasovagal 14% orthostatic hypotension 11% - neurological being the main (7%; meds 3% psychiatric 1%) others (carotid sinus syncope, hypoglycemia, hyperventilation) situation and organic heart disease 3% for exersional syncope Syncope after exercise may be due to left ventricular outflow tract obstruction from aortic stenosis or hypertrophic obstructive cardiomyopathy but can also suggest the diagnosis of postexercise hypotension in which an abnormality in autonomic regulation of vascular tone or heart rate results in vasodilation or bradycardia after moderate-intensity aerobic activity. | https://www.ahajournals.org/doi/full/10.1161/01.CIR.0000031168.96232.BA#

Answer 10

23mm mean adult value 22-25mm mean newborn 16-18mm tends to grow up to 16-18yo

Answer 11

Ans: C While relatively safe in early and mid pregnancy, NSAIDs can precipitate fetal cardiac and renal complications in late pregnancy, as well as interfere with fetal brain development and the production of amniotic fluid; they should be discontinued in gestational wk 32 APMSE

Answer 12

Unknown options but… Factors associated WITH difficulty during Gastroscopy were younger age, procedure indication, male sex, presence of a trainee, psychiatric history and benzodiazepine and opioid use. Factors associated with difficulty during COLONOSCOPY were younger age, female sex, BMI <25, procedure indication, tobacco, benzodiazepine, opioid and other psychoactive medication use

Answer 13

Ergometrin increases PVR and SVR

Answer 14

4. Medial Cutaneous nerve of the forearm

Answer 15

c) 7.0 mm Aintree - OD 19Fr = 19/3 = 6.33mm OD ID - 4.7mm - largest FOB = 4.2mm (paediatric fibreoptic bronchoscope) length 56cm Manufacture recommend smallest ETT to be 7.0mm https://www.cookmedical.com/products/cc_caeaic_webds/ In practice you can probably get away with 6.5mm

Answer 16

70-80ml/ kg/ min Controlled ventilation https://www.frca.co.uk/article.aspx?articleid=100141 A fresh gas flow of only 70 ml/kg is required to produce normocarbia. Bain and Spoerel have recommended the following: 2 L/min fresh gas flow in patients <10 kg 3.5 L/min fresh gas flow in patients 10-50 kg 70 ml/kg fresh gas flow in patients >60 kg The recommended tidal volume is 10 ml/kg and respiratory rate is 12-16 breaths/minute.

Answer 17

Increased latency, decreased conduction speed, decreased amplitude

Answer 18

Ans: D - failure to capture. There are regular pacing spikes, but no regular broad QRS (i.e. capture). The pacing spikes are not happening in a repolarising segment, therefore this does not explain why there is no ventricular response. C will be the only one with atrial and ventricular pacing spikes B only other one with atrial pacing spikes but no ventricular A would have pacing spike before ventrilcle when no p-wave occurs + some normal p then QRS Failure to capture if there’s no P wave or QRS after an atrial or ventricular pacing spike Failure to sense – the spike is going off at the wrong time, might change morphology Spike on T-wave

Answer 19

E) 12 puffs 6puffs< 6yrs 12 puffs> 6 yrs Continue adrenaline 0.1-2 mcg/kg/min Magnesium 50mg/kg to max 2g over 20minutes Aminophylline 10mg/kg over 1hr (max 500mg) Hydrocortisone 2-4mg/kg (max 200mg)

Answer 20

e) Interquartile Range Unlike range and interquartile range, variance is a measure of dispersion that takes into account the spread of all data points in a data set. It’s the measure of dispersion the most often used, along with the standard deviation, which is simply the square root of the variance. The variance is mean squared difference between each data point and the centre of the distribution measured by the mean. Standard deviation (SD) is the most commonly used measure of dispersion. It is a measure of spread of data about the mean. SD is the square root of sum of squared deviation from the mean divided by the number of observations. The other advantage of SD is that along with mean it can be used to detect skewness. The disadvantage of SD is that it is an inappropriate measure of dispersion for skewed data. SD is used as a measure of dispersion when mean is used as measure of central tendency (ie, for symmetric numerical data). For ordinal data or skewed numerical data, median and interquartile range are used

Answer 21

Serotonin Syndrome Hyper reflexia Usually has hypertension and hyperthermia https://static1.squarespace.com/static/5e6d5df1ff954d5b7b139463/t/617242e2ab18df2dee31f417/1634878179720/ICU_one_pager_hyperthermic_toxidromes.png

Answer 22

Ans: A) Ketamine A. Non-depolarising muscle relaxants - false - NMBDs abolish MEPs B. Nitrous oxide - false - N2O can completely abolish MEPs D. Propofol - false - PPF has less of an effect than volatiles, but still affects MEPs E. Volatiles - false - volatiles are the most likely NMBDs > volatiles > N2O > PPF > opioids Decrease MEP amplitude - volatiles, N2O, propofol, barbituates, high dose etomidate, dexmedetomidine at high doses, high dose benzo Increase MEP - low dose etomidate, low dose ketamine Minimal effect - low dose dexmedetomidine, opioids, lidocaine, low dose benzo https://www.uptodate.com/contents/neuromonitoring-in-surgery-and-anesthesia?search=SSEP&usage_type=default&source=search_result&selectedTitle=2~51&display_rank=2#H19658702 https://www.uptodate.com/contents/anesthesia-for-elective-spine-surgery-in-adults While neurologic injury can cause changes in recorded potentials, other factors can interfere with interpretation. Confounding factors that can occur during surgery include inhalational anesthetics, hypothermia, hypotension, hypoxia, anemia, and preexisting neurologic lesions. Inhaled anesthetics such as isoflurane, sevoflurane, and nitrous oxide can reduce the amplitude and prolong the latency of SSEP and can completely abolish MEP. Neuromuscular blocking agents (NMBAs) also abolish motor evoked potentials and cannot be used when monitoring. Intravenous anesthetics such as propofol, barbiturates, and opioids have less of an effect on monitoring, though very deep anesthesia, even with propofol, can affect waveforms. https://www.uptodate.com/contents/neuromonitoring-in-surgery-and-anesthesia Evoked potentials — Evoked potential monitoring is used to assess the integrity of the tested neural pathway. Somatosensory, visual, and brainstem auditory evoked potentials monitor neurologic structures between peripheral sites where specific stimulations are applied, and responses are recorded from central locations. Motor evoked potentials monitor such structures by stimulating the motor cortex and recording from the epidural space (D-wave) or, more commonly, from distal muscles. Changes in evoked responses can result from technical, positional, pharmacologic, physiologic, or surgical causes. For spine surgery, both MEPs and SSEPs are used to monitor spinal cord function to increase sensitivity. Motor and sensory tracts are anatomically distinct and have different vascular supply in areas of the cortex, brainstem, and spinal cord. Motor evoked potentials (MEPs) – MEP responses are affected by even very low concentrations of volatile anesthetic agents. In general, total intravenous anesthesia (TIVA) facilitates MEP monitoring. However, inhalation agents at 0.5 MAC or less can be used in many patients, especially during intracranial surgery Opioids – IV opioids cause small, dose-dependent depression of SSEP and MEP responses, though even at very high doses of opioids, evoked potentials can be recorded [76-78]. Infusions of remifentanil, fentanyl, or sufentanil are commonly used as part of TIVA during neuromonitoring. Opioids tend to produce high-amplitude slow waves in the EEG. Balanced anesthetic approach — When SSEPs and MEPs are monitored, a balanced anesthetic using both a low-dose inhalation anesthetic (up to 0.5-MAC isoflurane, sevoflurane, or desflurane) and low- to medium-dose propofol (eg, propofol, 40 to 75 mcg/kg/min IV) with a relatively high-dose opioid (eg, remifentanil 0.1 to 0.4 mcg/kg/min) offers several advantages: ●Movement with motor stimulation is reduced, which is particularly important during intracranial aneurysm surgery. ●The addition of a 0.3 to 0.5 MAC inhalation agent may reduce the chance of awareness under anesthesia. ●Compared with TIVA, the addition of a 0.5 MAC inhalation agent allows reduction of the dose of propofol infusion, facilitating more rapid wakeup and earlier neurologic examination. ●Compared with TIVA, the chance of accidental interruption of the anesthetic for mechanical reasons (ie, kinked or infiltrated IV catheter or tubing such that IV agents no longer infuse) is reduced.

Answer 23

7. Radial Nerve

Answer 24

B) Proprioception b - posterior columns (proprioception/vibraion/fine touch not affected) Anterior spinal artery syndrome - injury to anterior 2/3 of spinal cord - loss of bilateral motor function, pain and temperature sensation below level of injury. Preserved proprioception and light touch Brown Sequard - lateral damage to the cord with ipsilateral loss of motor function, proprioception, light touch and contralateral loss of pain and temperature below level of injury Central cord syndrome - secondary to haemorrhage, ischaemia or oedema of central grey matter. Commonly in cervical region. Disproportionately greater impairment of motor function in the upper vs lower extremeties, with bladder dysfunction and variable degree of sensory loss below level of injury. Posterior cord syndrome -injury to post 1/3 of spinal cord - loss of light touch and proprioception OHA (5th) p305

Answer 25

c. pneumothorax

Answer 26

Both C) and D) Guidelines changed in 2023 (ie this is an old question). Now C and D are wrong. Term used now is "temperature control" which means don't actively warm, and cool if >37.5. MAP target is at least 60-65mmHg or systolic >100mmHg ANZCOR give specific targets for SpO2 (94-98%), Hyperglycaemia (treat>10mmol/L). Temp: unclear if 32-34 degrees beneficial. Prevent hyperthermia - don't cool immediately; can lower up to 1.5 degrees BP: Suggest target mAP >60-65, or sBP >100 in arrest CO2: Normocapnoea https://www.resus.org.nz/assets/Uploads/ANZCOR-Guideline-11.7-Jan16.pdf

Answer 27

e. 60g Each 20mg dantrolene contains 3g mannitol

Answer 28

c) Decreased CO, Increased SVR It is plausible that a case of pre-eclampsia that occurs earlier in gestation and is associated with fetal growth restriction is related to low cardiac output and high peripheral vascular resistance with a much similar profile as observed in women with fetal growth restriction without HDP. In cases of later and term gestation pre-eclampsia, babies tend to be larger and there is a predominantly high cardiac output, low peripheral vascular resistance and raised intravascular volume state. Certainly, the clinical phenotype of a very ‘dry’, intravascularly depleted woman at 26 weeks with a growth restricted baby and conversely of a well-perfused oedematous woman with a bounding pulse and large baby at 38 weeks rings true: both have hypertension, but the mechanisms may be diametrically opposite. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5569150/ Our findings of a relatively hypodynamic circulation with a lower CO and higher TPR in women who develop preeclampsia/FGR lend credence to reports of hemodynamic dysfunction observed in the subclinical and clinical stage of preeclampsia and FGR. https://www.ahajournals.org/doi/full/10.1161/HYPERTENSIONAHA.118.11092#d1e1667

Answer 29

B) Taking > 1 month Duration: >3–4 weeks of therapy is generally sufficient to suppress the axis. Shorter courses (<1–2 weeks) do not cause suppression. Dose threshold (in children): Approx. ≥10 mg/m²/day of hydrocortisone equivalent for >1 month is enough to risk suppression. The child in the question is receiving 15 mg/day ÷ 0.97 m² ≈ 15 mg/m²/day, i.e. physiologic replacement range, not supraphysiologic — but still, >1 month duration triggers the need to consider stress dosing. Steroid potency equivalence: 15 mg hydrocortisone ≈ 3.75 mg prednisolone ≈ 0.75 mg dexamethasone. Perioperative supplementation (“stress dosing”) When to consider: Any patient with potential HPA suppression (i.e. corticosteroid use >1 month) facing moderate or major surgical stress. Elective surgery requiring general anaesthesia is a typical trigger for supplementation. When not required: <3 weeks of therapy Alternate-day dosing Low-dose topical or inhaled steroids only Low-dose physiological replacement in known Addison’s (these are continued, not doubled). https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/full/10.1111/anae.14963 Daily doses of prednisolone of 5 mg or greater in adults and 10–15 mg.m−2 hydrocortisone equivalent or greater in children may result in hypothalamo–pituitary–adrenal axis suppression if administered for 1 month or more by oral, inhaled, intranasal, intra-articular or topical routes; this chronic administration of glucocorticoids is the most common cause of secondary adrenal suppression, sometimes referred to as tertiary adrenal insufficiency All children who have known glucocorticoid deficiency (primary or secondary), or who are at risk of glucocorticoid deficiency (on significant exogenous dose of glucocorticoid >10–15 mg.m-2 per day) 38, should receive an i.v. dose of hydrocortisone at induction (2 mg.kg−1 for minor or major surgery under general anaesthesia).

Answer 30

b) VV ECMO VV ECMO Disadvantages - no cardiac support - local recirculation though oxygenator at high flows - reverse gas exchange in lung if FiO2 low - limited power to create high systemic arterial oxygen tension

Answer 31

c. myasthenia gravis a) Pul HTN: ↓DLCO (<0.8 predicted); FEV1:FVC often normal (<0.7) b) IPF: ↓DLCO, ↓FVC, normal/high FEV1:FVC (restrictive) c) MG: ↓FEV1, ↓FVC, normal FEV1:FVC. Normal DLCO d) Obesity: mild ↓FVC, normal/high FEV1:FVC, normal/high DLCO e) Sarcoidosis: ↓DLCO, restrictive pattern (sometimes obstructive or mixed) DLCO decreased in pulmonary HTN, IPF, sarcoidosis.

Answer 32

A. PECS I (PECS II Covers SA and will extend to the sternum) - between pecs major and pecs minor - blocks lateral and medial pectoral nerves Stenum innervated by interocostal nerves. All 3 options belwo can be used for sternal fracture PECS 2 - between pecs minor and serratous ant - blocks intercostal brachial, long throacic, intercostal III - VI nerve Subpectoral interfascial plane block - between pec major and interocstal Transverus thoracic plane block = parasternal plane block

Answer 33

b. 24 hours ASA guidelines -If creatinine clearance >=30 ml.min-1 (Cockcroft-Gault), proceed with surgery after two half lives (24 h) since the last dose, under general anaesthesia (or spinal anaesthesia if indicated) - If creatinine clearance < 30 ml.min-1, proceed with surgery after four half lives (48 h) since the last dose, under general anaesthesia (or spinal anaesthesia if indicated)

Answer 34

Atropine Reduce dose adrenaline with senior clinician advice ANZ CALS guideline

Answer 35

A codeine Oxycodone B Morphine C Tramadol C Fentanyl C

Answer 36

C. Oesophageal stricture "4 conditions that are absolute contraindications: esophageal stricture, tracheoesophageal fistula, post esophageal surgery, and esophageal trauma 2010 guidelines ## Footnote https://www.asecho.org/wp-content/uploads/2014/05/2013_Performing-Comprehensive-TEE.pdf

Answer 37

Ans: E decreased PA pulsatility index You will get a raised JVP but the question seems to be asking about PA catheter investigation. Low PA pulsatility is specific to right sided infarct PAPi goes down in acute RVF - actually designed to prognosticate in acute MI https://www.ahajournals.org/doi/10.1161/CIRCHEARTFAILURE.121.009085#:~:text=The%20pulmonary%20artery%20pulsatility%20index,left%20ventricular%20assist%20device%20implantation.

Answer 38

A . Cardiac tamponade Deranged physiology In summary The CVP is raised All CVP waveform components are elevated a and v waves are tall x descent is steep y descent is (usually) absent ----- Normal CVP trace a wave: atrial contraction c wave: tricuspid bulge during ventricular systole x descent: atrial relaxation v wave: atrial filling y descent: tricuspid opening and early ventricular filling Loss of a-wave = AFib Cannon a-waves 1) Retrograde conduction of ventricular depol - VTach - Ventricular pacing - Junctional rhythm 2) Asynchronous atrial activity - complete HB - accidental reversing of pacing wires Prominent a wave w/ attenuated y wave (lower amplitude, longer duration) - tricuspid stenosis - reduced RV compliance: pulmonary stenosis or pulmonary HTN Cannon waves - fused C &V waves = tricuspid regurg (prior MCQ) Bifid CVP (x and y descent steep and abrupt) = pericardial constriction CVP raised, x descent steep but absent y = tamponade

Answer 39

ALTERED 22.1 QUESTION D Spirometry FEV1 only GOLD 1 > 80% Pred GOLD 2 50-79% Pred GOLD 3 30-49% Pred GOLD 4 < 30% Pred

Answer 40

C https://academic.oup.com/bjaed/article/17/2/68/2907833

Answer 41

e. AAA acromegaly - excess GH (middle age) Airway - ^difficult of intubation due to macgnathia, macroglossia and expansion of upper airway soft tisssues Resp - ^OSA (up to 70%), kyphoscoliosis, proximal myopathy CVS - refractory HTN, LV hypertrophy, IHD, arrythmia, heart block, cardiomyopathy (^deposition of tissue -->fibrosis), bi-ventricular dysfunction CNS - ^ soft tissue --> ^ nerve entrapment syndromes Metabolic - *diabetes and other endocrine Osteoarthritis nerve compression syndrome due to bony overgrowth, and carpal tunnel syndrome Hypertension Diabetes mellitus Cardiomyopathy/HF Colorectal cancer Sleep Apnea Thyroid nodules and thyroid cancer Hypogonadism Compression of the optic chiasm Source: BJA

Answer 42

D Inhalational anaesthetic https://academic.oup.com/bja/article/118/3/335/2999642?login=false inhalational anaesthesia Occurs in 9-18% paeds - eye and ENT surgery at higher risk - higher incidence in preschool 2-5years (male), anxious patients, negative behaviour on induction TIVA better than Sevo in decreasing PoD

Answer 43

C 3L/min LVOT area x VTI = SV 3cm2 x 10cm = 30ml SV x HR = CO 30 x 100 = 3000 Calculation (using LVOT method): Stroke volume (SV) = VTI × LVOT area = 10 cm × 3 cm² = 30 cm³ = 30 mL Cardiac output (CO) = SV × HR = 30 mL × 100 beats/min = 3000 mL/min ≈ 3.0 L/min Notes: EF, RVSP, and IVC diameter aren’t required for this CO calculation. The low VTI (10 cm) with tachycardia fits a low-output state (~3 L/min).

Answer 44

a) 100-200 2012 BERLIN DEFINITION OF ARDS ARDS is an acute diffuse, inflammatory lung injury, leading to increased pulmonary vascular permeability, increased lung weight, and loss of aerated lung tissue…[with] hypoxemia and bilateral radiographic opacities, associated with increased venous admixture, increased physiological dead space and decreased lung compliance. Key components - acute, meaning onset over 1 week or less - bilateral opacities consistent with pulmonary edema must be present and may be detected on CT or chest radiograph - PF ratio <300mmHg with a minimum of 5 cmH20 PEEP (or CPAP) - “must not be fully explained by cardiac failure or fluid overload,” in the physician’s best estimation using available information — an “objective assessment“ (e.g. echocardiogram) should be performed in most cases if there is no clear cause such as trauma or sepsis. Severity - ARDS is categorized as being mild, moderate, or severe:

Answer 45

d. autoimmune disease (with potential vascular complications) RANZCOG Maternal characteristics that are associated with an increased likelihood of pre-eclampsia include: - previous pre-eclampsia, particularly when more serious or early onset before 34 weeks - pre-existing medical conditions (including chronic hypertension, underlying renal disease, or pre-gestational diabetes mellitus), - underlying antiphospholipid antibody syndrome, - multiple pregnancy UTD: Preeclampsia: Prevention https://www.uptodate.com/contents/preeclampsia-prevention Based on the available data (see 'Evidence of efficacy' above), we recommend low-dose aspirin prophylaxis for women at high risk for preeclampsia. There is no consensus on the exact criteria that confer high risk. It is reasonable to use the US Preventive Services Task Force (USPSTF) high-risk criteria, which are also endorsed by the American College of Obstetricians and Gynecologists (ACOG). The incidence of preeclampsia is estimated to be at least 8 percent for pregnant women with any one of these high risk factors: ●Previous pregnancy with preeclampsia, especially early onset and with an adverse outcome ●Multifetal gestation ●Chronic hypertension ●Type 1 or 2 diabetes mellitus ●Chronic kidney disease ●Autoimmune disease with potential vascular complications (antiphospholipid syndrome, systemic lupus erythematosus)

Answer 46

C Reduced due to increased volume of distribution and clearance 2010 Paper on major burns The pharmacokinetic characteristics of a propofol bolus administered in patients with major burns were enhanced clearance and expanded volume of distribution. BURN and WT were the important covariates. For sedation or anesthesia induction, a higher than recommended dose of propofol may be required to maintain therapeutic plasma drug concentrations in patients with severe burns. Vigilance regarding the burned individual and careful titration of hypnotics to the desired effect cannot be overemphasized. https://pubmed.ncbi.nlm.nih.gov/20510522/

Answer 47

C. Increased minute ventilation Cerebral oximetry (NIRS rSO₂) reflects the balance between cerebral oxygen delivery (CBF × CaO₂) and cerebral metabolic rate (CMRO₂). Interventions that raise CBF, raise CaO₂, or lower CMRO₂ tend to increase rSO₂. Hyperventilation (↑ minute ventilation) usually lowers PaCO₂, causing cerebral vasoconstriction → ↓ CBF → ↓ rSO₂, Cerebral blood flow Cardiac output Acid–base status Major haemorrhage Arterial inflow/venous outflow obstruction Oxygen content Haemoglobin concentration Haemoglobin saturation Pulmonary function Inspired oxygen concentration Inspired oxygen concentration

Answer 48

A) 3 months (see 2023.1 for reasoning)

Answer 49

B peak of T wave Triggering of the IABP is usually set according to the patient’s ECG tracing. When an R wave is detected the balloon is triggered to automatically start inflating in the middle of the T wave. Triggering can be impaired if the patient develops an arrhythmia, is paced or has a poor ECG trace. LITFL

Answer 50

D Na 154, 308 mOsm/L (Osmolality is 290 if measured) CSL: Na 131, Cl 111, osmlolality 280, pH 6.5 - HCO3- 29, K+ 5, Ca2+ 2 (same in plasma) - no Mg2+/glucose Albumin 4%: Na 140, Cl 128, osmolality 300, pH 7. Oncotic P = 25 (isotonic) Plasma: Na 140, Cl 100, osmolality 290, pH 7.4, glucose 5. - HCO3 24, K 4.

Answer 51

b. hypotension The use of dexmedetomidine did not increase the duration of PACU LOS but was associated with reduced emergence agitation, cough, pain, postoperative nausea and vomiting, and shivering in PACU. There was an increased incidence of hypotension but not residual sedation or bradycardia in PACU. Intaop dexmed associated with PACU: ↓ PONV, shivering, cough, emergence agitation, pain scores Decreased BP (hypotension) No change bradycardia and sedation and PACU LOS No change - BSL - bradycardia/sedation/LoS PACU Decreased everything else incl. BP (PONV, shivering, cough, agitation, pain) Loading infusion: Transient HTN (α2B receptors agonism) , bradycardia, hypotension https://pubmed.ncbi.nlm.nih.gov/35085107/#:~:text=Conclusions%3A%20The%20use%20of%20dexmedetomidine,sedation%20or%20bradycardia%20in%20PACU

Answer 52

A) Atropine VF immediate management per that EACTS protocol (on right) 1) 3 stacked shocks (150J) 2) start CPR 3) amiodarone 300mg +/- 150mg bolus. (IV lignocaine 1mg/kg alternative) 4) continue CPR Q2min DC shock until repeat sternotomy within 5 mins (repeat sternotomy for internal cardiac massage or defib at 20J) DO NOT give adrenaline unless a senior doctor advises (usually smaller doses) ECMO <30 mins ideal IABP: 1:1 ratio (i.e. with compressions), intrinsic rate 100bpm https://www.bjaed.org/article/S2058-5349(17)30182-8/pdf Atropine not recommended in 2018 BJA guidelines (were in 2009 for non-shockable rhythm) -You do not use full dose adrenaline (rather, give smaller doses) -You do three "stacked shocks" -You try pacing (rate of 90, DDD) in asystole if pacing wires are available -If they are already paced and in PEA, you turn off the pacing to "unmask" VF. -These shocks and attempted pacing are all measures you take before starting CPR, which is a departure from the ACLS norms. -If you can't control a shockable rhythm with three stacked shocks, you give amiodarone immediately rather than after three cycles. -Amiodarone is the only drug in the protocol, which makes it easy to remember. -After five minutes of unsuccessful resuscitation the chest should be re-opened. -External CPR is pointless in all of the common causes of arrest in this scenario. Therefore, CPR is something you do while waiting to re-open the chest. -Non-surgical staff are encouraged to re-open the chest in an emergency ## Footnote https://derangedphysiology.com/main/required-reading/cardiac-arrest-and-resuscitation/Chapter%20221/cardiac-arrest-following-cardiac-surgery

Answer 53

e) 1.5L or >200ml/hr over the next 2-4hrs - blood loss > 20ml/kg OR >1.5L (at first) - blood loss >200ml/hr in first 2-4hrs from chest tube placement - endobronchial blood loss - tracheobronchial or heart/great vessel injury (recent review suggests thoracotomy if penetrating trauma w/ or w/o vitals, and NO thoracotomy if blunt trauma without vital signs) (ATLS guidelines) Thoracotomy anterolaterally in 4-6th intercostal space - 20% of time will need to go clamshell or hemi-clamshell

Answer 54

Ans: B) analyse the difference between the means of more than two groupsc) comparisons of means between three groups in normally distributed data One sample t-test: compares mean or median of one sample group against a known value Unpaired or paired t-test: compares means or medians of two sample groups (unpaired or paired data

Answer 55

B II ASA II Paediatric examples: Asymptomatic congenital cardiac disease, well controlled dysrhythmias, asthma without exacerbation, well controlled epilepsy, non-insulin dependent diabetes mellitus, abnormal BMI percentile for age, mild/moderate OSA, oncologic state in remission, autism with mild limitations

Answer 56

b. 4/3/1 (<6mo) or c. 6/4/1 (>6mo) Solids: 6hrs Clear liquids: 1hr (at 3mL/kg/hr) Breast milk: 3hr Non-breast milk (formula/cow): 4hrs - 200mL or 20mL/kg - Same in >12 months EXCEPT non-breast milk is considered solid (6hrs i. For adults having an elective procedure, limited solid food may be taken up to six hours prior to anaesthesia and clear fluids may be taken up to two hours prior to anaesthesia. ii. For children over six months of age having an elective procedure, limited solid food or formula may be given up to six hours, breast milk up to four hours and clear fluids (no more than 3ml/kg/hr) up to one hour prior to anaesthesia. iii. For infants under six months of age having an elective procedure, formula may be given up to four hours, breast milk up to three hours and clear fluids (no more than 3ml/kg/hr) up to one hour prior to anaesthesia. iv. Prescribed medications may be taken with a sip of water less than two hours prior to anaesthesia unless otherwise directed (for example oral hypoglycaemics and anticoagulants). v. An H2-antagonist, proton pump inhibitor or other agent that decreases gastric secretion and acidity should be considered for patients with an increased risk of gastric regurgitation.

Answer 57

B 6 hours 6hrs using standard Parkland formula, which BJA advocates for (use standard unless modified Parklands specified): - maths easier if original Parkland 4 x 25 x 20 = 2L/24hrs - 1L over 8 hrs (but 2hrs since burn, so over 6 hrs) Parkland formula does NOT add maintenance fluid to resus fluids. Modified Parkland: fluid loss replacement in first 24hrs from burn 3 x TBSA x weight = 1500 / 24 hrs 750ml / 8hrs (so 750mL in first 6hrs = 150mL/hr) Maintenance = 40 + 20 = 60mL/hr Initial fluid rate = 210mL/hr (which would reach 1L at ~5hrs?) Hartmanns preferred! Paeds IV fluids incl. burns 20 x 25 x 4 = 2000 L (Parklands) In first 8 hours 50% 1 L in 8 hours FROM TIME OF BURN So in 6 hours.

Answer 58

B Morphine Histamine-releasing

Answer 59

C Neostigmine Acute colonic pseudo-obstruction (ACPO) — also known as Ogilvie’s syndrome — occurring postpartum (4 days post-caesarean) is a recognised clinical scenario. Typical setting: Postoperative, post-caesarean, orthopaedic, or trauma patients. Pathophysiology: Functional obstruction from autonomic imbalance (↓ parasympathetic tone → colonic hypomotility, sympathetic overactivity). Radiology: Marked caecal dilation (>9 cm significant; >12 cm risk of perforation). Mechanical obstruction must be excluded first (as per question). If > 9cm dilation, would need surgical management. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3168359/#!po=17.5000 UTD refers to diameters over 12cm as being cut off

Answer 60

c) Decreased clearance – same dose Elimination: Excreted unchanged by the kidneys (>90%) via glomerular filtration. No metabolism occurs; clearance is directly proportional to GFR. → Plasma clearance is decreased. → However, recommended dose is unchanged because: Recovery of neuromuscular function after sugammadex is determined by binding kinetics, not renal clearance. Once rocuronium is encapsulated, it is effectively inactivated, regardless of delayed excretion. Dose reduction risks incomplete reversal and recurarisation. The dose recommendations for mild and moderate renal impairment (creatinine clearance between 30 and 80 mL/min) are the same as for adults without renal impairment. Sugammadex is not recommended for use in patients with severe renal impairment (including patients requiring dialyses) 8.6 Renal Impairment This drug is known to be substantially excreted by the kidney. Effect of mild or moderate renal impairment on sugammadex PK and PD was obtained from a study in elderly patients [see Use in Specific Populations (8.5)]. Although clearance of drug decreased in elderly subjects with mild and moderate renal impairment, there was no significant difference in the ability of sugammadex to reverse the pharmacodynamic effect of rocuronium. Hence, no dosage adjustment is necessary for mild and moderate renal impairment. BRIDION is not recommended for use in patients with severe renal impairment due to insufficient safety information combined with the prolonged and increased overall exposure in these patients [see Warnings and Precautions (5.11), Clinical Pharmacology (12.3)]. ## Footnote PI

Answer 61

E. Decreased acute kidney injury Restrictive had more AKI Otherwise no outcome significant statistically https://www.thebottomline.org.uk/summaries/relief/

Answer 62

c) 30ml/kg To raise fibrinogen by 1g/L, give: - FFP 30mL/kg (i.e. 2.1L for 70kg pt) - Fibrinogen concentrate 3g (each vial 1g) - Cryoprecipitate (whole blood) 1 unit per 5kg BW (note 1 unit/5-10kg BW increases fibrinogen by 0.5-1g/L); -> typical adult dose is 10 units = ~3-4g fibrinogen -> if cryoprecipitate apheresis, 1 unit per 10kg (1 unit per 10-20kg increases fibrinogen by 0.5-1g/L) Cryo values are derived mathematically After a dose of 10 to 15 mL/kg of FFP, plasma clotting factors rise about 15%, and the fibrinogen level rises by 40 mg/dL (0.4g/l) https://www.sciencedirect.com/topics/medicine-and-dentistry/fresh-frozen-plasma 1g/0.4g= 2.5 2.5 x 10ml/kg= 25ml/kg 2.5 x 15ml/kg= 37.5ml/kg 30ml/kg best answer For cryoprecipitate: One unit of Cryo is 15-20 mL in volume and contains 150-250 mg of fibrinogen. Cryo is generally transfused in pools of 10 units, which should increase an adult recipient's fibrinogen level by 50-100 mg/dL. (0.5-1g/l) 10 units of cryo= 200-300ml 200ml/70kg= 2.8ml/kg 200ml/70kg= 4.2ml/kg Typically 1 bag of whole blood cryoprecipitate given per 5–10 kg body weight would be expected to increase the patient’s fibrinogen concentration by 0.5–1.0 g/L.1 Typically 1 bag of cryoprecipitate apheresis given per 10–20 kg body weight would be expected to increase the patient’s fibrinogen concentration by 0.5–1.0 g/L.1 A standard adult dose of cryoprecipitate (3-4g of fibrinogen for a 70kg adult) is equivalent to: y 10 bags of whole blood cryoprecipitate or y 5 bags of apheresis cryoprecipitate Paediatric dosing is not established however common practise is 5mL/kg or 1-2 whole blood cryoprecipitate units per 10kg.

Answer 63

e. Spinal level of drain According to AANN2 and SNACC4 Guidelines: * Patient positioning and leveling is crucial to prevent complications from lumbar drainage * The head of the bed, height of drainage chamber, and changes in patient positioning must be monitored closely to prevent sudden overdrainage * While making changes to the patient’s positioning, the lumbar drainage device should be clamped so that overdrainage does not occur https://www.integralife.com/file/general/1604065981.pdf (manufacturer's instructions)

Answer 64

d. transverse cervical SGLT Supraclavicular Great-auricular Lesser occipital Transverse cervical Skin over anterior and lateral regions of neck (plane block as per Anso - difficult to identify nerves. Sometimes adjunct to interscalane as supraclavicular nerve innervates 'cape' of shoulder ----- Supraclavicular nerve block. An initial injection of 3 mL local anesthetic is deposited at the midpoint of the sternocleidomastoid muscle, followed by 7 mL injected subcutaneously in a caudad and cephalad direction along the posterior border of the muscle. complications: 1.Infection 2.Hematoma 3.Phrenic nerve block 4.Local anesthetic toxicity 5.Nerve injury https://www.nysora.com/techniques/head-and-neck-blocks/cervical/cervical-plexus-block/

Answer 65

e. haloperidol Mx - treat underlying cause - infection, pain, dehydration, metabolic derangement, constipation, urinary retention - antipsychotics (e.g. haloperidol 0.5mg-1 PO/IM/IV, risperidone 0.5mg PO, olanzapine 2.5mg PO, quetiapine 25mg PO STAT = preferred w/ PD or demential w/ Lewy bodies) is first line for agitation but does not alter time course of delirium nor modify its prognosis - avoid benzo - may worsen symptoms NOF surgery - 70% risk of post op delirium Post-op (usually days 2-5) - non pharm mx - re-orientation, sleep optimisation, mobilisation, nutrition - prophylactic antipsychotic (risperidone, olanzapine), melatonin/ramelteon (melatonin agonist) Clonidine-> no mention in the evidence dexmedetomidine-> as an infusion seems to reduce risk of post-op delerium and could be used to treat but not necessarily practical in combative patient Propofol-> not mentioned Midazolam-> avoid benzos as can worsen delerium If pharmacological approaches are required to reduce risk of harm to the person with agitated delirium, then haloperidol can be administered in incremental 0.5-mg doses. Benzodiazepines should be used for people with alcohol-related cognitive disorders or in people with Parkinsonian dementia. There is no evidence to support the use of prophylactic pharmacological measures (cholinesterase inhibitors, antipsychotics, melatonin) in routine peri-operative care for patients at risk of POD https://anaesthetists.org/Portals/0/PDFs/Guidelines%20PDFs/Guideline_Perioperative_care_of_people_with_dementia_2019.pdf?ver=2019-02-11-121238-777×tamp=1549888049165&ver=2019-02-11-121238-777×tamp=1549888049165 Duan and colleagues conducted a meta-analysis of 18 clinical trials and found that intraoperative and postoperative dexmedetomidine administration significantly reduces the risk postoperative delirium (odds ratio 0.35). -> https://www.bjanaesthesia.org/article/S0007-0912(20)30566-3/fulltext

Answer 66

b) Propofol based on LBW

Answer 67

C. Elevated ICP - No Absolute contraindications - Relative contraindications 1. Raised ICP or space occupying lesion 2. MI within the last 3 months 3. Severe arterial hypertension 4. Acute Glacoma 5. Changes in the cerebral arteries e.g. aneurysm Pregnancy and Pacemakers are not contraindications to ECT Indications: 1. Depression (most common) 2. MDD with psychotic features 3. Schizoaffective disorder 4. Schizophrenia with catatonia 5. Highly suicidal or depressed pregnant patients (not first line) 6. Bipolar affective disorder 7. Neuroleptic malignant syndrome BJA: Relative CI: ↑ICP, recent (3 months) MI/CVA, untreated cerebral aneurysm/myocardial ischaemia/CCF. Unstable major # and severe OP i.e. bad brain, heart, bones. Non-coagulated DVT, phaeochromocytoma, retinal detachment or glaucoma. High-risk pregnancy, cardiovascular conduction deffects, aortic aneurysm. Resp: TB, pneumonia, asthma - Cochlear implants also CI, although unilateral ECT possible

Answer 68

1. Ulnar Nerve

Answer 69

d) 1:19000 repeat The estimated incidence of patient reports of AAGA was ~1:19,000 anaesthetics. However, this incidence varied considerably in different settings. The incidence was ~1:8,000 when neuromuscular blockade was used and ~1:136,000 without it. Two high risk surgical specialties were Cardiothoracic anaesthesia (1:8,600) and Caesarean section (~1:670). with NMBD (MC RF) 1: 8000 (136 000 without lol). cardiothoracic surgery 1:8600 GA C/S 1:670 1:60 000 paeds Higher risk: emergencies, cardiac, unexpected difficult airway, NMB, TIVA (two-fold)

Answer 70

A) Amitriptyline repeat 20.1 By order of favourable NNT: 1. TCAs (amitriptyline) NNT: 3.6, NNH: 9 2. Strong opioids NNT 4.3 NNH 11.7 3. Tramadol NNT: 4.7, NNH 12.6 4. SNRIs (duloxetine and venlafaxine) NNT 6.4, NNH 11.8 5. Gabapentin NNT: 7.2 NNH 25.6 6. Pregabalin NNT:7.7, NNH 13.9 ANZCA Pain book Treatment of chronic neuropathic pain after SCI (Guy 2016 GL). These guidelines recommend: * First line: pregabalin, gabapentin and amitriptyline; * Second line: tramadol and lamotrigine (in incomplete SCI); * Third line: Transcranial direct current stimulation (tDCS) alone and combined with visual illusion; * Fourth line: TENS, oxycodone and dorsal root entry zone lesions.

Answer 71

C. transfuse for Hb >100 emergency fixation = no time for exahnge transfusion Hb 80 g/L → significant anaemia. Emergency fixation → moderate surgical stress and risk of hypoxia. The perioperative aim is to reduce sickling risk while optimising oxygen delivery, but avoiding hyperviscosity. perioperative goals: - planning and optimisation - ensuring adequate O2 delivery - hydration - analgesia - performed at a centre with a multidisciplinary sickle cell team Vichinsky et al., NEJM 1995 compared two transfusion strategies in SCD: Aggressive (exchange to HbS < 30%). Conservative (simple transfusion to Hb ≈ 100 g/L). Findings: No difference in perioperative complications (vaso-occlusive crises, ACS, infections). Aggressive transfusion caused more alloimmunisation and hyperviscosity. Hence, simple transfusion is now preferred for most moderate-risk surgery. 3. Guidelines BCSH (2016) and BJA Education 2020 recommend: Simple transfusion to Hb ~100 g/L for moderate-risk surgery (orthopaedic, abdominal). Exchange transfusion only for major or high-risk procedures (cardiac, thoracic, neurosurgical). Low to medium risk surgery - - If Hb <90 -> transfuse to Hb>100 - If Hb >90 -> exchange transfusion to HbSS<60% High risk surgery (neurosurg/CTS/ complex ortho) or high-risk pts (prior CVA, acute CS, end-organ damage) - Hb>100 and HbSS<30% Results from TAPS study (transfusion alternatives preop in sickle cell disease) reports less periop complications with these targets. Not transfused group had greater incidence of blood transfusion intra or post op with common indication being acute chest syndrome ---------------------- Exchange transfusion vs. top-up transfusion Exchange Transfusion: - slowly removing the person’s blood and replacing with fresh donor blood or plasma - Performed in cycles lasting a few minutes with slow removal of 5-20ml of blood and an equal amount of fresh pre-warmed blood or plasma flows into the person’s body - in sickle cell disease blood is removed and replaced with donor blood to achieve a specific concentration of HbSS blood with a usual target of <30% - Exchange transfusion removes HbS and increases HBA Top-up transfusion: - standard transfusion process of giving donor blood - advantages of simple top-up include: 1. Increase oxygen carrying capacity 2. Decrease proportion of sickle haemoglobin HbS relative to Haemoglobin A (HBA) 3. Prevent or reverse complications of vast-occlusion 4. Can be given acutely - disadvantages include: 1. Hyperviscosity if the Hb is increased to significantly over the patients baseline (target Hb should be 100g/l) 2. HbS is not removed, only diluted 3. Prevent or reverse complications of vast-occlusion 4. Can be given acutely - disadvantages include: 1. Hyperviscosity if the Hb is increased to significantly over the patients baseline (target Hb should be 100g/l) 2. HbS is not removed, only diluted

Answer 72

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

Answer 73

b. Cold saline irrigation of brain Seizures, either focal or generalized, are most likely to occur during cortical mapping. They are treated by irrigating the brain tissue with ice-cold saline. They usually cease with this treatment alone, but occasionally benzodiazepines, anti-epileptic drugs, or re-sedation with airway control are required. An emergency plan for airway control has to be in place at all times and this can be challenging as the patient's head is fixed in head pins and often away from the ventilator. The options include the insertion of an LMA which may be easier than oro-tracheal intubation. Awake craniotomy is generally a well-tolerated procedure with a low rate of conversion to general anaesthesia and a low rate of complications. One of the most frequent complications is patient intolerance of the procedure, often because of the urinary catheter or prolonged positioning and intra-operative seizures.

Answer 74

d) Peak of R wave The appropriate energy level is then selected, and the discharge/shock button is pressed and held. The defibrillator does not release the shock immediately. Instead, it waits for the next R-wave to appear and delivers the shock at the time of the R-wave. This allows the shock to be provided safely away from the T wave, avoiding the R-on-T phenomenon. Synchronised cardioversion: (must hit sync button) - low energy shock - to peak of QRS (peak of R wave) - via delay - avoids shock during cardiac repolarisation (T-wave); ?R on T phenomena precipitates VFib) - indications: unstable (or medically refractory) AFib, flutter, atrial tachycardia, SVT

Answer 75

c) Continuation leads to increased risk of major bleeding Aspirin in patients undergoing non cardiac surgery https://www.nejm.org/doi/full/10.1056/nejmoa1401105 Conclusions Administration of aspirin before surgery and throughout the early postsurgical period had no significant effect on the rate of a composite of death or nonfatal myocardial infarction but increased the risk of major bleeding. (Funded by the Canadian Institutes of Health Research and others; POISE-2 ClinicalTrials.gov number

Answer 76

d. asepsis Asepsis: the prevention of microbial contamination of living tissues or sterile materials. Disinfection: the inactivation of non-sporing organisms using either thermal or chemical means. Sterilisation: complete destruction of all micro-organisms, including spores. https://www.anzca.edu.au/getattachment/e4e601e6-d344-42ce-9849-7ae9bfa19f15/PG28(A)-Guideline-on-infection-control-in-anaesthesia

Answer 77

b) cohort study What is a Cohort Study design? - Cohort studies are longitudinal, observational studies, which investigate predictive risk factors and health outcomes. - They differ from clinical trials, in that no intervention, treatment, or exposure is administered to the participants. - The factors of interest to researchers already exist in the study group under investigation. - Study participants are observed over a period of time. The incidence of disease in the exposed group is compared with the incidence of disease in the unexposed group. - Because of the observational nature of cohort studies they can only find correlation between a risk factor and disease rather than the cause. Cohort studies are useful if: - There is a persuasive hypothesis linking an exposure to an outcome. - The time between exposure and outcome is not too long (adding to the study costs and increasing the risk of participant attrition). - The outcome is not too rare.

Answer 78

e) Standards of quality improvement Quality Improvement (Standards for QUality Imporvement and Reporting Excellence) CONSORT: randomised trials PRISMA: systematic reviews and meta-analysis (Preferred Reporting Items for Systematic reviews and meta-analysis). STROBE: observational studies

Answer 79

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

Answer 80

e. 200mmol * K+ < 3.0 mmol/L: 200-400 mmol of potassium are required to raise it by 1 mmol/L * K+ > 3.0 mmol/L: 100-200 mmol of potassium are required to raise it by 1 mmol/L Hypokalaemia P. GLOVER https://www.cicm.org.au/CICM_Media/CICMSite/CICM-Website/Resources/Publications/CCR Journal/Previous Editions/September 1999/05-Sept_1999_Hypokalaemia.pdf If the serum potassium level is greater than 3 mmol/L, 100-200 mmol of potassium are required to raise it by 1 mmol/L; 200 - 400 mmol are required to raise the serum potassium level by 1 mmol/L when the potassium concentration is less than 3mmol/L, assuming a normal distribution between cells and the intracellular space, and a linear relationship between plasma potassium and body deficit (which has been described, i.e. 0.27 mmol/L/100 mmol deficit/70 kg), exists. The rate of administration of potassium will be influenced by the presence and seriousness of the pathophysiological changes caused by hypokalaemia. The underlying disorder should also be treated simultaneously.

Answer 81

d. acetazolamide acetazolamdie has been known to cause lactic acidosis but is less common than the other drugs listed unless there is a 5th option not remembered

Answer 82

b. increased bleeding and normal aptt and inr Bleeding because cold = we know this Haemtology analyzer in labs warms blood to 37.2 degrees (fixes hypothermia on sample)

Answer 83

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

Answer 84

c) 8 E=2 V=2 M=4 Total= 8

Answer 85

a. Electromyography of internal laryngeal muscles 0.5-2mA stimulating current given by surgeon's probe --> if laryngeal nerve located --> motion of vocal cords --> converts laryngeal muscle action potential into EMG signal Monitored via NIM tube - adjunctive tool (nerve exposure and direct visualisation are gold standards for RLN location) - converts laryngeal muscle APs into electromyography signals when RLN stimulated - ETT has integrated surface electrodes that contact true VC to monitor EMG activity -> assess position via direct laryngoscopy or respiratory EMG waveform

Answer 86

5. Long Thoracic Nerve

Answer 87

d) No difference Repeat Conclusions In patients undergoing mechanical ventilation, the rate of survival at 90 days associated with the use of an energy-dense formulation for enteral delivery of nutrition was not higher than that with routine enteral nutrition. (Funded by National Health and Medical Research Institute of Australia and the Health Research Council of New Zealand; TARGET ClinicalTrials.gov number, NCT02306746. opens in new tab.) https://www.nejm.org/doi/full/10.1056/NEJMoa1811687 Study details: Population: 3,957 mechanically ventilated ICU patients. Intervention: Energy-dense EN (1.5 kcal/mL) at 100% target rate. Comparator: Standard EN (1.0 kcal/mL) at 100% target rate. Duration: Until ICU discharge or cessation of EN. Primary outcome: 90-day all-cause mortality. Findings: 90-day mortality: No significant difference (26.8% vs 25.7%; p=0.58). Ventilator-free days: No significant difference. Incidence of VAP, AKI, or other complications: No significantdifference. Energy delivery: Higher in the energy-dense group (29 vs 21 kcal/kg/day). Protein delivery: Similar between groups (≈1.1 g/kg/day).

Answer 88

d) Esmolol Management of Arrhythmias After Heart Transplant https://www.ahajournals.org/doi/10.1161/CIRCEP.120.007954 In asymptomatic patients, additional cardiac monitoring such as 24-Holter or an event monitor can be useful to assess the SVT burden, and a trial of atrioventricular nodal blockers (β-blockers preferably) can be attempted with caution in view of potential risk of bradycardia. Calcium channel blockers such as diltiazem and verapamil are contraindicated in patients taking immunosuppression such as tacrolimus and cyclosporine as it can impair the metabolism CYP3A, which increases the levels of these drugs potentially causing renal toxicity. The use of adenosine in the management of SVT has remained a subject of controversy for over a quarter century. In the past, adenosine was contraindicated in patients post-OHT due to its supersensitivity and presumed risk of prolonged atrioventricular block. Thus, based on the aforementioned data, in patients with OHT, adenosine is feasible and safe at reduced doses (starting at 1.5 mg for patients ≥60 kg) as long as patients are closely monitored, with dose escalation as needed. Furthermore, the 2010 American Heart Association guidelines on advanced cardiovascular life support also recommended lowering the initial dose of adenosine to 3 mg for the acute management of SVT in patients with OHT.

Answer 89

B) Thrombin rivaroxiban 10 dabigatran thrombin direct thrombin inhibitor (2a) reversal = idarucizumab Normal TT (thrombin time) = no dabigatran effect Rivaroxaban & apixaban are direct F10a inhibitors Reversal = Andexanate alpha

Answer 90

a. 1% PPV = TP / TP + FP NPV = TN/ (TN + FN) Sensitivity = TP / (TP+FN) Specificity = TN / (TN+FP) i.e. what is the positive predictive value (PPV) for this test PPV= TP/ TP +FP Negative Predictive Value = TN / TN + FN Prevalence of 1/1000 Sensitivity of 100% Specificity of 90% Of patients that are disease positive in population of 1000 TP = 1 FN = 0 -> 100% sensitivity Of patients that are disease negative in population of 1000 FP = 99 TN = 900 -> 90% Specificity PPV= TP/ TP + FP = 1/ 1 + 99 = 1/100 =1% NPV= TN/ TN + FN =900/ 900 + 0 = 1/1 = 100%

Answer 91

d) Alprostadil https://www.rch.org.au/piper/neonatal_medication_guidelines/Alprostadil_(Prostin_VR)_%E2%80%93_(Prostaglandin_E1)/ Alprostadil (PROSTAGLANDIN E1) is a synthetic prostaglandin used to relax the ductus arteriosus in early post-natal life, where a patent ductus is critical for survival, including Tetralogy of Fallot, pulmonary atresia, pulmonary stenosis, tricuspid atresia and transposition of the great arteries. Dose To open a closed ductus arteriosus: 0.1 micrograms/kg/minute (100 nanograms/kg/min). An effect is usually seen within 30-60 minutes. Reduce the dose once an effect is seen or as directed by a Consultant.1 Doses > 0.1 micrograms/kg/minute are rarely more effective and may cause serious adverse effects.3 To maintain patency of ductus arteriosus: 0.01 to 0.02 micrograms/kg/minute (10-20 nanograms/kg/min).1, 2 For persistent pulmonary hypertension of the newborn (PPHN): 0.01 to 0.05 micrograms/kg/minute (10-50 nanograms/kg/min).2

Answer 92

a) Pupillary constriction and reaction to light Stellate ganglion block causes ipsilateral Horner's Syndrome: Ptosis (eyelid droop) Miosis (constricted pupils) Anhydrosis (loss of sweating) Enophthalmos (sinking of eyeball into the bony cavity that protects the eye) *Pupillary constriction in response to light is controlled by the Edinger-Westphal nucleus of CN3, which will remain intact.

Answer 93

B. Wedge PAC and insert BB Pulmonary rupture Miller: - Position pt with bleeding lung dependent - Perform endotracheal intubation, oxygenation, airway toilet - Isolate lung by endobronchial DLT or SLT or bronchial blocker - Withdraw PAC several centimetres, leaving it in the main PA. Do not inflate the balloon (except with fluoroscopic guidance) - Position pt with isolated bleeding lung nondependent. Administer PEEP to the bleeding lung if possible - Transport the patient to medical imaging for diagnosis and embolisation if feasible

Answer 94

REPEAT 20.2 b. Unstable angina UTD: Unstable angina (UA) and acute non-ST elevation myocardial infarction (NSTEMI) differ primarily in whether the ischemia is severe enough to cause sufficient myocardial damage to release detectable quantities of a marker of myocardial injury (troponins): ●UA is considered to be present in patients with ischemic symptoms suggestive of an ACS and no elevation in troponins, with or without electrocardiogram changes indicative of ischemia (eg, ST segment depression or transient elevation or new T wave inversion). ●NSTEMI is considered to be present in patients having the same manifestations as those in UA, but in whom an elevation in troponins is present. MINS: Myocardial injury after non-cardiac surgery (up to 30 days post-op): 1. Elevated postop troponin 2. Resulting from myocardial ischaemia (i.e. no evidence of a non-ischaemic aetiology), not requiring an ischaemic feature (i.e. no chest pain, no ECG change) VISION studies (Vascular Events in Noncardiac Surgery Patients Cohort Evaluation) demonstrated that severity of MINS strongly associated with 30-day mortality after NCS. hs-cTnT <20ng/L ~ 0.5% 30 day mortality 20-64ng/L ~3% 30 day mortality 65-999 ng/L ~9% 30 day mortality >1000ng/L ~30% 30 day mortality Whilst VISION trial identified MINS in at risk patients, the question now becomes what interventions are available to prevent this complication?

Answer 95

c) Normal 23 DPG https://www.bjaed.org/article/S2058-5349(20)30157-8/fulltext Intraoperative cell salvage (ICS) collects, washes, and reinfuses autologous red blood cells lost during surgery. The washing process removes plasma, platelets, white cells, and debris — leaving packed red cells suspended in saline. The composition of this salvaged blood is therefore quite different from whole blood. Advantages of Cell salvage: 1. reduction in need for donor blood transfusion 2. no restrictive transfusion triggers 3. superior oxygen delivery compared to donor blood -> red cells retain elliptical profiles and retain deformability -> increased concentrations of 2,3 DPG and ATP -> evidence supports early transfusion as oxygen carriage and deformability degrade over time 4. lack of adverse immunolgical effects -> no sensitisation to antigens; Kell, duffy or Lutheran -> donor blood transfusion causes dose-dependant transfusion related immunosupression (TRIM) this can lead to increased risk of post-op infection and posible increased risk of tumour growth in patients undergoing cancer surgery 5. Fulfills criteria for certain cultural groups to receive blood transfusion (JW) 6. Financial benefits despite equipment and staffing costs Disadvantages: 1. The salvaged blood contains clinically insignificant concentrations of clotting factors and platelets, and when large volumes of blood are processed, the use of clotting factors, platelets, and calcium may be necessary. 2. High initial cost of equipment and training 3. Processing of blood requires a few minutes, blood may not be immediately available in time critical scenariois 4. REinfusion hypotension can occur and can be very marked requiring vasopressors 5. More labor intensive than donor blood, increased diligence required when collecting blood 6. May not be appropriate for all situations of operative blood loss ->Malignancy: use is controversial but supported in some instances (cystectomy radical prostatectomy, nephrectomy) ->Sepsis: not absolute contraindication but colume of contaminated material and pus must be limited ->Haemaglobonpathy: relative contraindication in sickle cell trait/disease and thalassaemia due to red cell fragility and potential for haemolysis

Answer 96

b. low frequency high amplitude Changes in the electroencephalogram during anaesthesia and their physiological basis https://academic.oup.com/bja/article/115/suppl_1/i27/234261 Figure 1 shows raw EEG waveforms during isoflurane anaesthesia. During light anaesthesia: -amplitude is shallow and frequency is high. When a higher concentration is administered: -amplitude deepens and EEG frequency slows. During deep anaesthesia: - a ‘burst and suppression’ pattern becomes apparent, characterized by extreme activity, represented by high-frequency, large-amplitude waves (bursts), alternating with flat traces (suppression). - This pattern, excluding brain ischaemia or other factors, indicates that anaesthesia is too deep. Beyond this, flat traces become dominant and, eventually waveforms are no longer apparent. During isoflurane, sevoflurane or propofol anaesthesia, this sequence of changes in pattern is almost identical. The major difference in EEG between the volatile agents (isoflurane or sevoflurane) and propofol is apparent in power in the theta range. During propofol anaesthesia, theta power remains low regardless of concentration, but during isoflurane or sevoflurane anaesthesia, it increases at surgical concentrations of anaesthesia.

Answer 97

8. Suprascapular nerve

Answer 98

c. I:E ratio 1:3 SUMMARY: * The ventilator should initially be set to deliver VT ≤6–8 ml kg–1 PBW and PEEP=5 cm H2O. * Individualised PEEP can prevent progressive alveolar collapse. Recruitment manoeuvres can reverse alveolar collapse, but have limited benefit without sufficient PEEP * An I:E ratio of 1:1, which has been characterised as providing a ‘balanced stress to time product’, was associated with attenuation of lung damage. Evidence for specific I:E ratio lacking -> no recommendation. (^ mean airway P but reduces peak airway P) * high ventilator driving pressure (ΔP=plateau pressure [Pplat]–PEEP) has been recognised as a significant determinant of lung injury and is linked to PPCs -------------- BJA Lung-protective ventilation for the surgical patient: international expert panel-based consensus recommendations: An expert consensus was reached for 22 recommendations and four statements. The following are the highlights: (i) a dedicated score should be used for preoperative pulmonary risk evaluation; and (ii) an individualised mechanical ventilation may improve the mechanics of breathing and respiratory function, and prevent PPCs. The ventilator should initially be set to a tidal volume of 6–8 ml kg−1 predicted body weight and positive end-expiratory pressure (PEEP) 5 cm H2O. PEEP should be individualised thereafter. When recruitment manoeuvres are performed, the lowest effective pressure and shortest effective time or fewest number of breaths should be used. Inspiratory/expiratory ratio: Several studies have compared prolonged inspiratory-to-expiratory (I:E) ratios to the 1:2 ratio commonly used during mechanical ventilation. An I:E ratio of 1:1, which has been characterised as providing a ‘balanced stress to time product’, was associated with attenuation of lung damage. Prolonged I:E ratio increases mean airway pressure and concomitantly reduces peak airway pressure. Studies using prolonged inspiratory times have described beneficial effects, including increased CRS and PaO2, lower alveolar–arterial gradient, and reduced inflammatory markers. Given the lack of evidence for a clear benefit of a specific I:E ratio, no recommendation was offered by the panel. However, the panel noted that optimisation of inspiratory time for individual patients can be achieved by monitoring parameters, such as oxygenation, CRS, and ΔP. Intraoperative FIO2 Increased FIO2 during mechanical ventilation is administered to prevent or correct hypoxaemia, but may result in hyperoxia. The negative effects of hyperoxia are not clear, but it has been suggested that it may increase oxidative stress, peripheral vascular and coronary artery vasoconstriction, decrease cardiac output, increase resorption atelectasis, and increase the rate of PPCs. Recommendations for optimal use of oxygen and current evidence regarding the association between hyperoxaemia and clinically relevant outcomes during intraoperative mechanical ventilation are lacking. Few studies have revealed a protective effect of hyperoxaemia, some report an association with mortality, whilst others show no association with clinically relevant outcomes. Therefore, in the absence of evidence, the most prudent course of action during mechanical ventilation is to maintain normoxaemia. SpO2 monitoring can assist in the detection of hypoxaemia, but during oxygen therapy SpO2 cannot detect hyperoxia. Whilst SpO2 monitoring reduces the incidence of hypoxaemia, it does not improve the overall patient outcomes and does not reduce morbidity and mortality. Therefore, once the airway is secured, FIO2 should be set to ≤0.4 with the goal of using the lowest possible FIO2 to achieve normoxia (or SpO2 ≥94%) Unnecessarily high FIO2 should be avoided. Administering lower FIO2 will not only decrease the risk of hyperoxia, but will also reduce the masking effect of oxygen therapy and allow for earlier diagnosis of gas-exchange impairment.

Answer 99

b. Rocuronium 1.2mg/kg Cis not appropriate for intubation Sux with K 6.3 is risky. (I've never heard of reduced dose)

Answer 100

d. 65 to 85 per hundred 85% of australians are CMV positive by the age of 40 https://www.blood.gov.au/system/files/documents/cmv-blood-components.pdf

Answer 101

a) 50mg six times a day 42mg IV Morphine = 126mg Oral Morphine 126/8= 15.75 15.75 x 25 = 393.75 (*400mg/day Tapentadol) Oral Tapentadol 25mg = 8mg Oral Morphine Oral Oxycodone 5mg = 8mg Oral Morphine Oral Tramadol 25mg = Oral Morphine 5mg Oral Hydromorphone 4mg = Oral Morphine 20mg S/L Buprenorphine 200mcg = 8mg Oral Morphine IV Oxycodone 5mg = Oral Morphine 15mg IV Morphine 5mg = Oral Morphine 15mg IV Hydromorphone 1mg = Oral Morphine 15mg

Answer 102

a) dulaglutide The primary mechanism of action of dulaglutide, as an incretin mimetic hormone or an analogue of human glucagon-like peptide-1, is to increase insulin secretion when glucose levels are elevated, decrease glucagon secretion, and **delay gastric emptying** in an effort to lower postprandial glucose level. Acarbose: Acarbose is a complex oligosaccharide that acts as a competitive, reversible inhibitor of pancreatic alpha-amylase and membrane-bound intestinal alpha-glucoside hydrolase. Pancreatic alpha-amylase hydrolyzes complex carbohydrates to oligosaccharides in the small intestine By delaying the digestion of carbohydrates, acarbose slows glucose absorption, resulting in a reduction of postprandial glucose blood concentrations. -> causes delayed gastric emptying but is not necessarily a part of its therapeutic effect

Answer 103

c) Supine Moving from upright to supine affects the respiratory function of the tetraplegic and high paraplegic individual differently to the able-bodied person. The increase in abdominal girth when sitting in tetraplegia is secondary to decreased abdominal muscle strength and the associated increased abdominal wall compliance. In the seated position, the abdominal contents are less supported by the decreased abdominal wall muscle tone and fall forward, increasing the waist size and lowering the diaphragm. In able-bodied subjects, the FVC is reduced in the supine position, whereas in tetraplegia it is increased. Postural changes are associated with symptoms; patients with an acute, high SCI report less breathlessness when supine compared to sitting. In the supine position, the weight of the abdominal contents forces the diaphragm to a higher resting level so that contraction produces greater absolute excursion of the diaphragm; an effect that can be increased when the person with tetraplegia is tipped 15° head down from supine such that the vital capacity rises by a further 6%

Answer 104

a. Bleeding ECMO complications: - patient complications: bleeding & coagulopathy most common - mechanical complications: access insufficiency common Blue book 2017

Answer 105

d) >6 Medical emissions of N2O account for <4% of all emissions of N2O, the majority originating from microbial action on nitrogenous fertilizers N2O is responsible for majority of ongoing ozone depletion and ~6% of anthropogenic global warming Worldwide anaesthetic N2O use is estimated to contribute 1-3% of N2O global emissions.

Answer 106

b. serum separating tube (gold top tube or red) Potassium EDTA (purple) -> FBC sodium citrate (blue) -> clotting screen/Rotem sodium oxalate (green) -> heavy metals (lead copper zinc) -> glucose, blood alcohol

Answer 107

c. 30cmH2O paeds 20 cmH2O

Answer 108

c. 5 min Circulatory determination of death in the context of organ donation 12 Circulatory determination of death in the context of organ donation requires the absence of spontaneous movement, breathing and circulation. Absence of circulation is evidenced by absent arterial pulsatility for 5 minutes, using intra-arterial pressure monitoring and confirmed by clinical examination (absent heart sounds and/or absent central pulse). In cases without an arterial line, electrical asystole should be observed for 5 minutes on the electrocardiogram and confirmed by clinical examination. 13 For the purposes of organ donation, circulatory determination of death should be documented using a specific form (see Appendix E) to demonstrate explicitly that all criteria set out in this Statement are met. The same criteria should be listed in local hospital forms

Answer 109

d. Asthma What are the causes of an elevated DL CO ? The causes of an elevated DLCO are numerous, but is most commonly caused by asthma and obesity (increased pulmonary blood flow). Pulmonary hemorrhage is an additional important cause. Other causes of ^DLCO: asthma (^pulmonary BV), polycythemia, pulmonary haemorrhage (false elevation), large lung volumes, high altitude, left to right cardiac shunt, exercise prior to test (^CO) Emphsema, ILD --> decreased DLCO w/ obstruction Sarcoid -> decreased DLCO w/ restriction Obesity: normal DLCO w/ restriction https://www.atsjournals.org/doi/pdf/10.1513/AnnalsATS.201605-355CC

Answer 110

f. perindopril Hypotensive transfusion reactions, which account for almost 3% of all transfusion reactions, are associated with patients treated with angiotensin-converting enzyme inhibitors. The current hypothesis suggests that they are caused by bradykinin-induced vasodilation in the absence of allergic, hemolytic, or septic mechanisms. The hypotension observed frequently is unresponsive to conventional therapy with catecholamines. The suggested intraoperative management includes cessation of transfusion and washing red blood cells before blood replacement. Hypotensive reactions to transfusion may not always be recognized. To prevent these reactions, clinicians have several options: they may discontinue the ACE inhibitor (elective transfusion), not use a leukoreduction filter (if the patient has no absolute requirement for leukoreduced blood components), use washed cellular components, or use components that have undergone leukoreduction at the collection facility or the hospital blood bank before transfusion (since bradykinin is degraded during storage).

Answer 111

d) 6 months ANZCA PS 12 perioperative smoking https://www.anzca.edu.au/getattachment/5deb6800-e8f9-453f-b9a6-a151a9323249/PG12(POM)-Guideline-on-smoking-as-related-to-the-perioperative-period-(PS12) Effects of quitting 1 day - Reduced HbCO3-> increased O2 content - Reduced nicotine/ SNS stimulation 3 weeks - Increased wound healing 6-8 weeks - Reduced sputum volume - Increased lung function 6 months - Increased immune function

Answer 112

a) Smaller bolus smaller total dose Marsh = more, Schnider = sparing Marsh based on mass alone = MMA Schnider includes senescence, sex = SSS

Answer 113

b. Suprascapular nerve involves the posterior shoulder joint more. NB: If having shoulder surgery and cant do interscalene do suprascap and axillary block Suprascapula nerve (C5,6) - innervates supra and infraspinatus - comes off superior trunk of the brachial plexus, and is usually anaesthetised by an interscalene block - sensory innervation to 70% posterior-superior shoulders and portion of the anterior axilla and the ACJ Supraclavicular nerve (C3,4) - provides sensory to the 'cape' of the shoulder - component of the cervical plexus block - lies outside the brachial plexus - commonly missed during supraclavicular brachial plexus blocks Subscapular nerve: - subscapularis - medial rotation shoulder Dorsal scapular nerve: - branch of the brachial plexus - supplies rhomboid major muscle, rhomboid minor muscle, and levator scapulae muscle - causes the scapula to be moved medially towards the vertebral column - Dorsal scapular nerve syndrome can cause a winged scapula, with pain and limited motion Thoracodorsal nerve: - thoracodorsal nerve also branches from the posterior division of the brachial plexus - this nerve innervates the latissimus dorsi muscle. Interscalene block reliably anaesthetises the roots/trunks of C5–C7, thus covering: Suprascapular Axillary Lateral pectoral Musculocutaneous Partially long thoracic nerve However, coverage can be incomplete, especially for the suprascapular nerve, if the local anaesthetic spread does not reach the posterior division of the upper trunk. The posterior shoulder capsule and supraspinatus/infraspinatus tendons (common pain sources after rotator cuff surgery) are primarily innervated by the suprascapular nerve. - innerates osseous scapula and posterior humerus head - should have been effectively blocked with BP-ISB (but would cause posterior shoulder pain and can be blocked separately) OR supraclavicular C3/4 - Not part of brachial plexus; posterior cutaneous supply The shoulder receives sensory innervation from the cervical (C3,4) and brachial plexuses (C5,6). Shoulder nerve supply: (SA-SLaM the scapula) - Major sensation (motor & sensory) = suprascapular nerve (upper trunk of the brachial plexus) and axillary nerve (posterior cord of the brachial plexus). - Minor sensation = SLaM: subscapular, lateral pectoral, musculocutaneous ## Footnote https://resources.wfsahq.org/atotw/the-shoulder-block/

Answer 114

d) Reduced time to resumption of oral intake Intraoperative dexamethasone administration reduces postoperative pain, nausea and vomiting and time to resumption of oral intake after tonsillectomy (S) (Level I [Cochrane Review]), with no increase in adverse effects (U) (Level I [Cochrane Review]). https://www.anzca.edu.au/resources/college-publications/acute-pain-management/apmse5.pdf

Answer 115

b. sinus tachy with BBB The most correct answer would be Trifasicular block: RBBB with LAD (RBBB with left anterior hemiblock) and 1st degree heart block Barash 8E 2017: The term bifascicular block often refers to block in the right bundle and one of the two major fascicles of the left bundle. RBBB with left anterior hemiblock is present when the ECG shows an RBBB with a left axis deviation (usually greater than −60 degrees) in the absence of an inferior myocardial infarction. Complete RBBB with right axis deviation (greater than 90 degrees) is indicative of RBBB and left posterior hemiblock in the absence of a lateral myocardial infarction or evidence of right-sided heart failure. The term trifascicular block is used to describe first-degree AV block in the presence of bifascicular block. Is it necessary to insert a temporary pacemaker before general anesthesia for an asymptomatic patient with bifascicular or trifascicular block? The risk for progression to complete heart block in asymptomatic patients with bifascicular block is low. Further, no clinical characteristics have been identified that accurately predict the risk of development of complete heart block. Therefore, routine PPM implantation in patients with asymptomatic bifascicular block is not recommended. Observations made in the perioperative period have suggested that development of complete heart block during general anesthesia is also rare; therefore, it is generally not recommended that patients undergo temporary pacemaker insertion before general anesthesia. However, it is advisable to have an external pacemaker available in the operating room.

Answer 116

c. Hypocalcaemia Laryngospasm is a rare, but serious and potentially lethal, complication of hypocalcemia in adults. In every adult presenting with acute dyspnea and stridor, the possibility of hypocalcemia should be considered. Hypocalcemia should be treated promptly. Hypomagnesaemia less so (but also RF) ↑risk laryngospasm in thyroid surgery from: - superior laryngeal nerve injury - hypocalcaemia secondary to accidental parathyroidectomy

Answer 117

d. Noradrenaline Acute PE --> likely acute RHF Milrinone/dobutamine will decrease PVR but will also decrease SVR Isoprenaline = non-selective B agonist (^inotropy/chronotropy) but decreases SVR. Used in bradycardia and AV block Norad may ^RV inotropy by improving coronary perfusion so should be considered in setting of obstructive shock secondary to PE Supportive Management of Massive PE Coexisting left ventricular systolic dysfunction and diastolic dysfunction complicate the management of heart failure patients with massive PE. Although a common strategy in response to systemic arterial hypotension is to prescribe a fluid bolus, volume loading may worsen biventricular failure, pulmonary edema, and hypoxemia. An initial trial of volume expansion, limited to 250 to 500 mL, may be attempted in those heart failure patients without evidence of increased right-sided filling pressures or pulmonary edema.6 Although non–heart failure patients generally respond well to pure vasopressors for hemodynamic support in massive PE, many heart failure patients will not tolerate the isolated increase in systemic vascular resistance. PE patients with heart failure may require an agent with mixed vasopressor and inotropic properties such as norepinephrine, epinephrine, or dopamine. Whereas LV function often becomes hyperdynamic to compensate for RV failure, the presence of underlying LV systolic dysfunction in heart failure patients may limit the patient’s ability to maintain normal systemic cardiac output and may necessitate the addition of inotropes. https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.108.803965

Answer 118

A. Magnesium TdP For all patients with congenital LQTS and a history of syncope, seizures, or resuscitated SCA, we recommend treatment with a beta blocker [8]. In general, we suggest propranolol or nadolol, given their superior efficacy in this patient population. The use of atenolol and metoprolol has been associated with an increased rate of recurrences [25]. In addition, if the symptom was resuscitated SCA, then an ICD as secondary prevention is indicated as well in most circumstances | double check UTD bb ## Footnote https://www.uptodate.com/contents/congenital-long-qt-syndrome-treatment Statpearls Acute - mag Long term prevention of TDP - BB Treatment / Management The goal of management is the prevention of lethal arrhythmias such as torsade de pointes (TdP). As described earlier, the longer the QT interval, the higher the risk is for torsade de pointes. A patient who is hemodynamically unstable should receive non-synchronized electrical defibrillation. Also, first-line treatment is magnesium sulfate, and the benefit is seen independent of serum magnesium level. In those who do not respond to magnesium sulfate, temporary transvenous overdrive pacing should be considered. Isoproterenol and Class IB antiarrhythmic drugs, such as lidocaine and phenytoin may also be used. [5][11][12][13] For long-term management in congenital Long QT syndrome, beta-blockers are the first line choice, and they help prevent ventricular arrhythmias by stabilizing ventricular action potential and helping block sympathetic surges associated with arrhythmias. An implantable cardioverter defibrillator (ICD) is recommended in patients with Long QT syndrome who were resuscitated from a cardiac arrest. It is also indicated in those whom have beta-blocker resistant symptoms or have contraindications to beta-blockers. It also may be indicated in asymptomatic individuals who are suspected to be at high risk for ventricular arrhythmias.

Answer 119

d. Age >3 Can also be strabimus sugery if Age >3 not there. Key risk factors for paeds: - age ≥3 - postpubertal females - certain surgeries (mainly tonsillectomy and eyes) Other risk factors - FHx PONV, Hx PONV/travel sickness, surgery >30mins, volatile, anticholinesterases (hence use sugammadex), long acting opioids Bolded RFs from Eberhart: 10/10/30/50/70% PONV risk

Answer 120

b. pneumonia Air bronchogram

Answer 121

c. Doxycycline 400mg Insertion of Mirena-> no antibiotics exception is acute PID-> clindamycin Prophylaxis w/o STI Ix before surgical TOP: - doxycyline 100mg PO prior to and 200mg after surgery OR doxycycline 400mg PO 10-12hrs prior to procedure (with food) - alternative = metronidazole 2g PO + 1g azithromycin PO prior to procedure for high-risk pts (covers chlamydia?) https://ranzcog.edu.au/wp-content/uploads/2022/05/Prophylactic-Antibiotics-in-Obstetrics-and-Gynaecology.pdf

Answer 122

b) 2,5 Air: 1, 5 Oxygen: 2, 5 N2O: 3,5 CO2: 2, 6 He: 2, 4 Cyclopropane 3, 6 Entonox 7 (1 pin) ACONE for order ACE for 1 C has 6, everything else is 5

Answer 123

D) POSTERIOR CUTANOUS NERVE OF THE THIGH - purely cutaneous - skin of posterior thigh, popliteal fossa and proximal leg lat / int and medial cutaneous of the thigh femoral nerve (posterior division) saphenous obturator (post branch) tibial nerve - articulates to the knee sciatic (common perineal nerve) L3/4 = extensors of knee L5/S1 = flexors of the knee ## Footnote Anatomy for Anaesthetists

Answer 124

b) PR indomethacin APMSE 5th ed 8.6.1.3: Only rectal NSAIDs are effective for reducing post ERCP pancreatitis, particularly indomethacin. A Randomized Trial of Rectal Indomethacin to Prevent Post-ERCP Pancreatitis https://www.nejm.org/doi/full/10.1056/NEJMoa1111103 Nonsteroidal antiinflammatory drugs (NSAIDs) are potent inhibitors of phospholipase A2, cyclooxygenase, and neutrophil–endothelial interactions, all believed to play an important role in the pathogenesis of acute pancreatitis. NSAIDs are inexpensive and easily administered and have a favorable risk profile when given as a single dose, making them an attractive option in the prevention of post-ERCP pancreatitis. Preliminary studies evaluating the protective effects of single-dose rectal indomethacin or diclofenac in post-ERCP pancreatitis have been conducted, and a meta-analysis suggests benefit. Results A total of 602 patients were enrolled and completed follow-up. The majority of patients (82%) had a clinical suspicion of sphincter of Oddi dysfunction. Post-ERCP pancreatitis developed in 27 of 295 patients (9.2%) in the indomethacin group and in 52 of 307 patients (16.9%) in the placebo group (P=0.005). Moderate-to-severe pancreatitis developed in 13 patients (4.4%) in the indomethacin group and in 27 patients (8.8%) in the placebo group (P=0.03). Conclusions Among patients at high risk for post-ERCP pancreatitis, rectal indomethacin significantly reduced the incidence of the condition.

Answer 125

Hypoplastic mandible (micrognathia) – difficult intubation § Pierre Robin sequence § Treacher Collins § Hemifacial microsomia (Goldenhar syndrome) Midface hypoplasia – difficult bag-mask ventilation § Apert syndrome § Crouzon syndrome § Pfeiffer syndrome § Saethre-Chotzen syndrome Macroglossia – difficult bag-mask ventilation AND difficult intubation § Hurler’s/Hunter’s syndrome (mucopolysaccharidoses) § Beckwith-Wiedemann syndrome § Down’s syndrome https://www.frca.co.uk/Documents/250%20The%20Difficult%20Paediatric%20Ai Mucopolysaccharidoses, Down syndrome, muscular dystrophies, and other neurologic disorders have been associated with obstructive sleep apnea Prevalence of OSAS. Genetic Disorder Prevalence of OSAS Neuromuscular diseases 69.2% Prader–Willi syndrome 94.7% Arnold–Chiari syndrome 80% Achondroplasia 100% Crouzon syndrome 100% https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8156845/ | https://www.frca.co.uk/Documents/250%20The%20Difficult%20Paediatric%20Ai

Answer 126

Mechanical allodynia Allodynia IASP definition: pain due to a stimulus that does not normally provoke pain “The term allodynia was originally introduced to separate from hyperalgesia and hyperesthesia, the conditions seen in patients with lesions of the nervous system where touch, light pressure, or moderate cold or warmth evoke pain when applied to apparently normal skin.” References IASP https://www.iasp-pain.org/resources/terminology/?ItemNumber=1698 And APMSE 5th Ed pg64. "Ans = allodynia – normal touch = painful Dysaesthesia = normal touch or even just spontaneous pain. Unpleasant, abnormal sense of touch (e.g. burning, wetness, can be pain) Paraesthesia = abnormal sensation (or loss of sensation) Hyperalgesia = pain out of proportion"

Answer 127

C. Shockable: Adrenaline 1mg after 2nd shock Then every second cycle Amioderone 300mg after 3 shocks Non-shockable Adrenaline 1mg immediately (then every second cycle)

Answer 128

INR Has been asked before where hypoglycaemia was wrong answer SOFA - MAP/vasopressors, GCS, PaO2/FiO2 ratio +/- mechanical ventilation, PLT, bili, creat +/- U/O (Pretty Busy Cells) i.e. CVS/CNS/Resp/Liver/Renal SOFA <9 - <33.3% chance mortality SOFA 10-11 - 50% chance mortality SOFA >12 - 95.2% chance mortality

Answer 129

a) low profile Resource: ANZCA PG56(A)BP Difficult airway equipment BP 2021 First generation SADs (page 19) “classic design LMAs (cLMAs) with their low profile and lack of preformed curve have several advantages.”

Answer 130

A High risk of creating a false passage Blue book 2017 page 21 O2 CISCO O2 → apply 100% O2 to trache site and face C → check cuff is still up, remove caps and check CO2 trace I → remove inner tube +/- replace with new one S → attempt to pass suction catheter down trache C → take cuff down O → consider oral airway

Answer 131

No remembered options. Answer could be: Traumatic Brain injury Direct allergy Cardiac Failure SAFE trial

Answer 132

c) Cryo ?fibconc first line choice when bleeding?

Answer 133

HOCM if these remembered options are correct Alternative is Aortic Stenosis which is more common than HOCM in this age group As per Cardiology

Answer 134

b) Long thoracic The shoulder receives sensory innervation from the cervical (C3,4) and brachial plexuses (C5,6). Shoulder nerve supply: - Major sensation (motor & sensory) = suprascapular nerve (upper trunk of the brachial plexus) and axillary nerve (posterior cord of the brachial plexus). - Minor sensation = SLaM: Subscapular, LAteral pectoral, Musculocutaneous - Rotator cuffs are supplied by: axillary, suprascapular & subscapular nerves - SAX -SLaM Long thoracic innervates serratus anterior"

Answer 135

d) VT https://litfl.com/ventricular-tachycardia-monomorphic-ecg-library/

Answer 136

C - genitofemoral "I twice get laid on Fridays” Iliohypogastric, Ilioinguinal, Genitofermoral, Lateral cutaneous nerve of the thigh, Obturator, Femoral

Answer 137

a) Spinal all are safe in MS The MAB I think is to signify advanced MS (Really there isn’t heaps of evidence) - epidural / regionals - safe - spinal - probably safe - conflicting evidence that it might cause a MS flare - however Cat A and sounds like at least mod MS and still on DMARDS during pregnancy - triggers for MS - stress, sleep deperivation, hyperthermia, infection https://www.openanesthesia.org/keywords/multiple-sclerosis/#:~:text=MS%20is%20not%20a%20contraindication,relapse%20rate%20using%20epidural%20anesthesia "

Answer 138

Repeat 23.1 E. distance from anterior surface of dens to posterior surface of anterior arch of atlas The atlantodental interval is used in the diagnosis of atlanto-occipital dissociation injuries and injuries of the atlas and axis. The anterior atlantodental interval is the horizontal distance between the posterior cortex of the anterior arch of the atlas (C1) and the anterior cortex of the dens in the median (midsagittal) plane Normal values for anterior atlantodental interval are: radiographs: adults: males: <3 mm females: <2.5 mm 1 (although most authors describe <3 mm ref) children: <5 mm ref CT: adults: <2 mm

Answer 139

b) 20mmHg Mild: 20-40mmHg (ESC & AHA) Moderate: 40-55mmHg Severe: >55mmHg

Answer 140

d) 0.9% Saline Other fluids are all electrolyte free except 0.9% Saline ""Electrolyte-free hypotonic solutions such as glycine, mannitol, and sorbitol solutions are used as distending media to enable monopolar electrical systems to be used for coagulation and tissue resection. However, with the low viscosities, these irrigation fluids bear potential risks of rapid fluid absorption resulting in fluid overload, dilutional hyponatremia, and subsequent side effects. Nowadays, with the advancement in technology, bipolar electrical systems can be used in new operative arthroscopic and hysteroscopic equipment. T his enables electrolyte-containing isotonic solutions, for example, normal saline and lactated Ringer solution, to be used as irrigation media. This reduces complications of electrolytes disturbance by irrigation fluids. However, the risks of fluid overload or surrounding tissue oedema remain."" Monopolar Examples – electrolyte free hypotonic solution (which are less conductive) - sorbitol 3.5%, glycine 1.5%, mannitol 3% Bipolar Examples - saline, lactated Ringer Glycine toxicity – inhibitory CNS GABA/NMDA potentiation, cardiodepressant, nephrotoxicity

Answer 141

none of the remembered options Airway pressure release ventilation (APRV) is an open-lung mode of invasive mechanical ventilation mode, in which **spontaneous breathing is encouraged**. APRV uses **longer inspiratory times**; this results in **increased mean airway pressures**, which aim to improve oxygenation. Brief releases at a lower pressure facilitate carbon dioxide clearance. The terminology and methods of initiation, titration, and weaning are distinct from other modes of mechanical ventilation. The use of APRV is increasing in the UK despite a current paucity of high-quality evidence high intrathoracic pressure decreases the transmural left ventricular pressure, reducing the work of contraction and increasing cardiac output. In the context of hypoxaemia, a mode of mechanical ventilation that improves arterial oxygenation will improve myocardial oxygen delivery, myocardial function and cardiac output. As APRV is a spontaneous breathing mode, in addition to the benefits of spontaneous ventilation, reduced doses of sedative drugs can often be used, with subsequent reduction of requirement for vasoactive drugs and improvement in haemodynamic state. Airway pressure release ventilation (APRV) is an open-lung mode of invasive mechanical ventilation mode, in which spontaneous breathing is encouraged. APRV uses longer inspiratory times; this results in increased mean airway pressures, which aim to improve oxygenation https://www.bjaed.org/article/S2058-5349(19)30178-7/fulltext https://derangedphysiology.com/main/required-reading/respiratory-medicine-and-ventilation/Chapter%20518/airway-pressure-release-ventilation-aprv-ards

Answer 142

b) Pain score Aldrete score, which includes five elements (activity, respiration, circulation, consciousness, oxygen saturation) [16]. The original scoring system was developed before the invention of pulse oximetry and used the patient's colouration as a surrogate marker of their oxygenation status. A modified Aldrete scoring system was described in 1995 which replaces the assessment of skin colouration with the use of pulse oximetry to measure SpO2. The Modified Aldrete system includes five additional elements that are particularly useful during the Phase II recovery period prior to discharge to home (dressing, pain, ambulation, feeding, urine output)

Answer 143

C) Obstructive Pattern https://thoracickey.com/ventilator-graphics/ Image 9.6

Answer 144

"a) oesophageal stricture Absolute CI: perforated viscus, active GI bleed Oesophageal stricture/tumor/perforation/laceration/diverticulum, https://www.asecho.org/wp-content/uploads/2014/05/2013_Performing-Comprehensive-TEE.pdf " "Relative CI: Weak: post radiation therapy, dysphagia, prior GI surgery, neck restriction Bleeding: oesophageal varices, coaguopathy/thrombocytopenia, recent GI bleed Reflux: active PUD, hiatal hernia, active oesophagitis, Barret's oesophagus, "

Answer 145

a) No increased risk of bleeding There is no evidence that pre-operative aspirin administration resulted in a lower risk of death or thrombotic complications, or a higher risk of haemorrhage. The study aim (and title) was to compare stopping vs continuing aspirin, however the design insisted on all patients stopping aspirin and then being given a single dose of aspirin or placebo prior to surgery (and presumably all patients were given aspirin after surgery) – this method hasn’t really investigated the theory TheBottomLine.org.uk See Poise 2 trial results- increased bleeding

Answer 146

REPEAT Answer: c. Urgent transfer to theatre "Mx of rupture (GA preferred) - induce hypotension - deepen anaesthesia, IV antihypertensives eg labetol to MAP prior to bleed - reverse heparin with protamine (1mg per 100units heparin) - if high extravastated blood load --> may require CT + EVD (external ventricular drain; drains CSF) - usually treated by packing of defect with coils -- emergency craniotormy and clipping if coiling fails If vascular occlusion secondary to arterial thrombus/emboli/misplaced coil/vasospasm – ↑ collataral flow by ↑ MAP to 30-40% above baseline +/- thrombolysis " BJA Anaesthesia for interventional neuroradiology https://academic.oup.com/bjaed/article/8/3/86/293346 Clinical signs of a rise in ICP or a sudden rise in blood pressure with or without a fall in heart rate should alert the anaesthetist to this possibility. Extravasation of contrast may also be seen. The goals are to increase coagulability by reversing heparin, decrease bleeding by lowering blood pressure (to the level before the bleed), control ICP with hyperventilation, head elevation, steroids and osmotic agents, control seizures, and initiate cerebral protection. Once the bleeding is controlled, the pressure may be raised to check for leaks. Usually, the coiling continues; rarely, a ventriculostomy may be required. If the coiling is unsuccessful, a rescue craniotomy and clipping will be required. Management may also involve performance of CT scans and subsequent transfer to ICU.

Answer 147

E3 V3 M4 = GCS 10

Answer 148

c) residual sedation https://pubmed.ncbi.nlm.nih.gov/35085107/#:~:text=Conclusions%3A%20The%20use%20of%20dexmedetomidine,sedation%20or%20bradycardia%20in%20PACU

Answer 149

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

Answer 150

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

Answer 151

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

Answer 152

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

Answer 153

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

Answer 154

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

Answer 155

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

Answer 156

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

Answer 157

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

Answer 158

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

Answer 159

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

Answer 160

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

Answer 161

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

Answer 162

d) Atropine Blue book 2019 Denervated heart. Only drugs that act directly on the heart will be effective. Loss of predominant parasympathetic outflow - so SA node rate now 90-100. Preload dependent - frank starling mechanism. alpha and beta receptors remain intact but attenuated response to catecholamines. - Dopamine/isoprenaline - effective - Norad/adrenaline, dobutamine - exaggerated effect due to ↑adrenoceptor density↑ - depends on intrinsic stores of catecholamines and degree of reinnervation - Phenylephrine/metaraminol (latter mostly direct) - effective but no reflex brady - Ephedrine - less effective (indirect mechanism > direct) digoxin - inotropy OK, but conduction effects at AV node absent (PSNS dennervation)"

Answer 163

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

Answer 164

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

Answer 165

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

Answer 166

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

Answer 167

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

Answer 168

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

Answer 169

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

Answer 170

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

Answer 171

Repeat 22.2 Serotonin syndrome Hyperreflexia differentiates Usually has hypertension and hyperthermia

Answer 172

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

Answer 173

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

Answer 174

Repeat e) Ulnar nerve The cubital fossa is triangular in shape and consists of three borders, a roof, and a floor: Lateral border – medial border of the brachioradialis muscle. Medial border – lateral border of the pronator teres muscle. Superior border – horizontal line drawn between the epicondyles of the humerus. Roof – bicipital aponeurosis, fascia, subcutaneous fat and skin. Floor – brachialis (proximally) and supinator (distally). Contents: - radial nerve - biceps tendon - brachial artery - median nerve My Brother Throws Rad Parties (cub fossa contents medial to lat) Median nerve, brachial artery (branches into radial and ulnar artery), tendon of biceps, radial nerve, posterior interosseous branch of radial N. https://radiopaedia.org/articles/contents-of-the-cubital-fossa-mnemonic#:~:text=A%20useful%20mnemonic%20to%20remember,My%20Brother%20Throws%20Rad%20Parties"

Answer 175

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

Answer 176

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

Answer 177

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

Answer 178

REPEAT increased SVR EMSB handbook CO is reduced after Burn injury 2ry to: - myocardial depressant mediators - decreased blood volume - reduced venous return - increased pulmonary and systemic vascular resistance due to increased levels of catecholamines "Early CVS changes - shock phase first 24-48hrs -> mimics hypovolamic shock - low CO (halved): hypovolaemia, ↓SV, ↓CI, ↑HR. ↑SVR in response, ↑ADH, ↓BF to organs, ↑Hct - ↓oxygen delivery, (APO/bronchospasm/ARDS - particularly in inhalational injury), ↑PVR - resistance to NDMB Late CVS changes (hyperdynamic circulation 72-96hrs post burn) - driven by catecholamine surge - ↑CO proportional to size of burn (part of hypermetabolic response, most commonly seen in patients with>40% burn) - ↑HR, ↓SVR, ↑CI - ↑VO2, ↑VCO2 - ↑↑nAChR (sux ↑↑↑K+)"

Answer 179

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

Answer 180

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

Answer 181

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

Answer 182

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

Answer 183

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

Answer 184

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

Answer 185

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

Answer 186

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

Answer 187

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

Answer 188

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

Answer 189

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

Answer 190

b) Factor VII Redcross: Cryoprecipitate contains most of the following found in fresh frozen plasma: 1. factor VIII 2. fibrinogen 3. factor XIII 4. von Willebrand factor 5. fibronectin Prothrombinex-VF® is a lyophilised concentrate of human coagulation factors it contains: Factors: II IX X small amount of factor VII. Also contains: plasma proteins (human) Antithrombin III (human) Heparin sodium (porcine) Sodium Phosphate Citrate Chloride https://litfl.com/cryoprecipitate/ Fractionated plasma product consisting of Fibrinogen (Factor I), von Willebrand Factor, Factor VIII, and small amounts of Factor XIII and Fibronectin https://www.anzca.edu.au/getattachment/9ec71c61-8a66-4f81-b0f8-c87d65e36298/Australasian-Anaesthesia-2023

Answer 191

A. 30min All have cold perfusion as end point (but differ on withdrawal of life support vs sBP as the starting point) - heart - <30mins from sBP <90mmHg - liver and pancreas - <30mins from withdrawal of cardiorespiratory support - Kidney - Different between Aus and NZ. <60 mins from sBP<50mmHg (Aus). < 90 mins NZ - lungs - <90mins from sBP<50mmHg" Warm ischaemia time: - Time from treatment withdrawal to the start of cold perfusion of the donated organs - Significance is the impact on graft function - Most important phase of WIT begins when the systolic BP is < 60mmHg - This includes the waiting period from the absence of circulation to the declaration of death and the time before initiating the flow of cold perfusate through the cannula Maximum WARM Ischaemia time - Heart 30 mins - Liver 30 mins - Pancreas 30 mins - Kidney 60 mins - Lungs 90 mins Maximum COLD Ischaemia time: - Heart = 4 hrs - Lungs = 6-8hrs - Liver/Pancreas = 12hrs (DBD)/6 hrs (DCD) - Kidneys = 18hrs (DBD)/ 12 hrs (DCD)

Answer 192

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

Answer 193

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

Answer 194

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

Answer 195

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

Answer 196

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

Answer 197

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

Answer 198

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

Answer 199

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

Answer 200

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

Answer 201

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

Answer 202

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

Answer 203

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

Answer 204

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

Answer 205

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

Answer 206

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

Answer 207

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

Answer 208

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

Answer 209

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

Answer 210

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

Answer 211

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

Answer 212

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

Answer 213

d 60cm H2O

Answer 214

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

Answer 215

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

Answer 216

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

Answer 217

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

Answer 218

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

Answer 219

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

Answer 220

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

Answer 221

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

Answer 222

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

Answer 223

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

Answer 224

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

Answer 225

c) Vasopressin - =/↓ PVR Dobutamine: ↓SVR (β2)/PVR https://www.bjaed.org/action/showPdf?pii=S2058-5349%2821%2900031-7 - From UP TO DATE: > At low doses of 1 to 3 mcg/kg per min, dopamine acts primarily on dopamine-1 receptors to dilate the renal and mesenteric artery beds > At 3 to 10 mcg/kg per min (and perhaps also at lower doses), dopamine also stimulates beta-1 adrenergic receptors and increases cardiac output, predominantly by increasing stroke volume with variable effects on heart rate. > At medium-to-high doses, dopamine also stimulates alpha-adrenergic receptors, although a small study suggested that renal arterial vasodilation and improvement in cardiac output may persist as the dopamine dose is titrated up to 10 mcg/kg per min *clinically, the haemodynamic effects of dopamine demonstrate individual variability Dobutamine (inodilator): - selective β1-agonist that increases cardiac contractility and reduces pulmonary vascular and systemic vascular resistances Vasopressin: - vasopressin may have pulmonary vasodilatory effects in addition to a systemic vasoconstrictive effect Milrinone (inodilator): - the phosphodiesterase-3 inhibitors, milrinone and enxoimone, have positive inotropic effects combined with the capacity to reduce RV afterload (‘inodilators’) without significant chronotropic effect, but they can be associated with significant systemic hypotension

Answer 226

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

Answer 227

28 days Aprepitant PI: "Alternative or "back-up" measures of contraception should be used during treatment with this medicine and for one month following the last dose of this medicine." Pharmacokinetics: - aprepitant is a CYP3A4 inhibitor - caution is also advised with warfarin and phenytoin use https://www.merck.com/product/usa/pi_circulars/e/emend/emend_pi.pdf https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5809356/ Works as a centrally acting NK1 receptor antagonist by blocking actions of Substance P - also ↑activity of dexamethasone & ondansetron (in chemo)"

Answer 228

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

Answer 229

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

Answer 230

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

Answer 231

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

Answer 232

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

Answer 233

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

Answer 234

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

Answer 235

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

Answer 236

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

Answer 237

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

Answer 238

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

Answer 239

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

Answer 240

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

Answer 241

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

Answer 242

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

Answer 243

d) Von willebrand disease - autosomal dominant inheritance - may have normal or prolonged APTT, PT is normal - haemophilia A/B canNOT have been passed down from father to son (as father passes on Y chromosome) and Haemophilia A/B is X-linked. - APTT prolonged. Normal PLT/bleeding time/PT. Factor 8 low in Haem A. Factor 9 low in Haem B Factor 11 low in Haem C vWD (type 1 quantitative, type 2 qualitiative, type 3 complete absence; note vWF is carrier for VIII) - normal or prolonged APTT - normal or reduced PLT - normal or prolonged bleeding time - normal PT" Up to date: Inheritance patterns — Most cases of VWD are transmitted as an autosomal dominant trait; this includes types 1 and 2B, and most types 2A and 2M. Up to date: ●Hemophilia A – Inherited deficiency of factor VIII (factor 8 [F8]); an X-linked recessive disorder. ●Hemophilia B – Inherited deficiency of factor IX (factor 9 [F9]); also called Christmas disease; an X-linked recessive disorder.

Answer 244

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

Answer 245

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

Answer 246

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

Answer 247

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

Answer 248

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

Answer 249

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

Answer 250

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

Answer 251

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

Answer 252

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

Answer 253

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

Answer 254

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

Answer 255

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

Answer 256

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

Answer 257

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

Answer 258

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

Answer 259

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

Answer 260

Answers could also possibly be COPD, Acute stroke or Neonates c) Bleomycin toxicity Bleomycin is a particularly important chemotherapy drug for the anaesthetist to be aware of. Bleomycin is often used to treat germ cell tumours and Hodgkin's disease in a curative setting. The major limitation of bleomycin therapy is the potential for subacute pulmonary damage that can progress to life-threatening pulmonary fibrosis. Pulmonary toxicity occurs in 6–10% patients and can be fatal.2 Exposure to high-inspired concentration oxygen therapy, even for short periods, as experienced during anaesthesia, is often implicated in causing rapidly progressive pulmonary toxicity in patients previously treated with bleomycin.3 These claims have been considered controversial by some, but it is the authors' recommendation that any patient previously exposed to bleomycin therapy should be treated as high risk, and summary guidance regarding oxygen therapy is shown in Table 4. Summary guidance—oxygen therapy for patients who have received bleomycin > Patients have a life-long risk of bleomycin-induced lung injury > Oxygen therapy should be avoided if at all possible > Clinical procedures (and leisure activities) involving a high should be avoided If a patient is hypoxic > O2 therapy should be minimized to maintain O2 saturation of 88–92% > High oxygen concentrations should be used with extreme caution for immediate life-saving indications only (to maintain O2 saturation of 88–92%)

Answer 261

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

Answer 262

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

Answer 263

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

Answer 264

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

Answer 265

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

Answer 266

Ans: a - failure to capture. There are regular pacing spikes, but no regular broad QRS (i.e. capture). The pacing spikes are not happening in a repolarising segment, therefore this does not explain why there is no ventricular response. C will be the only one with atrial and ventricular pacing spikes B only other one with atrial pacing spikes but no ventricular A would have pacing spike before ventrilcle when no p-wave occurs + some normal p then QRS Failure to capture if there’s no P wave or QRS after an atrial or ventricular pacing spike Failure to sense – the spike is going off at the wrong time, might change morphology Spike on T-wave

Answer 267

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

Answer 268

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

Answer 269

Factor 7 - Recombinant, made from baby hamster kidney cells Albumin - Alburex® 5 AU (Human Albumin 50 g/L) is an Australian manufactured albumin product Fib conc - Lyophilised precipitate. manufactired from cryoprecipitate. PCC - Prothrombinex-VF® is a lyophilised concentrate of human coagulation factors containing factors II, IX and X and a small amount of factor VII. Red cross lifeblood. Correct answer is rVIIa

Answer 270

Plateltes Fibrinogen if low Fibtem TXA if curves tail off early FFP if MCF low

Answer 271

b) Reduced Lung compliance - Closure of abdominal wall post gastroschisis repair leads to significantly increased abdominal compartment pressures and can splint diaphragm. May need staged closure. Term neonate = ~3.5 kg 40ml/kg = ~140mls in Normal blood volume 90 x 3.5 = 315ml 10ml blood loss + added environmental losses from exposed bowel The key is the timing with closure, and to be aware that staged closures are frequently done. Most likely answer is lung complicance, and PCV which would result in a reduction in volumes on closing.

Answer 272

b) Pulmonary HTN Long QT + ST changes common Cardiomyopathy less common but well documented RVH possible, although more commonly LVH

Answer 273

Increased sensitivity to non depolarisers Ck -> Anaesthesia induced rhabdo Cardio- All at-risk females, regardless of their carrier status, should be monitored for development of cardiomyopathy

Answer 274

Moclobemide - Reversible MAOI SSRIs and SNRIs are lower risk Tapentadol - no serotonin effect Tranylcypromine or phenylzine are irreversible blockers and would be the highest risk

Answer 275

c) Inhibits guanylate cyclase Methylene Blue acts by inhibiting guanylate cyclase, thus decreasing C-GMP and vascular smooth muscle relaxation

Answer 276

AV block CI in - cardiac conduction block - Glaucoma - Anticoagulation Indications Complex regional pain syndrome of the head and upper limbs Peripheral vascular disease Upper extremity embolism Postherpetic neuralgia Chronic post-surgical pain Hyperhidrosis Raynaud disease Scleroderma Orofacial pain Phantom limb Atypical chest pain A cluster or a vascular headache Post-traumatic stress disorder Meniere syndrome Intractable angina Refractory cardiac arrhythmias

Answer 277

a) >1 0 normal Mild/mod/severe 1-5 5-10 >10

Answer 278

b) Myotonia congenita Myotonia congenita is a condition characterized by delayed relaxation of the muscles after voluntary contraction. Neostigmine can exacerbate this delayed relaxation, potentially worsening symptoms

Answer 279

c) Severe tricuspid regurgitation (TR) Severe TR can lead to increased right atrial pressure, which may impede the proper function of the TIPS and worsen outcomes. Contraindications: Severe Hepatic encephalopathy Severe Pulmonary Htn Severe TR Multiple Hepatic Cysts Coagulopathy (relative contraindication)

Answer 280

Preventing unrecognised oesophageal intubation: a consensus guideline from the Project for Universal Management of Airways and international airway societies Suggests b) is most correct answer Verifying the presence of sustained exhaled carbon dioxide requires all the following criteria to be met (Fig. 2; [93]): - Amplitude rises during exhalation and falls during inspiration. - Consistent or increasing amplitude over at least seven breaths [74, 91]. - Peak amplitude more than 1 kPa (7.5 mmHg) above baseline [74, 94]. - Reading is clinically appropriate.

Answer 281

D) End-stage renal disease. Why: The Eleveld propofol model was built from a very broad, mixed dataset including children, older adults, obesity and liver cirrhosis; it has since been clinically validated across children→elderly and obese adults, and is used from ~3 kg upwards (i.e., neonates in later reports). None of the primary descriptions indicate inclusion of ESRD cohorts in development. https://www.researchgate.net/publication/347597148_Prospective_clinical_validation_of_the_Eleveld_propofol_pharmacokinetic-pharmacodynamic_model_in_general_anaesthesia This second generation model3 was developed using PK-PD data from different studies from a broad, diverse, population, including data from neonates, children, adults, and older subjects, and including both volunteers and patients with conditions such as obesity, alcoholism, liver cirrhosis, and cancer, along with varying approaches to concomitant drug administration, such as opioids. https://www.bjanaesthesia.org/article/S0007-0912(20)30894-1/fulltext

Answer 282

a) FFP FFP - 20mmol/l (associated with highest rate of Citrate toxicity) - cannot find a great reference but is quoted in Citrate Toxicity During CRRT After Massive Transfusion (they then reference 1992 guidelines from Transfusion Med, 1994 article about plasma exchage, and Miller's 2009) Lifeblood - additive for plasmapheresis is highest concentration of 4% - could also argue that even if derived from whole blood donation, most of the citrate likely to be in the plasma anyway and when cellular components separated from plasma it will remain (no evidence for that) These numbers unclear source material Platelets - 15-20mmol/L Plasma - 13-15mmol/L Red cells 5-7.5mm/L Cryo 13-15mmol/L Fib conc - nil

Answer 283

Primum non nocere: First, do no harm - Non maleficence

Answer 284

Regional -ie Brachial plexus Anaesthesia Choice for Creation of Arteriovenous Fistula (ACCess) study protocol : a randomised controlled trial comparing primary unassisted patency at 1 year of primary arteriovenous fistulae created under regional compared to local anaesthesia supraclavicular or Axillary block

Answer 285

Assisted end diastolic

Answer 286

CarboxyHb - Probe cannot differentiate between HbO and COHb The others cause false readings

Answer 287

90 mins 30mins Liver Pancreas Heart 60mins Kidneys 90mins Lungs Page 35 ANZICS statement 2.4.3 Warm ischemia time Donate life

Answer 288

B Desflurane (Des): GWP100 around 2,500-3,000 Isoflurane (Iso): GWP100 around 1,000-1,100 Nitrous oxide (Nitrous): GWP100 around 298 Sevoflurane (Sevo): GWP100 around 130-210

Answer 289

c) Normal fundoscopy

Answer 290

D) I, II, III 3-electrode system - Uses 3 electrodes (RA, LA and LL) - Monitor displays the bipolar leads (I, II and III) Life in the Fast Lane

Answer 291

B) Bupivacaine CC/CNS Ratio: the ratio of the dose required to cause CVS collapse and the dose required to cause CNS toxicity (indicates the CNS is more vulnerable than CVS) Lignocaine: 7.1 Ropivacaine: 5.0 Bupivacaine: 3.7 Levobupivacaine: **not listed Petkov Ropivacaine and levobupivacaine, for example, have higher CC/CNS ratios than racemic bupivacaine; therefore, it seems logical to preferentially use these drugs when long-acting LAs are desired. Pubmed

Answer 292

5 mins - Essentially one circulation time Intravenously administer the dose of 5 g (2 vials, each contains 2.5 g) as o Two consecutive infusions or o Bolus injection by injecting both vials consecutively one after another via syringe Idarucizumab was administered as one 5 g intravenous infusion over five minutes Among the 90 patients with available data, the median maximum reversal of the pharmacodynamic anticoagulant effect of dabigatran as measured by ECT or dTT in the first 4 hours after administration of 5 g idarucizumab was 100%, with most patients (>89%) achieving complete reversal. Reversal of the pharmacodynamics effects was evident immediately after administration. FDA Product Guide See blue book article

Answer 293

b) Suprahyoid Suprahyoid muscles are extrinsic muscles of the larynx that attach outside the laryngeal framework and assist in swallowing and other movements. **Not in anatomy for anaesthetists!** The intrinsic muscles of the larynx have a threefold func- tion: they open the cords in inspiration, they close the cords and the laryngeal inlet during deglutition, and they alter the tension of the cords during speech. They comprise the posterior and lateral cricoarytenoids, the interarytenoids and the aryepiglottic, the thyroarytenoid, the thyroepiglottic, the vocalis and the cricothyroid muscles. Anatomy for Anaesthetists

Answer 294

b) Salicylate toxicity Salicylate toxicity can cause an elevated serum anion gap due to the production of organic acids (salicylic acid and its metabolites) that are not measured by the standard anion gap calculation. This leads to an increased anion gap metabolic acidosis. HAGMA results from accumulation of organic acids or impaired H+ excretion Causes (LTKR) Lactate Toxins Ketones Renal Causes (CATMUDPILES) CO, CN Alcoholic ketoacidosis and starvation ketoacidosis Toluene Metformin, Methanol Uremia DKA Pyroglutamic acidosis, paracetamol, phenformin, propylene glycol, paraladehyde Iron, Isoniazid Lactic acidosis Ethylene glycol Salicylates NAGMA results from loss of HCO3- from ECF Causes (CAGE) Chloride excess Acetazolamide/Addisons GI causes – diarrhea/vomiting, fistulae (pancreatic, ureters, billary, small bowel, ileostomy) Extra – RTA Causes (ABCD) Addisons (adrenal insufficiency) Bicarbonate loss (GI or Renal) Chloride excess Diuretics (Acetazolamide) LITFL

Answer 295

e) UGI bleed Stratifies upper GI bleeding patients who are "low-risk" and candidates for outpatient management. Use for adult patients being considered for hospital admission due to upper GI bleeding. Components: haemoglobin, BUN, initial systolic BP, heart rate > 100, melena present, recent syncope, hepatic disease history, cardiac failure present. Med-Calc

Answer 296

a) Spinal Elective surgery.Urological. Recurrent urinary tract infections and long-term catheterization increase the risk of bladder cancer. Cystoscopy is a common procedure as is insertion of suprapubic catheters and botox injections for the management of neuro- pathic bladders. Spinal anaesthesia is safe in patients with CSCI and is an effect- ive way of abolishing ADR15 and spasms. Spinal anaesthesia is becoming a widely accepted technique in patients with pre-exist- ing spinal cord pathology and is routinely used in Stoke Mande- ville Hospital, with a low dose (1.5–2 ml) hyperbaric bupivacaine 0.5%, for most procedures. Spinals can be challenging to site because of poor positioning as a result of spasms and contractures, the presence of spinal metal work, and bony deformities. The effectiveness and the level of the block are difficult to ascertain. The loss of the Babinski reflex and a change in tone from spasticity to flaccid paralysis indicate an established block; although the height of the block remains difficult to assess. The anaesthetist must be vigilant for the signs and symptoms of a total spinal block. Epidural anaesthesia has been demonstrated to be effective in reducing ADR in labouring women; however, it is less reliable for general and urological surgical procedures. I asked a boss about this - he said if previous autonomic dysreflexia definitely needs an anaesthetic! Perioperative management for patients with a chronic spinal cord injury. BJA 2015

Answer 297

d) CT British Heart Rhythm Societies guidelines

Answer 298

C: increase PEEP to 7 as per paeds anaesthetist - rationale that 92% leaves no reserve and is on lower end of target. Brainscape says E Targets for premature babies: * Volume-targeted or pressure-limited mode targeting tidal volumes of 5 ml kg1 * Ventilatory frequency: 30-60 bpm * PEEP: 6-8 cmH2O * Titrate above to maintain normocapnia or mild hypercapnia * Titrate FIO2 to achieve SpO2 90-95%.

Answer 299

Mitral valve prolapse Valsalva increases the strength of murmurs due to hypertrophic obstructive cardiomyopathy and mitral valve prolapse. It decreases the intensity of aortic stenosis, mitral stenosis, aortic regurgitation, mitral regurgitation, and ventricular septal defects. OPPOSITE IS TRUE FOR SQUATTING (Increases preload)

Answer 300

D) Plts- RBC -plasma according to Lifeblood guidelines, platelets MUST be given before RBC if in the same line, as red cell debris will trap platelets; platelets and plasma can be sequential through the same set; as platelets take a long time to transfuse, it makes sense to first transfuse plasma (fast), then platelets, then red cells

Answer 301

a) 40 40; if 50 was there the answer would be 50 NAP 6 says CPR if SBP<50mmHg ANZAAG says 50mmHg

Answer 302

A - Adductor Pollicis - Usual site for NMT Correct on ASA website

Answer 303

B is the answer Check 4th consensus guidelines Does show better analgesia PADDI Trial (Monash and ANZCA) 2021 No difference in infection with dex 8 vs placebo Anaesthesiology Nov 2021, Vol 135, issue 5 - article by Aus anaesthesiologists A higher dose - Will cause more hyperglycaemia in DM patients but not clinically/statiscally significant - Will improve PONV for 72 hours = possibly - Some studies show this can improve analgesia - ortho, ent cases particularly 8mg dose recommended Was the question related to addition of dex in block - Korean study compared 4vs8 in 2018

Answer 304

a) Psoas Tendon

Answer 305

c) Left maxillary Central incisor BJA education article - 2016 and Aagbi Left max central incisor most common from blade (fulcrum) 32% Right max central - 19% Right third molar if posterior injury Periodontitis and cvs risk link Reminder to link poor dentition with other risk factors - meth/smoking/poor diet/autoimmune conditions and their anaesthetic impact 1:4500 risk (Rcoa)

Answer 306

CO2 Pull/Aim/Squeeze/Sweep Don’t use fire blankets - concentrated heat on patient Saline or water for body cavity fire Dry powder and chemical can leave residues that could damage equipment

Answer 307

a) Blue/ White Blue and white shoulder White bottle Pre 2004 made cylinder is blue

Answer 308

C Neoresus 10-30mcg/kg

Answer 309

3 * 40 * 80 = 9600 Parkland seems to be trending toward 3ml these days rather than 4 Deranged physiology key points Urine output as end goal - risk of fluid creep with same Albumin reduces total volume of resus but not difference to survival Hypertonic fluids - increased mortality and AKI Other formula Brooke Evan’s Monafo Shriner’s -paeds Galvestons - paeds

Answer 310

d) 4 secs 15L Initial breath 4 seconds @ 15L (rate is 250ml/s i.e. total delivered in 4 seconds = 1L) If no improvement in SpO2 after 30 seconds give another 2 second breath Subsequent breaths once sats fall by 5% from maximum Spo2 achieved with initial jet ventilation breath = 2 secs (I.e. 500ml)

Answer 311

c) 12ml/kg Intralipid 20% treatment Initial bolus 1.5ml/kg (repeat up to Max 3 times 5 mins apart Infusion 15ml/kg /hr Max cumulative dose = 12 ml/kg

Answer 312

10 All current Australian and New Zealand laboratories follow the guidelines of the European Malignant Hyperthermia Group for In Vitro Contracture Testing. The EMHG guidelines are summarised as follows: Age and Weight The minimum weight limit for Australian and New Zealand laboratories is 30 kg and the minimum age for IVCT is 10 years. (Emhg actually says min age for muscle biopsy is 4 yrs but lab's should not test children under 10 yrs without relevant control data) IVCT details The biopsy should be performed on the quadriceps muscle (either vastus medialis or vastus lateralis), using local (avoiding local anaesthetic infiltration of muscle tissue), regional, or trigger-free general anaesthetic techniques. The muscle samples can be dissected in vivo or removed as a block for dissection in the laboratory within 15 minutes. The time from biopsy to completion of the tests should not exceed 5 hours. Muscle specimens should measure 20-25 mm in length and at least four tests should be performed each one using a fresh specimen. The tests should include a static cumulative caffeine test and a dynamic or static halothane test. The results should be reported as the threshold concentration, which is the lowest concentration of caffeine or halothane that produces a sustained increase of at least 2 mN (0.2 grams) in baseline force from the lowest force reached.

Answer 313

NSAIDS/aspirin should be avoided as it displaces thyroxine from protein and subsequently increases free T3 and T4 levels. Thyroid storm General measures Cooling IVF +/- glucose Paracetamol Propranolol Specific Hydrocortisone 200 mg QID IV PTU after PTU sodium iodide/lugols iodine

Answer 314

Type 2 MI MI: Myocardial injury with rise/fall cTn above 99th percentile of upper ref limit within 30 days post op plus at least one of: Ischemic symptoms New ischemic ECG changes New path Q waves on ECG Imaging evidence of myocardial ischemia Angiographic/autopsy evidence of coronary thrombus T1MI - usually precipitated by atherosclerotic plaque disruption (rupture or erosion. Identified by coronary thrombus. Plaque rupture may not only be complicated by intraluminal thrombosis but also by hemorrhage into the plaque through the disrupted surface T2MI -Coronary atherosclerosis is a common finding in type 2 MI patients selected for coronary angiography. Vasospasm, cornary dissection and supply/demand imbalance also in this categeory

Answer 315

B) higher in females despite same dose propofol BJA Feb 2023 https://www.bjanaesthesia.org/article/S0007-0912(22)00192-1/fulltext Females (13%, 31/232) responded more often than males (6%, 6/106). In logistic regression, the risk of responsiveness was increased with female sex (odds ratio [ORadjusted]=2.7; 95% confidence interval [CI], 1.1–7.6; P=0.022) and was decreased with continuous anaesthesia before laryngoscopy *supplementary table shows dosing between female and male responders vs non responders and dosing is the same

Answer 316

IASP Post-thoracotomy pain syndrome: "Pain that recurs or persists along a thoracotomy incision at least two months following the surgical procedure" in general it is burning or stabbing pain with dysesthesia thus shares many features of neuropathic pain. Dysesthesia: unpleasant abnormal sensation spontaneous or evoked

Answer 317

Greater occipital

Answer 318

Prednisolone https://media.anzaag.com/2022/09/26104018/testing-guidelines.pdf

Answer 319

10-20 min https://www.anzca.edu.au/getContentAsset/e2700653-ea93-4926-9e0a-129a7226e0f8/80feb437-d24d-46b8-a858-4a2a28b9b970/PG43(A)BP-Fatigue-BP-2020.pdf?language=en

Answer 320

Atrac - histamine release is bad. more Mastocytosis Info would be good

Answer 321

d) Flucloxacillin Black box warning for fluoroquinolones (ciprofloxacin) Probably also avoid Aminoglycosides (Amikacins/gentamicin/streptomycin) and tobramycin although TOBRAMYCIN probably least problematic of these. Macrolides (erythromycin) These antibiotics have not been shown to cause many problems for MG patients Tetracycline (doxycycline, minocycline) – this may worsen MG Sulfonamides (Bactrim), Penicillin – causes rare cases, usually not a problem for majority of MG patients https://myastheniagravis.org/mg-and-drug-interactions/#:~:text=These%20antibiotics%20have%20black%20box,Ketek%20(telithromycin) https://myasthenia.org/Portals/0/Cautionary%20Drugs.pdf

Answer 322

b) Nd:yag Modified Question: this question asks Greatest, old asks least Least = Er:yag Most = Nd:Yag Er:yag (Erbrium-Yag) used in dermatology which is the least penetrative CO2 laser has very little penetration (~ 10micrometres), as it has a wavelength of 10 600nm. Helium-Neon laser also has very little penetration. Nd:YAG is the most powerful, with a penetration of 2-6mm, as it has a wavelength of 1064nm. Argon penetration of 0.5mm

Answer 323

c) Erector spinae

Answer 324

c) GA vs Neuraxial Neuraxial versus general anesthesia in elderly patients undergoing hip fracture surgery and the incidence of postoperative delirium: a systematic review and stratified meta-analysis: This meta-analysis did not find any statistically significant difference in POD incidence between NA and GA groups or in any subgroup analyses. There was no difference in delirium incidence regardless of inclusion or exclusion of patients with pre-existing dementia or preoperative delirium a) Frailty, b) Age -> risk factors Most notably, neck of femur fracture repair is associated with up to 70% risk of postoperative delirium. There are several explanations: a neck of femur fracture is commonly associated with frail older patients; perioperative pain is a significant issue; and the surgery is usually done in an emergency setting with limited opportunity for preoperative optimisation BJA d) Male sex -> risk factor Male sex associated with increased risk of delirium, multiple studies on Google

Answer 325

b) Intravascular Volume Common Adverse Effects - genital infections (eg vulvovaginal candidiasis, balanitis) - polyuria - dysuria - UTI - dyslipidaemia - hypoglycaemia (when used with a sulfonylurea or insulin) - increased haematocrit - constipation - nausea - thirst - renal impairment, eg increased serum creatinine (related to volume depletion, generally occurs early in treatment and is reversible) Australian Medicines Handbook

Answer 326

NAOMI 72 hours ANZCA Blue Book 2023 Oral naltrexone should be stopped at least 24 hours and ideally 72 hours prior to elective surgery. And there is a lack of instruction re Contrave- so best to stop 72 hours prior. And limited evidence re low dose naltrexone for chronic pain - so for consistency blue book says 72 hours. Caution increased opioid sensitivity in patients using perioperative naltrexone.

Answer 327

B Thiopentone BJA article 2018 Propofol infusions have been associated with a brugada like ECG. https://www.brugadadrugs.org/avoid/

Answer 328

b) Middle third of clavicle Anterior triangle **contains IJ** Superiorly: inferior border of the mandible. Laterally: anterior border of the sternocleidomastoid. Medially: sagittal line down the midline of the neck. Posterior triangle **contains EJ** Anterior: posterior border SCM Posterior: anterior border trapezius Inferior: middle third clavicle StatPearls Anatomy, Head and Neck, Neck Triangle

Answer 329

c) Low BSL, hyperkaelamia, hyponatraemia Adrenal crisis is a medical emergency and should be considered in any patient presenting with one or more of the following symptoms: * altered consciousness * circulatory collapse * hypoglycaemia * hyponatraemia * hyperkalaemia * seizures * history of steroid use/withdrawal * any clinical features of Addison disease Adrenal crisis may be precipitated by stress, sepsis, dehydration or trauma; clinical features may be modified accordingly. In patients with known adrenal insufficiency, nonadherence with therapy, inappropriate cortisol dose reduction or lack of stress related cortisol dose adjustment can cause adrenal crisis. Aus Family Physician - RACGP

Answer 330

Bupivicaine Avoid - Lignocaine/lidocaine - Prilocaine Considering the specificity of patients with G6PD deficiency, attention should be given to the choice of local anesthetic, because for instance lidocaine and prilocaine are not recommended, while bupivacaine is shown to be safe to use. Management of Anesthesia and Perioperative Procedures in a Child with Glucose-6-Phosphate Dehydrogenase Deficiency J Clin Med. 2022 Nov Also avoid methylene blue (prev Q) Could only find - don't give lignocaine - can give bupivacaine Also found don't give articaine, prilocaine or benzocaine https://cdho.org/factsheets/glucose-6-phosphate-dehydrogenase/#:~:text=Local%20anaesthetic%20agents%20(e.g.%2C%20prilocaine,9%20in%20G6PD%20deficient%20persons.

Answer 331

a) its 50ml/kg bolus Also remembered as - meteraminol - glucagon - promethazine - vasopressin where answer is promethazine Resistant Hypotension * Additional IV fluid bolus 50 mL/kg * Continue Adrenaline Infusion * Add second vasopressor * Consider CVC * TOE/TTE * Cardiac bypass/ECMO if available Adult Recommendations - Additional IV fluid bolus 50 mL/kg - Noradrenaline Infusion 3 – 40 mcg/min (0.05 - 0.5 microg/kg/min) and/or - Vasopressin bolus 1– 2 units then 2 units per hour - If neither available use either Metaraminol or Phenylephrine - Infusion Glucagon 1– 2 mg IV every 5 min until response: draw up and administer IV (Counteract β blockers) Anaphylaxis during Anaesthesia Refractory Management ANZAAG-ANZCA guideline Also useful; resistant bronchospasm * Consider: - Oesophageal intubation - Circuit malfunction - Airway device malfunction - Tension pneumothorax * Continue Adrenaline Infusion * Add alternative bronchodilators Adult Recommendations Salbutamol * Metered Dose Inhaler 12 puffs (1200 microg) * IV bolus 100-200microg +/- infusion 5-25microg/min Magnesium 2 g (8 mmol) over 20 minutes Consider Inhalational Anaesthetics and Ketamine

Answer 332

NAOMI ECG features of hypokalemia: Increased P wave amplitude Prolongation of PR interval Widespread ST depression and T wave flattening/inversion Prominent U waves (best seen in the precordial leads V2-V3) Apparent long QT interval due to fusion of T and U waves (= long QU interval)

Answer 333

d) Supreme D - "The Supreme LMA™ does not seem to be suitable for this purpose as the angle of exit of the AIC from the device is unpredictable due to the epiglottic fins in its bowl.7" https://www.ccam.net.au/handbook/plan-b/

Answer 334

Albumin MELD uses the following parameters: - Bilirubin - INR - Creatinine - [Hyponatraemia] ○ Part of the MELD-Na score update in 2016 ○ Sodium (Na) Values < 125 are set to 125 and values >137 are set to 137 4 MELD levels are: - >/=25 (gravely ill) - 24-19 - 18-11 - 15 should avoid elective surgery Calculation: MELD = 3.8*loge(serum bilirubin [mg/dL]) + 11.2*loge(INR) + 9.6*loge(serum creatinine [mg/dL]) + 6.4 MELD-Na = MELD + 1.32 * (137-Na) - [0.033*MELD * (137-Na)]

Answer 335

repeat: Sheehans https://www.uptodate.com/contents/post-dural-puncture-headache Complications of PDPH 1. Chronic Back pain 2. Hearing loss 3. Acute onset headache consider pneumopcephalus headache 4. Persistent headache 5. Increased risk of subdural haematoma 6. postpartum depression 7. bacterial meningitis 8. Reversible cerebral vasoconstriction syndrome (RCVS) 9. Posterior reversible encephalopathy syndrome (PRES)

Answer 336

REPEAT with slightly reworded answers A is safest answer. Previous iterations of this Q have been controversial. NSAIDs technically safe in first trimester, but not in third (post 32 weeks) as can cause premature duct closure. a. Not safe or safe only in 1st trimester While relatively safe in early and mid pregnancy, NSAIDs can precipitate fetal cardiac and renal complications in late pregnancy, as well as interfere with fetal brain development and the production of amniotic fluid; they should be discontinued in gestational wk 32 APMSE

Answer 337

A - Foetal neuroprotection https://www.kemh.health.wa.gov.au/~/media/HSPs/NMHS/Hospitals/WNHS/Documents/Clinical-guidelines/Obs-Gyn-Guidelines/Preterm-Labour-Magnesium-Sulphate-for-Neuroprotection-of-the-Fetus.pdf?thn=0#:~:text=MgSO4%20is%20only%20given%20to,4%20hours%20prior%20to%20delivery.

Answer 338

Fetal bradycardia No idea - commonest sign is pv bleeding and fetal brady (non specific) and both answers are there! Mentioned on MELB course that foetal Brady

Answer 339

B Diagnostic criteria has been met. Consensus guidelines do not mandate spine imaging being prefomed prior to a patch https://jnnp.bmj.com/content/94/10/835 (acknowleding UTD has a "practice" of doing an MRI spine for all)

Answer 340

STEPH a) Anterior spinal artery syndrome Anterior spinal artery syndrome usually includes tracts in the anterior two-thirds of the spinal cord, which include the CSTs, the spinothalamic tracts, and descending autonomic tracts to the sacral centers for bladder control. CST involvements produce weakness and reflex changes. A spinothalamic tract deficit produces the bilateral loss of pain and temperature sensation. Tactile, position, and vibratory sensation are normal. Urinary incontinence is usually present. Dorsal cord syndrome results from the bilateral involvement of the dorsal columns, the corticospinal tracts, and descending central autonomic tracts to bladder control centers in the sacral cor. Dorsal column symptoms include gait ataxia and paresthesias. CST dysfunction produces weakness that, if acute, is accompanied by muscle flaccidity and hyporeflexia and, if chronic, by muscle hypertonia and hyperreflexia. Extensor plantar responses and urinary incontinence may be present. A single anterior and two posterior spinal arteries supply the spinal cord. The anterior spinal artery supplies the anterior two-thirds of the cord. The posterior spinal arteries primarily supply the dorsal columns. The anterior and posterior spinal arteries arise from the vertebral arteries in the neck and descend from the base of the skull. Various radicular arteries branch off the thoracic and abdominal aorta to provide additional blood supply to the spinal arteries.The largest and most consistently present of these radicular branches is the great ventral radicular artery or the artery of Adamkiewicz, which supplies the anterior spinal artery. Up To Date

Answer 341

STEPH b) 0.9% Normal Saline Hypernatraemia is classified as: Mild (146-149 mmol/L) Moderate (150-169 mmol/L) Severe (≥170 mmol/L) --> stem not hypernatraemia Head Injury - Isotonic fluids (eg NaCl 0.9% recommended) IV Fluids Glucose 5% should be given in maintenance fluids for children with no other source of glucose --> likely enteral fed in this setting **Also note: do not give hypotonic fluid - Do NOT give glucose 4% with sodium chloride 0.18% - Sodium chloride 0.45% solutions are only rarely indicated RCH Guidelines - Hypernatraemia - Head Injury - IV fluids

Answer 342

D) increase expiratory time Reworded repeat, but prev options don't directly align with these Low respiratory rates - Short inspiratory time, long expiratory time (decreases time in which there is a high intrathoracic pressure) - Low PEEP - Tidal volumes: 5-6mL/kg --> allows adequate pulmonary blood flow, normocarbia, low PVR Avoid CHAOS (hypercarbia, hypothermia, acidosis, hypoxia, SVR drop) Ideally spontaneous ventilation Patients who have undergone the Fontan procedure depend on blood flow through the pulmonary circulation without the assistance of the right ventricle. The difference between central venous pressure and systemic ventricular end-diastolic pressure (termed the “transpulmonary gradient”) is the primary force promoting pulmonary blood flow and, more importantly, cardiac output. Circulation in the Fontan patient is promoted by low pulmonary vascular resistance. Positive-pressure ventilation with increased tidal volumes, as described above, can result in excessive intrathoracic pressures, leading to decreased venous return to the heart and increased pulmonary vascular resistance. In periods of low oxygen saturation, 100% inspiratory oxygen is appropriate. The addition of PEEP will increase intrathoracic pressure, reducing venous return. Trendelenberg positioning would increase CVP and therefore bloodflow through pulmonary circulation. BJA: fontan circulation: For relatively short procedures, Fontan patients are probably better off breathing spontaneously, as long as severe hypercarbia is avoided. For major surgery, or when prolonged anaesthesia is required, control of ventilation and active prevention of atelectasis is usually advisable. Potential disadvantages of mechanical ventilation in Fontan patients relate to the inevitable increase in mean intrathoracic pressure. This causes decreased venous return, decreased pulmonary blood flow, and hence, decreased cardiac output. Low respiratory rates, short inspiratory times, low PEEP, and tidal volumes of 5–6 ml kg−1 usually allow adequate pulmonary blood flow, normocarbia, and a low PVR. Hyperventilation tends to impair pulmonary blood flow, despite the induced respiratory alkalosis, because of the increased mean intrathoracic pressure. https://academic.oup.com/bjaed/article/8/1/26/277637

Answer 343

STEPH c) Ask surgeon to release gag Summary of Management of Lost Ventilation During Pediatric Tonsillectomy * Manual ventilation with 100% oxygen, assessing compliance and leaks * Ask surgeon to release mouth gag * Bolus of propofol 2–3 mg/kg * Consider LMA malposition, bronchospasm, circuit or filter problem, laryngospasm * If no other cause apparent, assume laryngospasm and give suxamethonium 1–2 mg/kg as soon as SaO2 falls * Lung recruitment breaths as SaO2 improves * Deepen anesthesia, continue surgery SIMS A Guide to Paediatric Anaesthesia

Answer 344

REPEAT b. 60 BJA Article - Management of cardiac arrest following cardiac surgery - BJA Education In the CICU, the effectiveness of ECC is confirmed by monitoring the arterial pressure trace with a target compression rate and depth to achieve a systolic impulse of > 60 mm Hg to maintain a mean perfusion pressure, preventing ventricular distension, LV wall stress, and ischaemia.

Answer 345

c) Ventilate and wean bypass *Failure of oxygenation I think wean bypass and ventilate - thoughts? Asked about this at the Melbourne course - indicates failure of the oxygenator so agree ventilate and wean bypass, replace oxygenator. Steph.

Answer 346

A) Nasopharyngeal Proximity to brain Consistent correlation with core and brain temperature changes Accessibility Oxygenator blood temp represents temp of blood leaving circuit and doesnt reflect blood perfusing the brain Clinical Techniques in Cardiovascular and Thoracic Surgery: This textbook discusses the monitoring of cerebral temperature during CPB and often cites nasopharyngeal temperature as a standard method due to its proximity to the brain. Reference: Sabik, Joseph F., et al. "Temperature management and monitoring during cardiopulmonary bypass." In: Clinical Techniques in Cardiovascular and Thoracic Surgery, edited by Little Brown and Company, 1998. Perfusion: This journal article discusses various techniques for monitoring cerebral temperature during CPB, emphasizing the use of nasopharyngeal temperature probes. Reference: Zollinger, Andreas, et al. "Temperature Management and Monitoring During Cardiopulmonary Bypass." Perfusion, vol. 18, no. 1, 2003, pp. 3-9. doi:10.1191/0267659103pf582oa.

Answer 347

A) Anterior mitral leaflet RV is an anterior structure hence anterior leaflet

Answer 348

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

Answer 349

REPEAT d) Esmolol Management of Arrhythmias After Heart Transplant https://www.ahajournals.org/doi/10.1161/CIRCEP.120.007954 In asymptomatic patients, additional cardiac monitoring such as 24-Holter or an event monitor can be useful to assess the SVT burden, and a trial of atrioventricular nodal blockers (β-blockers preferably) can be attempted with caution in view of potential risk of bradycardia. Calcium channel blockers such as diltiazem and verapamil are contraindicated in patients taking immunosuppression such as tacrolimus and cyclosporine as it can impair the metabolism CYP3A, which increases the levels of these drugs potentially causing renal toxicity. The use of adenosine in the management of SVT has remained a subject of controversy for over a quarter century. In the past, adenosine was contraindicated in patients post-OHT due to its supersensitivity and presumed risk of prolonged atrioventricular block. Thus, based on the aforementioned data, in patients with OHT, adenosine is feasible and safe at reduced doses (starting at 1.5 mg for patients ≥60 kg) as long as patients are closely monitored, with dose escalation as needed. Furthermore, the 2010 American Heart Association guidelines on advanced cardiovascular life support also recommended lowering the initial dose of adenosine to 3 mg for the acute management of SVT in patients with OHT.

Answer 350

REPEAT e. 1:136,000 https://www.bjanaesthesia.org/article/S0007-0912%2817%2930746-8/fulltext 1/670 E-LSCS 1/8000 with muscle relaxation 1/8600 CTS 1/8200 Volatile + neuromuscular blocking Overall 1:19000

Answer 351

REPEAT C Transhiatal - laparotomy & cervical anastomosis Ivor-Lewis - laparotomy & R thoracotomy (tumour upper ⅔) Thoracoabdominal - L throacotomy crossing costal margin & diaphragm (tumour lower ⅔) Minimally invasive - thorascopic oesophageal mobilisation, laparoscopic gastric mobilisation & cervical anastomosis

Answer 352

REPEAT c) Normal Lung Normal lung = A lines (pleura) + batwing appearance + sliding

Answer 353

REPEAT E. Decreased acute kidney injury Restrictive had more AKI Otherwise no outcome significant statistically https://www.thebottomline.org.uk/summaries/relief/

Answer 354

REPEAT c) Allow the eye to proptose Orbital Compartment Syndrome The orbital compartment is a fixed space with limited capacity for expansion. If something like blood fills part of that space the pressure increases and may result in ischaemia of the optic nerve or the retina. A lateral canthotomy is a way of releasing this pressure. You have up to approximately 2 hours before irreversible visual loss occurs. It may occur in less than 2 hours however, so speed is of the essence. use local anesthetic but warn the patient that they may feel pain Perform the canthotomy: place the scissors across the lateral canthus and incise the canthus full thickness Perform cantholysis: Grasp the lateral lower eyelid with toothed forcepsPull the lower eyelid anteriorlyPoint the scissors toward the patient’s nose, place the blades either side of the lateral canthal tendon, and cut. By cutting the canthal tendon,the counter pressure of the eyelid on the is relieved and the eye is allowed to proptose and pressure is relieved. LITFL Goal of procedure: to release pressure on the globe & to decrease intraocular pressure enough to reinstitute retinal artery blood flow. The canthotomy allows trhe eye to move forward and open up the space, reducing pressure. The globe itself should not swell.

Answer 355

B) Metoprolol Guidelines from the American College of Cardiology/American Heart Association (ACC/AHA) and the European Society of Cardiology (ESC) recommend beta-blockers as a first-line therapy for rate control in atrial fibrillation. Reference: January CT, Wann LS, Calkins H, et al. 2019 AHA/ACC/HRS focused update of the 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. Circulation. 2019;140(2)

Answer 356

REPEAT 0.5% lidocaine = 5mg/ml Max dose - 3mg/kg 30kg = 90mg max dose for this pt. 90/5=18mls of 0.5% solution Therefore D.

Answer 357

d) Proceed ANZCA PG07 appendix 1 - Chewing gum and boiled sweets should be discarded prior to inducing anaesthesia to avoid them being Inhaled as a foreign body but do not constitute an indication for delaying any procedure unless they have been ingested. Therefore D

Answer 358

REPEAT b) transfuse for Hb >100 Emergency fixation means there is no time for an exchange transfusion perioperative goals: - planning and optimisation - ensuring adequate O2 delivery - hydration - analgesia - performed at a centre with a multidisciplinary sickle cell team Children presenting for high-risk surgery (for example neurosurgical, cardiothoracic, or complex orthopaedic surgery) or high-risk children (previous stroke, acute CS, or end-organ damage), who were not included in this study, commonly receive an exchange transfusion or top-up transfusion, aiming for a preoperative haemoglobin concentration of 10 g dl−1 and Hb SS <30%. There is less evidence available for the role of transfusion in children with other forms of SCD. Exchange transfusion vs. top-up transfusion Exchange Transfusion: - slowly removing the person’s blood and replacing with fresh donor blood or plasma - Performed in cycles lasting a few minutes with slow removal of 5-20ml of blood and an equal amount of fresh pre-warmed blood or plasma flows into the person’s body - in sickle cell disease blood is removed and replaced with donor blood to achieve a specific concentration of HbSS blood with a usual target of <30% - Exchange transfusion removes HbS and increases HBA Top-up transfusion: - standard transfusion process of giving donor blood - advantages of simple top-up include: 1. Increase oxygen carrying capacity 2. Decrease proportion of sickle haemoglobin HbS relative to Haemoglobin A (HBA) 3. Prevent or reverse complications of vast-occlusion 4. Can be given acutely - disadvantages include: 1. Hyperviscosity if the Hb is increased to significantly over the patients baseline (target Hb should be 100g/l) 2. HbS is not removed, only diluted

Answer 359

c) L5-S1 https://www.nysora.com/pediatric-atlas-of-ultrasound-and-nerve-stimulation-guided-regional-anesthesia/chapter34-spinal-anesthesia-preview/

Answer 360

REPEAT 70 Term 1 hr - 70 Term 12 hr - 66 Day 1 asleep - 70 Day 1 awake - 71 Week 2 - 78 Week 4 - 85 According to RCH term 3.5kg SBP normal range is 60-95. https://www.safercare.vic.gov.au/best-practice-improvement/clinical-guidance/neonatal/blood-pressure-disorders#goto-noninvasive-bp-measuring

Answer 361

REPEAT b) Midazolam 4.5mg IV Status epilepticus is defined as: - Continuous seizure activity for 5 minutes or more without return of consciousness, - recurrent seizures (2 or more) without an intervening period of neurological recovery So needs urgent treatment. APLS (in order) Midaz dose is 0.15/kg IV/IM or 0.3mg buccal/IN After first dose, if still seizing, repeat midaz, IV/IO Levetiracetam of phenytoin Lev = 40-60mg/kg, phen = 20mg/kg) RSI 1st line: Midazolam IV/IO/IM --> 0.15mg/kg 2nd line: Midazolam IV/IO/IM --> 0.15mg/kg 3rd line: Keppra 40mg/kg (max 3g) 4th line: Phenytoin 20mg/kg or phenobarbitone 5th line: Intubation and deep sedation with midazolam, propofol +/- phenobarbitone

Answer 362

Repeat b. 150mcg Up to 6 years 150 IM Over 6 years 300 IM (ideally 10microg/kg) Then commence adrenaline infusion 0.1mcg/kg/min to 2mcg/kg/min Refractory management: Additional IV fluid 20-40ml/kg, Noradrenaline infusion 0.1- 2mcg/kg/min Vasopressin infusion 0.02-0.06 units/kg/hr, glucagon 40mcg/kg IV

Answer 363

4 x 15 = 60mg

Answer 364

REPEAT c) Reduced due to increased volume of distribution and clearance 2010 Paper on major burns The pharmacokinetic characteristics of a propofol bolus administered in patients with major burns were enhanced clearance and expanded volume of distribution. BURN and WT were the important covariates. For sedation or anesthesia induction, a higher than recommended dose of propofol may be required to maintain therapeutic plasma drug concentrations in patients with severe burns. Vigilance regarding the burned individual and careful titration of hypnotics to the desired effect cannot be overemphasized. https://pubmed.ncbi.nlm.nih.gov/20510522/

Answer 365

B. herniation

Answer 366

REPEAT 1,500 mL immediately OR 200 mL/hr in the first 2-4 hours

Answer 367

D) pneumothorax From BJA 2016 lung US article The features of a pneumothorax are abolished sliding, absence of B lines, absence of the lung pulse, and presence of the lung point Extra info from BJA The US feature of Intersititial syndrome is B lines. These are artifacts generated by the juxtaposition of alveolar air and septal thickening (from fluid or fibrosis). Their characteristics are Occasional B lines can be seen in normal lungs (especially at the bases). Up to two between two adjacent ribs can be considered normal. Three or more between rib spaces (or close together in a transverse image) are pathological

Answer 368

AT - 1 hour 1.2.3 Time of lumbar drain placement to systemic intravenous heparinization should be greater than 60 minutes Perioperative Management of Adult Patients with External Ventricular and Lumbar Drains Guidelines from the Society for Neuroscience in Anesthesiology and Critical Care ASRA: 1 hour Although the occurrence of a bloody or difficult neuraxial needle placement may increase risk, there are no data to support mandatory cancellation of a case. Direct communication with the surgeon and a specific risk-benefit decision about proceeding in each case are warranted. Currently, insufficient data and experience are available to determine if the risk of neuraxial haematoma is increased when combining neuraxial techniques with the full anticoagulation of cardiac surgery. We suggest postoperative monitoring of neurologic function and selection of neuraxial solutions that minimise sensory and motor block to facilitate detection of new/progressive neurodeficits. NYSORA: Administration of intravenous heparin intraoperatively should be delayed for at least 1 hour after epidural placement; a delay before administration of subcutaneous heparin is not required. In cases of full heparinization for CPB, additional precautions include delaying surgery for 24 hours in the event of a traumatic tap, tightly controlling the heparin effect and reversal, and removing catheters when normal coagulation is restored.

Answer 369

REPEAT e. Increased risk of non fatal cardiac arrest POISE II * clonidine 200mcg per day - did not reduce the rate of composite outcome of death or nonfatal MI - but it increased the risk of clinically important hypotension and nonfatal cardiac arrest * aspirin initiation or continuation – no significant effect on rate of composite of death or non fatal MI but increased risk of major bleeding Clonidine, as compared with placebo, was associated with an increased rate of nonfatal cardiac arrest POISE 2 TRIAL

Answer 370

A) esmolol They get anti impulse therapy which usually starts off with beta blockade before alpha blockade. Up to date: Patients often present with severe hypertension and are initially stabilized with fast-acting, intravenous beta blockers (eg, esmolol or labetalol) or calcium channel blockers. Anti-impulse therapy lowers blood pressure

Answer 371

KATE Catastrophizing Page 24 APMSE In children 8-18 yrs old "parent pain catastrophising" was main risk factor for development of CPSP Significance of each risk factor varies with operation but pre existing psych factors (high state anxiety and pain magnification as a component of catastrophising) increases the risk across two types of surgery (TKR+Breast CA surgery)

Answer 372

REPEAT reconsidered as Amitriptyline a) Amitriptyline https://www.bjaed.org/article/S2058-5349(18)30073-8/fulltext#tbl1 APMSE 5th edition: Tramadol is an effective treatment for neuropathic pain with NNT of 4.4 (95%CI 2.9 to 8.8) Alpha-2-delta ligands (gabapentinoids) are the only anticonvulsants with proven efficacy in the treatment of chronic neuropathic pain. At doses of 1,800 mg to 3,600 mg/d, gabapentin is effective in treating neuropathic pain, in particular caused by postherpetic neuralgia (NNT 6.7; 95%CI 5.4 to 8.7) Pregabalin Postherpetic neuralgia: 300 mg/d pregabalin (NNT 5.3; 95%CI 3.9 to 8.1) (4 RCTs, n=713) and 600 mg/d (NNT 3.9; 95%CI 3.1 to 5.5) (4 RCTs, n=732); * Painful diabetic neuropathy: 600 mg/d pregabalin (NNT 7.8; 95% CI 5.4 to 14) (5 RCTs, n=1,015); * Mixed or unclassified post-traumatic neuropathic pain: 600 mg/d pregabalin (NNT 7.2; 95%CI 5.4 to 11) (4 RCTs, n=1,367); * Central neuropathic pain (mainly SCI): 600 mg/d pregabalin (NNT 9.8; 95%CI 6.0 to 28) (3 RCTs, n=562). Amitriptyline NNT 4.6 (TCAs are effective in treatment of neuropathic pain (amitrip NNT 4.6)) Amitriptyline By order of favourable NNT: 1. TCAs (amitriptyline) NNT: 3.6, NNH: 9 2. Strong opioids NNT 4.3 NNH 11.7 3. Tramadol NNT: 4.7, NNH 12.6 4. SNRIs (duloxetine and venlafaxine) NNT 6.4, NNH 11.8 5. Gabapentin NNT: 7.2 NNH 25.6 6. Pregabalin NNT:7.7, NNH 13.9 ANZCA Pain book Treatment of chronic neuropathic pain after SCI (Guy 2016 GL). These guidelines recommend: * First line: pregabalin, gabapentin and amitriptyline; * Second line: tramadol and lamotrigine (in incomplete SCI); * Third line: Transcranial direct current stimulation (tDCS) alone and combined with visual illusion; * Fourth line: TENS, oxycodone and dorsal root entry zone lesions.

Answer 373

REPEAT A) 4 4 yo = wong baker faces score 3-18. 8 yo = Visual analogue scale. https://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Pain_assessment_and_measur ement/ APMSE 5 also

Answer 374

Nikki: B) Opioid induced hyperalgesia; The key features are long case with Remi running, as well as increased pain following additional opioids. https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/full/10.1111/anae.13602

Answer 375

REPEAT E. Upper GI bleed Incompressible sites, large volume blood loss and mortality risk are a few of the things that made GI bleeds seem like a natural fit for TXA administration. Early research seemed promising, but trials were small. The HALT-IT trial examined over 15,000 patients to see if TXA reduced death [14]. Not only did TXA have no effect on mortality, it increased the risk of seizure and thromboembolic events. Take home: No demonstrated benefit with TXA in GI bleeding

Answer 376

B) prothrombinex. Prothrombinex product information states don’t give if hx of HITS PROTHROMBINEX CONTAINS HEPARIN

Answer 377

REPEAT d) Reduced time to resumption of oral intake The effect of preoperative dexamethasone on early oral intake, vomiting and pain after tonsillectomy https://pubmed.ncbi.nlm.nih.gov/15979735/ Conclusion: Preoperative dexamethasone use significantly reduces early posttonsillectomy pain, improves oral intake and facilitates meeting the discharge criteria while using standard anesthesia technique and sharp dissection tonsillectomy without any significant side effects.

Answer 378

REPEAT b) 250mcg IM q15mins, up to 2mg 15-methyl-PGF2α (carboprost; Prostinfenem) which may be administered in one of two ways: Intra-muscular injection of 0.25mg, in repeated doses as required at intervals of not less than 15 minutes to a maximum total cumulative dose of 2.0mg (ie up to 8 doses) Source RANZCOG PPH Guideline 2021

Answer 379

B) 15mg 50mg x0.3 Tapentadol Conversion at 0.3 Tramadol conversion at 0.2 Oxycodone 1.5 Hydromorphone 5 Buprenorphine patch mcg/hr@2 Fentanyl patch mcg/hr @3 Oral Tapentadol 25mg = 8mg Oral Morphine Oral Oxycodone 5mg = 8mg Oral Morphine Oral Tramadol 25mg = Oral Morphine 5mg Oral Hydromorphone 4mg = Oral Morphine 20mg S/L Buprenorphine 200mcg = 8mg Oral Morphine IV Oxycodone 5mg = Oral Morphine 15mg IV Morphine 5mg = Oral Morphine 15mg IV Hydromorphone 1mg = Oral Morphine 15mg

Answer 380

REPEAT AT - Rocuronium Anaphylaxis to neuromuscular blocking drugs: incidence and cross-reactivity in Western Australia from 2002 to 2011 by Sadleir et al (This paper was referenced in NAP 6 "Cross-sensitivity, based on skin testing and specific IgE, is common, with suxamethonium being the most commonly crossreacting drug (Sadleir 2013).") Fig 4 shows Rates of cross-reactivity for patients diagnosed with anaphylaxis according to the triggering NMBD. - for sux anaphylaxis: highest cross-reactivity was roc (24%), then interestingly vec and cis were both tied at 12%, as were panc and atrac at 6% PREVIOUS NOTES: BJA Anaphylaxis to neuromuscular blocking drugs: incidence and cross-reactivity in Western Australia from 2002 to 2011 https://academic.oup.com/bja/article/110/6/981/245571 Rocuronium has a higher rate of IgE-mediated anaphylaxis compared with vecuronium, a result that is statistically significant and clinically important. Cisatracurium had the lowest rate of cross-reactivity in patients who had previously suffered anaphylaxis to rocuronium or vecuronium. Anaphylaxis rates (highest to lowest) Primary anaphylaxis: rocuronium > atracurium > vecuronium > pancuronium = cisatracurium Cross-reactivity: suxamethonium > rocuronium > vecuronium > pancuronium > atracurium > cisatracurium

Answer 381

REPEAT b. serum separating tube (gold top tube or red) Potassium EDTA (purple) -> FBC sodium citrate (blue) -> clotting screen/Rotem sodium oxalate (green) -> heavy metals (lead copper zinc)

Answer 382

REPEAT 4 hours As per Lifeblood Start the transfusion as soon as possible after removing the blood component from approved temperature-controlled storage. Transfusion of each pack should be completed prior to the labelled expiry or within four hours, whichever is sooner. Redcross: "Transfusion of each pack should be completed prior to the labelled expiry or within four hours, whichever is sooner. " Shelf life of platelets: 5 days (Stored at 20-24 degrees, must be agitated gently and continuously) FFP: Once FFP is thawed, must use within 24 hours. Albumin administration: At RCH we allow the product to be administered within 6 hours of piercing the bottle. (from RCH.org) Cryoprecipitate Thawed cryoprecipitate should be maintained at 20°C to 24°C until transfused. Once thawed, should be used within six hours if it is a closed single unit, or within four hours if it is an open system or units have been pooled.

Answer 383

AT a) TRALI Both TACO and TRALI are characterised by: - hypoxia - acute dyspnoea - diffuse bilateral infiltrates However, presence of fever is more in keeping with TRALI. Reference: Distinguishing between transfusion related acute lung injury and transfusion associated circulatory overload Robert C. Skeatea and Ted Eastlund

Answer 384

Longer length Different cuff size/ length: The MLT® has a cuff size/ length that would be typical for an adult-sized 'standard' ETT. A 'standard' pediatric 5.0 enndotracheal tube has a smaller cuff made for a pediatric-sized trachea (see picture below). Distance of cuff from tube tip: In an MLT® the cuff is further away from the tube tip which is acceptable as the adult trachea is obviously longer than the pediatric one (see picture below).

Answer 385

AT REPEAT C. 30cmH2O (c.f. 60cmH20 for same question but for LMA cuff pressure) References (a bit old now): "Guidelines1,2 recommend a cuff pressure of 20 to 30 cm H2O. Inflation of the cuff in excess of 30 cm H2O damages the tracheal mucosa by compromising capillary perfusion. When pressures are greater than 50 cm H2O, total obstruction of tracheal blood flow occurs.3 In rare instances, massive overinflation of the cuff may lead to acute complications such as tracheal bleeding or rupture.4 " - from Cuff Pressure of Endotracheal Tubes After Changes in Body Position in Critically Ill Patients Treated With Mechanical Ventilation by Lizy et al 2014 Whereby: 1 American Thoracic Society; Infectious Diseases Society of America. Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med. 2005; 171(4):388–416. 2 Lorente L, Blot S, Rello J. Evidence on measures for the prevention of ventilator-associated pneumonia. Eur Respir J. 2007;30(6):1193–1207. https://link.springer.com/article/10.1007/s10877-020-00501-2

Answer 386

AT - REPEAT a. Electromyography of internal laryngeal muscles True - the NIM-EMG tube tests RLN function via EMG of the muscles wiki: Notably, the only muscle capable of separating the vocal cords for normal breathing is the posterior cricoarytenoid. If this muscle is incapacitated on both sides, the inability to pull the vocal folds apart (abduct) will cause difficulty breathing. Bilateral injury to the recurrent laryngeal nerve would cause this condition. It is also worth noting that all muscles are innervated by the recurrent laryngeal branch of the vagus except the cricothyroid muscle, which is innervated by the external laryngeal branch of the superior laryngeal nerve (a branch of the vagus). Anaesthesia: Nerve Integrity Monitor tubes for thyroid surgery (2014) Recurrent laryngeal nerve function should be monitored during thyroid surgery [1], either by direct observation of vocal cord function during surgery [2], which can be difficult, or by electromyography (EMG), during which electrodes are placed adjacent to the vocal cords to detect motion when the laryngeal nerves are stimulated. Electrodes can be secured to the outside of a tracheal tube so that they come into contact with the vocal cords during intubation [3]. Indeed, electrodes have been embedded into the material of the tracheal tube (Medtronic Nerve Integrity Monitor (NIM) Standard Reinforced EMG Endotracheal Tube, Medtronic Xomed Inc., Jacksonville, FL, USA), albeit leading to an increase in bulk and external diameter in comparison with equivalent internal diameter tubes (Fig. 2). The size and rigidity of the NIM tubes mandate oral tracheal intubation rather than nasal intubation, which itself is further inhibited by the positioning of cable attachments for the electrodes along the tube's length. http://smpp.northwestern.edu/bmec66/weightlifting/emgback.html An electromyography (EMG) is a measurement of the electrical activity in muscles as a by product of contraction. An EMG is the summation of action potentials from the muscle fibers under the electrodes placed on the skin. The more muscles that fire, the greater the amount of action potentials recorded and the greater the EMG reading. http://www.shanahq.com/main/content/reliable-technique-make-nim-tube-work-preview The specialized endotracheal tubes (ETT), such as Xomed and TriVantage Nerve Integrity Monitoring (NIM) ETTs (Medtronic Xomed Inc., Jacksonville, FL USA) allow for RLN identification through continuous intraoperative EMG monitoring of the laryngeal muscles. https://www.aana.com/newsandjournal/Documents/jcourse1_0410_p151-160_rev2.pdf The Medtronic NIM electromyographic (EMG) endotracheal tube (Medtronic Xomed) is constructed of a flexible silicone elastomer and has a distal inflatable cuff. The tube is fitted with 4 stainless steel wire electrodes (2 pairs) that are embedded in the silicone of the main shaft distance, slightly superior to the cuff. The electrodes are designed to make contact with the patient’s vocal cords to facilitate EMG monitoring of the RLN when connected to a multichannel EMG monitoring device. If monitoring correctly, the EMG monitor should show a consistent sound signal and an action potential tracing. J Anaesthesiol Clin Pharmacol: The neural integrity monitor electromyogram tracheal tube: Anesthetic considerations (2013) When attempting to identify LNs, a stimulating electrical current of 0.5-2.0 mA is used by the surgeon. This current is administered via a sterile probe, which is placed directly on the anatomical site in question. Additionally, return electrodes are positioned in the skin above the sternum. When a LN is located, an electrical signal is subsequently generated by the motion of the vocal cords. An audibly recognizable “machine gun click” is then produced from the device's associated monitor. This sound has a set frequency of 4 times/s (4 Hz). Simultaneously, an oscilloscope-like screen displays an identifiable sinusoidal response.

Answer 387

AT - Two sets of pads, <1 second apart (OR - Two sets of pads, <5 seconds apart) Following 3 standard shocks for refractory VF Two defibrillators are used to provide sequential defibrillation with pads oriented in anterio-lateral and anterior posterior The shocks are delivered near-simultaneously - Anteriolateral first - Then Anterioposterior DOuble SEquential External Defibrillation for Refractory Ventricular Fibrillation (DOSE VF): study protocol for a randomized controlled trial DSED: For paramedic services randomized to DSED, paramedics will apply a second set of defibrillation pads in the anterior-posterior configuration (Fig. 1) Application of the second set of defibrillation pads for the second defibrillator will occur during the 2-min cycle of CPR following the third defibrillation attempt, minimizing any interruptions in CPR. All subsequent defibrillation attempts will be carried out by sequential defibrillation shocks provided by two defibrillators. To ensure that shocks are not administered at the exact same moment, we will employ a short (less than 1 s) delay to provision of the second defibrillator shock. This will be accomplished by having a single paramedic pressing the “shock” button on each defibrillator in rapid succession as opposed to simultaneously. This technique will be performed across all sites when randomized to the DSED arm to maintain consistency in application within the trial. NOTES ON PREVIOUS QUESTION 23.1 For DSED, to avoid possible defibrillator damage caused by shocks applied at the same instant, a short delay (<1 second) between shocks was created by having a single paramedic depress the “shock button” on each defibrillator in rapid sequence (anterior–lateral followed by anterior–posterior) Among patients with refractory ventricular fibrillation, survival to hospital discharge occurred more frequently among those who received DSED or VC defibrillation than among those who received standard defibrillation. https://www.nejm.org/doi/full/10.1056/NEJMoa2207304

Answer 388

Nikki A) cold saline irrigation Intraoperative seizures have a higher incidence of transient motor deterioration and longer hospital stays.[10] First-line treatment should be irrigation of the brain with sterile iced saline. Propofol bolus (10 to 20 mg IV) or midazolam (1 to 2 mg IV) should be administered to terminate the seizure if iced saline is ineffective. https://www.ncbi.nlm.nih.gov/books/NBK572053/

Answer 389

AT REPEAT (base rate is 10%, experimental group is 8% (20% below 10%) therefore 100/ 2 = 50 or 1 divided by risk reduction population risk = 10/100 patients get PONV population risk + new antiemetic = 8/100 patients get PONV (8/100 as reduction by 20% with new drug) RR= 0.10-0.08=0.02 NNT= 1/RR =1/0.02 =50

Answer 390

AT REPEAT b) Hypoxia Hypoxia Local anaesthetics are bases with pKa above physiological pH. The more alkalaemic the environment the more unionionised (B) form there is – which will speed diffusion across plasma membrane = can exert Na+ channel blockade. https://www.bjanaesthesia.org/article/S0007-0912(17)38238-7/pdf https://academic.oup.com/bjaed/article/15/3/136/279390 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6087022/ Hypoxia – metabolic acidosis = ion trapping = increased toxicity Alkalaemia = prevents ion trapping in tissues (intralipid can work) = reduced toxicity High a1GP = reduced free fraction (a1gp high affinity, low capacity) = reduced toxicity Low CO2 = alkalosis = prevents ion trapping in tissues (intralipid can work) = reduced toxicity Carnitine deficiency = increased toxicity, therefore increased carnitine will reduce toxicity https://pubmed.ncbi.nlm.nih.gov/19849674/ a. Hypoxia - Yes b. Alkalemia - No - acidosis causes increased ionised fraction due to its weak base properties c. High α1-acid glycoprotein - No, normally bound to alpha-1 acid glycoprotein d. Hypocarbia < (decreased seizure threshold) - No - hypercarbia increases CNS blood flow and increases risk of seizures due to more LA delivered to CNS e. Increased carnitine levels -s - Never heard of it

Answer 391

If the confidence interval lies between the noninferiority margin and the line of no difference (Fig. 1D), the intervention is non-inferior to standard care.

Answer 392

AT Repeat Delta waves present, therefore WPW = AVRT WPW + delta wave = AVRT → anatomical re-entry circuit (Bundle of Kent) AVNRT is a functional re-entry circuit within the AV node ECG features of AVNRT ● Regular tachycardia ~140-280 bpm ● Narrow QRS complexes (< 120ms) unless there is co-existing bundle branch block, accessory pathway, or rate-related aberrant conduction ● P waves if visible exhibit retrograde conduction with P-wave inversion in leads II, III, aVF. They may be buried within, visible after, or very rarely visible before the QRS complex https://litfl.com/supraventricular-tachycardia-svt-ecg-library/

Answer 393

REPEAT B) analyse the difference between the means of more than two groups

Answer 394

musculocutaneous previously

Answer 395

AT Repeat Can occur in healthy young people The third heart sound is mainly created by the early-diastolic rapid distension of the left ventricle that accompanies rapid ventricular filling and abrupt deceleration of the atrioventricular blood flow S3 may be normal in people under 40 years of age and some trained athletes but should disappear before middle age. Re-emergence of this sound late in life is abnormal[5] and may indicate serious problems such as heart failure. 'Sounds like Ken-tu-cky'

Answer 396

REPEAT D. Adductor Canal unclear phenomonenon prolonged exposure and high concentrations of local anaesthetic

Answer 397

REPEAT a) Critical appraisal PICO is a mnemonic used to describe the four elements of a good clinical foreground question: P = Population/Patient/Problem - How would I describe the problem or a group of patients similar to mine? I = Intervention - What main intervention, prognostic factor or exposure am I considering? C = Comparison - Is there an alternative to compare with the intervention? O = Outcome - What do I hope to accomplish, measure, improve or affect?

Answer 398

a) LAD Wellens syndrome- Lad https://litfl.com/wellens-syndrome-ecg-library/

Answer 399

c Give oral iron therapy and defer surgery for 6 weeks IV Iron is probably best, however all in agreement that surgery should be delayed making C the correc t choice based on guidlines accepting the flaws in oral iron therapy https://www.blood.gov.au/module-2-perioperative-patient-blood-management-guidelines Iron therapy Oral iron in divided daily doses. Evaluate response after 1 month. Provide patient information material. IV iron if oral iron contraindicated, is not tolerated or effective; and consider if rapid iron repletion is clinically important (e.g. <2 months to non deferrable surgery). NOTE: 1 mcg/L of ferritin is equivalent to 8–10 mg of storage iron. It will take approximately 165 mg of storage iron to reconstitute 10 g/L of Hb in a 70 kg adult. If preoperative ferritin is <100 mcg/L, blood loss resulting in a postoperative Hb drop of ≥30 g/L would deplete iron stores. In patients not receiving preoperative iron therapy, if unanticipated blood loss is encountered, 150 mg IV iron per 10g/L Hb drop may be given to compensate for bleeding related iron loss (1 ml blood contains ~0.5 mg elemental iron Footnotes 1 Anaemia may be multifactorial, especially in the elderly or in those with chronic disease, renal impairment, nutritional deficiencies or malabsorption. 2 In an anaemic adult, a ferritin level <15 mcg/L is diagnostic of iron deficiency, and levels between 15–30 mcg/L are highly suggestive. However, ferritin is elevated in inflammation, infection, liver disease and malignancy. This can result in misleadingly elevated ferritin levels in iron-deficient patients with coexisting systemic illness. In the elderly or in patients with inflammation, iron deficiency may still be present with ferritin values up to 60–100 mcg/L. 3 Patients without a clear physiological explanation for iron deficiency (especially men and postmenopausal women) should be evaluated by gastroscopy/colonoscopy to exclude a source of GI bleeding, particularly a malignant lesion. Determine possible causes based on history and examination; initiate iron therapy; screen for coeliac disease; discuss timing of scopes with a gastroenterologist. 4 CRP may be normal in the presence of chronic disease and inflammation. 5 Consider thalassaemia if MCH or MCV is low and not explained by iron deficiency, or if long standing. Check B12/folate if macrocytic or if there are risk factors for deficiency (e.g. decreased intake or absorption), or if anaemia is unexplained. Consider blood loss or haemolysis if reticulocyte count is increased. Seek haematology advice or, in presence of chronic kidney disease, nephrology advice

Answer 400

REPEAT b. Unstable angina UTD: Unstable angina (UA) and acute non-ST elevation myocardial infarction (NSTEMI) differ primarily in whether the ischemia is severe enough to cause sufficient myocardial damage to release detectable quantities of a marker of myocardial injury (troponins): ●UA is considered to be present in patients with ischemic symptoms suggestive of an ACS and no elevation in troponins, with or without electrocardiogram changes indicative of ischemia (eg, ST segment depression or transient elevation or new T wave inversion). ●NSTEMI is considered to be present in patients having the same manifestations as those in UA, but in whom an elevation in troponins is present. MINS: Myocardial injury after non-cardiac surgery (up to 30 days post-op): 1. Elevated postop troponin 2. Resulting from myocardial ischaemia (i.e. no evidence of a non-ischaemic aetiology), not requiring an ischaemic feature (i.e. no chest pain, no ECG change) VISION studies (Vascular Events in Noncardiac Surgery Patients Cohort Evaluation) demonstrated that severity of MINS strongly associated with 30-day mortality after NCS. hs-cTnT <20ng/L ~ 0.5% 30 day mortality 20-64ng/L ~3% 30 day mortality 65-999 ng/L ~9% 30 day mortality >1000ng/L ~30% 30 day mortality Whilst VISION trial identified MINS in at risk patients, the question now becomes what interventions are available to prevent this complication?

Answer 401

B https://litfl.com/super-axis-man-sam/

Answer 402

VICTORIA Surviving Sepsis 2021 guidelines D

Answer 403

REPEAT b. Octreotide 50mcg bolus Vasoactive hormone release intra-operatively is best treated with intravenous boluses of 20–50 µg of octreotide, titrated to haemodynamic response. Vasopressin as an alternative vasoconstrictor that may be useful if prolonged vasoconstriction is required; however, the evidence base is small. It must be borne in mind that concomitant fluid losses, especially bleeding, may be responsible for intra-operative instability rather than hormone excess and that fluid resuscitation may be the answer rather than further octreotide therapy https://academic.oup.com/bjaed/article/11/1/9/285683

Answer 404

A) vasoplegia Vasoplegia is characterized by a normal or augmented cardiac output with low systemic vascular resistance (SVR) causing organ hypoperfusion. The exact definition has varied but typically is considered when shock occurs within 24 h of CPB in the setting of a cardiac index (CI) is greater than 2.2 L/kg/m2 and SVR less than 800 dyne s/cm5

Answer 405

REPEAT B) 02 consumptiom at rest One metabolic equivalent (MET) is the amount of oxygen consumed while sitting at rest, equal to 3.5 mL O2 per kg body weight × min

Answer 406

A) 8cm ANZCOR: In patients with an ICD or a permanent pacemaker the defibrillator pad/paddle is placed on the chest wall ideally at least 8 cm from the generator position

Answer 407

REPEAT C) Increased PVR Initial - may lead to burns shock Increased SVR (by 200%) Increased PVR Increased capillary permeability- loss of intravascular volume/Increased interstitial oedema Reduced CO SIRS By day 5 hyperdynamic circulation Tachycardia Increased CO (remains for at least 2 years maybe longer)

Answer 408

c) Desaturation Total spinal anesthesia has been reported in neonates. It is most commonly manifested by apnea with no change in systemic blood pressure or heart rate, although should pronounced bradycardia occur, a reduction in cardiac output is likely and should be treated aggressively. It can occur after a dose of as little as 0.6 mg/kg of tetracaine. Alteration in position, particularly by raising the lower body above the level of the head or thorax, may be the most common cause of a high spinal block. Although the rate of administration of the local anesthetic does not appear to affect the level of spinal anesthesia in adults, similar studies have not been conducted in neonates or infants. It is possible that factors, such as the use of a relatively large-bore needle (22-gauge) and a tuberculin syringe providing the means for injecting with high pressure, along with the small distance between vertebrae, combines to make the rate of injection an important consideration in neonates and infants by producing unintended barbotage. We have observed this complication with rapid drug administration. Management consists of assisted or controlled ventilation until the return of spontaneous respiratory function. Cote. Practice of Anesthesia for Infants and Children, A, Seventh Edition - confirmed by QCH consultant

Answer 409

REPEAT Hypoglossal (deviates to the affected side) Nerve injuries : (pressure neuropraxia) Lingual nerve injury (most common) RLN (most serious) Hypoglossal Glossopharyngeal Inferior alveolar Infra orbital Usually self resolve except for RLN

Answer 410

REPEAT Axillary Nerve

Answer 411

Hypovolaemia Normal for end diastole is 3.5 to 5.6cm Image https://thoracickey.com/cardiac-chambers/ PSAX End diastolic AREA: Hypovolemia <8cm2 Normal 8-14cm 2 Hypervolemia > 14cm2 IVSd and IVSs – Interventricular septal end diastole and end systole. The normal range is 0.6-1.1 cm. LVIDd and LVIDs – Left ventricular internal diameter end diastole and end systole. The normal range for LVIDd is 3.5-5.6 cm, and the normal range for LVIDs is 2.0-4.0 cm. LVPWd and LVPWs – Left ventricular posterior wall end diastole and end systole. The normal range is 0.6-1.1 cm. RVDd – Right ventricular end diastole. The normal range is 0.7-2.3 cm. Ao Root Diam – Aortic root diameter. The normal range is 2.0-4.0 cm. LA Diameter – Left atrium diameter. The normal range is 2.0-4.0 cm. The IVSd and IVPWd measurements are used to determine left ventricular hypertrophy, which is the thickening of the muscle of the left ventricle. LV hypertrophy is a marker for heart disease. In general, a measurement of 1.1-1.3 cm indicates mild hypertrophy, 1.4-1.6 cm indicates moderate hypertrophy, and 1.7 cm or more indicates severe hypertrophy. Hypovolaemia Normal for end diastole is 3.5 to 5.6cm

Answer 412

Pplat-PEEP driving pressure is defined as distending pressure above the applied Peep Required to generate Vt - key variable for optimisation when performing mechanical ventilation in ARDS - also Vt/CRS (Ratio of Tidal volume to static resp system compliance)

Answer 413

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.

Answer 414

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

Answer 415

Ans: A) Quality improvement SQUIRE → Quality Improvement PRISMA → Systematic Reviews CONSORT → Randomised Controlled Trials STROBE → Observational studies

Answer 416

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).

Answer 417

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)

Answer 418

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).

Answer 419

Flush port

Answer 420

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

Answer 421

https://www.bjaed.org/article/S2058-5349%2819%2930047-2/fulltext

Answer 422

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.

Answer 423

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.

Answer 424

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).

Answer 425

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

Answer 426

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

Answer 427

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"

Answer 428

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)

Answer 429

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

Answer 430

Ans: 2+ (1.2 x baseline) Uptodate

Answer 431

Ans: Glucagon 1-2mg every 5 minutes

Answer 432

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.

Answer 433

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%”

Answer 434

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).

Answer 435

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

Answer 436

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.

Answer 437

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

Answer 438

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.

Answer 439

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

Answer 440

Tricuspid regurgitation

Answer 441

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

Answer 442

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).

Answer 443

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.

Answer 444

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.

Answer 445

Ans: D) 60 cmH2O for both classic LMA as well as a Supreme

Answer 446

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.

Answer 447

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.

Answer 448

Ans: A Gelofusine and gelatin is associated with anaphylaxis to MMR

Answer 449

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.

Answer 450

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.

Answer 451

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.

Answer 452

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.

Answer 453

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.

Answer 454

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.

Answer 455

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

Answer 456

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.

Answer 457

Class 1 30-35 Class 2 35-40 Class 3 40+ ASA II for class II (and class I) ASA III for class III

Answer 458

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)

Answer 459

Sensitive to non-depol (use a 1/10 - 1/5 dose) Resistant to suxamethonium (2.5 times dose)

Answer 460

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.

Answer 461

5mmol bolus IV

Answer 462

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/

Answer 463

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.

Answer 464

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.

Answer 465

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.

Answer 466

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.

Answer 467

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.

Answer 468

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

Answer 469

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)

Answer 470

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

Answer 471

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

Answer 472

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.

Answer 473

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

Answer 474

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

Answer 475

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.

Answer 476

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)

Answer 477

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

Answer 478

Wine glass shape --> hyperfibrinolysis, give TXA

Answer 479

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

Answer 480

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

Answer 481

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

Answer 482

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.

Answer 483

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.

Answer 484

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%

Answer 485

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.

Answer 486

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).

Answer 487

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

Answer 488

As per Chrimes paper 7.5mmHg

Answer 489

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.

Answer 490

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.

Answer 491

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

Answer 492

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).

Answer 493

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.

Answer 494

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.

Answer 495

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.

Answer 496

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.

Answer 497

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.

Answer 498

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

Answer 499

Ans A) Factor IX Contents of Cryoprecipitate Fibrinogen (high concentration) Factor VIII Factor XIII Von Willebrand Factor (vWF) Fibronectin

Answer 500

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.

Answer 501

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.

Answer 502

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.

Answer 503

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.

Answer 504

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

Answer 505

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.

Answer 506

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.

Answer 507

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.

Answer 508

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.

Answer 509

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).

Answer 510

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).

Answer 511

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

Answer 512

Rhomboid "TRE"- trap, rhomboid, erector spinae

Answer 513

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.

Answer 514

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.

Answer 515

1/8000 (answer) GA LSCS = 1/670 Overall GA = 1/19,000 GA no muscle relaxant = 1/130,000

Answer 516

Ans: major haemorrhage (17%) bradyarrhythmia 9% cardiac ischaemia 7%

Answer 517

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.

Answer 518

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.

Answer 519

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.

Answer 520

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.

Answer 521

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.

Answer 522

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

Answer 523

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

Answer 524

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.

Answer 525

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."

Answer 526

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.

Answer 527

C. 72 hours CT within 48 hours also mentioned by anzcor

Answer 528

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).

Answer 529

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

Answer 530

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).

Answer 531

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

Answer 532

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.

Answer 533

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.

Answer 534

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).

Answer 535

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.

Answer 536

Ans: Metoprolol Giving B blockade may lead to reduced myocardial contractility and HR in the setting of unopposed alpha effects (peripheral vasoconstriction etc.) --> failure

Answer 537

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

Answer 538

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.”

Answer 539

T5 complete injury

Answer 540

Ans: A - 37 mmHg Conversion factor 1 kPa = 7.50062 mmHg

Answer 541

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.

Answer 542

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

Answer 543

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.

Answer 544

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

Answer 545

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.)

Answer 546

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.

Answer 547

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.

Answer 548

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.

Answer 549

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).

Answer 550

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

Answer 551

b) Clear Proximal, Blue Distal https://www.medtronic.com/content/dam/covidien/library/us/en/product/intubation-products/shiley-laser-oral-nasal-tracheal-tube-information-sheet.pdf

Answer 552

a) Tell the surgeons to stop stimulus https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1821135/ https://jamanetwork.com/journals/jamaotolaryngology/fullarticle/1864754 Careful dissection for prevention and early intervention with stimulus removal and anticholinergic use as needed are paramount to ensure good outcomes N.B Trigeminocardiac reflex refers to the sudden development of bradycardia or even asystole with arterial hypotension from manipulation of any sensory branches of the trigeminal nerve. Although it has only rarely been associated with morbidity and tends to be self-limited with removal of the stimulus, it is an important phenomenon for head and neck surgeons to recognize and respond to

Answer 553

a) 10 Dose of Dantrolene = 2.5mg/kg Repeat every 10 minutes to a Maximum dose of 10mg/kg (Total Vials = 35) Each Vial Dantrolene = 20mg 80 x 2.5mg = 200mg Therefore 10 Vials of 20mg Dantrolene Or, TBW(kg)/8 = number of vials required for initial dose repeat Q5-10mins until signs of MH regress (ETCO2 <45/temp <38.5), Dantrium 20mg/vial to be mixed with 60mL of sterile water Ryanodex 250mg/vial to be mixed with 5mL sterile water (50mg/ml) As per MHANZ - each hospital needs at least 24 (20mg) vials of Dantrium or 2 (250mg) vials of Ryanodex - larger or remote hospitals -> at least 36 vials https://malignanthyperthermia.org.au/wp-content/uploads/2018/09/MALIGNANT-HYPERTHERMIA-RESOURCE-KIT-2018-1.pdf"

Answer 554

a) TXA Hyperfibrinolysis https://derangedphysiology.com/main/required-reading/haematology-and-oncology/Chapter%201.2.0.1/intepretation-abnormal-rotem-data

Answer 555

b) Trigeminal, greater and lesser occipital nerves 2005 blue book article: six nerves need to be blocked bilaterally - supratrochlear - supraorbital - zygomaticotemporal - auriculotemporal - lesser occipital nerve - greater occipital nerve Minor contributions from the greater auricular nerve and third occipital nerve rarely encroach into the surgical field

Answer 556

a) Closing capacity see graph in Millers

Answer 557

a) reintubate from the mouth O2 CISCO O2 - apply 100% oxygen to both the tracheosomy site and the face C - Check the cuff is still up, remove any caps and check CO2 trace is present I - Remove the inner tube ± replace with a new one S - Attempt to pass a fine-bore suction catheter down the tracheostomy C - Take the cuff down O - Consider oral airway The key principles of the algorithm are: 1.Waveform capnography has a prominent role at an early stage in emergency management. 2.Oxygenation of the patient is prioritised. 3.Trials of ventilation via a potentially displaced tracheostomy tube to assess patency are avoided. 4.Suction is only attempted after removing a potentially blocked inner tube. 5.Oxygen is applied to both potential airways. 6.Simple methods to oxygenate and ventilate via the stoma are described. 7.A blocked or displaced tracheostomy tube is removed as soon as this is established and not as a ‘last resort’ BJA: Update on management of tracheostomy https://www.bjaed.org/article/S2058-5349(19)30125-8/fulltext https://www.tracheostomy.org.uk/storage/files/Patent%20Airway%20Algorithm.pdf

Answer 558

a. 35 Major updates (2022) to 1991 National Institutes of Health guidelines for bariatric surgery Metabolic and bariatric surgery (MBS) is recommended for individuals with a body mass index (BMI) 35 kg/m2 , regardless of presence, absence, or severity of co-morbidities. MBS should be considered for individuals with metabolic disease and BMI of 30-34.9 kg/m2 BMI thresholds should be adjusted in the Asian population such that a BMI 25 kg/m2 suggests clinical obesity, and individuals with BMI 27.5 kg/m2 should be offered MBS. Long-term results of MBS consistently demonstrate safety and efficacy. Appropriately selected children and adolescents should be considered for MBS. https://www.soard.org/article/S1550-7289(22)00641-4/fulltext#:~:text=The%201991%20NIH%20Consensus%20Statement,surgery%20that%20is%20applied%20universally.

Answer 559

a) Phosphate hypophosphate: Clinical symptoms range from muscle weakness and paraesthesia to severe cardiac failure, seizures and diaphragmatic paralysis Refeeding malnourished patients with anorexia nervosa can be associated with hypophosphatemia, cardiac arrhythmia and delirium. Phosphorus repletion should be started early with and serum levels maintained above 3 mg/dL weakness and fatigue, in the context of a recent history of starting a regular diet while in a state of chronic malnutrition, are concerning for refeeding syndrome, which typically occurs 2 to 5 days after beginning nutritional repletion. Depleted phosphate stores due to prolonged starvation, hypocalcemia, and hypokalemia can lead to impaired muscle contractility and subsequently weakness, myalgia, and tetany. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4168120/

Answer 560

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

Answer 561

b) anterior communicating artery https://case.edu/med/neurology/NR/SubarachnoidHemorrhageAComm3.htm https://www.thieme-connect.com/products/ejournals/pdf/10.1055/s-0039-1681979.pdf https://case.edu/med/neurology/NR/NRHome.htm (scroll down to subarachnoid imaging area)

Answer 562

MPAP – PCWP = Transpulmonary gradient 40-13 = 27 27mmHg TPG = mPAP – PCWP

Answer 563

F) no impact conflicting evidence best paper we could find https://pubmed.ncbi.nlm.nih.gov/31645288/ published in the lancet in 2019 and seems tailored to this question. In summary, regional anaesthesia-analgesia by paravertebral blocks and propofol did not reduce breast cancer recurrence after potential curative surgery compared with general anaesthesia with the volatile anaesthetic sevoflurane and opioids for analgesia. The incidence and severity of persistent incisional breast pain was unaffected by anaesthetic technique. Chronic pain did not differ between the study groups at 6 months and 12 months could also be: e) reduced CPSP at 12 months ANZCA pain book https://www.bjaed.org/article/S2058-5349(18)30101-X/fulltext For breast cancer surgery any form of regional anaesthesia (18 RCTs, n=1,297) reduces CPSP 3 to 12 months after surgery compared with systemic analgesia (OR 0.43; 95%CI 0.28 to 0.68) (NNT 7); specifically paravertebral block (PVB) (6 RCTs, n=419) is effective (OR 0.61; 95%CI 0.39 to 0.97) (NNT 11). APMSE 2020: Page Iv: Following breast cancer surgery, paravertebral block (S) (Level I [Cochrane Review]) and lidocaine IV infusions *reduce the incidence of chronic postsurgical pain *(N) (Level I PRISMA]). Page 349: **Paravertebral block for breast cancer surgery** For mastectomy, PVB reduces the risk of CPSP at 12 mth postoperatively (OR 0.43; 95% CI 0.28 to 0.68) (18 RCTs, n=1,297) (Weinstein 2018 Level I (Cochrane), 63 RCTs, n=3,027).

Answer 564

d) less maternal bradycardia (repeat) "d) less maternal bradycardia (26 vs 42%) - nil pt required anticholinergic so clinical significance unclear No difference in N/V No difference in hypotension No difference in acid base profiles and APGAR at 1min and 5mins https://www.bjanaesthesia.org.uk/article/S0007-0912(20)30442-6/fulltext Norad vs phenyl in spinal LSCS 2020 BJA"

Answer 565

Hypotension Citrate is the anticoagulant used in blood products. It is usually rapidly metabolised by the liver. Rapid administration of large quantities of stored blood may cause hypocalcaemia and hypomagnesaemia when citrate binds calcium and magnesium. This can result in myocardial depression or coagulopathy. Patients most at risk are those with liver dysfunction or neonates with immature liver function having rapid large volume transfusion https://litfl.com/citrate-toxicity/ Hypocalcaemia resulting in long QT, reduced inotropy, hypotension systemic hypocoag Metabolic Met alk with HCO3 formation HAGMA with citrate accumulation Hypernatraemia from Na citrate Hypomag due to citrate chelation Hypokalaemia due to low mag and met alk

Answer 566

a) polydipsia Hypocalcemia varies from a mild asymptomatic biochemical abnormality to a life-threatening disorder. Acute hypocalcemia can lead to paresthesia, tetany, and seizures (characteristic physical signs may be observed, including Chvostek sign, which is poorly sensitive and specific of hypocalcemia, and Trousseau sign). https://bestpractice.bmj.com/topics/en-us/160 polydipsia (occurs in hypercalcaemia) - stones (renal), (painful) bones, groans (abdo - N/V, constipation, GORD), psychic moans, thrones (polyuria, constipation) Signs of Low Ca CNS - mental status changes - circumoral tingling, tetany, confusion, memory loss, depression, delirium, hallucination, seizures CVS - prolong QTc, arrythmia, hypotension Airway - laryngospasm "

Answer 567

a) Smaller bolus smaller total dose

Answer 568

a) PE D-shaped left ventricle ECHO features of PE - RV dilatation * End-diastolic diameter >30 mm in parastemal view * RV larger than LV in sobcostal or apical view * Small LV cavity size with normal LV systolic function * Septal flattening consistent with RV pressure overload * RV wall hypokinesis: Moderate or severe * McConnell’s sign: Echocardiographic pattern of RV dysfunction consisting of akinesia of the mid free wall but normal motion at the apex"

Answer 569

reduce onset time c) faster onset of anaesthetic https://pubmed.ncbi.nlm.nih.gov/28708665/ agrees with faster onset but for non obstetric surgery UTD hyperbaric bupivacaine because of its rapid onset and the option to modify the spinal level by changing the position of the operating table. Plain bupivacaine (ie, slightly hypobaric, prepared in saline) may also be used for spinal anesthesia for CD. The literature comparing safety and efficacy of hyperbaric with isobaric bupivacaine for CD is inconclusive No difference in AE or inadequate analgesia (i.e. conversion to GA or additional analgesia) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6457713/ 2016 Cochrane review"

Answer 570

d) 100 x PPmax - PPmin / PPmean PPV >13% fluid responsive 2011 Anaesthesiology paper: 9-13% is grey zone PPV <9% not fluid responsive https://anesthesia.ucsf.edu/sites/anesthesia.ucsf.edu/files/wysiwyg/Pulse%20Pressure%20Variation.pdf "

Answer 571

"Deep anaesthesia increases POD and no change in mortality - Inclusion criteria: age>60, ASA 3/4, >2hr duration of surgery, hospital stay>2days - delirium assessed for 5 days - light anaesthesia prevented 1 in 10 cases of POD https://www.bjanaesthesia.org/article/S0007-0912(21)00493-1/fulltext "

Answer 572

a) 1:670 (or 1:700) Overall 1:20 000 with NMBD (MC RF) 1: 8000 (136 000 without lol). cardiothoracic surgery 1:8600 GA C/S 1:670 1:60 000 paeds Higher risk: emergencies, cardiac, unexpected difficult airway, NMB, TIVA (two-fold) 2/3 experienced during induction or emergence 1/3 during maintenaince "

Answer 573

C. Left heart failure causing PulmHTN Normal PAPs/d is 25/7. This would be classed as severe (55) - (if image is correct) PAWP >15 means ‘ post-capillary’ cause or combined pre- and post. This is either group 2 or 5. A PVR might help differentiate. All other options (group 1,3,4 and 5) would likely have a isolated ‘pre-capillary’ PAWP of <15 LITFL and blue book 2015 article

Answer 574

a) anterior third of the tongue

Answer 575

a) over-expansion https://www.respiratorytherapyzone.com/ventilator-waveforms/#:~:text=Note%3A%20A%20pressure%2Dvolume%20loop,hand%2C%20indicates%20increased%20lung%20compliance.

Answer 576

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

Answer 577

e) hypoglycaemia

Answer 578

A Massive bronchopleural fistula. Nick Chrimes 2022 - Journal of Anaesthesia ‘Preventing unrecognised oesophageal intubation: a consensus guideline from the Project for Universal Management of Airways and international airway societies’ Causes of exhaled carbon dioxide detection despite oesophageal intubation No alveolar ventilation occurring -Prior ingestion of carbonated beverages or antacids -Gastric insufflation of CO2 for upper gastrointestinal endoscopy -Prolonged ventilation with facemask or poorly positioned supraglottic airway before attempting tracheal intubation -Bystander rescue breaths Some alveolar ventilation potentially occurring -Tracheo-oesophageal fistula with tube tip proximal to fistula -Proximal oesophageal intubation with uncuffed tube in a paediatric patient

Answer 579

c. Two sets of pads, <1 second apart For DSED, to avoid possible defibrillator damage caused by shocks applied at the same instant, a short delay (<1 second) between shocks was created by having a single paramedic depress the “shock button” on each defibrillator in rapid sequence (anterior–lateral followed by anterior–posterior) Among patients with refractory ventricular fibrillation, survival to hospital discharge occurred more frequently among those who received DSED or VC defibrillation than among those who received standard defibrillation. https://www.nejm.org/doi/full/10.1056/NEJMoa2207304

Answer 580

e. Hypotension https://www.safetyandquality.gov.au/sites/default/files/2022-06/sepsis_clinical_care_standard_2022.pdf | SIRS criteria: 2 or more Temp >38 or <36 HR >90 RR >20 or PaCo2 <32 WBC

Answer 581

c. inc extracellular fluid https://derangedphysiology.com/main/required-reading/electrolytes-and-fluids/Chapter%20531/hyponatremia-lazy-mans-classification ECF/fluid status differentiates the two ECF = Plasma volume + ISF; Key feature: CSWS - dehydrated w/ high urine output - ↓plasma volume SIADH - euvolaemic (or hypervolaemic) w/ low urine output ->↑ADH in both (appropriately 2o to hypovolaemia in CSWS, inappropriate in SIADH) ∴ -> hyponatraemia and low uric acid level in both https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2912080/#:~:text=The%20key%20differentiation%20is%20that,CSW%2C%20despite%20correction%20of%20hyponatremia"

Answer 582

b. AR https://litfl.com/oesophageal-doppler/

Answer 583

c) 50mmHg Initial Fluid bolus/adrenaline Gr 2: 500mL; 10-20mcg, then 50mcg if no response Gr 3: 1L; 50mcg-100mcg, then 200mcg if no response Gr 4: 2L >3 boluses of adrenaline -> start infusion (can be peripheral) Give 100% FiO2

Answer 584

E. Urine output 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. https://journals.lww.com/ccmjournal/Fulltext/2021/11000/Surviving_Sepsis_Campaign__International.21.aspx

Answer 585

a) electrical alternans Physical findings in Tamponade: - A number of findings may be present on physical examination, depending upon the type and severity of cardiac tamponade - None of the findings alone are highly sensitive or specific for the diagnosis. Beck's triad 1. Low arterial blood pressure 2. Dilated neck veins 3. Muffled heart sounds - Are present in only a minority of cases of acute cardiac tamponade. Diagnosis: Clinical diagnosis is usually suspected based on the history and physical examination findings, which may include: ●Chest pain ●Syncope or presyncope ●Dyspnea and tachypnea ●Hypotension ●Tachycardia ●Peripheral edema ●Elevated jugular venous pressure ●Pulsus paradoxus - most common ECG finding is sinus tachy, electrical alternans in severe"" Pulsus alternans = arterial pulse with alternating strong and weak beats. Indicative of severe LV dysfunction (HF, cardiomyopathy) Kussmaul breathing: deep, laboured breathing in MA (DKA)

Answer 586

a) musculocutaneous RT - DCB; Read That Damn Cadaver Book Roots - Interscalene Trunks - Superior trunk Divisions - Supraclav Cords - Infraclav Branches - Axillary""

Answer 587

e) ensure leads securely attached https://journals.lww.com/nursing/Citation/2006/11000/Cables_and_electrodes_can_burn_patients_during_MRI.12.aspx#:~:text=The%20radiofrequency%20fields%20that%20occur,enough%20to%20require%20plastic%20surgery. https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.107.187256#d1e281 bullshit question. the radiographers in MRI had no clue

Answer 588

b. FFP or recombinant ATIII concentrates (better) >600IU/kg heparin = heparin resistance (if cannot achieve ACT >480s) - may be due to ATIII deficiency or ^protein binding of heparin - aquired defiiciency can be due to recent heparin administration Heparin resistance: ACT >480s using 300-400IU/kg; generally up to 600IU/kg acceptable - can be due to AT deficiency (e.g. prior heparin), AT-independent or pseudoresistance"

Answer 589

c) 93% ANZCOR suggests against the routine administration of oxygen in persons with chest pain.13 [2015 COSTR, weak recommendation, very-low certainty evidence] For persons with heart attack, routine use of oxygen is not recommended if the oxygen saturation is >93% [National Heart Foundation of Australia & Cardiac Society of Australia and New Zealand: practice advice]. AHA go with 90%

Answer 590

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

Answer 591

b) 4yo 4 yo = wong baker faces score 3-18. 8 yo = Visual analogue scale. https://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Pain_assessment_and_measur ement/ APMSE 5 also

Answer 592

c. 200mg hydrocortisone 200mg Hydrocortisone or 25mg Prednisolone Dex:pred:hydrocort conversion 4:25:100 8:50:200"

Answer 593

a) inhalational anaesthesia https://resources.wfsahq.org/atotw/emergence-delirium-in-pediatric-patients/ occurs in 9-18% paeds - eye and ENT surgery at higher risk - higher incidence in preschool 2-5 years old (male), anxious patients, negative behaviour on induction TIVA better than Sevo in decreasing PoD https://academic.oup.com/bja/article/118/3/335/2999642 2017 review"

Answer 594

c) 0, 1, 4, 24 Serum tryptase levels are recommended to be collected as soon as possible after the onset of symptoms and then at 1 hour, 4 hours and after 24 hours. https://www.anzca.edu.au/resources/professional-documents/endorsed-guidelines/anaphylaxis-guideline-2022.pdf

Answer 595

a) saphenous To block foot/ankle completely, need saphenous to complement popliteal sciatic nerve block"

Answer 596

d. Augments Cardiac output in patients with LV failure Airway pressure release ventilation (APRV) is an open-lung mode of invasive mechanical ventilation mode, in which spontaneous breathing is encouraged. APRV uses longer inspiratory times; this results in increased mean airway pressures, which aim to improve oxygenation. Brief releases at a lower pressure facilitate carbon dioxide clearance. The terminology and methods of initiation, titration, and weaning are distinct from other modes of mechanical ventilation. The use of APRV is increasing in the UK despite a current paucity of high-quality evidence high intrathoracic pressure decreases the transmural left ventricular pressure, reducing the work of contraction and increasing cardiac output. In the context of hypoxaemia, a mode of mechanical ventilation that improves arterial oxygenation will improve myocardial oxygen delivery, myocardial function and cardiac output. As APRV is a spontaneous breathing mode, in addition to the benefits of spontaneous ventilation, reduced doses of sedative drugs can often be used, with subsequent reduction of requirement for vasoactive drugs and improvement in haemodynamic state. Airway pressure release ventilation (APRV) is an open-lung mode of invasive mechanical ventilation mode, in which spontaneous breathing is encouraged. APRV uses longer inspiratory times; this results in increased mean airway pressures, which aim to improve oxygenation https://www.bjaed.org/article/S2058-5349(19)30178-7/fulltext https://derangedphysiology.com/main/required-reading/respiratory-medicine-and-ventilation/Chapter%20518/airway-pressure-release-ventilation-aprv-ards

Answer 597

c) DOO The pacing mode will be DOO when the programmed pacing mode is a dual chamber mode, VOO when the programmed pacing mode is a single chamber ventricular mode, and AOO when the programmed pacing mode is a single chamber atrial mode.

Answer 598

a) 10 Paeds: 1-5 mild, 5-10 mod, 10+ severe (i.e. 1+ = OSA); 1 - 5 - 10 https://www.sleepfoundation.org/sleep-apnea/ahi ADULT (note scale always inclusive of lower number); 5 - 15 - 30 normal <5 mild 5-15 moderate 15-30 severe > 30 Apnoea = breathing stop or reduce to 10% of normal levels for 10 secs Hypopnea = airflow decreases by more than 30% for 10 seconds AHI = total apnoea+hypopnoea / total no. of hours asleep"

Answer 599

a) methylene blue "a) methylene blue G6PD deficiency most common enzymatic disorder of RBC --> enzyme G6PD generateds NADPH --> protects RBC from oxidative stress. G6PD deficiency -->haemolytic anaemia https://www.uptodate.com/contents/diagnosis-and-management-of-glucose-6-phosphate-dehydrogenase-g6pd-deficiency?search=G6PD%20deficiency&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1#H5" Drugs to avoid: Antibiotics Sulphonamides (check with your doctor) Co-trimoxazole (Bactrim, Septrin) Dapsone Chloramphenicol Nitrofurantoin Nalidixic acid Antimalarials Chloroquine Hydroxychloroquine Primaquine Quinine Mepacrine Chemicals Moth balls (naphthalene) Methylene blue Foods Fava beans (also called broad beans) Other drugs Sulphasalazine Methyldopa Large doses of vitamin C Hydralazine Procainamide Quinidine Some anti-cancer drugs

Answer 600

(base rate is 10%, experimental group is 8% (20% below 10%) therefore 100/ 2 = 50 or 1 divided by risk reduction population risk = 10/100 patients get PONV population risk + new antiemetic = 8/100 patients get PONV (8/100 as reduction by 20% with new drug) RR= 0.10-0.08=0.02 NNT= 1/RR =1/0.02 =50

Answer 601

a) case control https://www.cdc.gov/csels/dsepd/ss1978/lesson3/section5.html

Answer 602

a. Drugs that absolutely must not be used for pregnancy. (absolute contraindication) https://www.tga.gov.au/australian-categorisation-system-prescribing-medicines-pregnancy

Answer 603

c. Decreased amplitude, increased latency SSEP used for spine, intracranial, endovascular, carotid surgeries - stimulate peripheral nerves (ulnar/median/posterior tibial) Brainstem auditory evoked potential - post fossa surgery https://www.bjaed.org/article/S2058-5349(19)30019-8/fulltext 2019 BJA intraop neuromonitoring in paed spinal surgery"

Answer 604

a) Cold Saline Irrigation 1st line: Irrigation of the brain with sterile iced saline. 2nd line:Propofol bolus (10 to 20 mg IV) or midazolam (1 to 2 mg IV) to terminate seizure https://www.ncbi.nlm.nih.gov/books/NBK572053/"

Answer 605

b) severe dermatographia ABSOLUTE CONTRAINDICATIONS to skin testing - no healthy skin (at all) - severe dermatographism - hx of severe non-immediate hypersensitivity - erythema multiforme, stevens johnson syndrome, toxic epidermal necrolysis, lucocytoclastic vasculitis, DRESS RELATIVE contraindication: - recent antihistamine use - severe asthma – b-blocker /ACEI (may worsen severe reaction - usually still continued) - should not be carried out on limbs affected by lymphoedema, paralysis, neurogenic abnormalities - pregnancy"

Answer 606

a) turn left lateral "suspect cardiac herniation - turn pt to non-operative side down and then return to OT ASAP https://www.bjaed.org/article/S2058-5349(19)30078-2/fulltext#secsectitle0135 2019 - mortality >50%; can occur in R - acute hypotension, shock, cyanosis, w/ SVC obstruction (chest pain/dyspnoea) PS: chest drains removed for 1min every hour to assess for haemorrhage (if unclamped for prolonged periods -> risk of acute mediastinal shift into empty hemithorax -> circulatory collapse" UTD: Cardiac herniation is usually seen within three days of surgery, presenting as sudden onset of hypotension and shock, cyanosis, chest pain, and superior vena cava syndrome. The acute event is usually preceded immediately by coughing, moving the patient, vomiting, or extubation. Treatment involves emergent surgery to reposition the heart and close the pericardial defect to prevent recurrence. ?bleeding Rapid filling of the PPS with blood can occur within 24 hours of surgery. This complication is more common after pleuropneumonectomy or pneumonectomy for suppurative lung disease. The clinical presentation may be with hypotension and shock due to the loss of intravascular blood volume. The mainstay of treatment is surgical reexploration and control of bleeding sources.

Answer 607

b) vasoplegia Vasoplegia - vasodilatory shock post cardiac bypass - normal or high cardiac output state with low SVR causing organ hypoperfusion - within 24hrs if CI >2.2 AND SVR <800dynes - criteria non specific and found in other diseased states like adrenal insufficiency, sepsis, liver failure - main distintion being aetiology (ie. post bypass - likely vasoplegia, infection - sepsis) - ^ risks of vasoplegia if on ACEI / b-blockers / CCB; also w/ vasodilatory inotropes (e.g. dobumatine, milrinone)"

Answer 608

b) flaccid paralysis Guillain–Barré syndrome (GBS) is an inflammatory disease of the PNS and is the most common cause of acute flaccid paralysis

Answer 609

a. Dysaesthesia Chronic pain that may involve itchiness, burning, electric shock, or a general tightening in any part of the body. Allodynia Pain from stimuli which are not normally painful. The pain may occur other than in the area stimulated. Hyperalgesia is an abnormally increased sensitivity to pain Hyperesthesia is a condition that involves an abnormal increase in sensitivity to stimuli of the sense https://www.iasp-pain.org/resources/terminology/#:~:text=DYSESTHESIA,sen

Answer 610

d. 65 to 85 per hundred Risk of acquiring CMV through a leucodepleted blood product is estimated at around 1 in 13,575,000. This compares to a community acquired risk where 85% of Australian adults are infected by the age of 40. 85% of australians are CMV positive by the age of 40 https://www.blood.gov.au/system/files/documents/cmv-blood-components.pdf CMV negative blood recommended for: pregnant women. May be considered for: transplant recipeints, chemotherapy, intrauterine RBC transfusion, premature or immunocompromised neonates,.

Answer 611

d) diltiazem Nondihydropyridine calcium channel blockers should be used cautiously in patients with HFrEF because of their negative inotropic effects, and the role of these agents in LVAD recipients remains unclear https://www.ahajournals.org/doi/10.1161/CIR.0000000000000673 Should also avoid sotolol Atrial arrythmia mx: - already on anticoagulation of LVAD - rate control: b-blocker (carvedilol, bisoprolol, metoprolol approved for HFrEF) + digoxin ↓hospitalisations -> NON-dihydropyridine CCB usually avoided due to negative inotropy effects (e.g. verapamil, diltiazem) (note amloDIPINE is a dihydropyriDINE) - rhythm control w/ amiodarone, sotalol (caution -ve introopy) - controversial if works. Ventricular arrhythmia: no antiarrhythmic drug better than ICD therapy for survival Amiodarone probably good (but beware SEs) AFlutter: ablation first-line (>95% success rate)"

Answer 612

a) Accurate delivery of volatile concentration from vaporiser PS31 Level two check should be performed at the start of each anaesthetic list. 4.2.3.2 Inhalational anaesthesia delivery devices (vapouriser) 4.2.3.2.1 Ensure electricity is connected to vapourisers that require it. 4.2.3.2.2 Check the anaesthetic liquid level is within marked limits. 4.2.3.2.3 Ensure all filling ports are sealed. 4.2.3.2.4 Check correct seating, locking and interlocking of detachable vapourisers or casettes. 4.2.3.2.5 Test for circuit leaks with a cassette installed or for each vapouriser in the “on” and “off” state. 4.2.3.3 Check for machine leaks upstream from the common gas outlet or breathing system, using a protocol appropriate for the anaesthesia delivery system. One: detailed check (by trained personnel) of all systems (new or after service/repair) Two: at start of every anaesthetic list Three: prior to each pt (all anaesthesia personnel should be trained and accredited for two/three)"

Answer 613

b) diclofenac LIthium perioperative concerns: - Prolongation of NMB - Reduction in anaesthetic agent requirement - Avoid NSAIDs - No withdrawl symptoms - Discontinue 24hrs before surgery NSAIDs differentially alter lithium concentrations by multiple mechanisms, and one of these is to reduce prostaglandin E2 BJA: perioperative advice for psychotropic drugs

Answer 614

a. <110ml leak with cuff deflated approach is to use 110 mL or 10% of tidal volume as the cut-off https://litfl.com/cuff-leak-test/ "Normal cuff leak is >110ml (cuff leak volume = between inspiratory TV pre-deflation and average expiratory TV (after deflation) - average three lowest values over next six breathing cycles post-deflation - if <110mL associated with increased post extubation stridor - >110mL difference in exp TV before and after cuff down has NPV 98% for post extubation stridor (essentially rules it out in original study from 1996) - 2009 meta-analyses: absence of leak -> higher risk airway obstruction presence of a leak -> low predictive value; does NOT rule out obstruction absence of a leak should alert the clinician to a higher risk of upper airway obstruction; however, the presence of a leak has a low predictive value and does not rule out the occurrence of upper airway obstruction 2017 BJA postop mx difficult airway We define a ‘failed CLT’ as the RT being unable to identify air leak during auscultation. 2019 BMJ The positive cuff-leak test can, in a high percentage, predict post-extubation airway obstruction. However, due to its low to moderate sensitivity, a negative test cannot exclude potential complications after the patient has been extubated. GE cuff leak "

Answer 615

b) no limitation in neck movement One of the most commonly used mnemonics is “NSAID” which stands for: N eurological deficit S pinal tenderness A ltered mental status I ntoxication D istracting injury

Answer 616

e) haloperidol Bluebook - suggest antipsychotics with caution Mx - treat underlying cause - infection, pain, dehydration, metabolic derangement, constipation, urinary retention - antipsychotics (e.g. haloperidol 0.5mg-1 PO/IM/IV, quetiapine 25mg PO STAT = preferred w/ PD or demential w/ Lewy bodies) is first line for agitation but does not alter time course of delirium or modify its prognosis - avoid benzo - may worsen symptoms NOF surgery - 70% risk of post op delirium Post-op (usually days 2-5) - non pharm mx - re-orientation, sleep optimisation, mobilisation, nutrition - prophylactic antipsychotic (risperidone, olanzapine), melatonin"

Answer 617

d) loss of pain and temperature Brown Sequard - lateral damage to the cord with ipsilateral loss of motor function, proprioception, light touch and contralateral loss of pain and temperature below level of injury

Answer 618

A. Pecs 1 - between pecs major and pecs minor - blocks lateral and medial pectoral nerves Stenum innervated by interocostal nerves. All 3 options below can be used for sternal fracture PECS 2 - between pecs minor and serratous ant - blocks intercostal brachial, long throacic, intercostal III - VI nerve Subpectoral interfascial plane block - between pec major and interocstal Transverus thoracic plane block = parasternal plane block https://www.asra.com/news-publications/asra-newsletter/newsletter-item/asra-news/2020/05/01/how-i-do-it-transversus-thoracic-plane-and-pecto-intercostal-fascial-block "

Answer 619

C. 3 Appearance - pink > peripherial cyanosis > blue/pale Pulse - >100 > (<100) > absent Grimace - cry/active withdrawal > grimace > no response Activity - active motion (flexed arms/legs resisting extnesion) > some flexion > limp Respiration - strong cry/good breathing > irregular/shallow breathing, weak cry > apnoea "

Answer 620

Category GFR ml/min/1.73 m2 Terms G1 ≥90 Normal or high G2 60-89 Mildly decreased* G3a 45-59 Mildly to moderately decreased G3b 30-44 Moderately to severely decreased G4 15-29 Severely decreased G5 <15 Kidney failure Assign Albuminuria category as follows: Albuminuria categories in CKD Category ACR (mg/g) Terms A1 <30 Normal to mildly increased A2 30-300 Moderately increased* A3 >300 Severely increased** Abbreviations: ACR, albumin-to-creatinine ratio; CKD, chronic kidney disease. *Relative to young adult level. **Including nephrotic syndrome (albumin excretion ACR >2220 mg/g) **Collectively referred to as “CGA Staging” REPEAT

Answer 621

E. distance from anterior surface of dens to posterior surface of anterior arch of atlas The atlantodental interval is used in the diagnosis of atlanto-occipital dissociation injuries and injuries of the atlas and axis. The anterior atlantodental interval is the horizontal distance between the posterior cortex of the anterior arch of the atlas (C1) and the anterior cortex of the dens in the median (midsagittal) plane Normal values for anterior atlantodental interval are: radiographs: adults: males: <3 mm females: <2.5 mm 1 (although most authors describe <3 mm ref) children: <5 mm ref CT: adults: <2 mm Atlantoaxial subluxation ~25% of patients with severe RA - ~80 % ant subluxation (so atlas (C1) moves forward on axis (C2) - due to destruction of transverse ligament (>3mm distance is signficant) - worsened by neck flexion

Answer 622

A. Move medial

Answer 623

d) myasthenia gravis or d) Cerebral palsy ->sux and volatiles are not contraindicated -> presence of extrajunctional receptors may cause hyperkalaemia if responses remembered incorrectly but of this list CP is probably the answer a. Becker muscular dystrophy -> essentially milder Duchenne's (see duchenne response to Sux) b. Cerebral palsy -> Sux and volatiles not contraindicated -> reduced MAC requirement -> increased sensitivity to muscle relaxants c. Guillain Barre -> sux contraindicated due to risk of hyperkalaemia -> increased sensitivity to Non depolarising NB d. Frederich’s ataxia -> sux should be avoided due to risk of hyperkalaemia e. Duchenne muscular dystrophy -> sux and volatiles contraindicated due to rick of hyperkalaemia and rhabdomyolysis In contrast to other neuromuscular disorders, succinylcholine may be used in myasthenia gravis. The required dose may need to be increased by up to two-fold, as those with the disease show a relative resistance to the drug. Sux is not recommended in patients with neuromuscular disease due to: 1. presence of extrajunctional receptors and risk of hyperkalaemia and rhabodmyolysis 2. fasiculations causing temperomandibular muscle spasm preventing intubation REPEAT

Answer 624

B. 7.32 https://emj.bmj.com/content/18/5/340 The values of pH on arterial and venous samples were highly correlated (r=0.92) with an average difference between the samples of −0.4 units. There was also a high level of agreement between the methods with the 95% limits of agreement being −0.11 to +0.04 units. https://litfl.com/vbg-versus-abg/ VBG vs ABG pH + 0.035 PCO2 - mean difference +6mmHg; good correlation in normocapnoea (unreliable when PaCO2>45mmHg) Correlate well: HCO3-, Base Excess, Lactate - dissociation above 2mmol/L https://litfl.com/vbg-versus-abg/ "

Answer 625

D. Substance P Development of aprepitant, the first neurokinin-1 receptor antagonist for the prevention of chemotherapy-induced nausea and vomiting (2011) https://www.ncbi.nlm.nih.gov/pubmed/21434941 Aprepitant acts centrally at NK-1 receptors in vomiting centres within the central nervous system to block their activation by substance P released as an unwanted consequence of chemotherapy. REPEAT

Answer 626

c) 110 Brain trauma foundation Level III recommendation. To decrease mortality and improve outcomes: Maintain SBP at >100mmHg for patients 50 - 69 Maintain SBP at >110 for patients 15 - 49 Maintain SBP at >110 for patients 70 or older

Answer 627

A. AION Answer is more likely ‘A - Anterior Ischaemic Optic Neuropathy, because: 1. Most common 2. One or two days post - up to 12 3. Optic disc oedema (CRAO - fundoscopic appearance is that retina appears pale with cherry red central spot). PION fundoscopy is normal at first but has late developing oedema. It is less common than AION. https://eyewiki.aao.org/Non-Arteritic_Anterior_Ischemic_Optic_Neuropathy_(NAION) Symptoms: The classic description of patients with AION presenting with acute, painless unilateral vision loss that is often described as a blurring or cloudiness of vision, often inferiorly, has been expanded. Although the majority of patients do not have accompanying pain, headache or periocular pain is reported in 8-12% of patients, which can make it difficult to differentiate from optic neuritis post op ischaemic optic neuropathy - most common cause of POVL after nonocular surgery - ^risk with cardiac, spine, orthopaedic, steep trendelenberg positions - anterior ION - more common with cardiac - posterior ION - more common with prone procedures, steep trendelenberg, cardiac - presents with painless b/l vision loss - risk factors for POVL with spine surgery - male, ^BMI, wilson frame, long duration, ^ blood loss - PION more common however only AION has fundoscopic changes -- AION - fundoscopy - swollen disc - can be uni or bilateral -- AION onset usually immediate after awakening but can also have onset a day or so afterwards - sudden unilateral or bilateral, progressive vision loss Central retinal artery occlusion - most common retinal cause of POVL - usually unilateraly and immediately after awakening from anaesthesia - fundoscopy - ischaemic retina + cherry red spot at macula https://www.uptodate.com/contents/postoperative-visual-loss-after-anesthesia-for-nonocular-surgery#H437018973 "

Answer 628

a. 3 months is the minimum time period for delay (one could argue that a major joint can wait 9 months but they specified minimum) Elective surgery should preferably be delayed for 9 months after a previous stroke; emergency surgery should not be delayed. - <3 months high risk (68-fold increase) cf. 9 months - ↓stroke/MI/death risk at 9 months

Answer 629

C. Between lowest renal artery to bifurcation of aorta https://litfl.com/reboa-in-resuscitation/ Anatomy: The aorta is divided into three separate zones for the purposes of REBOA (aortic length varies between individuals) Zone I of the aorta extends from the origin of the left subclavian artery to the coeliac artery (approx 20cm long in a young adult male) Zone II extends from the coeliac artery to the most caudal renal artery (approx 3cm long) Zone III extends distally from the most caudal renal artery to the aortic bifurcation (approx 10cm long) REBOA location based on injury: >suspected or diagnosed intra-abdominal haemorrhage due to blunt trauma or penetrating torso injuries (Zone I REBOA), or >blunt trauma patients with suspected pelvic fracture and isolated pelvic haemorrhage (Zone III REBOA), or >patients with penetrating injury to the pelvic or groin area with uncontrolled haemorrhage from a junctional vascular injury (iliac or common femoral vessels) (Zone III REBOA) Simplistic rendering of aorta. Zone 1 (from left subclavian artery to the upper border of the celiac trunk), Zone 2 (the upper border of the celiac trunk to the lower border of the distal take-off of the renal arteries), and Zone 3 (from the lower border of the lower renal artery to the aortic bifurcation). Zone 1 is occluded in the case of cardiac arrest or life-threatening intra-abdominal hemorrhage; Zone 2 has no current indication; and Zone 3 is occluded in the case of life-threatening pelvic or lower limb haemorrhage7. REBOA Resuscitative Endovascular Balloon Occlusion of the Aorta.

Answer 630

D. Withholding information to the patient if you think it will cause harm https://www.sciencedirect.com/topics/medicine-and-dentistry/therapeutic-privilege “Therapeutic privilege,” also known as “therapeutic nondisclosure,” is defined as the withholding of relevant health information from the patient if nondisclosure is believed to be in the best interests of the patient (President’s Commission, 1982; Berger, 2005). The two most common justifications for such nondisclosure are that the disclosure would create incapacitating emotional distress and that disclosure would violate a patient’s personal, cultural, or other social requirements (Crawley et al., 2001; Berger, 2005). ANZCA PG 67 - Therapeutic privilege - in an emergency, consent does not need to be obtained for treatment that will save a person's life or prevent sigfnicant harm or distress to the patient. - this applies WHEN patients lack decision-making capacity and their substitute decision maker is unavailable in a reasonable time frame to provide consent. - Advance care directives, where known, can be used to guide treatment."

Answer 631

a) Open repair Flow chart from Blue book https://jamanetwork.com/journals/jamasurgery/fullarticle/1741862 - recommended when injury is recognised >4hrs after cannulation or where no endovascular treatment service available Other options - percutaneous closure device, temporary balloon tamponade with concurrent external mannual pressure or external pressure alone (in palpable artery like common carotid) Current ASA guidelines - leave catheter in place (note all adult CVCs are ≥7 Fr) and contact general or vascular surgeon or interventional radiologist. Postpone elective surgery https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9503793/ 2022"

Answer 632

a) delayed gastric emptying

Answer 633

e. 45ml/hr 0.9% NS 5% dextrose Total fluid requirement = maintenaince + replacement of deficit + replacement of ongoing losses - replace deficit over 24-48hrs (first 5% over 24hrs, then rest over next 24hrs). -> deficit (L) = weight change in kg (most accurate) ->Deficit (mL) = weight (kg) x % dehydration x 10 - ongoing losses replaced over 4hr period (or hourly if significant) 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 maintenance rate due to ^ADH secretion (risk fluid overload/hyponatraemia)**

Answer 634

B. Cardiac hernation https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.109.896829

Answer 635

a) day of and 2 days prior For surgery/procedures requiring 1 or more days in hospital / colonoscopy requiring bowel prep - omit SGLT2i for at least 3 days (2 days pre-procedure and day of procedure) For day stay procedures (including gastroscopy) that does not require bowel prep - SGLT2i can be stopped just for day of procedure. Limit fasting before/after procedure https://www.diabetessociety.com.au/wp-content/uploads/2023/05/ADS-ADEA-ANZCA-NZSSD_DKA_SGLT2i_Alert_Ver-May-2023.pdf

Answer 636

d) Supraclavicular Axillary nerve innervates skin to inferior deltoid (regimental badge)+ motor to terres minor and deltoid. Lateral pectoral nerve innervates the anterosuperior part of the glenohumeral joint. Subscapular nerves - upper subscapular nerve serves the upper portion of the subscapularis muscle; the middle subscapular nerve (thoracodorsal nerve) innervates latissiumus dorsi; lower subscapular nerve innervates subscapularis and terres major. Supraclavicular nerve - sensory only and innervates skin across entire shoulder and trapezius in a ‘cape-like’ fashion - sometimes missed in interscalene block. Suprascapular nerve sensory innervation to glenohumeral joint and acromiovlavicular joint + motor to supraspinatus/infraspinatous (rotator cuff) https://pubmed.ncbi.nlm.nih.gov/32712453/

Answer 637

A. Aspirin 150mg daily (option was definitely 150mg not 100mg) or D. Ca Aspirin should be given at a dose between 75 and 150 mg per day, started preferably before 16 weeks, possibly taken at night, and continued until delivery; https://www.somanz.org/content/uploads/2023/06/SOMANZ_Hypertension_in_Pregnancy_Guideline_2023.pdf Calcium supplementation (1.5g/day) should therefore be offered to women with moderate to high risk of preeclampsia, particularly those with a low dietary calcium intake (247) - 100-150mg /day for moderate to high risk groups ideally before 16weeks gestation to K36 - NNT 61 Calcium 1.2-1.5g/day in high risk women where there is deficient calcium intake (<600mg/day) Mg, Zinc, salt restriction and antioxidants not supported https://www.health.qld.gov.au/__data/assets/pdf_file/0034/139948/g-hdp.pdf "

Answer 638

c) Foetal RBC All others removed with leukodepletion filter Leucocyte depletion filters are adhesive filters (removes 98-100% bacteria) - removes plasma phase elements of amniotic fluid, AFP (plasma protein in fetus), vernix and squamous cells, but RBCs still present - can cause bradykinin mediated hypotension - removes most cancer cells but not all (no evidence of increased recurrence of metastatic disease) No absolute contraindications to cell salvage. Relative contraindications - potential contamination of aspirated blood with bowel contents, infection or tumor cells (specific consent for latter).

Answer 639

b. Insufficient fludrocortisone replacement In Primary Adrenal Insufficency, cortisol deficiency results in decreased feedback to the HPA axis, leading to increased secretion of ACTH to stimulate the adrenal cortex. Simultaneously, MCs deficiency causes increased release of renin by the juxtaglomerular apparatus of the kidneys.

Answer 640

c. Pain at site 1 month prior to surgery Pain itself is a risk factor: the strongest predictors of CPSP are chronic preoperative pain and the severity of acute postoperative pain https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5741327/#:~:text=Pain%20its CPSP - pain develoing or increasing in intesnity after a surgical procedure, in the area of the surgery, persisting beyond the healing process (~3mths) and not better explained by another rcause such as infection, malignancy or pre-exisiting pain condition.

Answer 641

b) 1 or more RF Risk factors - female (MC), age<50, post-op opioids, hx PONV, non-smoker recommendation from new consensus guideline - 2 forms of prophylaxis for patients with 1-2 risk factors and 3-4 for more risk factors https://www.ashp.org/-/media/assets/policy-guidelines/docs/endorsed-documents/endorsed-documents-fourth-consensus-guidelines-postop-nausea-vomiting.pdf "

Answer 642

D. 4 WFNS (based on GCS) (survival; based on GCS); FND = morbidity I – GCS 15 (70%) II – GCS 13-14 w/o focal neurological deficit (60%) III – GCS 13-14, focal neurological deficit (e.g. hemiparesis, aphasia) (50%) IV – GCS 7-12 (20%) V – GCS 3-6 (10%) * alternatively her Fisher score is: grade 2 (diffuse thin (<1 mm) SAH, no clots; which estimates an incidence of symptomatic vasospasm of 25%) Note the new modified Fischer scale. G0 No SAH or IVH (0%) G1 Focal or diffuse thin SAH but no IVH (6-24%) G2 Focal or diffuse thin SAH with IVH (15-33%) G3 Thick SAH no IVH (33-35%) G4 Thicc SAH with IVH (34-40%) The main differences between the Fisher scale and modified Fisher scale are: 1) Fisher scale, no SAH is grade 1, but 0 in modified Fisher scale 2) Fisher scale, thin SAH & no IVH is grade 2, but 1 in modified Fisher scale 3) Fisher scale, thick SAH with no IVH is grade 3 and the same 3 in modified Fisher scale 4) Fisher scale, any IVH is grade 4, irrespective of the presence of SAH but in modified Fisher scale it is either 2 if thin or no SAH, or grade 4 if thick SAH REPEAT

Answer 643

2-3weeks if asymptomatic PG68(A) If not symptomatic: 2-3 weeks for major surgery. No delay if minor surgery (must be beyond infectious period as per local guidelines) If symptomatic: delay 7 weeks for major surgery clock starts from first symptoms or first positive test For most patients, it is safe to proceed with surgery TWO TO THREE WEEKS post SARS-CoV-2 infection provided no ongoing symptoms are present. For high-risk patients, it is recommended to perform an individualised risk assessment and utilise Shared Decision Making to determine optimal timing of surgery post SARS-CoV-2 infection. Patients who are asymptomatic, have returned back to baseline, are vaccinated, aged <70 years and without comorbidity can proceed with non-urgent elective minor surgery (day case) and endoscopy procedures without delay beyond the infectious period (timeframe as per local guideline and expertise ALL patient with ongoing symptoms, especially those who have not returned to baseline function and those patients with a history of moderate or more severe25 SARS-CoV-2 infection: recommended delay for non-urgent elective surgery is still 7 weeks

Answer 644

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

Answer 645

a) NT ProBNP Sacubitrilat inhibits the enzyme neprilysin, which is responsible for the degradation of atrial and brain natriuretic peptide, two blood pressure–lowering peptides that work mainly by reducing blood volume. In contrast, in comparison with enalapril, patients receiving LCZ696 had consistently lower levels of NTproBNP (reflecting reduced cardiac wall stress) and troponin (reflecting reduced cardiac injury) throughout the trial. ## Footnote https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.114.013748?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%20%200pubmed

Answer 646

c. dobutamine - causes dose dependent vasodilation --> hypotension Vasodilatory shock - norad, vasopressin, methylene blue, angiotensin II, vitamin C, hydroxycobalamin (vit B12) (UpToDate) - norad, adrenaline, dopamine, terlipressin, angiotensin II, methylene blue (BJA) https://docs.google.com/document/d/1aIYS372hPVynvKXATrMBakn4T43vi2OoWqW-Vi4cjKw/edit?usp=sharing " ## Footnote UTD

Answer 647

a. Normal - Normal A normal or high oximetry reading should be disregarded because saturation monitors cannot differentiate between carboxyhaemoglobin and oxyhaemoglobin, owing to their similar absorbances. The blood gas PO2 will also be normal in these cases (despite the presence of tissue hypoxia). SpO2 (pulse ox can't differentiate COHb and OxyHb) -> SpO2 not useful PaO2 (PaO2 reflects dissolved O2 in blood - not affected by CO) - only SaO2 (Hb-bound O2) is reduced (in presence of CO binding) https://www.uptodate.com/contents/carbon-monoxide-poisoning#:~:text=Diagnosis%20–%20The%20diagnosis%20of%20CO,in%20smokers%20confirms%20the%20diagnosis. " ## Footnote file:///Users/newuser/Downloads/BTS%20Guideline%20for%20oxygen%20use%20in%20adults%20in%20healthcare%20and%20emergency%20settings.pdf

Answer 648

A. Lupus anticoagulant (normal PT, raised APTT) Lupus anticoagulant (more likely to be associated with thrombosis than bleeding) "Lupus anticoagulant (i.e. antiphospholipid syndrome) - cause prolonged APTT, and is associated w/ thrombosis. BJA 2007 - Abs that block phospholipids important for coagulation Haemophilia A (VIII deficiency) and B can cause isolated prolonged APTT, but associated with bleeding (repeat MCQ 2017B – guy with dental bleeding). Cold agglutinins prolongs PT and APTT -> (IgM autoantiboidies against RBC antigens that bind at cold temperature --> haemolytic anaemia) Factor VII deficiency prolongs PTs w/ normal APTT " ## Footnote https://www.uptodate.com/contents/image?imageKey=HEME%2F79969

Answer 649

b. high HDL-C 3 or more of: (5 H's) 1) Heavy: central obesity: waist >94cm men, >80cm women 2) HTN (>140/90) 3) High levels of triglycerides 4) HDL - low levels 5) High blood surgar (impaired fasting glucose or diabetes)" ## Footnote https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.105.169405

Answer 650

a. medial cutanous brachial nerve C8/T1 roots are often missed. Therefore, interscalene blocks tend to fail on the ulnar side of the arm Medial brachial cutaneous nerve (C8-T1, arises from the medial cord of the brachial plexus): upper medial arm ## Footnote NYSORA

Answer 651

D. Albumin MELD-Na score components: (BICS) Bilirubin INR Creatinine Sodium (serum) Low serum sodium is an independent predictor of mortality in patients with cirrhosis estimates 90 day survival >15 - listed for deceased donor transplant. TIPS best if MELD <15" ## Footnote https://www.tamingthesru.com/blog/r1-diagnostics/labs-in-hepatic-failure

Answer 652

"d) lateral antebrachila cutaneous N (continuation of musculocutaenous nerve) tracks behind cephalic vein in upper forarm and provides cutaneous innervation to forearm"

Answer 653

d) 120s Optimal seizure duration somewhere between 10-120seconds. https://academic.oup.com/bjaed/article/10/6/192/299664 Apparently Oxford Handbook says 60 secs (MCQ TL) ""It is recommended that motor and/or EEG seizures lasting more than 120 seconds be terminated pharmacologically by a benzodiazepine (for example, diazepam or midazolam) or anaesthetic agent in consultation with the anaesthetist."" QLD Health ECT guidelines"

Answer 654

Dopamine - least likely to cause pulmonary vasodilation (all the others do to my knowledge) - From UP TO DATE: > At low doses of 1 to 3 mcg/kg per min, dopamine acts primarily on dopamine-1 receptors to dilate the renal and mesenteric artery beds > At 3 to 10 mcg/kg per min (and perhaps also at lower doses), dopamine also stimulates beta-1 adrenergic receptors and increases cardiac output, predominantly by increasing stroke volume with variable effects on heart rate. > At medium-to-high doses, dopamine also stimulates alpha-adrenergic receptors, although a small study suggested that renal arterial vasodilation and improvement in cardiac output may persist as the dopamine dose is titrated up to 10 mcg/kg per min *clinically, the haemodynamic effects of dopamine demonstrate individual variability Dobutamine (inodilator): - selective β1-agonist that increases cardiac contractility and reduces pulmonary vascular and systemic vascular resistances Vasopressin: - vasopressin may have pulmonary vasodilatory effects in addition to a systemic vasoconstrictive effect Milrinone (inodilator): - the phosphodiesterase-3 inhibitors, milrinone and enxoimone, have positive inotropic effects combined with the capacity to reduce RV afterload (‘inodilators’) without significant chronotropic effect, but they can be associated with significant systemic hypotension ## Footnote https://pubs.asahq.org/anesthesiology/article/121/5/914/13855/VasopressinThe-Perioperative-Gift-that-Keeps-on

Answer 655

C. 3 lap chole, insulin, stroke Not originally specified as open verse lap. One of the big critiques of the RCRI. https://www.bjaed.org/article/S2058-5349(18)30128-8/fulltext ## Footnote UTD

Answer 656

C. Cryoprecipitate contains Factor VIII, XIII, fibrinogen (factor I), fibronectin, vWF Cryo - volume 10-20mL - fibrinogen (i.e. Factor I, 150-250mg) , F VIII, vWF, fibronectin, FXIII -> Cryo -> think VolksWagen (lucky unlucky one) - vWF, fibronectin - eight, thirteen, one). - not used to replace factors as factor concentrates and recombinant products are safer and better FFP - volume 250-300mL - fibrinogen (700-800mg) - all coag factors including II, VII, VIII, IX, X, XI, vWF" ## Footnote https://www.lifeblood.com.au/health-professionals/products/blood-components/cryoprecipitate

Answer 657

a) 15 mins 50UI/kg, Prothrombinex-VF is able to completely reverse a supratherapeutic INR within 15 minutes however, vitamin K is also required to sustain the reversal effect as the half-lives of the infused clotting factors are similar to endogenous factors. ## Footnote https://www.mja.com.au/journal/2013/198/4/update-consensus-guidelines-warfarin-reversal#:~:text=Prothrombinex%2DVF%20is%20able%20to,similar%20to%20endogenous%20clotting%20factors.

Answer 658

Longer length Different cuff size/ length: The MLT® has a cuff size/ length that would be typical for an adult-sized 'standard' ETT. A 'standard' pediatric 5.0 endotracheal tube has a smaller cuff made for a pediatric-sized trachea (see picture below). Distance of cuff from tube tip: In an MLT® the cuff is further away from the tube tip which is acceptable as the adult trachea is obviously longer than the pediatric one (see picture below). - same diameters and larger cuff size (i.e. 5.0 MLT cuff would be typical for adult-sized standard ETT) - MLT cuff further away from tube tip - size of tube is internal diameter MLT = Massively Long Tube - for vocal cord surgery - beware high AWR -> high airway pressures - gas flow slow in expiration -> may need lower I:E ratio for complete expiration" ## Footnote https://aam.ucsf.edu/microlaryngoscopy-tube-mlt%C2%AE

Answer 659

d. pregnancy "S3 at apex normal in children, pregnant females, well trained athletes, but disappears before middle age. Can also be systolic heart failure (if re-emerges later in life) - during passive ↑LV filling (when blood strikes compliant LV) 'ventricular gallop' - can be severe MR/TR https://www.healio.com/cardiology/learn-the-heart/cardiology-review/topic-reviews/s3-heart-sound "

Answer 660

d. 54 Ex-preterm infants at risk of post-operative apnoea should not be considered for same day discharge unless they are medically fit and have reached a postmenstrual age of 54 weeks. Term infants should not be considered for same day discharge unless they are medically fit and have reached a postmenstrual age of 46 weeks.d) 54 weeks ## Footnote https://www.anzca.edu.au/getattachment/568bad2d-7517-4eea-9c5d-cb7aa1c60

Answer 661

B. Aphasia All can happen in pts with MS but aphasia is less common (more commonly associated with disease of grey matter) - only a handful of case reports in literature https://jamanetwork.com/journals/jamaneurology/fullarticle/777200 " ## Footnote UTD

Answer 662

c) 20mmHg Intra-abdominal hypertension is defined as a sustained intra-abdominal pressure of >12 mm Hg, and abdominal compartment syndrome occurs at a pressure >20 mm Hg in association with new organ dysfunction. Intra-abdominal hypertension is graded as follows: Grade 1=12–15 mm Hg; Grade 2=16–20 mm Hg; Grade 3=21–25 mm Hg; and Grade 4 >25 mm Hg. ## Footnote https://academic.oup.com/bjaed/article/12/3/110/258792

Answer 663

B. distal to LSCA The appropriate performance of the IABP is dependent on proper position. Ideally, the tip of the balloon should be positioned 2–3 cm distal to the origin of the left subclavian artery (LSCA) https://radiopaedia.org/articles/intra-aortic-balloon-pump - femoral artery sheath extends to proximal descending aorta ~1cm below subclavian artery -> if left radialpulse lost -> balloon is too high - radio-opaque tip lies in 2nd intercostal space just above left main bronchus -> lower end of balloon cephalad to renal arteries" ## Footnote https://academic.oup.com/bja/article/110/2/316/228037

Answer 664

E. Upper GI bleed Incompressible sites, large volume blood loss and mortality risk are a few of the things that made GI bleeds seem like a natural fit for TXA administration. Early research seemed promising, but trials were small. The HALT-IT trial examined over 15,000 patients to see if TXA reduced death [14]. Not only did TXA have no effect on mortality, it increased the risk of seizure and thromboembolic events. Take home: No demonstrated benefit with TXA in GI bleeding ## Footnote https://www.ems1.com/research-reviews/articles/understanding-txa-AFkqRLajUv46X7xV/

Answer 665

c) inf alveolar The conventional inferior alveolar nerve block is the most commonly used nerve block technique in dentistry The nerves anesthetized are the inferior alveolar, incisor, mental, and lingual nerves. The mandibular teeth to the midline, the body of the mandible, the lower part of the mandibular ramus, buccal periosteum and mucous membrane to the premolars, anterior 2/3 of the tongue, oral floor, lingual soft tissue, and the periosteum are all anesthetized Mental nerve is terminal branch of inf alveolar and exits mental foramen - innervates skin over lower lip and chin region ## Footnote https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6218392/

Answer 666

"50J UK resus - defib Internal defib requires less energy. Biphasic more effective than monophasic. For biphasic shocks, use 10- 20 J, delivered directly to the myocardium through internal paddles. Monophasic shocks require approximately double these energy levels. Do not exceed 50 J when using internal defibrillation - failure to defibrillate at these energy levels requires myocardial optimisation before defibrillation is attempted again. Energy selection is automatically limited to a range of 2—50 joules when internal paddles are connected. Stryker PDI Make sure the maximum energy available is 50 Joules. Product PDI " ## Footnote https://www.ncbi.nlm.nih.gov/books/NBK499899/

Answer 667

Pre-ductal -> right "d) Right hand/wrist (pre-ductal): avoids right to left shunt of ductus arteriosus - reliable 90 secs after birth Post-ductal = either foot (preductal higher immediately after birth) Time after birth (mins) / targets: 1 / 60-70% 2 / 65 - 85% 3 / 70-90% 4 / 75-90% 5 / 80-90% 10 / 85-90%"

Answer 668

A A - Alcohol is a common cause of macrocytosis and macrocytic anemia. (UpToDate) B - No - normally nomrocytic chronic disease anaemia C - No - microcytic D - I can't find anything on macrocytosis with thyrotoxicosis, but hypothyroidism definitely does E - Possibly.... https://hemonc.mhmedical.com/content.aspx?bookid=1783§ionid=121720217 Causes of macrocytic anaemia: (lacking vit/B12, Thyroid/BM function, liver from alcohol) Vitamin B12 deficiency, folate deficiency Liver disease (↑cholesterol/phospholipids deposit on RBC -> ↑size), alcoholism Hypothyroidism Myelodysplastic disease Medication - for cancer, seizure, autoimmune disorrder ↑ RBC production to correct anaemia post blood loss "

Answer 669

B - prevention of electrocution. BJA Education

Answer 670

A The situation in adults is straightforward: there is convincing evidence that propofol is safe in patients who are allergic to peanut and/or soy and/or egg. BJA Ed https://academic.oup.com/bja/article/116/1/11/2566111 safe in egg anaphlaxis (and soy/peanuts). Shellfish/contrast allergy no ↑risk to povidone iodine ""Current literature supports the administration of propofol in patients allergic to egg, soy and peanuts. Patients with shellfish allergy or allergy to contrast material have the same risk of allergy to povidone iodine as the general population"". ANZCA 2021 bulletin Risk of anaphylaxis 1:10 000"

Answer 671

A Apnea is defined as the cessation of airflow for ten or more seconds. Hypopnea is defined as a recognizable, transient reduction, but not a complete cessation of, breathing for ten or more seconds. Hypopnea requires a 4% fall in SpO2 https://www.ncbi.nlm.nih.gov/books/NBK441909/#:~:text=Obstructive%20Sleep%20Apnea%20(OSA)%2C,for%20ten%20or%20more%20seconds.

Answer 672

C. Foetal neuroprotection (Mg infusion for 4g over 20 mins, then 1g/hr for 24hrs - further 2g over 5 mins if seizure during load) <30 weeks GA = fetal neuroprotection https://www.bjaed.org/article/S2058-5349(20)30114-1/fulltext 2020 BJA on pre-eclampsia https://www.health.qld.gov.au/__data/assets/pdf_file/0034/139948/g-hdp.pdf " https://www.kemh.health.wa.gov.au/~/media/HSPs/NMHS/Hospitals/WNHS/Documents/Clinical-guidelines/Obs-Gyn-Guidelines/Preterm-Labour-Magnesium-Sulphate-for-Neuroprotection-of-the-Fetus.pdf?thn=0#:~:text=MgSO4%20is%20only%20given%20to,4%20hours%20prior%20to%20delivery.

Answer 673

"b) paracetamol, ibuprofen, tramadol PRN PROSPECT guideline - Paracetamol + NSAIDS (pre op, intraop and postop) - single dose IV dexamethasone (For pain and antiemetic) - note ↑risk of reoperation but not ↑risk of bleeding - opioids for rescue in post op - preop gabapentinoids or intra op (peritonsillar) ketamine (for children) or intraop dexmed when basic analgesia contraindicated - adjuncts - dextramorphan, magnesium, acupuncture, honey - both work https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/full/10.1111/anae.15299 " "DO NOT use codeine after andenotonsillectomy due to risk of apnoea/death (ANZCA pain) Note ibuprofen may ↑severity of haemorrhage post tonsillectomy Aspirin/ketorlac ↑risk of reop in adults, but not children Celecoxib optimal (selective) Note giving peritonsillar ketamine/tramadol or parenterally were similar in Pain Book"

Answer 674

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

Answer 675

C) Cease clopidogrel for 5 days, continue aspirin WFSA update document https://resources.wfsahq.org/wp-content/uploads/uia29-Perioperative-management-of-patients-with-coronary-stents-for-non-cardiac-surgery.pdf "b) cease clopidogrel for 5 days (high risk), continue aspirin 2016 AHA 1) Elective noncardiac surgery should be delayed 30 days after BMS implantation and optimally 6 months after DES implantation - if P2Y12 needs to stop, can consider surgery 3 months after DES if risk of further delay > risk of stent thrombosis -> Do NOT perform surgery <3 months post DES 1st year DES = riskiest; 1% risk after 6 mths of adverse cardiac events 2) If pts on DAPT (post PCI), and P2Y12 needs to stop -> continue with aspirin -> Spanish (European) guidelines say switch clopidogrel only to aspirin 2023 CHEST (see top right) - Elective surgery, DAPT for Stents within last 3-12 months, stop P2Y12 inhibitor (without bridging) "

Answer 676

A. Inhalational anesthesia or b. Clonidine Prospect: two studies focused on tonsillectomy, and those did not show any additional analgesic effect of clonidine when used on top of adequate baseline medication after tonsillectomy. PROSPECT https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/10.1111/anae.15299#:~:text=The%20basic%20analgesic%20regimen%20should,analgesic%20and%20anti%2Demetic%20effects.

Answer 677

d. Hyalase/hyaluronidase reaction/allergy https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4850816/ " retrobulbar haemorrhage - will have ^IOP and decreased VA https://pubmed.ncbi.nlm.nih.gov/16362314/ 12-72hrs post cataract surgery: - axial proptosis, - periorbital erythema with swelling. Periorbital pain/itch - extraocular muscle (EOM) function restriction (5/5) - conjunctival chemosis (4/5). Retrobulbar haemorrhage: 2-3 hrs severe orbitalpain, periorbital ecchymosis, eyelid hematoma, ophthalmoplegia, proptosis, subconjunctival hemorrhage. Visual loss and RAPD +ve in orbital compartment syndrome Periorbital cellulitis = infection of eyelid and surrounding skin (swelling/pain/erythema)"

Answer 678

E Can't remember if this was the exact ECG but it had LAD

Answer 679

D - AB Group AB plasma or group A plasma that is high-titre negative can be given in an emergency when the blood group is unknown. Group AB plasma is universal but in short supply. Our guidelines say type A is appropriate as type AB is very rare. In neonates, infants under 1 use group AB. FFP - volume 250-300mL - fibrinogen (700-800mg) - all coag factors including II, VII, VIII, IX, X, XI, vWF - Deranged: preferably ABO-typed, as donor plasma may contain anti-ABO antibodies. Crossmatch/RhD not necessary"

Answer 680

E - SSRIs ANZCA PG12 Background Paper

Answer 681

Cefazolin A first-generation cephalosporin is recommended, such as 2g intravenous cefazolin. The dose should be increased to 3g for women weighing over 120kg. Consideration should also be given to a repeat dose if the procedure is prolonged (over 3 hours). * For women with a history of immediate or delayed nonsevere hypersensitivity to penicillins, cefazolin, as above, remains appropriate. * For women with a history of immediate or delayed severe hypersensitivity to penicillins, use Clindamycin 600mg iv plus Gentamicin 2mg/kg iv. * For women colonised with Methicillin-resistant Staphylococcus aureas (MRSA) or at increased risk of being colonised with MRSA, add Vancomycin 15mg/kg iv. * Azithromycin may be considered at caesarean sections performed during labour or at least four hours after rupture of membranes (2). Administration of azithromycin 500mg has been shown to reduce a composite outcome of endometritis, wound infection or other infection (3). However, a strong recommendation in favour of routine use is not yet warranted given the concerns around the external validity of the paper, inducing resistance to azithromycin and possible effects on the establishment of the indigenous microbiome. According to MSH guidelines - alternate therapy If severe hypersensitivity - Teicoplanin 400mg IV (800mg if >80kg) + tobramycin 2mg/kg IV Lincomycin 600mg in practice"

Answer 682

"a) c/s rate Epidural does not affect c/s rate (with either type of epidural, compared to those without) 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 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

Answer 683

repeat a) Less transfusion, same thrombosis 2020 Cochrane review: Moderate-quality evidence suggests that preoperative rHuEPO + iron therapy for anaemic adults prior to non-cardiac surgery reduces the need for RBC transfusion and, when given at higher doses, increases the haemoglobin concentration preoperatively. The administration of rHuEPO + iron treatment did not decrease the mean number of units of RBC transfused per patient. There were no important differences in the risk of adverse events or mortality within 30 days, nor in length of hospital stay. Further, well-designed, adequately powered RCTs are required to estimate the impact of this combined treatment more precisely. https://www.cochrane.org/evidence/CD012451_use-erythropoietin-plus-iron-correct-anaemia-surgery-reduce-risk-blood-transfusion

Answer 684

a. Reduced Myoglobinaemia Repeat but its not myoglobinuria it was myoglobinaemia - There is NOT reduced myoglobinuria with AIR compared to MH (both have myoglobinuria) - There IS less increase in ETCO2 - There IS less muscle rigidity

Answer 685

"d) rocuronium (as severe) - diazepam if mild #Hyperthermia in SS - mostly mediated by muscle hyperactivity - paracetamol, dantrolene ineffective - mild: topical cooling and benzos to ↓muscle activity - severe (>41.1 degrees) -> rhabdo, metabolic acidosis, DIC -> Rx = sedation, NDMB necessary (avoid suxamethonium due to hyperkalaemia) https://www.medsafe.govt.nz/profs/PUArticles/Dec2012Neuroleptic.htm#:~:text=However%2C%20NMS%20is%20characterised%20by,are%20indicative%20of%20serotonin%20syndrome "#Agitation/anxiety -> benzos #Autonomic instability - IV fluids for hypotension (helps with rhabdo as well) +/- direct acting (phenyl/norad/Adr) - HTN/Tachycardia -> esmolol and GTN (short-acting as unpredictable); dexmedetomidine also an option -> avoid hydralazine (inhibits MAO) and indirect (e.g. ephedrine, dopamine) -> unpredictable) Consider cyproheptadine (H1 antagonist) -> helps w/ symptoms and in severe presentations Algorithm on right from BJA 2020 https://www.bjaed.org/article/S2058-5349(19)30153-2/fulltext "

Answer 686

A. High frequency

Answer 687

* D. perindopril isolated hypotension is rare - most likely due to excess bradykinin, especially when bradykinin metabolism is inhibited (eg. In patients on ACEi) https://www.lifeblood.com.au/health-professionals/clinical-practice/adverse-events/hypotension " Acute hypotensive transfusion reaction (AHTR) is characterized by the abrupt onset of hypotension immediately after the start of transfusion and usually resolves when transfusion ceases. Recent studies have shown an association with pre-operative treatment with an angiotensin-converting enzyme (ACE) inhibitor https://www.lifeblood.com.au/health-professionals/clinical-practice/adverse-events/hypotension

Answer 688

"c) variable extrathoracic (d made up) Extrathoracic is below (on inspiration) Intrathoracic is above (on expiration) Fixed is both - if inspiration affected -> extrathoracic - if expiration affected -> intrathoracic - if both affected -> large airway obstruction Flow-volume loops "

Answer 689

c. Diuretic chronic frusemide - low Na/K/Cl CSWS - hyponatraemia, hypovolaemia, elevated urinary Na (>40) w/ elevated urine osmolality SIADH - hyponatraemia, euvolaemia/hypervolaemia, elevated urine Na (>20) hypothryoid - hypervolaemia hyponatraemia (high ADH in response to hypothyroidism decreasing CO), high urine sodium adrenal insufficiency - hyponatraemia, hyperkalaemia, metabolic acidosis (H+ retention) (aldosterone usually retains sodium, excretes potassium/H+)"

Answer 690

RCA or LCx

Answer 691

5 mmol 3.6 Potassium Potassium is an electrolyte essential for membrane stability. Low serum potassium, especially in conjunction with digoxin therapy and hypomagnesaemia, may lead to life threatening ventricular arrhythmias. Consider administration for: * Persistent VF due to documented or suspected hypokalaemia. [Class A; Expert consensus opinion] ANZCOR Guideline 11.5 August 2016 Page 9 of 13 Adverse effects: * Inappropriate or excessive use will produce hyperkalaemia with bradycardia, hypotension and possible asystole * Extravasation may lead to tissue necrosis. Dosage: A bolus of 5 mmol of potassium chloride is given intravenously

Answer 692

"4xv^2 = peak gradient = 4 x 9 = 36mmHg velocity of 3m/s is moderate AS VSD haemodynamics Aortic stenosis classifications (Mild/mod/severe & v severe) Mean P gradients: <20/20-39/40 (& 60) Vmax: 2-3/3-4/>4 (&>5) AVA <1.0 or AVAi <0.6 = severe"

Answer 693

400mls of clear fluids pre op Safe upper limit - definitely has not not been identified and will vary from patient to patient. Clear fluids Water / CHO rich fluids / pulp free fruit juice / clear cordial / black tea and coffee

Answer 694

Nebulised Adrenaline 1mg 0.5ml/kg of 1:1000 Adrenaline nebulised up to 5ml once adrenaline given consider dose of Steroid dexamethasone 0.6mg/kf up to 10mg ETT cuffed = age/4 + 3.5 = size 4 (would be appropriate size if uncuffed) Likely stridor secondary to large ETT, 1hr intubation, frequent head manipulation

Answer 695

A. subarachnoid injection due to timeline

Answer 696

Dominant EEG frequency decreases, and amplitude increases with increasing concentrations of anaesthetic. End result is burst suppression https://academic.oup.com/bja/article/115/suppl_ 1/i27/234261 Figure 1 shows raw EEG waveforms during isoflurane anaesthesia. During light anaesthesia: -amplitude is shallow and frequency is high. When a higher concentration is administered: -amplitude deepens and EEG frequency slows. During deep anaesthesia: - a ‘burst and suppression’ pattern becomes apparent, characterized by extreme activity, represented by high-frequency, large-amplitude waves (bursts), alternating with flat traces (suppression). - This pattern, excluding brain ischaemia or other factors, indicates that anaesthesia is too deep. Beyond this, flat traces become dominant and, eventually waveforms are no longer apparent. During isoflurane, sevoflurane or propofol anaesthesia, this sequence of changes in pattern is almost identical. The major difference in EEG between the volatile agents (isoflurane or sevoflurane) and propofol is apparent in power in the theta range. During propofol anaesthesia, theta power remains low regardless of concentration, but during isoflurane or sevoflurane anaesthesia, it increases at surgical concentrations of anaesthesia.

Answer 697

"a) Posterior 1/3 tongue (taste and touch) is glossopharyngeal nerve (Lingual nerve (CN V3 mandibular branch) - sensory anterior 2/3 tongue). *** Lingual nerve most associated with damage due to LMA insertion**

Answer 698

Does not remove foetal red cells or vasoactive molecules (eg don’t use in pheochromocytoma surgery).

Answer 699

B "Swing normally occurs due to cyclical changes in pleural pressure from spont breathing No swing or reduced swing occurs when suction is applied, kinked/dislodged tube or resolution of pneumothorax. Wall suction must have at least -80mmHg of vacuum to operate a suction container at -20cmH2O. (suction inhibits pressure fluctuations in fluid column) Previous MCQ 2016B had the exact same stem but no water in third chamber, which leads to no suction created (as no water level)"

Answer 700

A. Leave in situ and contact vascular surgeons "Algorithm from 2019 Blue book article. If <7Fr & artery not dilated: remove & apply pressure with imaging & monitoring. If>7Fr/dilated w/ sheath: LEAVE needle/sheath/CVC in-situ - If elective: cancel OT & immediate endovasc or open - If emergency OT/haemodynamic instability: continue operation then immediate endovasc or open If no IR or surgeon immediately available then heparin. - BUT don’t give the heparin intra-arterial through the CVL. "

Answer 701

Give 3mg of Vitamin K and re-check on day of surgery proceed if INR <1.5 on DOS

Answer 702

Line isolation monitor alarms when single fault in system. If the alarm is going off, the last piece of equipment plugged in is usually suspect and should be unplugged.

Answer 703

200mg Hydrocortisone or 25mg Prednisolone Conversion Prednisone 1mg = Hydrocortisone 4mg = Dexamethasone 0.15mg = Triamcinolone 0.8mg = Methylprednisolone 0.8mg = Betamethasone 0.15mg = (https://litfl.com/corticosteroids-overview/)

Answer 704

b) Decreased mortality due to bleeding "TXA in treatment of PPH cf. placebo > 1g TXA over 10mins + second dose after 30mins if ongoing. PPH (>500ml blood loss in 1st 24hrs). LSCS & Vaginal delivery - No difference composite endpoint (all cause death or hysterectomy) Death due to bleeding less in TXA group > absolute risk reduction 0.4% (NNT 267). No difference thromboembolic events (VTE, PE, MI, Stroke). Sub-analysis showed TXA given within 3hrs birth decrease death due to bleeding (>3hrs -> similar rates death)"

Answer 705

"Control of venous bleeding associated with unstable pelvic fracture - pelvic ring fracture (haemodynamically unstable) - Arterial bleed -> need IR (angiography and embolisation) (incl. w/ haemodynamic instability) - Iliac artery/prostate would need retroperitoneal intervention - PPP alternate lifesaving haemorrhage control as most bleeding venous - if IR not available -> helps ~80% bleeding from presacral venous plexus & bony # sites -> arterial only 10-15% - won't control haemorrhage PPP - 20 mins with experienced surgeons; 8cm midline incision. Directly packs retroperitoneum w/o need for laparotomy"

Answer 706

Nitrous oxide Nitrous oxide boiling point -88.6C, critical temperature +36C -> so is below critical temp at room temp, therefore exists as a vapour in equilibrium with its liquid phase and is dependent upon pressure applied to it. Pressure gauge not informative – will always read ~52 bar (the pressure at which N2O liquefies at 20C). As vapour is drawn off, N2O moves from liquid to vapour phase, maintaining the equilibrium and same vapour pressure within the cylinder. To determine contents: cylinder must be weighed and weight of empty cylinder subtracted, then number of moles of N2O in cylinder calculated using Avogadro’s number.

Answer 707

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

Answer 708

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

Answer 709

D. 30 ml/kg "c) 30mL/kg To raise fibrinogen by 1g/L, give: - FFP 30mL/kg (i.e. 2.1L for 70kg pt) - Fibrinogen concentrate 3g (each vial 1g -> 3 vials) - Cryoprecipitate (whole blood) 1 unit per 5kg BW (note 1 unit/5-10kg BW increases fibrinogen by 0.5-1g/L); -> typical adult dose is 10 units ~3-4g fibrinogen -> if cryoprecipitate apheresis, 1 unit per 10kg (1 unit per 10-20kg increases fibrinogen by 0.5-1g/L) Cryo values are derived mathematically"

Answer 710

B 5-10% https://www.heartfoundation.org.au/for-professionals/guideline-for-managing-cvd

Answer 711

a) Sheehan syndrome - postpartum ANTERIOR pituitary gland necrosis - usually due to signficant PPH (can be also be antepartum blood loss) - first sign often unable to breastfeed w/ no periods "evidence showed an association between inadvertent dural puncture and/or PDPH with chronic headache, backache, neckache, depression, cranial nerve palsy, SDH, or Cerebral vein sinus thrombosis (level of certainty: moderate)" Consensus guidelines: https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2808365 UTD: ● Infection (eg, meningitis) ●Bleeding, including spinal epidural hematoma ●Intracranial hypotension syndromes (eg, cranial neuropathies, subdural hematoma, cerebral venous thrombosis) ●Cerebral herniation ●Cerebral vasoconstriction and encephalopathy syndromes (uncertain evidence, assoc. PET) ●Pneumocephalus ●Radicular or back pain ●Late onset of epidermoid tumors of the thecal sac ●Chronic back pain, headache and neck pain Has been asked with PRES: Quite a few case reports of PRES and PDPH: proposed mechanism is that development of intracranial hypotension following a cerebrospinal fluid (CSF) leak causes traction on meningeal vessels, which leads to cerebral vasospasm, headache and visual disturbance https://pmc.ncbi.nlm.nih.gov/articles/PMC4461750/#:~:text=The%20pathophysiologic%20process%20underlying%20PRES,illustrative%20diagram%2C%20Figure%202).

Answer 712

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

Answer 713

d) Peak of R wave The appropriate energy level is then selected, and the discharge/shock button is pressed and held. The defibrillator does not release the shock immediately. Instead, it waits for the next R-wave to appear and delivers the shock at the time of the R-wave. This allows the shock to be provided safely away from the T wave, avoiding the R-on-T phenomenon.

Answer 714

"c) Bolus 100mg and then 200mg/24hours = 8mg/hr For both primary/secondary adrenal insufficiency or chronic steroid use, labour and vaginal delivery glucocorticoid management is: 1) 100mcg hydrocortisone STAT then 2) 200mcg/24 hours (8mg/hr) or 50mg IM q6h until after delivery 2020 AAGBI Periop steroid guidelines:"

Answer 715

A. Digitalis toxicity Miller’s The ECG made easy http://lifeinthefastlane.com/ecg-library/pmi/ Normal Q waves - Due to depolarisation of the interventricular septum from left to right - Seen in the left-sided leads (I, aVL, V5, V6) Pathological Q waves - > 1 mm depth - > 1 mm (= 40 ms) across Digoxin ECG changes - Therapeutic: prolonged PR interval (AV nodal delay), shortened QTC intervals (rapid ventricular repolarisation), ST depression (↓ slope of phase 3), T wave inversion - Toxic: atrial or ventricular arrhythmias (↑ automaticity), prolonged PR interval → heart block, SA node inhibition → sinus arrest - Atrial tachycardia with block = most common arrhythmia attributed to digoxin toxicity - VF = most frequent cause of death - QRS = normal! Q waves in MI - Occur with transmural infarctions, and are less likely with subendocardial infarctions - Develops days after the onset of AMI, and is usually permanent - Indicates the part of the heart that has been damaged LBBB ECG changes - Wide QRS - Wide QS complex in lead V1 - Wide R wave in lead V6 with slight notching at the peak and TWI - The axis is highly variable: can be normal or deviated to the left or right Wolff-Parkinson-White syndrome - Due to the presence of an accessory bundle between the atrium and ventricle, which has no AV node to delay conduction - Short PR interval - Early slurred upstroke of the QRS complex due to delta wave

Answer 716

B. Programability Position 1 - chambers paced (O / A / V /D) Position 2 - chambers sensed ( O / A / V / D) Position 3 - response to sensing ( O / T / I / D ) Position 4 - programabillity / rate modulation ( O / P (simple) / M (multi) / C (communicating) Position 5 - anti-tachycardia function: (O / P / S / D / Multi-site pacing)"

Answer 717

150mcg IM Then commence adrenaline infusion 0.1mcg/kg/min to 2mcg/kg/min "0 - 6 yo - 150mcg IM 6 - 12 yo - 300mcg IM >12 yo - 500mcg IM Refractory management: Additional IV fluid 20-40ml/kg, Noradrenaline infusion 0.1- 2mcg/kg/min Vasopressin infusion 0.02-0.06 units/kg/hr, glucagon 40mcg/kg IV

Answer 718

80mg Age + 4 x 2-> 4 + 4 x 2 =16kg 5 x 16mg =80mg

Answer 719

d. XIII Cryo - volume 10-20mL - fibrinogen (i.e. Factor I, 150-250mg), F VIII, vWF, fibronectin, FXIII - not used to replace factors as factor concentrates and recombinant products are safer and better FFP - volume 250-300mL - fibrinogen (700-800mg) - all coag factors including II, VII, VIII, IX, X, XI, vWF"

Answer 720

"BJA 2007 jet ventilation: A typical parameter-set for HFJV via a subglottic catheter is DP, 2 atm; f/150 min; FIO2, 1.0; I-time, 50%. Equipment in Anaesthesia & critical care: Manual jet ventilation: from wall therefore P=4bar initially, Sanders injector P=4bar, ManuJet has pressure regulator therefore P0.5-3.5bar (50-350kpa). High frequency jet ventilation: Dirving pressure adjustable 0.4-3.5bar but usually start at 1.5bar (150kpa)." Also asked as a) 0-1 atm b) 1-4atm c) 4-8 atm B

Answer 721

"a) 1-3days 5-10% within first 72hours (worse w/ large aneurysms & poor grades) Aneurysmal SAH MxhASA (stroke) subarachnoid 2023 guidelines Minimise risk by: - prevent HTN - prevent fluctuations in ICP by avoiding coughing/Valsalvas, effective enalgesia/antiemetics and smooth anaesthesia Caution with EVD (external ventricular drain) which can rapidly reduce ICP and -> rupture aneurysm"

Answer 722

b) Internal SLN Recurrent laryngeal nerve = inferior LN Sensation inferior to VC + intrinsic muscles larynx (except cricothyroid) SLN (Internal sensation superior; External tension) Internal branch = sensation superior to VC External branch = cricothyroid (external people tense cricothyroid)"

Answer 723

c) 15mg Conversion PO factors: - oxycodone 1.5 - codeine 0.13 - tramadol 0.2 - tapentadol 0.3 - hydromorphine 5 - buprenorphine 40 (sublingual)"

Answer 724

d. Female Risk factors - QTc prolongation >500msec (or >60msec increase from baseline, drugs prolonging QT (droperidol/methadone, others), hypokalaemia/hypomag/calcaemia (hypo electrolytes prolong QT) - Heart: bradycardia, MI/CCF, diuretics - Surg: Cardiac or craniotomy - Other: elderly, female, drug-drug interaction or hepatic failure Torsades 2010 AHA https://pubmed.ncbi.nlm.nih.gov/24020938/#:~:text=Results%253A%2520Risk%2520factors%2520for%2520drug,QT%2520(QTc)%2520interval%2520prolongation "

Answer 725

a. Lupus anticoagulant Factor VII -> prolonged PT but not APTT Cold Agglutinins -> prolonged PT and APTT -> "sole abnormality" Haemophilia A -> isolated prolonged APTT -> associated with bleeding and not clotting Lupus Anticoagulation -> increased risk of clotting -> prolonged APTT and normal PT

Answer 726

b. 2 (size 1)

Answer 727

HCO3- is derived from pCO2 and pH Base excess is derived from pH SaO2 is derived from oxyHb and Hb Source LITFL

Answer 728

a. HR increases

Answer 729

70mmHg neonate sBP 60-95mmHg; HR 120-170, RR 25-60 - tends to be 5mmHg lower when asleep and higher post feed https://www.rch.org.au/clinicalguide/guideline_index/normal_ranges_for_physiological_variables/

Answer 730

b. RR >16 conjugate gaze facial grimace eye opening purposeful movement tidal volume greater than 5 ml/kg Source: SPANZA 2019 article

Answer 731

Adenosine Denervated heart (from UTD) - indirect agents that acts via ANS (eg. Ephedrine) are ineffective - direct agents (eg Phenyl) effective as acting on intrinsic alpha/ beta receptors - vasodilator agents (GTN/hydralazine/propofol) can cause profound hypotension as transplanted heart cannot mount a reflex tachy response - anticholinergics not effective for HR but retain effects in non cardiac tissue - ADENOSINE will have significantly prolonged and profound bradycardic effect on denervated heart"

Answer 732

b. OIH >0.25mcg/kg/min assoc/ with tolerance (higher opioid consumption post op) >0.2mcg/kg/min assoc/ with hyperalgesia (lower pain/pressure/cold threshold) (can be due to high dose infusion or high cumulative dose (ie in this scenario) - concurrent ketamine may prevent this https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/10.1111/anae.13602 Common practice: 0.1-0.5mcg/kg/min (manufacturer up to 2mcg/kg/min) - >0.2mc/kg/min unlikely to benefit, but lowers BP -> bolus 1mcg/kg or TCI 12ng/ml attenuates SNS to intubation TCI: 3-7ng/mL usual Treatment options established OIH= - decrease/cease opioid, ketamine, - opioid rotation (e.g. methadone) -opioid sparing (NSAIDS, antidepressants, anticonvulsants), non-pharm (physio, psych, spinal cord stimulators).

Answer 733

a. Splenomegaly Associated with high doses >4mg/kg/hr and prolonged use (>48hrs) Safe doses of propofol infusion for sedation in ICU are considered to be 1-4mg/kg/hr -> fatal Cases pf PRIS have been reported after infusion doses as low as 1.9-2.6mg/kg/hr Risk factors: i. Young age ii. Critical illness iii. High fat and low Carbohydrate intake iv. Inborn errors of mitochondrial fatty acid oxidation v. Catecholamine infusion/ High catecholamine and glucocorticoid levels vi. Steroid therapy vii. Severe head injuries Characteristics: i. Bradycardia ii. Severe metabolic acidosis iii. Cardiovascular collapse iv. Rhabdomyolysis v. Hyperlipidaemia vi. Renal failure vii. Hepatomegaly Management: - Routine monitoring of CK and triglycerides should be performed for the at risk population ○ Daily CK and triglyceridees after 48hrs of propofol infusion ○ Increasing CK in the absence of other pathology triggers suspiscion of PRIS - Propofol immediately stopped and alternative (midazolam and alfentanil) are used - PRIS is difficult to treat once it occurs - CVS support provided as needed - Renal replacement therapy may be required to treat lactic acidosis, clear propofol and its metabolites from the patient rapidly - Catecholamine resistant shock has been reported - Pacing has been used with limited success ECMO has been reported and successfully used in the CVS support of PRIS

Answer 734

a. Calcium gluconate calcium has no affect on serum potassium NaHCO3 - decrease serum potassium by alkalinsing systemic blood volume --> intracellular shift of K via H/K exchange"

Answer 735

B https://www.thelancet.com/journals/lancet/article/PIIS0140673610611932/abstract Prospective cohort study >9000 kids 2010 Perth Findings from this large prospective cohort study show that factors easily obtained at a preanaesthetic assessment, including respiratory symptoms, eczema, or a family history of asthma, rhinitis, eczema, or exposure to tobacco smoke, were associated with an increased risk for the occurrence of perioperative respiratory adverse events. Additionally, an upper respiratory tract infection was associated with an increased risk for perioperative respiratory adverse events only when the symptoms were present or had occurred** within the 2 weeks** before the procedure. https://www.thelancet.com/journals/lancet/article/PIIS0140673610611932/abstract APRICOT study The presence of one of the main risk factors for perioperative respiratory events (asthma, wheezing, upper respiratory tract infection **in last two weeks**, snoring and passive smoking) revealed an increased risk for bronchospasm for tracheal tubes and SGA and stridor for tracheal tubes

Answer 736

Endothelial damage due to ischaemia - occurs after massive trauma when shock, hypoperfusion and vascular damage are present MOA: protein C activation, endothelial glycocalyx disruption, depletion of fibrinogen and PLT dysfunction EXACERBATED by hypothermia and acidaemia LEADS to hyperfibrinolysis, decreased clot strength, autoheparinisation haemodilution and prolonged surgical times --> worse outcomes 2016 BJA - acute traumatic coagulopathy

Answer 737

A Return of some native cardiac function, but pulmonary gas exchange remains poor. Oxygenated ECMO blood will perfuse lower body, but inadequately oxygenated LV blood perfuses coronary/cerebral circulations Monitor saturations in R arm (or ear lobe) Surrogate monitoring of coronary/cerebral oxygenation (brachiocephalic trunk supplies R arm and carotid originates immediately after coronary arteries)"

Answer 738

d. Able to turn head 45 deg NEXUS criteria: One easy mnemonic for these criteria is NSAID: Neuro Deficit Spinal Tenderness (Midline) Altered Mental Status/Level of Consciousness Intoxication Distracting Injury

Answer 739

RLN - pressure neuropraxia from overinflated LMA SLN - sensory to area above vocal cord (internal branch), external branch- motor to cricothryoid only (adductor) RLN - sensory to area below cords and motor to all musces except cricothryoid posterior cricoarytenoid - abductor https://www.amboss.com/us/knowledge/larynx "

Answer 740

D Static compliance = Tidal volume/(Plateau pressure – Total PEEP) = 600/ (32-12) = 600/20 = 30 Total PEEP = intrinsic PEEP (or autoPEEP) + extrinsic PEEP= 8+4

Answer 741

Rectal indomethacin APMSE 5th edition 8.6.1.3: Only rectal NSAIDs are effective for reducing post ERCP pancreatitis, particularly indomethacin. Epidural > PCA for severe acute pancreatitis

Answer 742

c) Dabigatran Idarucizumab (Praxbind) is a monoclonal antibody to dabigatran Dabigatran bleeding may be treated with: - idarucizumab - haemodialysis - TXA will decrease fibrinolysis and has some effect - FFP also has some effect Humanized monoclonal antibody fragment (Fab) indicated in patients treated with dabigatran (Pradaxa) when reversal of the anticoagulant effects are needed for emergency surgery or urgent procedures, or in the event of life-threatening or uncontrolled bleeding - 5 g IV, provided as 2 separate vials each containing 2.5 g/50 mL (see Administration) - Limited data support administration of an additional 5 g Dosage Modifications Renal impairment: Renal impairment did not impact the reversal effect of idarucizumab; no dosage adjustment required Hepatic impairment: Not studied Dosing Considerations This indication is approved under accelerated approval based on a reduction in unbound dabigatran and normalization of coagulation parameters in healthy volunteers; continued approval for this indication may be contingent upon the results of an ongoing cohort case series study

Answer 743

Less phrenic nerve block

Answer 744

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

Answer 745

D? UTD: In the Coxib and Traditional NSAID Trialists' (CNT) Collaboration analysis, which had a mean duration of follow-up of approximately one year, the risk of cardiovascular disease events was similar for all comparisons with the exception of high-dose naproxen. However, in PRECISION, where the duration of follow-up was nearly three years, no significant difference was found between naproxen and the other agents (ibuprofen and celecoxib). CNT and PRECISION found a similar rate of adverse cardiovascular outcomes between some coxibs and some nonselective NSAIDs. The cardiovascular risk with celecoxib at doses of 200 mg twice daily is similar to nonselective NSAIDs Multiple observational studies have demonstrated consistently higher risk of a cardiovascular event for diclofenac compared with other NSAIDs Naproxen OR 1.00 Ibuprofen OR 1.49 Celecoxib OR 1.30 (and other COX2s) Diclofenac OR 1.63 Indomethacin and Naproxen are more COX1 selective compared to the rest. Thought to be Pro thromboitic effects of COX 2 inhibition" https://pmc.ncbi.nlm.nih.gov/articles/PMC6281031/

Answer 746

Increased non fatal MI POISE II * clonidine 200mcg per day - did not reduce the rate of composite outcome of death or nonfatal MI - but it increased the risk of clinically important hypotension and nonfatal cardiac arrest * aspirin initiation or continuation – no significant effect on rate of composite of death or non fatal MI but increased risk of major bleeding

Answer 747

Gilberts Isolated elevation in unconj bili - Gilbert (MCC - non-pathological impairment of bilirubin conjugation), haemolysis or megaloblastic anaemia Normal bilirubin in uncomplicated cirrhosise, early liver failure, or early hepatic metastases https://www.rcpa.edu.au/Manuals/RCPA-Manual/Pathology-Tests/B/Bilirubin "

Answer 748

Intracranial haemorrhage Of all 93 cases of maternal death from pre-eclampsia, 80 (86%) were available for further analysis. Cerebral haemorrhage (36 cases, 45%) was the leading mode of death and, in most cases, was associated with high systolic blood pressure (n = 32, 89%) and low platelet counts (n = 26, 72%). https://obgyn.onlinelibrary.wiley.com/doi/10.1111/j.1471-0528.2009.02382.x C AHA https://www.ahajournals.org/doi/epub/10.1161/HYPERTENSIONAHA.118.11513

Answer 749

b. II ASA 1 - normal healthy patient ASA 2 - mild systemic disease (BMI 30-40) ASA 3- severe systemic disease (BMI>/=40 ASA 4 - severe systemic disease that is a constant threat to life (Recent <3mths MI/CVA/TIA/stents, sespsis, shock, ESRD not undergoing regular dialysis) ASA 5 - moribund pt not expected to survive without operation (includes uterine rupture) ASA 6 - brain dead for organ donation"

Answer 750

Intellectual impairment LA is less effective in EDS (case studies) however no mention of increased LA toxicity (hypermobile can have complete LA resistance) EDS definitely assoicated with vessel fragility, glaucoma, MR (mitral prolapse, aortic issues too) https://www.uptodate.com/contents/overview-of-the-management-of-ehlers-danlos-syndromes?search=ehlers%20danlos&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1#H3552559000 (on right is ZF) https://www.frontiersin.org/journals/psychiatry/articles/10.3389/fpsyt.2021.803898/full "

Answer 751

c. Decreased platelet function

Answer 752

Life threatening organ dysfunction caused by a dysregulated host response to infection

Answer 753

10% "NAP 6: Penicillin allergy MC ~10% of population labelled as allergic. At least 90% could be de-labelled if an adequate description of the original reaction could be obtained or the patient investigated in an allergy clinic (NICE 2014). The distribution of 199 identified culprit agents was antibiotics 47%, neuromuscular blocking agents (NMBA) 33%, chlorhexidine 9%, and Patent Blue dye 4.5%. Non-depolarising NMBAs had similar incidences to each other Onset was rapid for NMBAs and antibiotics but delayed with chlorhexidine and Patent Blue dye."

Answer 754

TBW SOBA guidelines recommends TBW for sux and LMWH LBW (think induction) - propofol induction, thiopentone, non-depolarising NMBD, fentanyl/alfentanil/morphine, paracetamol, LA. - Gentamicin, remifentanil/Schnider TCI IBW: Adr/Norad ABW (think maintenance/emergence) - Propofol infusion, neostigmine (max 5mg), antibiotics (except aminoglycosides) TBW: sux, LMWH (titrate with Xa levels), sugammadex (as per PDI; SOBA lists ABW)"

Answer 755

Start exercise Decreased perfusion resulting in onset of ischemia RWMA--> ECG changes--> angina Echocardiographic images recorded during ischemia show abnormalities of wall motion, thus allowing for the detection of significant coronary artery disease https://www.sciencedirect.com/topics/nursing-and-health-professions/stress-echocardiography

Answer 756

c= Drugs which, owing to their pharmacological effects, have caused or may be suspected of causing, harmful effects on the human fetus or neonate without causing malformations. These effects may be reversible. Cat A: Lots of pregnant ladies, no harm Cat B: Limited pregnant ladies, no harm (B1, 2, 3 -> vary by animal study findings) Cat C: Known or suspected harm, no malformations. May be reversible Cat D: Known or suspected malformations and/or irreversible harm Cat X: High risk permanent damage – should not be used in pregnancy"

Answer 757

Hereditary spherocytosis. Auto-haemolytic, intraplenic haemolysis. High reticulocyte count (6-20%) (normal range 0.5-2%) All others have low reticulocyte count: Pernicious anaemia (lack B12): a type of megaloblastic anaemia. Macrocytic, normochromic, low reticulocytes, megaloblasts. Aplastic anaemia: loss of precursors. Normocytic, normochromic. Acute leukaemia: primitive undifferentiated cells. Chronic disease: normo- or microcytic (especially if with Fe deficiency).

Answer 758

4 hrs "a) 4hrs Transfusion of each pack should be completed prior to the labelled expiry or within four hours, whichever is sooner. Lifeblood "

Answer 759

SS /GCS In any patient who is given an opioid, oversedation should be considered to indicate OIVI until proven otherwise, regardless of a patient’s respiratory rate or oxygen saturation levels. "SS 2 = easy to rouse but unable to remain awake (> 10 sec?) - 1 = easy to rouse, 3 = difficult to rouse

Answer 760

Straight = anterior column issues (+ epiglottis) https://www.anzca.edu.au/getattachment/9ef4cd97-2f02-47fe-a63a-9f74fa7c68ac/PS56BP-Guideline-on-equipment-to-manage-difficult-airways-Background-Paper Straight laryngoscope blades These may be considered for patients with anterior column problems including prominent maxillary incisors, retrognathia, large tongue and large floppy epiglottis 74. The Miller straight blade with its low profile produces a higher pressure on the submandibular tissues with the same force (pressure = force/area), and can be used to lift the epiglottis directly 75 to facilitate intubation. There is evidence to support better success rates with straight blades as a rescue device when the Macintosh blade has failed 76, 77. However, comparative studies of straight blades and videolaryngoscopy are lacking. As the paraglossal technique for straight laryngoscope blades is different from Macintosh blades, training and ongoing volume of practice is recommended for optimal use. It should be recognised that while straight blades provide better laryngoscopic views, the incidence of difficult intubation due to the narrower field of vision is increased 78. * Corazelli, London, McCoy (CLM) laryngoscope blades When “McCoy” laryngoscope blades are in their flexed position, they apply pressure at the base of the tongue lifting the epiglottis anteriorly and are therefore, suitable for posterior column problems (e.g. manual inline stabilisation of head and neck 79, 80) where the mandible and submandibular tissues are normal. However, the effect of this levering action of McCoy blades has not been shown to consistently improve laryngeal view 81, 82. When compared to Glidescope TM videolaryngoscopes, McCoy laryngoscope blades resulted in longer tracheal intubation times in bariatric patients 83. Recommendations concerning Straight and McCoy laryngoscope blades Page 15 PG56(A)BP Difficult airway equipment BP 2021 Advanced equipment, such as videolaryngoscopy and the common availability of flexible bronchoscopes and intubation guides/bougies, may prove to be better alternatives to difficult airway management. While evidence is currently lacking, it is recommended that Straight and McCoy laryngoscope blades are not required in DATs unless operators have been trained in their use and have ongoing volume of practice (Weak recommendation for, level of evidence moderate quality)

Answer 761

Ventilate and wait for recovery - FFP: can improve cholinesterase activity, but risk > benefits - neostigmine variable: transient improvement, may increase paralysis - if cholinesterase not readily available, mechanical ventilation recommended until return of spontaneous resp function

Answer 762

Plasmin blocks lysine receptor on plasminogen --> inhibiting formation of plasmin TXA"

Answer 763

B; MS "Local anaesthetics may exacerbate symptoms due to the increased sensitivity of demyelinated axons to local anaesthetic toxicity." https://www.bjaed.org/article/S1743-1816%2817%2930244-5/fulltext

Answer 764

Bolus 1 IU oxytocin; start oxytocin infusion at 2.5–7.5IU.h (0.04–0.125 IU.min) EmLSCS; 3 IU oxytocinover≥30 s; start oxytocininfusion at 7.5–15 IU.h (0.125–0.25 IU.min). https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/10.1111/anae.147571 unit RANZCOG still say 5units

Answer 765

a) paracoxib LIthium perioperative concerns: - Prolongation of NMB - Reduction in anaesthetic agent requirement - Avoid NSAIDs which ↑Lithium levels (by ↓renal excretion)" - No withdrawl symptoms NSAIDs differentially alter lithium concentrations by multiple mechanisms, and one of these is to reduce prostaglandin E2 BJA: perioperative advice for psychotropic drugs Lithium - stop on day of (major) surgery; continue if minor - dehydration -> toxicity (> 1.5mmol/L) -> toxicity also with methylene blue, which is a MAO-A inhibitor - small risk of serotonin syndrome (see other list)

Answer 766

MELD --> E creatinine MELD-Na score components: (BICS) Bilirubin INR Creatinine Sodium (serum) estimates survival over next 3 months >15 - listed for deceased donor transplant "

Answer 767

c) Embolic Blue Book 2017 Perioperative Stroke Epidemiology A perioperative stroke is defined as one that occurs either intra-operatively or in the post-operative period within 30 days70. Perioperative strokes are associated with an increased length of stay and a six-fold increased mortality. Any combination of surgery and anaesthesia is associated with an increased risk of stroke irrespective of the type of surgery. This may relate to coagulation changes The most common type of perioperative stroke is ischaemic stroke of embolic origin (heart or aorta). Hypotension is rarely the cause of perioperative stroke. Haemorrhagic stroke is uncommon which probably reflects the fact that severe hypertension during anaesthesia is a rare event, and anticoagulants have typically been withheld. The risk of perioperative stroke varies depending on the type of the surgery and patients’ risk factors. Procedural risk Urgent surgery is associated with an increased risk of stroke when compared to elective surger. Cardiac, vascular and brain surgeries are defined as “high-risk” as these have an increased risk of stroke when compared to other types of surgery. Valvular and aortic repair surgeries have a stroke risk as high as 8 to 10 per cent. Perioperative strokes in non-high-risk surgery are relatively rare and are estimated to have an incidence of about 1/1000 cases80. Patients’ risk factors >Age >history of previous stroke or transient ischaemic attack >renal failure >atrial fibrillation >history of cardiovascular diseases are identified risk factors for perioperative stroke. Atrial fibrillation is associated with a two-fold increase in the risk of death and stroke after carotid endarterectomy.

Answer 768

50 4th consensus guidelines for management of PONV risk factors - female, age<50, post-op opioids, hx PONV, non-smoker, high-risk surgery (bariatric, lap chole, gynae) Recommendation from new consensus guideline - 2 forms of prophylaxis for patients with 1-2 RFs and 3-4 for 3+ RFs Paeds: 3+ years of age = RF PONV guidelines Cochrane meta-analysis – NK1 receptor antagonist most effective prevention (aprepitant 40mg PO pre induction).

Answer 769

Cephazolin

Answer 770

Aortic stenosis

Answer 771

d a. Accessory nerve (Trapezius paralysis, causing lateral winging) b. Long thoracic N- (Serratus anterior paralysis, causing medial winging) c. Dorsal scapular N (Rhomboids paralysis, causing lateral winging) d. Suprascapular nerve (Infra and supraspinatus – doesn’t affect scapula)

Answer 772

Elevated IGF1 with GH non suppression Dx of acromegaly is raised IGF1 > age/sex matched controlled AND failure for GH suppression after glucose tolerance test. "

Answer 773

Hypoasthesia - Veldman criteria Pain distal to primary injury – Not mentioned specifically in Budapest criteria, but in Veldman Hypoaesthesia = reduced sensation to pain

Answer 774

e. Defer and refer to haematology for further Ix

Answer 775

6.5mm Aintree 4.7mm ID, 6.5mm ED (will accept a 42mm FOB and size 7 ETT) repeat

Answer 776

5 days Previous MCQ2015A – cryoprecipitate once thawed must use within 4 hours. Previous MCQ2015B – FFP must be transfused within 4 hours once thawed, or stored at 2-6 degrees for 5 days.

Answer 777

Sx and exacerbations GOLD ABCD assessment tool "Criteria -frequency of exacerbations, symptom burden New classification A B E A - minimal restriction to exercise (nMRC 0-1) and 0-1exacberations not leading to hospitalisation - Rx: bronchodilator (LABA or LAMA) B - nMRC 2+, and 0-1 exaacerbation not leading to hospitalisation - LABA + LAMA E - 2+ moderate exacebations or 1 leading to hospitalisation - LABA + LAMA + ICS (if blood eosiniophil >300) COPD classification"

Answer 778

Mast cell degranulation - anaphylactic reaction

Answer 779

Tell surgeon to deflate / remove pneumoperitoneum Options that could cause this is Endobronchial intubation OR atelectasis > if ‘pull ETT back’ is an option then consider it. Lung pulse = USS sign which means parietal layers are still together > so not a pneumothorax. Ddx no lung sliding = PTX (-ve if lung pulse present), atelectasis, prior pneumonectomy, one-lung ventilation on opposite side (intentional or unintentional primary bronchus intubation), large consolidation."

Answer 780

HOCM: pathopneumonic A person who has syncope during exertion is more likely to have an obstruction to blood flow (aortic stenosis or hypertrophic cardiomyopathy) or ventricular tachycardia as a cause. On the other hand, syncope after completion of exercise is more likely of reflex origin, such as the common faint. https://www.uptodate.com/contents/syncope-fainting-beyond-the-basics#:~:text=A%20person%20who%20has%20syncope,such%20as%20the%20common%20faint

Answer 781

No change in outcomes "2018 NCBI meta-analysis from ZF: At present there is no evidence that bowel preparation makes a difference to clinical outcomes in either colonic or rectal surgery, in terms of anastomotic leak rates, surgical site infection, intra-abdominal collection, mortality, reoperation or hospital length of stay. Given its potential adverse effects and patient dissatisfaction rates, it should not be administered routinely to patients undergoing elective colorectal surgery. Jess/Esmond: SSI, anastomotic leak, postop ileus and hospital LoS all the same"

Answer 782

RUL "Bronchopulmonary segments: 3/2/5, 4/4 3 RUL: Apical, Posterior, Anterior 2 RML: Lateral, Medial 5 RLL: Superior, Medial, Anterior, Lateral, Posterior 4 LUL: Apicoposterior, Superior, Inferior, Anterior (lingula italicised) 4 LLL: Anteromedial, Lateral, Posterior, Superior RL: A PALM Seed Makes Another Little Plam LL: ASIA ALPS"

Answer 783

ION - ^risk with cardiac, spine (MC), orthopaedic, steep trendelenberg - anterior ION - more common with cardiac - posterior ION - more common with prone procedures, steep trendelenberg, cardiac - presents with painless b/l vision loss - risk factors for POVL with spine surgery - male, obese, wilson frame, long duration (>6hrs), ^ blood loss (no clear assoc/ w/ PVD/DM or intraop hypotension) Central retinal artery occlusion - most common retinal cause of POVL - usually unilateral (w/ other signs of ^IOP, opthalmoplegia, ptosis, altered supraorbital sensation); - check head every 30 mins; avoid horseshoe-shaped headrest"

Answer 784

100 < PaO2/FiO2 ≤ 200 with PEEP ≥5 cmH2O https://link.springer.com/article/10.1007/s00134-012-2682-1/tables/3 Berlin criteria: 1. Acute onset hypoxaemia within 7d triggering event. 2. bilateral infiltrates on CXR/imaging 3. Not completely explained by fluid overload or CCF 4. P:F ratio <300 with PEEP 5cmH2O Severity (applicable only if intubated) based on P:F ratio: Mild = 300-200; Moderate = 200-100; Severe <100"

Answer 785

"AION - PION more common however only AION has fundoscopic changes retinal artery occlusion - has fundoscopic changes but unilateral (white with cherry red spot on macula) https://www.uptodate.com/contents/postoperative-visual-loss-after-anesthesia-for-nonocular-surgery#H94404107 "

Answer 786

"C Both ACCP and ESTS guidelines recommend performing DLCO regardless of whether spirometry is abnormal. ESTS guidelines recommend if either FEV1 or DLCO is <80% of predicted value, then recommends stair climbing test as exercise testing, followed by CPET if >4% desaturation UTD says American College of Chest Physicians recommends calculating predicted post-op FEV1 and DLCO if either FEV1 or DLCO is <80% of predicted, this involves either quantitative lung scintigraphy (i.e. V/Q scan) or lung segment counting. BUT the guideline itself seems to recommend calculating predicted post-operative values for all patients, and if predicted values are both >60% then proceed. 30-60% then do low-tech exercise testing (e.g. stair-climb or 6MWT), <30% do CPET"

Answer 787

a. Electrical alternans Beck's Triad - Muffled heart sounds - Engorged veins - Widened pulse pressure (hypotension) IVC shouldn’t collapse in tamponade due to raised ra pressure Electrical alternans is seen in tamponade/pericardial effusion - most common ECG finding is sinus tachy, electrical alternans in severe"" Pulsus alternans = arterial pulse with alternating strong and weak beats. Indicative of severe LV dysfunction (HF, cardiomyopathy) Kussmaul breathing: deep, laboured breathing in MA (DKA)"

Answer 788

hydroxycobalamin "IV hydroxocobalamin (B12) 5mg with repeat dosing upt to 15mg sodium thiosulfate used in case series also appears affective with no AE https://www.resuscitationskills.com/library/algorithms/all-adult-als-guidelines-june-2017.pdf "

Answer 789

HYPERCa2+ - electrolytes: ALL lowered - arrhythmias: prolonged QT, STD, TwI, SVT - airway issues: delayed gastric emptying + dental carries -> consider all pts unfasted (ETT RSI w/ roc) - cardiomyopathy common; also hypotension AND bradycardia (if sBP<80 or HR <40 -> defer elective surgery) (See summary POM pg 120)"

Answer 790

Peaked p wave, no negative deflection As PICC tip approaches SA node at CAJ, Pwave starts to elevate and reaches max height at the CAJ --> starts to invert post this point https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5995413/#:~:text=As%20the%20PICC%20tip%20approaches%20the%20sinoatrial%20node%20at%20the,the%20ECG%20shows%20maximal%20P. 2018 NHS presentation good progression NB: this won't work in AFib (no P waves)" Maximum P-wave corresponds to placement in the Cavo-atrial Junction (CAJ) Benefits of CAJ placement - furthest distance from "high risk" areas - Largest vein diameter - highest blood flow capacity - minimal risk for catheter migration and looping Too short placement: Increased risk of: - DVT - Phlebitis Too long placement: Increased risk of: - arrhythmias - tricuspid valve dysfunction atrial dysfunction ECG and corresponding anatomy: - Normal P-wave = upper vasculature prior to CAJ - Max P-wav= CAJ - Initial negative P-wave deflection = Right Atrium - Biphasic P-wave = Right Atrium - Inverted P-wave = Right Ventricle

Answer 791

a. Saphenous sensory only rapid onset more suggestive or direct injury to nerve, later onset suggestive of ischaemia relating to oedema mulscular injury related to tourniquet results in swelling/pain/weakness of affected muscle post tourniquet syndrome - swollen, pale, stiff, weakness but not paralysis L5 radiculopathy would affect knee flexion, but would have presented immediately post op if spinal related common peroneal - most common (significant) injury after TKR - 2018A MCQ

Answer 792

c. 30cmH2O Paeds 20cmH20 Cuff pressures greater than 30 cmH2O impede mucosal capillary blood flow. Multiple prior studies have recommended 30 cmH2O as the maximum safe cuff inflation pressure https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5102598/#:~:text=Cuff%20pressures%20greater%20than%2030,maximum%20safe%20cuff%20inflation%20pressure. "

Answer 793

e. Sotalol Answer could also be c. Beta Blockers (have no effect on threshold) Drugs that INCREASE defibrillation threshold: + Amiodarone (Chronic) + Atropine + lignocaine + Diltiazem + Flecainide + Verapamil + Venlafaxine + Anaesthetic agents. Drugs that DECREASE defibrillation threshold: - Sotalol - Amiodarone (acute) - Nifekalant Drugs with No Change in DFT = B- blocker = Disopyramide = Procainamide = Propafenone https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6304797/

Answer 794

"c) radial nerve Lateral cord - MC Lateral cord + Medial cord - Median Posterior cord - Radial, axillary Medial cord - Ulnar"

Answer 795

a. 1% i.e. what is the positive predictive value (PPV) for this test PPV= TP/ TP +FP Negative Predictive Value = TN / TN + FN Prevalence of 1/1000 Sensitivity of 100% Specificity of 90% Of patients that are disease positive in population of 1000 TP = 1 FN = 0 -> 100% sensitivity Of patients that are disease negative in population of 1000 FP = 99 TN = 900 -> 90% Specificity PPV= 1/ 1 + 99 = 1/100 =1% NPV= 900/ 900 + 0 = 1/1 = 100%

Answer 796

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

Answer 797

Reduced Myoglobinaemia Repeat but its not myoglobinuria it was myoglobinaemia There is NOT reduced myoglobinuria with AIR compared to MH (both have myoglobinuria) There IS less increase in ETCO2 There IS less muscle rigidity

Answer 798

increased SVR Ebb - Initial high SVR/PVR low CO low DO2/VO2 Flow – Then (within 24-48hrs -> vasoplegic/hyperdynamic state) high CO, increased DO2/VO2, low SVR https://pubs.asahq.org/anesthesiology/article/129/3/583/22270/Early-Hemodynamic-Management-of-Critically-Ill EMSB handbook CO is reduced after Burn injury 2ry to: - myocardial depressant mediators - decreased blood volume - reduced venous return - increased pulmonary and systemic vascular resistance due to increased levels of catecholamines In the first 24hrs reduced cardiac output persists even after restoration of blood volume Between 24-48hrs post burn a hyperdynamic state develops with reduced peripheral resistance, increased oxygen consumption and increased cardiac outputuestion 6 Discuss the implications of anticoagulation as well as an appropriate anticoagulant management strategy for a 25-year-old with a mechanical aortic valve for the duration of pregnancy, delivery and the postpartum period.

Answer 799

D. Down Syndrome - difficult BMV but usually straightforward laryngocoscopy 2015 BJA managing syndromic airways

Answer 800

Muscle relaxants Muscle relaxants don’t affect SSEPs at all. Repeat MCQ 2021A had the same stem, but different choices (propofol, fentanyl, desflurane, midazolam, sevoflurane) which fentanyl would be correct."

Answer 801

cerebral palsy - CP - sux is not contraindicated, NDMB - are less potent and have shorter duration of action due to upregulation of AchR but usually offset by smaller Vd https://www.bjaed.org/article/S2058-5349(21)00116-5/fulltext Beckers and Duchennes --> AIR GBS and Frederich --> hyperkalaemia"

Answer 802

Postpone 3 months and give oral iron - target ferritin for major procedures - 100 ferritin <30 = Fe deficiency ferritin <100 in setting of ^ CRP>5 or transferrin sat <20% = Fe deficiency In setting of Fe deficiency, major non urgent surgery should be postponed to allow for tx target Hb to be >130g/L for both sexes daily Fe 40-60mg/day for 2mths, IV Fe if not tolerating oral not responding of if surgery is <6 weeks"

Answer 803

3b Category GFR ml/min/1.73 m2 Terms G1 ≥90 Normal or high G2 60-89 Mildly decreased* G3a 45-59 Mildly to moderately decreased G3b 30-44 Moderately to severely decreased G4 15-29 Severely decreased G5 <15 Kidney failure

Answer 804

Inconclusive "If the confidence interval of this difference is totally above zero, then the experimental group can be considered superior to the control group (Figure A). If the confidence interval is below zero but totally above the non-inferiority limit, then the experimental group can be considered not inferior to the control group (Figure B). On the other hand, if the confidence interval is completely below the non-inferiority limit, the experimental group should be considered inferior to the control group (Figure C). Finally, non-inferiority studies whose 95% confidence interval cross the non-inferiority limit, presenting superior and inferior values (Figure D, and E) are considered inconclusive."

Answer 805

C late inflation Inflation of IABP after closure of the aortic valve https://www.bjaed.org/article/S1743-1816%2817%2930329-3/fulltext

Answer 806

5d ANZCA - CrCl >80 (3D) 80-50 (4D) <50 (5D) ASRA: if no additional RFs for bleeding, and CrCl > 80ml/min -> 72hrs (3 days) 50-79 -> 96hrs (4 days) 30-49 -> 120hrs (5 days) <30 - avoid If unknown -> 5 days Nysora regional guidelines Stanford 2019 neuraxial doc "

Answer 807

b. Octreotide 50mcg bolus Carcinoid crisis - is an exagerrated form of carcinoid syndrome --> flushing, bronchospasm, tachycardia, widely fluctuating BP (high and low) -- most common trigger is anaesthetic, radiological/surgical intervention. Peri-op try to prevent uncontrolled hormone release precipitated by haemodynamic variation, anaesthetic or surgical stimulus using OCTREOTIDE (exerts activity similar to somatostatin) - pre op - octreotide 50mcg/hr for at least 12hrs pre surgery Intraop crisis - octreotide IV 20-50mcg boluses titrated to haemodynamic response. 2nd line - vasopression (avoid NA/Adr due to ANS stimulation) - monitor for bleeding (Rx w/ fluid if so) - if HTN -> labetalol infusion Post-op - HDU for 48hrs " Vasoactive hormone release intra-operatively is best treated with intravenous boluses of 20–50 µg of octreotide, titrated to haemodynamic response. Vasopressin as an alternative vasoconstrictor that may be useful if prolonged vasoconstriction is required; however, the evidence base is small. It must be borne in mind that concomitant fluid losses, especially bleeding, may be responsible for intra-operative instability rather than hormone excess and that fluid resuscitation may be the answer rather than further octreotide therapy https://academic.oup.com/bjaed/article/11/1/9/285683

Answer 808

d. Superficial peroneal and tibial Sural nerve would also need blocked for skin surface - see anso

Answer 809

a. Normal SpO2, Normal PaO2 SpO2 (pulse ox can't differentiate COHb and OxyHb), PaO2 (PaO2 reflects dissolved O2 in blood - not affected by CO) - only SaO2 is reduced (in presence of CO binding) https://www.uptodate.com/contents/carbon-monoxide-poisoning#:~:text=Diagnosis%20–%20The%20diagnosis%20of%20CO,in%20smokers%20confirms%20the%20diagnosis." ABG HbCO (elevated levels are significant, but low levels do not rule out exposure) lactate (tissue hypoxia) PaO2 should be normal, SpO2 only accurate if measured (not calculated from PaO2) MetHb (exclude) https://litfl.com/carbon-monoxide-poisoning/

Answer 810

c. Superior sagittal Higest incidence of VAE during sitting craniotomy ~15-76%. 0-12% for craniotomy in other positions Air enters through venous system above level of heart, increased risk with negative pressure ventilation, sudden changes in PEEP Frontal crani - superior sagittal sinus Temporal crani - vein of Labbe Parietal crani - superior sagittal sinus, vein of Trolard Retrosigmoid crani - mastoid emissary vein Occiptal crani - transverse and occipital sinus https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7771396/ " Risk factors for venous air embolism include sitting craniotomy, posterior fossa surgery and procedures near the superior sagittal sinus. In these situations, the surgical site is often above the level of the right atrium and hence venous air entrainment is facilitated, or there is a large risk of venous exposure through which air may be entrained. Depending on the volume of air entrained, reduced end-tidal carbon dioxide, arrhythmias or right heart failure and cardiovascular collapse are all possible. However, changes in clinical parameters often occur late and are nonspecific for small volumes of entrainment. Specific monitoring for detection of venous air embolism includes non-invasive means such as end-tidal nitrogen, precordial Doppler or stethoscope and transcranial Doppler. Invasive methods include transoesophageal echocardiography, oesophageal stethoscope, pulmonary artery catheter and central venous pressure monitoring. https://resources.wfsahq.org/atotw/anaesthesia-for-craniotomy-and-brain-tumour-resection/

Answer 811

c. Warfarin St John's wort is an enzyme inducer --> ^metabolism and reduced effects of many meds: Indinavir, cyclosporin, WARFARIN, DIGOXIN, THEOPHYLLINE, HIV protease inhibitors, ANTICONVULSANTS - can ^ serotonin - risk of serotonin syndrome with other SSRI https://www.tga.gov.au/news/safety-alerts/st-johns-wort-important-interactions-between-st-johns-wort-hypericum-perforatum-preparations-and-prescription-medicines " It is a potent inducer of hepatic cytochrome P450 CYP3A4 isoform. Hence, it may significantly increase the metabolism of many concomitantly administered drugs such as alfentanil, midazolam, and lidocaine. It also induces the P450 2C9 isoform that results in the reduction in effect of warfarin and NSAIDs

Answer 812

c. Long E time Spont vent not appropriate for this surgery as will require RSI so spont vent can't be ensured Blue Book 2021 Maintaining pulmonary blood flow and therefore cardiac output in the absence of a sub-pulmonary ventricle is the priority. Therefore, maintenance of adequate oxygen saturations and normocarbia should be ensured, with avoidance of acidosis or excessive positive pressure ventilation that could contribute to an increase in pulmonary vascular resistance. Such strategies include: - limiting peak inspiratory pressure (<20 cm H2O) - using low RR (<20/min) - short inspiratory times - avoiding excessive PEEP Fontan goals (CEACCP 2008): Spont if possible, otherwise low RR//short inspiratory times//low PEEP//TV 5-6ml/kg//preload . If you agree that most likely need relaxant-tube GA and mechanical ventilation for appendicectomy, then shorter inspiratory time is a better answer than spont vent. Short inspiratory time minimizes blood flow disruption to pulmonary vasculature. Long inspiratory time with lower than usual pressures increase mean airway pressure BJA: fontan circulation: For relatively short procedures, Fontan patients are probably better off breathing spontaneously, as long as severe hypercarbia is avoided. For major surgery, or when prolonged anaesthesia is required, control of ventilation and active prevention of atelectasis is usually advisable. Potential disadvantages of mechanical ventilation in Fontan patients relate to the inevitable increase in mean intrathoracic pressure. This causes decreased venous return, decreased pulmonary blood flow, and hence, decreased cardiac output. Low respiratory rates, short inspiratory times, low PEEP, and tidal volumes of 5–6 ml kg−1 usually allow adequate pulmonary blood flow, normocarbia, and a low PVR. Hyperventilation tends to impair pulmonary blood flow, despite the induced respiratory alkalosis, because of the increased mean intrathoracic pressure. https://academic.oup.com/bjaed/article/8/1/26/277637

Answer 813

b. 1 or more RF In this iteration of the PONV guideline, one of the major changes is that we now recommend the use of multimodal prophylaxis in patients with one or more risk factors. This decision was made due to the concern over inadequate prophylaxis as well as the availability of antiemetic safety data.

Answer 814

Fibrinolysis In APTEM, coagulation is also activated as in EXTEM. By the addition of aprotinin or tranexamic acid in the reagent, fibrinolytic processes are inhibited in vitro. The comparison of EXTEM and APTEM allows for a rapid detection of fibrinolysis. Furthermore, APTEM enables the estimation if an antifibrinolytic therapy alone normalises the coagulation or if additional measures have to be taken (e.g. administration of fibrinogen). EXTEM - similar to PT (assess extrinsic pathway) INTEM - similar to APTT (assesses intrinsic pathway) FIBTEM - asesses fibrinogen function APTEM - excludes fibrinolysis - uses aprotinin to inhibit fibrinolytic proteins. Shortened CT and higher MCF in APTEM test compares to EXTEM suggests hyperfibrinolysis is taking place. HEPTEM - assess for heparin effect If HEPTEM CT < INTEM CT - heparin effect present ECATEM - tests for direct thrombin inhibitors"

Answer 815

b. Clonidine PROSPECT 2021 https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/full/10.1111/anae.15299 Pre-operative and intra-operative interventions that improved postoperative pain were: - paracetamol; - non-steroidal anti-inflammatory drugs; - intravenous dexamethasone; - ketamine (only assessed in children); - gabapentinoids; - dexmedetomidine; - honey; - acupuncture. Inconsistent evidence was found for: - local anaesthetic infiltration; - antibiotics; - magnesium sulphate. Limited evidence was found for - clonidine. The analgesic regimen for tonsillectomy should include: 1. paracetamol; 2. non-steroidal anti-inflammatory drugs; and 3. intravenous dexamethasone, 4. with opioids as rescue analgesics. Analgesic adjuncts such as: 1. intra-operative and postoperative acupuncture as well as 2. postoperative honey are also recommended. 3. Ketamine (only for children); dexmedetomidine; or gabapentinoids may be considered when some of the first-line analgesics are contra-indicated ?peritonsilar infiltration --> increased risk of upper airway obstruction

Answer 816

c. Dobutamine Dobutamine and milrinone can cause systemic vasodilation leading to reduction in systemic blood pressure and RCA perfusion pressure, Both adrenaline and Dopamine do not cause pulmonary vasodilation and can lead to tachyarhythmias Pulmonary hypertension and its management in patients undergoing non-cardiac surgery https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/10.1111/anae.12831 Vasoconstrictors, inotropes and inodilators Maintaining the gradient between aorta and right ventricle is achieved by using sympathomimetic and non-sympathomimetic vasopressors. Noradrenaline and vasopressin improve perfusion of the right coronary artery, reduce the pulmonary/systemic vascular resistance ratio, enhance right ventricular performance and marginally improve cardiac output However, the evidence of their impact on mortality related to right heart failure is weak. Inotropes that enhance right ventricular performance, such as adrenaline, dobutamine and levosimendan are effective in treating right-sided heart failure. The use of inotropes has a modest impact in reducing the overall mortality related to PH, and their wide availability and ease of administration make this group of drugs very attractive for use in the peri-operative setting. Inodilators, such as the phosphodiesterase-3 inhibitors milrinone and enoximone, have been shown to be beneficial when compared with conventional inotropic support only. It appears that the influence of phosphodiesterase-3 inhibitors on reducing pulmonary vascular resistance is more pronounced than the reduction in systemic vascular resistance. However, reduction in systemic vascular resistance can compromise right coronary artery blood flow in patients with severe PH and therefore they should be administered cautiously. Treatment of pulmonary hypertensive crisis: General principles - Avoid hypoxic pulmonary vasoconstriction - Avoid hypercarbia, acidosis and hypothermia - Avoid high airway pressures - Optimise right ventricular preload - Reduce right ventricular afterload - Maintain coronary blood flow - Maintain sinus rhythm - Maintain arterial blood pressure and cardiac output Vasopressors– noradrenaline; vasopressin Inotropes– adrenaline; dobutamine Inodilators– milrinone; enoximone Intravenous vasodilators (caution if low systolic blood pressure) - Milrinone (25–50 μg.kg−1 bolus, followed by 0.5–0.75 μg.kg−1.min−1 continuous infusion) - Prostacyclin (4–10 ng.kg−1.min−1 continuous infusion) - Iloprost (1–3 ng.kg−1.min−1 continuous infusion) - Sildenafil (10 mg bolus three times a day) Selective pulmonary vasodilation - Iloprost (5–10 μg diluted in 10 ml saline, nebulised over 10 min, repeated every 2–4 h) - Prostacyclin (25–50 μg diluted in 50 ml saline, nebulised over 15 min, repeated every hour) - Nitric oxide (5–40 ppm continuously)

Answer 817

Forming a research question and literature review SQUIRE - framework for reporting new knowldge and how to improve healthcare RCT - CONSORT Observational studies - STROBE Systematic review - PRISMA Study protocols - SPIRIT Clinical practice guidelines - AGREE Qualitative research - SRQR Research question - PICO"

Answer 818

d. L5/S1 disc prolapse with compression of interveterbral foramina pathology BJA: Chronic BAck Pain https://academic.oup.com/bjaed/article/6/4/152/387156?itm_medium=sidebar&itm_source=trendmd-widget&itm_campaign=BJA_Education&itm_content=BJA_Education_0 Neurological examination may reveal sensory, motor and reflex abnormalities. Nerve root pain can be caused by disc herniation, spinal stenosis and epidural adhesions. The nerve roots leave the spinal canal via the intervertebral foramina. Difficulty with big toe extension - extensor hallucis longus innervated by Deep Peroneal Nerve (L4, L5 nerve roots) Nerve root exit from under the vertebral body so L4 will be L4/5 and L5 will be L5/S1 Unilateral so should be foraminal pathology https://www.orthobullets.com/anatomy/10117/deep-peroneal-nerve "

Answer 819

b. 100ml 4mg/kg blood will raise Hb by 10g/L Paediatric weight estimation: RCH: Weight (kg) = (age + 4) x 2 = 20kg Formula for calculating transfusion volume (mL) Children <20 kg: PRBC (mL) = wt (kg) x Hb (g/L) rise (desired Hb – actual Hb) x 0.5 (transfusion factor) Children >20 kg: 1 unit PRBC Example: 6 + 4 x 2 = 20kg 20kg x 10g/l x 0.5 = 100ml

Answer 820

a. obesity ? although normally dont have a reduced RV e. bilateral phrenic nerve palsy if FEV1/FVC and misremembered (previous 2015 mcq similar question given FEV1/FVC ratio instead) Phrenic nerve palsy A reduced forced vital capacity (FVC), vital capacity (VC), and total lung capacity (TLC) are typically seen; forced expiratory volume in one second (FEV1)/FVC ratio (greater than 70 percent of predicted) and DLCO are often preserved. (Did the stem have FEV1/FVC ratio rather than above?) Obesity and pulmonary function testing https://www.jacionline.org/article/S0091-6749(05)00164-8/fulltext - Full pulmonary function tests are often necessary to better characterize the spirometric abnormalities seen in the obese patient - The most sensitive indicator of obesity is a low expiratory reserve volume (ERV) and functional residual capacity - Restriction is seen in more severe obesity, with reductions in TLC and FVC. - However, residual volume is often preserved because of the relative high closing volume in relation to ERV.

Answer 821

b. Procainamide BJA: Perioperative cardiac arrhythmias https://academic.oup.com/bja/article/93/1/86/265716 - Paroxysmal SVT (PSVT) due to re‐entrant circuits that involve accessory pathways (congenital electrical connections between the atrium and ventricle that bypass the AV node, such as Wolff–Parkinson–White Syndrome) pose caveats in the management of SVT. - It should be noted that patients with accessory pathways, in addition to PSVT, may also develop atrial fibrillation, and in the latter situation are at increased risk for developing ventricular fibrillation (VF) upon exposure to classic AV‐nodal blocking agents (digoxin, calcium channel blockers, beta blockers, adenosine) because these agents reduce the accessory bundle refractory period. - In such cases, i.v. procainamide, which slows conduction over the accessory bundle, is an acceptable option. Flecainide and amiodarone should also be considered, and cardiology consultation may be helpful.2 Overall Haemodynamically unstable - syncrhonised DCCV Haemodynmaically stable SVT with narrow QRS complex - adenosine 6mg or esmolol 0.5mg/kg, metoprolol 1-5mg, diltiazem 0.25mg/kg SVT with broad QRS complex - amiodarone, consider VT Antidromic AVRT - a regular **broad complex** tachcardia (anterograde conduction via accessory pathway and retrograde via AV node) - PROCAINAMIDE Orthodromic AVRT - a regular **narrow complex** tachycardia (anterograde conduction via AV node and retrograde via accessory) - ADENOSINE Irregular broad complex tachcyardia - AF with rapid anterograde conduction via accessory pathway https://academic.oup.com/bjaed/article/15/2/90/248695#2937337 "

Answer 822

b. 0.4 BJA: Monitoring of neuromuscular block https://academic.oup.com/bjaed/article/6/1/7/347026 When neuromuscular monitoring is used, visual or tactile evaluation of the degree of neuromuscular block is unreliable. Even experienced anaesthetists are unable to detect fade when the TOF ratio is >0.4. It is now thought that significant residual curarization is still present if the TOF ratio is <0.97 (not 0.7 as previously suggested8). (Double burst up to TOFR >0.6)

Answer 823

d. Severe liver failure but could also be e. Sepsis High SvO2 due to, ^O2 delivery (hyperbaric oxygen, increased FiO2), decreaed O2 demand (hypothermia, anaesthesia, neuromuscular blockade), High flow states (sepsis, hyperthryoid, severe liver disease), histotoxic hypoxia (CN poisoning) ESLD - usually low SVR, high CI, ^SvO2 Sepsis - can be high or low SvO2 https://litfl.com/mixed-venous-oxygen-saturation-svo2-monitoring/ " LIFTL: INTERPRETATION High SvO2 - increased O2 delivery (increased FiO2, hyperoxia, hyperbaric oxygen) - decreased O2 demand (hypothermia, anaesthesia, neuromuscular blockade) - high flow states: sepsis, hyperthyroidism, severe liver disease Low SvO2 - decreased O2 delivery: 1. decreased Hb (anaemia, haemorrhage, dilution) 2. decreased SaO2 (hypoxaemia) 3. decreased Q (any form of shock, arrhythmia) - increased O2 demand (hyperthermia, shivering, pain, seizures) - Causes of High SvO2 despite evidence of End-organ Hypoxia: 1. microvascular shunting (e.g. sepsis) 2. histotoxic hypoxia (e.g. cyanide poisoning) 3. abnormalities in distribution of blood flow Anesthesia Monitoring Of Mixed Venous Saturation: https://www.ncbi.nlm.nih.gov/books/NBK539835/ In sepsis, ScvO2 less than 70% or SvO2 lower than 65% correlate with poor prognosis.[2] In application, certain studies have shown that maintaining a goal ScvO2 greater than 70% leads to reduced mortality.[11] Therefore, ScvO2 is used to guide treatment algorithms in the Surviving Sepsis Campaign (SSC). Studies have shown that normal to higher levels of mixed venous oxygen saturation in patients with clinically worsening sepsis do not rule out tissue hypoxia due to the inability to utilize O2.[11][7] Therefore, several studies support the conclusion that abnormally low or high ScvO2 correlates with higher mortality in patients with septic shock.

Answer 824

d. 7 days A bolus dose of sugammadex is thought to have the following consequences: (i) the equivalent of missing one daily dose of oral contraceptives, and (ii) reduced efficacy of other hormonal contraceptives (e.g. implant, vaginal ring, or intrauterine system) requiring additional non-hormonal contraception be used for 7 days. https://www.bjanaesthesia.org/article/S0007-0912(18)30198-3/fulltext Although I am dubious on this as the amount of hormone packed into a COCP is far in excess of what is required to suppress ovulation. Along with surgical stress and impact on the reproductive cycle its probably BS. Looks like Devoy (and anzca are all over it) https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/10.1111/anae.15902 https://oce-ovid-com.ezproxy.anzca.edu.au/article/00001503-202408000-00003/PDF He notes that the effect on the POP might be significant (would need a three day backup)

Answer 825

a. 5-10 PAED mild >1 - <5 Moderate >/=5 - <10 Severe >/=10 ADULT normal <5 mild >/=5 - < 15 moderate >/=15 - 30 severe >/= 30 Apnoea = breathing stop or reduce to 10% of normal levels for 10seconds Hypopnea = airflow decreases by more than 30% for 10 seconds AHI = total apnoea+hypopnoea / total no. of hours asleep"

Answer 826

b) 250mcg IM q15mins, up to 2mg 15-methyl-PGF2α (carboprost; Prostinfenem) which may be administered in one of two ways: Intra-muscular injection of 0.25mg, in repeated doses as required at intervals of not less than 15 minutes to a maximum total cumulative dose of 2.0mg (ie up to 8 doses) Source RANZCOG PPH Guideline 2021

Answer 827

RCA (Inferior STEMI) - 80% RCA - 18% LCx - 2% rare wrap around LAD Source LITFL "II, III, aVF = inferior = RCA. V1,V2 = anterior = LAD V3,V4=septal = LAD V5,V6, avL, I = lateral = Circumflex V1-V6 + aVL= anteriolateral = LCA. https://derangedphysiology.com/main/required-reading/cardiology/Chapter%201.1.8/ecg-localisation-coronary-artery-territories"

Answer 828

c) Ocular massage Hyalase Mixing with lignocaine Higher concentration Higher volume Occular pressure (spread and IOP reduction) Source: 2x BJA Ed articles

Answer 829

ASA 3 Source: ASA Classification https://www.asahq.org/standards-and-guidelines/asa-physical-status-classification-system

Answer 830

BE and Hco3 are derived

Answer 831

"a. Urine osmol <100 High ADH -> Highly concentrated urine. Cortisol Suppressed ADH release - likely to be low but not necessarily BJA education: Criteria for diagnosing SIADH include: clinical euvolaemia, serum osmolality <275 mOsm/kg urine osmolality >100 mOsm/kg urinary Na >30 mmol/litre normal thyroid/adrenal function, no use of diuretics within a week of testing"

Answer 832

b) Male gender Patient-related risk factors for OIVI are older age, female gender, sleep disordered breathing (SDB), obesity, renal impairment, pulmonary disease (in particular chronic obstructive pulmonary disease), cardiac disease, diabetes, hypertension, neurologic disease, two or more comorbidities, genetic variations in opioid metabolism, and opioid-tolerant patients. Modifiable risk factors include: * Coadministration of sedatives (e.g. benzodiazepines, gabapentinoids, antipsychotics and sedating antihistamines) * Simultaneous use of multiple opioid agents (this does not include verified doses of opioids taken for management of chronic pain, where the patient has developed a tolerance to and physical dependence on these medications) * Continuous infusions of opioids * Initiation of long-acting opioid preparations (including methadone) * Multiple prescribers * Inadequate nursing assessments or responses * Reliance on unidimensional pain scores alone to assess adequacy of analgesia, and chasing’ pain scores – that is, titrating opioids to pain scores alone to reduce them to a predetermined acceptable number * Using opioids for pain that is not opioid-responsive Source ANSCA PS 41

Answer 833

d) major haemorrhage - blood loss is significantly less with RALP Up to date: RALP

Answer 834

a) Arterial puncture - thoracic duct injury is a risk with left sided IJ CVC insertion, but it is a rarer complication. Complications by site: IJ - arterial puncture (6-9%) > haematoma (<2%) > PTX (<0.2%) Subclavian - arterial puncture (3-5%) > PTX (1.5-3%) > haematoma (2%) > haemothorax (<1%) Femoral - arterial puncture (9-15%) > haematoma (3-4%) ANZCA blue book 2019 pg 77

Answer 835

a) Critical appraisal PICO is a mnemonic used to describe the four elements of a good clinical foreground question: P = Population/Patient/Problem - How would I describe the problem or a group of patients similar to mine? I = Intervention - What main intervention, prognostic factor or exposure am I considering? C = Comparison - Is there an alternative to compare with the intervention? O = Outcome - What do I hope to accomplish, measure, improve or affect?

Answer 836

a) Alprostadil Prostin (PGE1)

Answer 837

1,500 mL immediately OR 200 mL/hr in the first 2-4 hours

Answer 838

d) Creatinine Albumin Bilirubin COAG (INR/PT) Ascites Encephalopathy

Answer 839

b) pKa BJA: Basic pharmacology of local anaesthetics https://www.bjaed.org/article/S2058-5349(19)30152-0/fulltext Local anaesthetic agents are amphipathic molecules. They bind primarily to sodium channels but also to potassium and calcium channels, and G-protein-coupled receptors. Structural modifications alter the physicochemical characteristics of a local anaesthetic. Speed of onset, potency, and duration depend on the pKa, lipid solubility and protein binding, respectively. All local anaesthetic agents carry a risk of toxicity.

Answer 840

a.Decreased SpO2 Increased SctO2

Answer 841

Death in bleeding trauma patients Early administration of TXA safely reduced the risk of death in bleeding trauma patients and is highly cost-effective. Treatment beyond 3 hours of injury is unlikely to be effective. no decrease in blood product use

Answer 842

b) 90 PAO2: 0.4 (760 - 47) - 48/0.8 = 285 - 60 = 225mmHg 225 - 135 = 90mmHg.

Answer 843

18mL Local anaesthetic for the block: Dilute lidocaine (lignocaine) 1% with an equal quantity of normal saline to make a 0.5% solution Lidocaine (lignocaine) dose: 3 mg/kg (0.6 mL/kg of 0.5%; max 200 mg or 40 mL) Source RCH Melbourne Bier’s block guideline

Answer 844

"b) 45ml/hr 0.9% NS 5% dextrose maintenanicne fluid = 4,2,1 rule = 65ml/hr in unwell children (acute CNS/ post op/ trauma/ pulmonary conditions) - 2/3 maintenaince rate due to ^ADH secretion. preferred maintenaince fluid type 0.9% NS + 5% glucose +/- potassium most sick children will retain water and need less than full maintenaince fluid resuscutation fluid: 10-20ml/kg 0.9% NS rehydration: maintenaince + replacement of deficit + replacement of ongoing losses - replace deficit over 24-48hrs https://www.rch.org.au/clinicalguide/guideline_index/intravenous_fluids/ "

Answer 845

A) stopping caffeine as per UTD Eat a well-balanced diet that's low in salt Limit alcohol Enjoy regular physical activity Manage stress Maintain a healthy weight Quit smoking https://www.nps.org.au/assets/86042695e7c1533b-5d322735f00c-a9e13c1e8cdb8709bc57547d423afb379103db7ef4be0ffbd0acf22125a6.pdf

Answer 846

"a. Nasociliary. It is a branch of the Trigeminal nerve. https://academic.oup.com/bjaed/article/17/7/221/3800526"

Answer 847

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

Answer 848

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

Answer 849

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

Answer 850

Incidence of staphyloma

Answer 851

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

Answer 852

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

Answer 853

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

Answer 854

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

Answer 855

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

Answer 856

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

Answer 857

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

Answer 858

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

Answer 859

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

Answer 860

Now no time frame

Answer 861

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

Answer 862

-30 Left Axis Deviation LITFL

Answer 863

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

Answer 864

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

Answer 865

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

Answer 866

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

Answer 867

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

Answer 868

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

Answer 869

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

Answer 870

e) Reversible hypermetropia

Answer 871

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

Answer 872

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

Answer 873

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

Answer 874

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

Answer 875

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

Answer 876

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

Answer 877

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

Answer 878

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

Answer 879

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

Answer 880

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

Answer 881

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

Answer 882

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

Answer 883

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

Answer 884

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

Answer 885

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

Answer 886

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

Answer 887

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

Answer 888

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

Answer 889

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

Answer 890

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

Answer 891

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

Answer 892

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

Answer 893

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

Answer 894

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

Answer 895

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

Answer 896

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

Answer 897

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

Answer 898

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

Answer 899

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

Answer 900

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

Answer 901

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

Answer 902

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

Answer 903

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

Answer 904

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

Answer 905

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

Answer 906

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

Answer 907

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

Answer 908

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

Answer 909

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

Answer 910

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

Answer 911

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

Answer 912

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

Answer 913

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

Answer 914

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

Answer 915

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

Answer 916

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

Answer 917

b) Diaphragm

Answer 918

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

Answer 919

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

Answer 920

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

Answer 921

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

Answer 922

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

Answer 923

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

Answer 924

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

Answer 925

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

Answer 926

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

Answer 927

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

Answer 928

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

Answer 929

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

Answer 930

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

Answer 931

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

Answer 932

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

Answer 933

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

Answer 934

e) Low resistance

Answer 935

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

Answer 936

a) face, legs, activity, cry, consolability

Answer 937

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

Answer 938

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

Answer 939

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

Answer 940

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

Answer 941

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

Answer 942

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

Answer 943

c) Genitofemoral

Answer 944

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

Answer 945

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

Answer 946

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

Answer 947

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

Answer 948

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

Answer 949

Dilated RA and RV

Answer 950

NIM tube: Neural Integrity Monitor Electromyogram Tracheal Tube

Answer 951

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

Answer 952

"c - posterior intercostal. Superficial breast innervation - Anterior intercostal nerves T3-5 - Anterolateral intercostal nerves T3-6 - Supraclavicular nerves - Intercostobrachial nerve Deep breast innervation (radical mastectomy) - Long thoracic nerve (serratus anterior) - Medial pectoral (pec minor and major) - Lateral pectoral (pec minor and major) - Thoracodorsal (lat dorsi) Anterior and lateral breast - branches of thoracic intercostal nerves T2-6 superior (under clav) - supraclav (C3/4) Axilla - intercostal brachial nerve Ant surface serratus anterior - long throacic N (C5-7) Lat dossi - thoracodorsal N (C6-8) - PURE MOTOR NERVE Pectoral muscles - lateral (C5-7) and medial (C8-T1) pectoral nerves [runs between pec major and pec minor - blocked with PECS1] [PECS2] between pecs minor and serratus ant - blocks lateral cutaneous spinal nerves, long thoracic and possibly intercostal N https://www.researchgate.net/figure/Innervation-of-the-axilla-and-breast-ICBN-indicates-intercostobrachial-nerve-LTN-long_fig2_340867787"

Answer 953

"a. Dopamine Benztropine is a centrally acting Anticholinergic / Antihistamine / Dopamine re-uptake inhibitor. Used to improve the side effects of acute dsytonic reactions (1-4mg OD to BD) and Parkinson (up to 6mg daily). LITFL"

Answer 954

c. Anterior to erector spinae and posterior to transverse process 5th rib Place anterior to transverse process and posterior to erector spine Midpoint between T5-6 (Usual Incision T4-5, ICC T6) Source - Blue book 2019

Answer 955

b. hepatic vein Pringle Manoeuvre = clamping hepatoduodenal ligament (clamps hepatic artery, portal vein, CBD)

Answer 956

"c) pharyngeal muscles onset and offset of block is faster in central muscles with good blood supply (eg. diaphgram and larynx) slower onset/offset in peripheral muscle groups (adductor pollicis0 airway/pharynx - quick onset but slow recovery (due to ^sensitivity) Neuromuscular monitoring: visual/tactile evaulation of degree of block is unreliable - unable to detect fade when TOF is>0.4 - unable to detect difference in DBS >0.6 https://academic.oup.com/bjaed/article/6/1/7/347026 "

Answer 957

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

Answer 958

"c) reduce by 50% Polio --> widespread neural change - not just destruction of spinal cord anterior horn (motor cells) and changes gets worse as patient ages. Implications for anaesthesia: - VERY sensitive to sedatives - emergence can be prolonged (probably due to central neuronal changes at RAS) - nNMB - greater degree of block for LONGER duration - start with 50% usual dose. - sux - often causes severe generalised muscle pain post op - AVOID if possible - post op pain common - wind up from original disease affecting pain pathways - multimodal analgesia – ANS dysfunctional - IAL - respiratory muscles affected - spiro pre-op. ^risk of post op ventilation if VC<1L or OSA, may be permanent venitlation post-op - bulbar sx due to muscle weakness -- many patients have 1 paralysed cord - ENT FNE prior - positioning, osteopenia, ^risk peripherla nerve damage https://post-polio.org/education/summary-of-anesthesia-issues/ "

Answer 959

Lean Body Weight For infusion: Adjusted body weight NDMB: Lean Body weight Sux: Total body weight Source: SOBA UK

Answer 960

"a) AAA acromegaly - excess GH Airway - ^difficult of intubation due to macgnathia, macroglossia and expansion of upper airway soft tisssues Resp - ^OSA, kyphoscoliosis, proximal myopathy CVS - refractory HTN, LV hypertrophy, IHD, arrythmia, heart block, cardiomyopathy (^deposition of tissue -->fribrosis), bi-ventricular dysfunction CNS - ^ soft tissue --> ^ nerve entrapment syndromes Metabolic - *diabetes and other endocrine https://academic.oup.com/bjaed/article/11/4/133/266875#3195851"e.

Answer 961

B. Normal 2,3 DPG higher Hct-60% No immunimodulation require reinfusion within 6hrs pause with sement, caution metal fragments

Answer 962

Ultrasound view of right axillary brachial plexus AA = axillary artery AV = axillary vein McN = musculocutaneous nerve RN = radial nerve UN = ulnar nerve MN = median nerve CoBM = coracobrachialis muscle CT = conjoint tendon

Answer 963

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

Answer 964

"c) cardiac arrest ANZCOR give specific targets for SpO2 (94-98%), Hyperglycaemia (treat>10mmol/L), TTM (32-36oC). They say HD goals are important BUT DO NOT SPECIFY A TARGET. "

Answer 965

"b) deep posterior compartment Anterior: - deep fibular nerve - foot dorsiflexion and toe extension, sensation between big and second toe Lateral: superficial fibular nerve - foot eversion and sensation over lateraland dorsum of lower leg/foot Deep posterior - tibial nerve - (becomes post.tibial nerve once it passes below the upper level of fibrous arch of soleus muscle) - foot plantar flexion and inversion and toe flexion. Tibial nerve also branches off sural nerve - sensory over lateral foot and malleous Superficial posterior - no nerves"Deep Posterior Compartment Source: UpToDate

Answer 966

d. 2/7/9/10 Hypovitaminosis of Vitamin K (Bile required for absorption) Source: BMC Article https://bmcpregnancychildbirth.biomedcentral.com/articles/10.1186/s12884-022-04875-w

Answer 967

Right lateral Decubitus BJA: ultrasound

Answer 968

Anaemia of chronic inflamation with iron deficiciency

Answer 969

"a) cefaclor 10% reports penicillin allergy, <1% truly allergic 1-2% of confirmed penicillin allergy is allergic to cephalosporin cross-reactivity can be due to b-lactam ring, R1 side chain / thiazolidine ring in penicillin or R1/R2 /dihyrothiaxine ring in cepalosporins. - highest risk is with R1 side chain - same shared R1 - ampicillin, amoxicillin, cefalexin, cefaclor - cefazolin - no shared side chains with penicillin or cephalosporins (but if reaction to the rings, may stil happen https://www.nps.org.au/assets/p192-Devchand-Trubiano.pdf "

Answer 970

"d) PEA PEA 50.8% asystole 25.6% shocable 11.7% (VF 6.5%, pulseless VT5.2%) unknown 11.9%"a)

Answer 971

d. none Increase in presence of mycobacterium vaginosis, doxycylcine will kill commensal bacteria Doxycycline is used for copper IUD in the setting of emergency insertion with PID

Answer 972

"b) GA BCIS incidence ~20%, severe reaction-->CVS collapse 0.5-1.7% 3 features - hypoxia, hypotension/arrythmia, LOC - time limited phenomena - usually PAP normalises within 24hrs - thought to be shower of emboli clogging up the pulmonary vasculature Grade 1 (moderate) - SpO2<94%, >/=20% drop in BP, no change in LOC Grade 2 (sever) - SpO2<88%, >/=40% drop in BP, unexpected LOC Grade 3 - cardiovascular collapse requiring CPR -- should be treated as RV failure Pt riskfactors: - increasing age - male - significant cardiopulmonary disease - diuretics.warfarin - ASA iii / IV Surgical risk factors: - cemented hemiarthroplasty highest risk - previously un-instrumented femur - more ptential for emoblic material https://resources.wfsahq.org/wp-content/uploads/351_english.pdf"

Answer 973

LAD LAD LESIONS (STE): V1-2 - septal MI V3-4 anterior MI V5-6, I, avL - lateral MI II, III, aVF, I, aVL, V5-6 +/- V4R - inferior lateral MI - LAD+LCx occlusion in left dominant ciruclation RCA LESIONS (STE) II, III, aVF - inferior MI (reciprocal STD in avL) - RCA lesion distal to RV (58% of MI) II, III, aVF, V1 and V4R - inferior and RV MI (RCA lesion proximal to LV) (40% of Inferior MI) II, III, aVF, V7-9 - inferior posterior MI (STD V1-2) (RCA + LCx occlusion IF V1-V2 STD - need to do posterior ECG to exclude POSTERIOR MI - V7-9 STE (RCA and LCx occlusioN) https://litfl.com/wp-content/uploads/2018/10/ECG-Anatomy-LITFL.jpg "

Answer 974

The lungs are hyperinflated with relatively flat diaphragms - a sign of pulmonary emphysema. There is a dense triangular opacity overlying the cardiac shadow with increased lucency of the left upper zone relative to the right upper zone. This is the "sail sign" of left lower lobe collapse with subsequent left upper lobe hyper-expansion.

Answer 975

e. 1:136,000 1/670 E-LSCS 1/8000 with muscle relaxation 1/8600 CTS Overall 1:19000

Answer 976

"b - fentanyl ^SSEP amplitude - ketamine, low dose etomidate decrease SSEP - volatiles > N2O, barbituates > propofol Minimal change - opioids, low dose benzo, dexmedetomidine, lidocaine No affect - muscle relxant https://www.uptodate.com/contents/neuromonitoring-in-surgery-and-anesthesia#H3106240"""B) fentanyl Drugs which have the least impact on SSEPs 1. Ketamine 2. Opioids 3. Dexmedetomidine Article in Anaesthesiology https://pubs.asahq.org/anesthesiology/article/99/3/716/40407/Pharmacologic-and-Physiologic-Influences-Affecting

Answer 977

c. 5mg/kg Methylene blue due to its monoamine oxidase(MAO) inhibiting property may precipitate potentially fatal serotonin toxicity at doses >5mg/kg.

Answer 978

e. Decreased neuropathic pain at 12 months ANZCA pain book

Answer 979

d. 7500 7.5L (Average increase around 48%) pregant = 100ml/kg , neonate 90ml/kg, adult 70ml/kg , paeds 80ml/kg """

Answer 980

25ml/cm H2O The answer is 30ml/cmH20 because total PEEP is 8+4=12 Static lung compliance (Cstat), mL/cm H2O = TV / (Plateau pressure (Pplat) – PEEP)

Answer 981

d) modified valsalva HD stable: narrow QRS - likely SVT – vagal manouvres, adenosine 6 , 12, 12 Unstable.- HR>150, sBP <90 (in conscious and lower in anaesthetised pt) - synchrnised DCCV 1J/kg and can be increased to 2J/kg "conscious VT or something stupid....

Answer 982

"3 mths AHA Guidelines. ""we suggest that elective noncardiac surgery be deferred at least 6 months after a prior stroke, and possibly as long as 9 months to reduce the risk of perioperative stroke in patients undergoing noncardiac surgery. Alternatively, patients who stand to gain significant improvements in quality of life with elective surgery may consider waiting only 6 months after a prior stroke."" https://www.ahajournals.org/doi/10.1161/CIR.0000000000000968 https://www.bjaed.org/article/S2058-5349(20)30123-2/fulltext"

Answer 983

c) initial bradycardia PSNS during seizure 10-15sec - brady/hypotension followed by SNS (5mins) - tachycardia/ hypertension/ dysrhythmia, ^myocardial oxygen requirement seziure --> ^ICP and ^CMRO2 --> ^CBF Other - hypersalivation, ^gastric pressure, ^IOP, incontinence absolute CI - recent MI or CVA, phaeochromocytoma, intracranial mass lesion, intracranial or aortic aneurysm Oxford handbook pg 273-274"

Answer 984

?? XR Reviews

Answer 985

"a) hypophosphataemia - due to renal wasting of phosphate - usually transient and asymptomatic "osphataemia

Answer 986

"a) staphyloma BJA - regional anaesthesia for ophthalmic surgery - Myopic eyes with an axial length of > 26mm are at increased risk of perforation with retrobulbar / peripulbar . This risks is increased in by the associated likelyhood of staphylomas (sclera outputting), which are typically posterior or inferior"

Answer 987

b. 45ml/hr N saline w 5% dextrose A guide to paediatric anaesthesia fluid management -421 rule overestimates fluid resus -due to stress response from ADH release -post-op fluid maintenace is 2/3rds calculated -never use hypotonic solution -unlikely to need glucose as not a neonate

Answer 988

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

Answer 989

"b) gelofusine (succinylated gelatin) 25% of children suffering anaphylaxis to MMR is due to gelatin gelatin also found in Haemaccel and Gelofusine https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/full/10.1111/j.1365-2044.2005.04529.x"

Answer 990

"b) berinert another remembered option had icatibant instead of berinert. ?give FFP in this instance as icatibant wont have time to work Tx of acute flare: – C1 inhibitor concentrate eg Berinert, Cinryze – Recombinant C1 inhbitor (conestat alfa) – bradykinin B2 receptor antagonist (Icatibant – FFP - 2units initially- repeated Q2-4H HAE - causes recurrent episodes of angioedema in the upper respiratory tract , GIT or subcut tissue Due to C1 esterase inhibitor deficiency. Rare autosominal dominat condition 2 types (type1 - reduced, type 2 poorly functional C1 esterase inhibitor) Triggers - infection, stress, menstruation, surgery, dental work, trauma, medicine (COCP and ACEi) or may have no clear trigger Pre-op prevention: 1st line - Danazol 10mg/kg/day for 5-10days before and 2-5days after procedur) (androgen increase C1 esterase inhibitor synthsis) Emergency or high risk procedures - 25u/kg infusion of C1 esterase inhibitor concentrate (Berinert) given 1hr prior to procedure **antihistamines and cortiocsteroids have no role in management of HAE related angiodema. Role of adrenaline not well established https://www.rch.org.au/clinicalguide/guideline_index/C1_Esterase_inhibitor_deficiency/ "

Answer 991

"a. Nasociliary. It is a branch of the Trigeminal nerve (V1) https://academic.oup.com/bjaed/article/17/7/221/3800526 V1 (Ophtlamic) divides into Fronal, lacrimal, nasocillary Frontal (largest of V1 branches) branches into supraorbita (innervates upper eyelid and contiva and scalPl and supratrochlear (innervavtes upper eyelid, conjunctiva, forehead) Lacrimal (smallest of V1 branches and receive branch from V2 containing parasympathetic fibres) - lacrimal gland, upper eyelid, conjunctiva Nasocillary (4 branches - ant ethmoid, post ethmoid, infratrochlea, long ciliary nerves) - sensatotion to sinuses, nasal cavity, external nose. Long ciliary - sensory innervation to eye (CORNEA, ciliary bodies, iris) sympathetic fibres to dilator pupillae muscle Occulomtor - CN III - innervates all extraoccular muscles EXCEPT - SO4 and LR6 Optic CN II - sight"

Answer 992

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

Answer 993

"a) 100microamp Microshock - enters body through internal devices close to heart - 10micramp - unsafe - 100microamp - can induce VF macroshock - current through 2 points of body – 1mA - pain - 10mA - tetany (unsafe) -100mA - VF"

Answer 994

a. Increases NIRS , decreases peripheral SctO2 up, SpO2 down. Source: Korean Journal Anaesthesia https://www.researchgate.net/publication/274570990_Effects_of_intravenously_administered_indocyanine_green_on_near-infrared_cerebral_oximetry_and_pulse_oximetry_readings

Answer 995

no longer has time frame

Answer 996

"insulin and sulfonylureas (eg. Gliclazide) high risk of hypoglycaemia when fasting (stimulates pancreatic cells to make more insulin) "

Answer 997

Control seizures first a) Midazolam if an option or c) propofol or treat seizures 1st followedLAST - ABCD - Intralipid 1.5mL/kg

Answer 998

"d) DLCO low MG won't affect DLCO Pulmonary HTN won't show restrictive pattern Emphsema/asthma - high DLCO Other causes of ^DLCO: asthma, polycythemia, pulmonary haemorrhage, large lung volumes, high altitude, left to right cardiac shunt, exercise prior to test (^CO) Emphsema, ILD, sarcoid --> decreased DLCO "

Answer 999

"a) sevo, morph, phenyl moclobemide - MAO-Ai - AVOID indirect acting sympathomimetics (ephedrine, metaraminol -->hypertensive crisis) - AVOID serotonin crisis precipitants (including pethidine) MAO-A - involved in breakdown of norad and serotonin MAO-B- involved in breakdown of tyraime and phenyethyamine https://academic.oup.com/bjaed/article/10/6/177/299579 "

Answer 1000

C) droplet "Standard + contact precuations: Standard - hand hygiene, PPE, effective cleaning of all equipment/enivronment Contact: - single room isolation - PPE - glove + gowns - dedicated equipment to patients – enahnced cleaning + disinfection - x2 / day https://www.safetyandquality.gov.au/sites/default/files/2020-09/cpe_for_clinicians_sept_2020.pdf"

Answer 1001

b? The sciatic nerve block results in anesthesia of the posterior aspect of the knee, hamstring muscles, and entire lower limb below the knee, both motor and sensory block, with the exception of skin on the medial leg and foot (supplied by the saphenous nerve). The skin of the posterior aspect of the thigh is supplied by the posterior femorocutaneous nerve, which deviates away from in the sciatic nerve proximal to the level of the anterior approach, and is therefore not blocked. NYSORA

Answer 1002

"c) Dopamine 2 antagonist Indicatoins: Parkinson, drug induced EPSE, acute dystonia MOA: antimuscurinic - reduction of relative excess of cholinergic activity that accompanies dopamine deficienc in PD. partially blocks cholinergic activity in basal ganglia and has been shown to increase availability of dopamine by blocking its reuptake and storage in central sites https://www.sciencedirect.com/topics/pharmacology-toxicology-and-pharmaceutical-science/benzatropine#:~:text=Benzatropine%20partially%20blocks%20cholinergic%20activity,of%20Parkinson%27s%20disease%20and%20dystonia."

Answer 1003

a. Barrier protection for a week

Answer 1004

60 mmol 1mmol/kg 1mmol/kg given over 2-3minutes as guided by ABG 8.4% sodium bicarb 100mmol = 1mmol/ml Routine use not recommended for cardiac arrest Consider if: - hyperkalaemia - tx of documented metabolic acidosis - overdose with TCA - protracted arrest (>15mins) https://www.resus.org.nz/assets/Uploads/ANZCOR-Guideline-11.5-Medications-Aug16.pdf"

Answer 1005

e) Standards of quality improvement Quality Improvement (Standards for QUality Imporvement and Reporting Excellence) Quality improvement - SQUIRE RCT - CONSORT Observational studies - STROBE Systematic review - PRISMA Study protocols - SPIRIT Clinical practice guidelines - AGREE Qualitative research - SRQR Research question - PICO"

Answer 1006

e. Disregard not required "Conitnue to breast feed as per usual. Do not need to express and discard. Monitor infant for signs of respiratory depression and drowsiness especially if multiple doses of opioids/bzd AVOID codeine in breastfeeding https://anaesthetists.org/Home/Resources-publications/Guidelines/Anaesthesia-and-sedation-in-breastfeeding-women-2020"

Answer 1007

c. Ischemic optic neuropathy post op ischaemic optic neuropathy - most common cause of POVL after nonocular surgery - ^risk with cardiac, spine, orthopaedic, steep trendelenberg positions - anterior ION - more common with cardiac - posterior ION - more common with prone procedures, steep trendelenberg, cardiac - presents with painless b/l vision loss - risk factors for POVL with spine surgery - male, ^BMI, wilson frame, long duration, ^ blood loss - PION more common however only AION has fundoscopic changes -- AION - fundoscopy - swollen disc - can be uni or bilateral -- AION onset usually immediate after awakening but can also have onset a day or so afterwards - sudden unilateral or bilateral, progressive vision loss Central retinal artery occlusion - most common retinal cause of POVL - usually unilateraly and immediately after awakening from anaesthesia - fundoscopy - ischaemic retina + cherry red spot at macula https://www.uptodate.com/contents/postoperative-visual-loss-after-anesthesia-for-nonocular-surgery#H437018973 """

Answer 1008

Prostaglandin RCH say give 10ml/kg bolus rather than 20ml/kg https://www.safercare.vic.gov.au/best-practice-improvement/clinical-guidance/neonatal/cyanosed-neonate-assessment low threshold to give Most frequent side effects include: fever 12 per cent apnoea 12 per cent flushing 10 per cent hypotension tachycardia. Apnoea rarely occurs at 10 ncg/kg/min and is not an indication to decrease the dose if the infant is responding clinically. Ensure adequate respiratory support. The likelihood of apnoea is very high at a dose of 100 ncg/kg/min and most infants on this dose should have ventilatory support.

Answer 1009

a) High C-spine injury - at high risk of passive regurgitation and then aspiration due to loss of gag and cough response https://trauma.reach.vic.gov.au/guidelines/spinal-trauma/primary-survey Absolute Contraindications: midface injury, basal skull fracture, recent nasal surgery Relative Contraindications: coagulation abnormality, eosophageal varices or stricture, recent banding of varices, alkaline ingestion https://iem-student.org/nasogastric-tube-placement/"

Answer 1010

decreased SVR High CO state (+/- failure -- LVEF does not ^ appropriately during exercise suggesting presence of cardiomyopathy) - ^CO state due to ^ peripheral oxygen needs and ^ cardiac contractility - increased HR, contractiliity, sBP (widened pulse pressure), pulmnoary artery pressure, myocardial oxygen https://www.uptodate.com/contents/cardiovascular-effects-of-hyperthyroidism?search=cardiovascular%20effects%20of%20hyperthryod&topicRef=7833&source=see_link in HYPOthryoid - opposite occurs - decreased CO - decreased contractility, HR, diastolic relaxation (so decreased compliance and diastolic filling), peripheral tissue oxygen utilisation - blunted response to catecholamine mediated ^ in inotropy - ^ SVR, ^Qtc"

Answer 1011

Fluoxetine All other effective NRT, buproprion, nortriptyline, clonidine, nicotine receptor patial agonists (varenicline -(champix)) Individual counselling, group behaviour therapy, rapid smoking aversive therapy https://www.anzca.edu.au/getattachment/a3591188-1d7d-41cf-807a-b3b2f0226109/PS12BP-Guideline-on-smoking-as-related-to-the-perioperative-period-Background-Paper"

Answer 1012

less maternal bradycardia b) less maternal bradycardia - nil pt required anticholinergic so clinical significance unclear no difference in N/V norad non inferior to phenyl in terms of acid base profiles and APGAR at 1min and 5mins https://www.bjanaesthesia.org.uk/article/S0007-0912(20)30442-6/fulltext

Answer 1013

100 years Desflurane: 10yrs Sevoflurane 1yr

Answer 1014

A. expereince of anaesthetist assuming they are implying that an experienced anaesthetist is operating (as inexperienced anaesthetists operating increase risk PRAE). APRICOT doesnt mention snoring but BJA does https://www.bjanaesthesia.org/article/S0007-0912(24)00497-5/fulltext

Answer 1015

increased incidence of major bleeding APREE trial 2018 (NEJM) - low dose aspirin as primary prevention in pts>70 --> ^ risk of major haemorrhage (mostly GI bleed) and DID NOT lower risk of CVS disease compared to placebo. Primary prevention of CVD with aspirin among pts 40-59yo who have a 10% or grater 10yr CVD risk - has a small net benefit. https://jamanetwork.com/journals/jama/fullarticle/2791399"

Answer 1016

"d) sucralfate or honey - give within 12hrs of ingestion - don't give honey to <12mth old"""sucrulfate or honey

Answer 1017

c) lateral bladder wall resection obturator nerver - responsible for hip adduction - obturator nerve (L2-4) travels alongside the posterolateral bladdder wall before exiting the pelvis - stimulation of obturator nerve during TURBT --> adductor spasm --> ^risk of bladder perf spinal does not prevent unintended stimulation of obturator nerve - need Neuromuscular blocker or obturator nerve block decreased riks with lower diathermy current https://karger.com/cur/article/12/1/1/103204/Avoiding-the-Obturator-Jerk-during-TURBT"

Answer 1018

no difference TARGET trial 2019 energy dense vs routine enteral nutrition in critically ill ventillated Conclusion - no differenc in 90day survival (primary outcome) - ^ GI effects in high caloric group - ^ gastric residual volumes, regugitation, ^use of insulin and prokineitc drugs https://www.thebottomline.org.uk/summaries/target/"

Answer 1019

neurological damage due to methionine deficit chronic exposure --> deplete B12 stores through oxidation of cobalt --> inactivation of methionine synthase --> decreuased methionine synthesis --> megaloblastic anaemia, peripheral neuropathy, memory loss Potetntially teratogenic (in Rats) Acutely Resp - ^PVR - avoid in pulmonary HTN - expansion of existing air filled spaces - diffusion hypoxia CNS ^CBF --> ^ICP"

Answer 1020

high level of education Risk factors for CPSP Demographic: young adults, low level of education, seeking compensation, smokers Psychological: fear, anxiety, depression Pain related: pre-existing pain, stronger post-op intensity and duration Clincal: greater prior disability Surgery: longer operative time, increased complication rate Blue Book 2019 pg 176 "

Answer 1021

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

Answer 1022

4 hours RBC out of temperature controlled storage for <30mins can be returned to blood bank. Once RBC out of tempeature controlled storage for 30mins, transfusion of the unit must be completed within 4hrs and NO LONGER than 4.5hrs. Blood components must be transfused using a set that has a standard filter to remove clots and small clumps of debris. Recommended filter pore size is 170-200micron. https://anzsbt.org.au/wp-content/uploads/2018/06/ANZSBT_Guidelines_Administration_Blood_Products_3rdEd_Jan_2018.pdf"

Answer 1023

supraclavicular or suprascap Intrinsic muscles = rotator cuff muscles - supraspinatus, infraspinatus, subscapularis, teres minor Innervated by suprascapula, subscapular and axillary nerves (Branches off C5/C6/C7) Stabilisation scapula and rotational movements - levator sacpuale, trapezius, rhomboid, serratus anterior Innervation - axillary, spinal accessory (inn trapezius), dorsal scapula (inn rhomboid and levator scap), long thoracic (inn. serratus) Damge = winged scapula "

Answer 1024

c Rivaroxaban or apixaban are generally favoured over dabigatran or warfarin as they do not require a period of parenteral anticoagulation or routine laboratory monitoring. EXCEPT - if active cancer or pregnancy - LMWH - CKD 4 or 5, extreme body weight (/=120) or antiphospholipid syndrome - LMWH followed by warfarin Initial dose rivaroxaban 15mg BD for 21 days. Maintenaince 20mg OD for up to 6mths Apixaban 10mg BD for 7 days. Maintenaince 5mg BD for up to 6mths Rivaroxaban contraindicated if CrCl <30ml/min and Apixaban CI if CrCl<25ml/min Dabigatran - not on PBS. Also needs parenteral anticoagulant (eg clexane) for the first 5 days before starting dabigatran. Surgically provoked or distal DVT: (low risk recurrence at 12mths) Proximal DVT or PE - at least 3mths anticoag Distal DVT (ie. distal to popliteal vein) - 6weeks to 3mths. If high risk bleeding - surveillance uss x 2 over 2 weeks to monitor extension. If extension - anticoagulate Non surgically provoked (ie travel or COCP) or unprovoked - intermediate risk for recurrence - onggoing low dose apixaban (2.5mg BD) or rivaroxaban (10mg OD) commonly used https://australianprescriber.tg.org.au/articles/venous-thromboembolism-current-management.html"

Answer 1025

3 Appearance - pink > peripherial cyanosis > cyanotic Pulse - 100-140 > (<100) > 0 Grimace - cry > grimace > no response Activity - well flexed > some flexion > limp Respiration - strong cry > irregular breathing > apnoea "

Answer 1026

renal tubular acidosis-> NAGMA

Answer 1027

"a. Urine osmol <100 High ADH -> Highly concentrated urine. Cortisol Suppressed ADH release - likely to be low but not necessarily BJA education: Criteria for diagnosing SIADH include: clinical euvolaemia, serum osmolality <275 mOsm/kg urine osmolality >100 mOsm/kg urinary Na >30 mmol/litre normal thyroid/adrenal function, no use of diuretics within a week of testing"

Answer 1028

"a) empty bladder - suspect autonomic dysreflexia Treatment 1. Declare emergency and make surgical team aware of issues * Sit patient up if possible to reduce pressure to the head 2. Remove stimulus * Stop surgical insult * Check catheter is draining unblocked * May be able to check for constipation but less likely to be possible while on operating table mid surgery * Remove tight clothing 3. Drugs * Vasodilators ○ GTN bolus and subsequent infusion ○ Hydralazine ○ Mg, phentolamine, clonidine * Be careful with betablockers as may cause heart failure due to very high SVR and addition of betablocker may cause loss of contractility * Analgesia (opioids etc.) to reduce afferent nociceptive stimulation * Treat any arrythmias that may occur 4. Prevention of this by spinal anaesthesia * This can be done pre-op and prevents transmission of afferents which cannot then go on to cause ↑SNS outflow Not a treatment as such, more preventative in patients who are high risk"

Answer 1029

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

Answer 1030

"c) neostigmine or fluid Ogilvie syndrome - colonic pseudo-obstruction '3 , 6, 9 ' rule 10% related to O&G cases small bowel >/=3cm, large bowel >/=6cm, caecum >/=9cm caecum >/= 9cm -- ^ risk of perforation tx - first line (if <12cm) - correction of serum electrlytes, fluid resuscitation, avoid/minimize narcotics, avoid anticholinergic, trat infection if present, ambulation, bowel rest, alternating position to promote GI motility, decompression with NG or rectal tube. Avoid osmotic or stimulant laxatives -- can worsen dilation IF not resolved with above - neostigmine is indcated https://www.uptodate.com/contents/approach-to-acute-abdominal-pelvic-pain-in-pregnant-and-postpartum-patients?search=ogilvie&source=search_result&selectedTitle=2~50&usage_type=default&display_rank=2#H39 https://fascrs.org/getattachment/Healthcare-Providers/Education/Clinical-Practice-Guidelines/2021-Colonic-Volvulus-CPG.pdf?lang=en-US"

Answer 1031

"hypocalcaemia hypocalcaemia --> tetany hypomagnaesaemia --> QT prolongation HYPERkalaemia acidosis ALL can lead to life threatening arrythmia HF - F- bind directly with calcium and magnesium and disrupts potassium channels --> cell dysfunction and death Tx - ALS. I+V. Cacium Chloride 10% 20mL repeat every 5mins until calcium >1mmol/L Sodium bicarb 100mmol Mag 10mmol https://litfl.com/hydrofluric-acid/ "

Answer 1032

B lines (AKA comet tails) - a lines and z lines both normal - pulse is movement of pleura with cardiac pulsation - also normal A-lines - horizontal lines below the pleura with the same spacing as the distance between the probe and the pleura - indicates air - so it is seen in NORMAL lung and PTX B-lines - (aka comet tails) - artifacts generated by juxtaposition of alveolar air and septal thickening (from fluid or fibrosis) – up to 2 between ribs is normal – 3+ pathological - any disease affecting interstitium - pulmonary oedema (cardiac or ARDS) – B lines occur with interstitial oedema (before alveolar oedema) Atelectasis and consolidation difficult to differentiate on USS – see bronchograms - air bronchograms are white and fluid brochograms are black - atelectasis - no or static air borchograms - large consolidation - appears like liver Z-lines - artifact - looks like b lines but are ill-defined https://www.pocus101.com/lung-ultrasound-made-easy-step-by-step-guide/#Consolidations https://academic.oup.com/bjaed/article/16/2/39/2897763 "

Answer 1033

"a) A group (or AB) - has no plasma antibodies Plasma compatibility - should be combatible with ABO group of recipient to prevent haemolytic reaction. ANY RhD subtype can be given Pt group: A --> compatible with A, AB plasma B --> compatible with B, AB plasma AB --> compatible with AB plasma O --> compatible with all "

Answer 1034

"c) multiple sclerosis - temperature monitoring important. Pyrexia to be avoided and treated aggressively. - demyelinated axons more sensitvie to heat - hypothermia may dlay recovery from anaesthesia OXFORD handbook pg 248"s NB overheating can precipitate myasthenic crisis also

Answer 1035

"c) Transhiatal - laparotomy + neck (L) incision Ivor lewis – laparotomy + R thoracotomy McKeown/ tri-incision - laparotomy + R thoracotomy + L cervica Transdiaphgramatic - thoracolaparotomy - incision from thoracotomy site to umbilicus https://academic.oup.com/bjaed/article/17/2/68/2907833l"

Answer 1036

"normal PCWP 4-12mmHg. need other values. Likely either COPD or PE acute suggests PE "

Answer 1037

"e) pain Aldreate scoring system used for PACU discharge criteria - activity, respiration, circulation, consciousness, colour (O2 sat) (Score >= 9 for discharge A- SpO2 > 92% on RA (2pts) B - deep breath/cough (2pts) C - BP within 20% baseline (2pts) D - conscious and fully alert (2pts) move 4 limbs (2pts) "

Answer 1038

"1st line - labetolol 2nd line - nifedipine 3rd line - methyldopa NICE guideline if severe sBP>160 - than nifedipine QLD guideline says follow local prefernce/protocol https://www.health.qld.gov.au/__data/assets/pdf_file/0034/139948/g-hdp.pdf?back=%2Fsearch%3Fkeywords%3Dpre%2Beclampsia%2C%2C%2Fcondition%2Fhypertensive-emergency%3Fsearch%3Dpre%2Beclampsia%23view%2F728%2F1410"

Answer 1039

doing an epidural on a patient who is labouring with normal pregnancy and no comorbidities 1. Avoid routinely performing preoperative blood investigations, chest X-ray or spirometry prior to surgery, but instead order in response to patient factors, symptoms and signs, disease, or planned surgery. 2. Avoid ordering cardiac stress testing for asymptomatic patients prior to undergoing low to intermediate risk non-cardiac surgery. 3. Avoid administering packed red blood cells (blood transfusion) to a young healthy patient with a haemoglobin of ≥70g/L who does not have on-going blood loss, unless the patient is symptomatic or hemodynamically unstable. 4. Avoid initiating anaesthesia for patients with limited life expectancy, at high risk of death or severely impaired functional recovery, without discussing expected outcomes and goals of care. 5. Avoid initiating anaesthesia for patients with significant co-morbidities without adequate, timely preoperative assessment and postoperative facilities to meet their needs. 6. Avoid routine prescription of SR opioids for acute pain unless demonstrated need, close follow up & cessation plan. https://www.choosingwisely.org.au/recommendations/anzca

Answer 1040

NSTEMI MINS includes myocardial infarction and ischemic myocardial injury that do not fulfill the Universal Definition of Myocardial Infarction (myocardial injury with a rise or fall of cTn above the 99th percentile of the upper reference limit and at least 1 of the following: ischemic symptoms, new ischemic electrocardiographic changes, development of new pathological Q waves on ECG, imaging evidence of myocardial ischemia, or angiographic or autopsy evidence of coronary thrombus). https://www.ahajournals.org/doi/10.1161/CIR.0000000000001024 This history meets the diagnosis of type 1 MI and given there are no ST changes is a NSTEMI. https://www.ahajournals.org/doi/10.1161/CIR.0000000000000617 If the patient had a supply/demand mismatch it would be a type 2 MI and be a type 2 NSTEMI

Answer 1041

"d) 54weeks PMA well children ASA 1 or 2 Term infants >46weeks PMA (so 6 weeks old) Ex Preterm infants >54weeks PMA (they are more at risk of post-op apnoea) When discharged should travel home by car with 2 adults (1 to drive and 1 to watch the child) https://www.anzca.edu.au/getattachment/568bad2d-7517-4eea-9c5d-cb7aa1c60c01/PG29(A)-Guideline-for-the-provision-of-anaesthesia-care-to-children-(PS29)"

Answer 1042

who bloody knows recent Meta analysis shows that delerium may be reduced https://journals.plos.org/plosone/article?id=10.1371%2Fjournal.pone.0306308#abstract0 recent systematic review with cochrane 2022: no effect on mortality or LOS, might stop unplanned hospital readmission https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD012705.pub2/full from 2021: probably reduces LOS and mortality https://www.bjaed.org/article/S2058-5349(21)00034-2/fulltext cochrane review from 2018: no evidence of mortality benefit, might influence LOS https://www.cochrane.org/evidence/CD006211_comprehensive-geriatric-assessment-older-adults-admitted-hospital

Answer 1043

"Maple E Pros: low resistance, valveless, low dead space, light weight, compact, easy to transport/clean/sterilise Cons: require 2-3MV to prevent rebreathe, no bag – no tactile feedback or ability to ventilate or provide CPAP, difficult to scavenge, inefficient"

Answer 1044

Bolus 1 IU oxytocin; start oxytocin infusion at 2.5–7.5IU.h1(0.04–0.125 IU.min1) EmLSCS; 3 IU oxytocinover≥30 s; start oxytocininfusion at 7.5–15 IU.h1(0.125–0.25 IU.min1).

Answer 1045

"a) son The medical treatment decision maker is the first person in the list below who is reasonably available, and willing and able to make the decision: 1) a medical treatment decision maker appointed by the patient 2) a guardian appointed by VCAT to make decisions about medical treatment 3)the first person in the list below who is in a close and continuing relationship with the patient: - the patient's spouse or domestic partner - the patient's primary carer (not a paid service provider) - an adult child of the patient - a parent of the patient - an adult sibling. If there are two or more relatives who are first on this list, it is the eldest person. https://www.publicadvocate.vic.gov.au/your-rights/your-healthcare/appointing-a-medical-treatment-decision-maker "

Answer 1046

"Bleomycin - oxygen toxicity -lifelone risk of bleomycin induced lung injury from oxygen - aim O2sats 88-92% if hypoxic - pulmonary fibrosis in lower lobes "

Answer 1047

NSW course - give 4ml/kg for electrical burns "Parkland = 4 x TBSA% x weight = 400 x 30 = 12 000mL 50% in first 8hrs so 6L in 6hrs so 1000mL /hr " https://www.vicburns.org.au/severe-burns/early-management-of-severe-burns/fluid-resuscitation/

Answer 1048

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

Answer 1049

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

Answer 1050

"a) low K diet High K diet, etoh reduction, exercise, low Na diet, smoking cessation https://www.nps.org.au/australian-prescriber/articles/lifestyle-management-of-hypertension:"

Answer 1051

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

Answer 1052

"d) anaemia Hepcidin - peptide hormone produced in liver. degrades transport protein for iron. Hepcidin REDUCES oral absorption of iron and INHIBIT iron release from cellular storage. Decreases when anaemic - want to absorb more iron. Increased in infection and inflammation (hepcidin is an acute phase reactant --> ^ hepcidin --> decreased transport of iron out of cells --> decrease in serum iron), anaemia of chronic disease cancer deficiency in hepcidin production --> iron overload (hereditary haemachromatosis) https://www.ncbi.nlm.nih.gov/books/NBK538257/#:~:text=Hepcidin%20is%20a%20peptide%20hormone,and%20the%20electron%20transport%20chain. "

Answer 1053

bottle A = fluid trap or collection bottle, can be independently emptied and allows accurate record of drainage amount - first tube connecting drain to drainage bottles must be wide to decreased resistance - volume capacity of this tube should exceed ½ of patient’s maximum inspiratory volume (otherwise H2O may enter chest) bottle B = underwater seal drain, maintained at a predetermined level whilst still allowing for drainage of pleural fluid (if bubbling continuously -> bronchopleural fistula) - volume of H2O in bottle B should exceed ½ patient’s maximum inspiratory volume to prevent indrawing of air during inspiration bottle C = manometer or pressure-regulating bottle allows suction to be attached and should bubble continuously - The maximum negative pressure (in cm H2O) generated by suction equals to the distance (in cm) the vent tube is below the water line (this can be adjusted) -The negative pressure generated by the vent tube is independent of the amount of pleural drainage that is collected in the trap bottle - If suction is turned off then tubing must be unplugged -> so air can escape into atmosphere

Answer 1054

age Domains: 1. Cognition 2. General health status 3. Functional independance 4. social support 5. Medication use 6. Nutrition 7. Mood ?interpreted as mental illness in stem? 8. Continence 9. Functional performance Scoring 0-5= Not frail 6-7= Vulnerable 8-9= Mild Frailty 10-11= Moderate Frailty 12-17= Severe Frailty

Answer 1055

"a) supine, trendelenbergy, increased chest wall rgidity all improve ventilation in tetraplegic assume C3-5 injury --> diaphragm and accessory muscles involved --> expiration is difficult --> head down allows passive excursion https://www.bjaed.org/article/S2058-5349(17)30152-X/fulltext"

Answer 1056

b. Thoracodorsal Thoracodorsal nerve (C6-C8) is a branch of the posterior cord of the brachial plexus. Its primary function is motor innervation of the latissimus dorsi muscle. Its blockade is relevant in more extensive breast reconstruction procedures. The Pecs I, Pecs II and Serratus Plane blocks are superficial thoracic wall blocks which through blockade of the 1. Pectoral N. 2. Intercostal N. 3. Thoracodorsal N. 3. Long thoracic N. It can be used to provide analgesia for breast surgery and other procedures/surgery involving the anterior chest wall.

Answer 1057

"a) reduce RR HFNP - reduce RR, increase end expiratory lung volume, PEEP up to 7cmH2) with closed mouth, reduced airway surface dehydration, decrease atelectasis, improve secretion clearance, CO2 washout, reduction in anatomical dead space https://www.bjaed.org/article/S2058-5349(17)30029-X/fulltext"

Answer 1058

D. Cerebral Abscess HBOT Indications: - air or gas embolism - arterial insufficiencies (central retinal artery occlusion, enhancement of healing in wound problems) - Carbon monoxide poisoning - Clostridium myonecrosis (gas gangrene) - Compromised grafts and flaps - Acute traumatic ischaemia - Decompression sickness - Delayed radiation injuries - Sudden sensorineural hearing loss - Intracranial abscess - Necrotising soft tissue infections - Refractory osteomyelitis - Severe Anaemia - Thermal burns Absolute Contraindications to HBOT: - untreated PTx - Premature Infants - Bleomycin - Disulfiram (antabuse) - Cisplatin Relative contraindications: - Pregnancy - Asthma - Thoracic Surgery - Emphysema with CO2 retention - upper respiratory tract infections - History of middle ear surgery or disorder - History of seizures - Fevers - Congenital spherocytosis - Optic neuritis

Answer 1059

" 35 according to new guideline (ANZMOSS 2022) (MBS is recommended for individuals with BMI >35 kg/m2, regardless of presence, absence, or severity of comorbidities and for patients with type 2 diabetes and BMI>30 kg/m2.) https://anzmoss.com.au/ifso-guidelines/ Diabetes Aus guideline 2011 or BMI >35 with co-morbidities secondary to obesity (ie. Poorly controlled diabetes despite lifestyle and optimal medical therapy) BMI 30-35 - can consider bariatric surgery if uncontrolled hyperglycaemia despite optimal medical therapy https://www.diabetesaustralia.com.au/wp-content/uploads/Position-statement-Bariatric-Surgery.pdf "

Answer 1060

a. Tricuspid regurg Regurgitant CV waves: tricuspid regurgitation In tricuspid regurgitation, the backflow of blood out of the right ventricle obliterates the normal x descent. The c wave becomes accentuated and fuses with the v wave, as both are the results of right ventricular contraction (and the v wave peak pressure is often the same as the right ventricular peak systolic pressure). the reality is that they usually fuse completely to produce huge mutant waves, as seen here: -------------------------------------- "cardiac tamponade - sawtooth W or M pattern with all pressures raised (can't pump out blood so all pressures elevated) - pulsus parodoxus (>10mmHg fall in sBP with inspiration) - tachycardia - low QRS voltage trace - electrical alternans (alternating high and low QRS complexes) - associated with large pericardial effusion to the extent that the pericardial effusion is associated with tamponade https://derangedphysiology.com/main/required-reading/cardiac-arrest-and-resuscitation/Chapter%20221/cardiac-tamponade Other abnormal CVP trace: AF - loss of a waves (a wave = atrial contraction) Retrograde conduction of ventricular deplarisation (VT, junctional rhythm, ventricular pacing)/ Asynchronous atrial activity (reversal of atrial and ventricular pacing wires, complete heart block) - cannon a waves (fusion of a and c waves) - due to atrial contraction ocurring at the same time as ventricular contraction (so atrium contracting against closed TV with force of this contraction being reflected off the valve --> cannon a wave) TR - fused c and v waves - c wave due to tricuspid cusp protruding into RA. with regurg - loss of x decent due to backflow of blood Tricuspid stenosis / PS / Pulmonary HTN or reduced RV compliance (pericardial disease) - prominent a wave (contraction) Pericardial constriction - bifid CVP waveform (steep and aburpt x and y descent), raised CVP. -- different from cardiac tamponade because y-descent usually prolonged https://derangedphysiology.com/main/cicm-primary-exam/required-reading/cardiovascular-system/Chapter%20784/abnormal-central-venous-pressure-waveform-patterns "

Answer 1061

e. Peripheral RICC line, 8.5 Fr RICC > 14g cannula > MLC > Swan sheath > 14G cannula with large volume extension > 16g cannula > 18g cannula > 14g cannula with bung > central line so if want quick infusion, don't use central line and don't put on bung"

Answer 1062

b) conscious state No mention of BP or HR in ANZCA OIVI monitoring document In many published reports of patient deaths resulting from OIVI, undue reliance has been placed on respiratory rate as a unidimensional measure of OIVI, either without formal assessment of patient sedation, or without recognising the significance of excessive sedation Respiratory rate and oxygen saturation levels are not direct measures of adequacy of ventilation. Sedation scores should be assessed repeatedly at intervals that are appropriate to the route of opioid administration Continuous measurement of a patient’s carbon dioxide concentrations is more likely to identify OIVI than continuous pulse oximetry

Answer 1063

"c) right hypoglossal Deviation to side of LMN lesion as that side has decreased power. Tongue Motor: Vagus (CN10) does palatoglossus; Hypoglossal (CN12) dose all other muscle. Tongue Sensory: Glossopharyngeal (CN9) does taste/sensory posterior 1/3; Lingual (CN5) sensory ant. 2/3; Chordaie tympani (CN7) taste anterior 2/3."

Answer 1064

b. 18ml 3mg/kg max dose as per RCH guidelines 3mg x 30kg = 90mg 90mg/5mg/ml = 18ml or 0.6ml/kg of 0.5% Lignocaine 0.6ml x 30kg = 18ml

Answer 1065

a) hypoxaemia After LA administration, any abnormal cardiovascular or neurological symptoms and signs, including isolated cardiac arrest, should raise suspicion of LAST Presenting features of LAST vary widely. Cardiovascular collapse may occur without preceding neurological changes. Clinical features of LAST: CNS - 2 stage process of excitatory phase followed by a depressive phase - early signs: 1. perioral tingling 2. tinnitus 3. slurred speech 4. lightheadedness 5. tremor 6. change in mental state: confusion and agitation - excitatory phase culminates in generalised convulsions -Depressive phase: 1. Coma 2. Respiratory depression CVS - 3 phases: - initial phase: Htn and tachycardia - intermediate phase: myocardial depression and hypotension - terminal phase: peripheral vasodialtion severe hypotension arrhythmias: 1. sinus bradycardia 2. conduction blocks 3. VT 4. Asystole

Answer 1066

a. Diclofenac LIthium perioperative concerns: - Prolongation of NMB - Reduction in anaesthetic agent requirement - Avoid NSAIDs - No withdrawl symptoms - Discontinue 24hrs before surgery BJA: perioperative advice for psychotropic drugs

Answer 1067

b. 0.5% Chlorhexidine/ETOH For skin preparation, 0.5 per cent chlorhexidine in alcohol, where available, is recommended for neuraxial techniques although it should be noted that very small quantities of neuraxial chlorhexidine have been implicated in cases of severe neurotoxicity

Answer 1068

f)Cricothyroid Nerve supply of larynx: 1. Superior laryngeal nerve: - Cricothyroid muscle - sensory supply to the interior of larynx down to vocal cords 2. internal laryngeal nerve - 3. Recurrent laryngeal nervs - motor supply to the intrinsic muscles of the larynx apart from cricothyroid - sensory supply to laryngeal mucosa inferior to the cords Intrinsic muscles of the larynx a) Posterior Cricoarytenoid - abducts the cords, opens the glottis - only muscle to open glottis b) Lateral Cricoarytenoid - adducts the cords and closes the glottis c) Interarytenoid - only unpaired muscle - closes the glottis - continues upwards to form the aryepiglottic muscle which acts as a weak sphincter d) Thyroarytenoid - relaxes vocal cords e) Vocalis -adjusts tension in the cords f) Cricothyroid - only intrinsic muscle that lies outside the cartilagenous framework - only tensor of the vocal cords actions of intrinsic laryngeal muscles 1. Abductor of the cords: posterior cricoarytenoids 2. Adductors of the cords: lateral cricoarytenoids, interarytenoids 3. Sphincter to the vestibule: aryepiglottics, thyroepiglotics 4. Tension regulators of the cords: Cricothyroids (tensors), Thyroarytenoids (relaxors), Vocales (fine adjustment)

Answer 1069

"b. physical dependance - Presence of withdrawal symptoms. Tolerance - predictable physiological decrease in effect of drug over time (more drug to achieve same effect Abuse - intentional use of opioid for non medical purose, such as euphoria or altering one's state of consciousness Addiction - pattern of continued use with experience of or demonstrated potential for harm. Pain book page 806"

Answer 1070

1st a) atorvastatin 2nd c) Digoxin All of the DOACs are avid substrates for the excretory P-gp system of the gastrointestinal epithelial cells, and drugs that inhibit or induce the P-gp system may affect plasma DOAC levels Dabigatran and edoxaban are substrates for P-glycoprotein (P-gp) Apixaban and rivaroxaban are metabolised by cytochrome P450 enzyme CYP3A4 and are substrates for P-gp There is study evidence that among patients taking DOACs for non-valvular atrial fibrillation, concurrent use of amiodarone, fluconazole, rifampicin, and phenytoin compared with the use of DOACs alone, was associated with increased risk of major bleeding It is unlikely that clinically significant interactions occur between dabigatran and other drugs that are merely substrates for P-gp-mediated excretion. When dabigatran was coadministered with digoxin neither digoxin nor dabigatran plasma levels were significantly altered Rivaroxaban and apixaban are metabolised to an extent of 40–50 % in the liver to variable degrees by CYP3A4 and may interact with drugs that inhibit this enzyme. The metabolism of Apixaban and rivaroxaban can be decreased when combined with Atorvastatin which is also metabolised by CYP3A4

Answer 1071

Chronic obstructive pulmonary disease (COPD) is the most common cause of cor pulmonale leads to an increase in RV afterload secondary to changes in pulmonary vascular structure and mechanics, and lung hyperinflation. Patients with COPD who subsequently develop RV dysfunction have an increased risk of admission to hospital and mortality

Answer 1072

b) atropine Priority is to correct reversible caues of arrest followed by immediate chest re-opening if these measures fail - stop sedative infusions if on any - VF coomon 25-50% of cases - bleeding and tampoande also common (non shockable rhythm usually) CALS (cardiac ALS) 1) Ax rhythm 2) Start BLS 3) emergency re-sternotomy (should happen within 5mins to facilitate interncal cardiac massage or defib at 20J) - VF/VT - DC shock - 3 attempts 150J --> amiodarone 300mg --> continue CPR with single DC shock every 2mins until resternotomy - asystole or severe brady - PACE if wires available (DDD 80bpm, max stimulation threshold) --> external pacing if no wires --> CPR until resternotomy - PEA - if paced, turn off pacing to identify underlying rhythm ---> if VF follow VF path otherwise contiue CPR until resternotomy * ATROPINE not recommended ** Adrenaline to be given by senior clinician in small doses (apparently this is going to be someone like us eventually) https://www.bjaed.org/action/showPdf?pii=S2058-5349%2817%2930182-8

Answer 1073

d) pregnancy A third heart sound reflects rapid left ventricular distention along with an increased atrioventricular flow Heard in Congestive heart failure Associated with Dilated Cardiomyopathy with dilated ventricles Less commonly valvular regurgitation and left to right shunts May be normal physiological finding in patients less than 40yrs old

Answer 1074

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

Answer 1075

a. Cholecystitis Example and explanation taken from RACGP: The raised AlP relative to Alt suggests cholestasis and the high GGt confirms liver origin. The mild hyperbilirubinaemia confirms the clinical impression of jaundice. Biliary disease is highly likely with gallstones the most likely differential diagnosis. however, this clinical picture may also occur in drug reactions or infiltrative conditions. After a careful history, abdominal ultrasound is the most appropriate next investigation. ------------------------------------------------------------- Not acute hep C - not significant rise, Not Alcoholic Liver disease - AST not >ALT. Paracetamol OD should mainly affect ALT and coags ALP > 3 x ALT suggest cholestasis picture ^ALT and ^AST suggest hepatocellular injury - >10x upper limit suggest acute severe insult - hepatitis or hypoxia - mildly elevate suggest infection, alcohol, fatty liver or medication AST high - S = shit faced cholestatic picture = ^ GGT and ^ ALP Elevated AST: ALT = 1 --> associated with ischaemia (CCF, ischaemic necrosis, hepatitis) AST: ALT >2.5 --> alcoholic hepatitis, AST: ALT <1 --> high rise in ALT specific for hepatocellular damage - paracetamol OD with hepatocellular necrosis, viral hipatitis, ischaemic necrosis, toxic hepatitis ^ALP - primarily associated with cholestasis and malignant hepatic inflitration (marker of rapid bone turnover and extensive bone mets) ^GGT - sensitive to alcohol ingetsion, marker of hepatocellular damage but non-specific, sharpest rise associated with biliary and hepatic obstruction https://litfl.com/liver-function-tests/ https://www.racgp.org.au/getattachment/36d1c5e0-9c1d-43fc-a8a0-b323e3ed8fbe/Liver-function-tests.aspx"

Answer 1076

"a) no difference VA vs TIVA for cardiac surgery NEJM 2019 - multicentre single blinded RCT - specific for elective CABG https://sci-hub.hkvisa.net/10.1056/NEJMoa1816476"

Answer 1077

d) myasthenia gravis In contrast to other neuromuscular disorders, succinylcholine may be used in myasthenia gravis. The required dose may need to be increased by up to two-fold, as those with the disease show a relative resistance to the drug. Sux is not recommended in patients with neuromuscular disease due to: 1. presence of extrajunctional receptors and risk of hyperkalaemia and rhabodmyolysis 2. fasiculations causing temperomandibular muscle spasm preventing intubation MS - if significant decreased mobility --> hyperK Neuromuscular disease (dystrophies) - increased sensitivity to NDMB. ethonium / volatiles or cholinesterase inhibitors can induce mytonia - can induce MH or anaesthsia induced rhabdomyoliysis --> hyperkalaemia --> cardiac arrest GBS - also contraindicated as can cause hyperK HypoPP - sux / anticholinesterases and K causes severe muscle stiffnesss "

Answer 1078

b) Thumb abduction (flexor pollicis brevis) D. Paraesthesia/sensory loss over medial forearm (medial antebrachial cutaneous) Severing Ulnar nerve alone results in numbness of the 4th (ring) and 5th (little) fingers alone C8 and T1 supply the medial antebrachial cutaneous nerve Muscles weak in C8-T1 radiculopathy but intact in ulnar neuropathy 1. flexor pollicis brevis 2. abductor pollicis brevis 3. opponens pollicis 4. lateral lumbricals AbOF the Law may be useful—the abductor (Ab) and flexor (F) pollicis brevis, opponens pollicis (O), and lateral lumbricals (Law) are “above the law” that intrinsic hand muscles are ulnar-innervated

Answer 1079

PG 28 4.2.2.2 Laryngoscopes Reusable laryngoscope blades are considered semi-critical medical devices owing to their contact with the mucous membranes of the oropharynx and require sterilisation or high-level disinfection between uses. Reusable laryngoscope handles are non-critical devices and should be cleaned then undergo low-level disinfection, as a minimum, following use.

Answer 1080

a) Brachiocephalic artery Major vessels, most commonly the brachiocephalic artery, traverse the anterior tracheal wall in up to 53% patients at the suprasternal notch

Answer 1081

"D Type 1: -Quantitative defect of VWF Type 2: -Qualitative Defect of VWF -Type 2 subclassification depending on plt binding function, F8 binding capcacity, number of high molecular weight VWF multimers Type 3: - complete absence of VWF Treatment: - do not need blood components to control haemorrhage -F8 plasma concentration >100 for major surgery and >50 for minor surgery -DDAVP approved for use in Type 1, no use in type 3, discuss its use with haematology in type 2 due to its variable effect -DDAVP given atleast 90mins before operation -TXA may be useful -VWF/F8 concentrates indicated in severe cases, type 3 and qualitiative defects in VWF -Plt infusions should be considered in persistent bleeding -Cryo has an unpredictable effect, only used if other treatments have failed

Answer 1082

a) LUSCS Rates of VAE by surgical procedure: LUSCS: 10%-97% Neurosurgery: Posterior Fossa: 76% Cervical Laminectomy: 7-25% Lateral/Prone Neurosurgery: 15-25 % Total Hip Replacement: 30% Lap Cholecystectomy: 69%

Answer 1083

Hunsaker Mon-jet ventilation tube for microlarnygeal surgery Description: -Laser-safe -fluoroplastic -self-centring catheter Uses: -subglottic ventilation during microlaryngeal surgery Components: - proximal end for attaching to jet insufflation system -proximal end allows passage of stylet to aid insertion -Side port at proximal end for monitopring airway pressure and ETCO2 -Outer diameter 4.3mm for maintaining good surgical access -Green basket to keep the centre port at its tip away from tracheal mucosa and avoiding potential damage from jet ventilation

Answer 1084

EXCEPT C) RV dilation Echo findings in Aortic Dissection: 1. Intimal flap 2. Type A dissection: - Aortic regurgitation -Acute dilation of aortic root -Aortic leaflet prolapse -Dissection flap prolapse -Pre-existing disease -Pericardial Effusion/Tamponade -RWMA 3. Colour flow doppler -identifies true and false lumen -aortic branch occlusion/dissection RWMAs with possible MI, AR due to involvement of the root pericardial effusion/tamponade severe proximal aortic dilatation intimal flap https://academic.oup.com/ehjcimaging/article/10/1/i31/2465433#41562550"

Answer 1085

A. 100mg QID 42mg IV Morphine = 126mg Oral Morphine 126/8= 15.75 15.75 x 25 = 393.75 (*400mg/day Tapentadol) Oral Tapentadol 25mg = 8mg Oral Morphine Oral Oxycodone 5mg = 8mg Oral Morphine Oral Tramadol 25mg = Oral Morphine 5mg Oral Hydromorphone 4mg = Oral Morphine 20mg S/L Buprenorphine 200mcg = 8mg Oral Morphine IV Oxycodone 5mg = Oral Morphine 15mg IV Morphine 5mg = Oral Morphine 15mg IV Hydromorphone 1mg = Oral Morphine 15mg

Answer 1086

B. 29 PaCO2= 1.5 x 14 + 8 PaCO2= 21 + 8 PaCO2= 29 Winter’s formula: expected PaCO2 = [1.5 x (serum HCO3)] + [8±2] if PaCO2 lower, there is a concomitant primary respiratory alkalosis if PaCO2 higher, there is a concomitant primary respiratory acidosis

Answer 1087

RLL 1.Superior (apical bronchus 6) -> most common site for foreign body or secretions to collect if patient laying flat in bed A PA LM Seed Makes Another Little Palm (R Side) ASIA ALPS (L side) "

Answer 1088

d. perinephric cant see the whole kidney https://www.msdmanuals.com/professional/critical-care-medicine/how-to-do-other-emergency-medicine-procedures/how-to-do-e-fast-examination#Step-by-Step-Description-of-Procedure_v52127123

Answer 1089

linear probe 8-12Hz https://www.nysora.com/techniques/upper-extremity/ultrasound-guided-wrist-block/

Answer 1090

metoclopramide https://www.researchgate.net/profile/Melvin-Leow/publication/221935481_Accidental_Provocation_of_Pheochromocytoma_-_The_Forgotten_Hazard_of_Metoclopramide/links/0fcfd508ada5acf5e7000000/Accidental-Provocation-of-Pheochromocytoma-The-Forgotten-Hazard-of-Metoclopramide.pdf

Answer 1091

4mg/kg https://resources.wfsahq.org/wp-content/uploads/332_english.pdf

Answer 1092

a. female or d. opioid naivity depends what you reaaaadddd ANZCA document The PRODIGY (Prediction of Opioid-induced respiratory Depression in patients monitored by capnoGraphY) trial studied the occurrence of OIRD in postoperative patients on potent opioids. A risk prediction tool was developed that showed that five independent patient-related variables were associated with a high likelihood of OIRD: **age ≥60 yrs, male sex, opioid naivety, sleep disorders and the presence of chronic heart failure.** https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/10.1111/anae.15030

Answer 1093

d. opioid naivity but mixed answers online I would probably go with anzcas answer https://www.anzca.edu.au/getContentAsset/136f5a83-d1d0-4f34-be72-87b62b721d14/80feb437-d24d-46b8-a858-4a2a28b9b970/PS41(G)-Acute-pain-2023.pdf?language=en ANZCA lists female as RF. No mention of opioid naivity in there. pub 2023 The PRODIGY (Prediction of Opioid-induced respiratory Depression in patients monitored by capnoGraphY) trial studied the occurrence of OIRD in postoperative patients on potent opioids. A risk prediction tool was developed that showed that five independent patient-related variables were associated with a high likelihood of OIRD: **age ≥60 yrs, male sex, opioid naivety, sleep disorders and the presence of chronic heart failure.** Pub 2020 https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/10.1111/anae.15030

Answer 1094

a) clinical diagnosis or confirmed on autopsy

Answer 1095

b) ibuprofen "It is estimated that NSAIDs may cause clinical relapse in ∼20% of patients with quiescent inflammatory bowel disease (IBD).32 Coxibs do not appear to be associated with relapse of IBD, but caution should still be exercised." 2023 BJA NSAIDs

Answer 1096

b) low tv/rate https://litfl.com/bronchopleural-fistula/ strategy: controlled, assist control, intermittent mandatory lowest possible TV lowest possible PEEP short inspiratory time encourage spontaneous breathing

Answer 1097

e. Infection and Thrombosis. https://www.ncbi.nlm.nih.gov/books/NBK557798/

Answer 1098

c. 3 https://www.asahq.org/standards-and-practice-parameters/statement-on-asa-physical-status-classification-system

Answer 1099

d. connected to uninterrupted power supply Electrical circuits connected to the UPS are denoted by a dark blue power socket, and are reserved for essential equipment without adequate battery backup. 2015 BJA environmental emergencies

Answer 1100

"A) overtreatment and subclinical hyperthyroidism - Overtreatment: ↓TSH (-ve feedback), ↑ T4/T3 - Subclinical hypothyroidism: ↑TSH, normal T4/3 (sufficient thyroid hormones, but not enough to keep TSH levels normal) - Sick euthyroid syndrome, aka non-thyroidal illness syndrome: low T3 (MC observed change), normal T4, low-normal TSH (low if ↓production) - Fanconi anaemia: hypothyroidism (↑TSH), ↓T4 - Previous hypophyseal resection (i.e. pituitary): hypopituitarism -> ↓/normal TSH -> ↓T3/T4 (i.e. secondary hypothyroidism)"Subclinical Hyperthyroidism

Answer 1101

Methaemoglobinaemia https://www.tga.gov.au/news/safety-updates/risk-overdose-infants-when-using-prilocainelidocaine-cream-emla-and-generics

Answer 1102

c. 30mL The manufacturers recommend inflating the laryngeal mask cuff until the intracuff pressure reaches 60 cmH2O or to inflate with the volume of air not exceeding the maximum recommended volume (size 3, 20 ml; size 4, 30 ml) if a manometer is not available https://pmc.ncbi.nlm.nih.gov/articles/PMC7206679/#:~:text=The%20manufacturers%20recommend%20inflating%20the,available%20%5B7%E2%80%9311%5D.

Answer 1103

Papillary Oedema post op ischaemic optic neuropathy - most common cause of POVL after nonocular surgery - ^risk with cardiac, spine, orthopaedic, steep trendelenberg positions - anterior ION - more common with cardiac - posterior ION - more common with prone procedures, steep trendelenberg, cardiac - presents with painless b/l vision loss - risk factors for POVL with spine surgery - male, ^BMI, wilson frame, long duration, ^ blood loss - PION more common however only AION has fundoscopic changes -- AION - fundoscopy - swollen disc - can be uni or bilateral -- AION onset usually immediate after awakening but can also have onset a day or so afterwards - sudden unilateral or bilateral, progressive vision loss Central retinal artery occlusion - most common retinal cause of POVL - usually unilateraly and immediately after awakening from anaesthesia - fundoscopy - ischaemic retina + cherry red spot at macula https://www.uptodate.com/contents/postoperative-visual-loss-after-anesthesia-for-nonocular-surgery#H437018973 "

Answer 1104

c) Injection of epidural blood patch <48hrs after accidental dural puncture Risk factors identified for failure include a history of migraine headache, accidental dural puncture at higher lumbar levels, and injection of epidural blood patch <48 h after accidental dural puncture. BJA 2022 failed epidural

Answer 1105

Inferior Alveolar

Answer 1106

c. 6yo GCS can be used >5yrs according to this website https://www.glasgowcomascale.org/faq/#:~:text=The%20scale%20can%20be%20applied,responses%20were%20modified%20as%20below. RCH say that you can use the GCS >4 and pGCS <4

Answer 1107

a) Pneumoperitoneum on CXR Indications for laparotomy as per RCH - Haemodynamic instability - despite resuscitation. - Transfusion requirements of more than 40 ml / kg during the period of acute resuscitation - All patients with free intraperitoneal air require a laparotomy. (20ml/kg is an MTP) Activation criteria for code crimson : Persistent haemodynamic instability: * following blunt or penetrating trauma * despite standard trauma care * secondary to ongoing haemorrhage * unresponsive to intravenous fluids and/or blood transfusion. Examples of injuries: * Abdominal trauma with **grossly positive E-FAST** * Uncontrolled maxillo-facial haemorrhage * Severe pelvic disruption * Massive haemothorax * Traumatic amputation * Penetrating trauma to chest or abdomen * * Pericardial tamponade on E-FAST * Penetrating neck wounds with hard signs of vascular injury https://aci.health.nsw.gov.au/__data/assets/pdf_file/0003/382917/ACI-ITIM-Trauma-code-crimson-pathway.pdf https://www.starship.org.nz/guidelines/code-crimson/

Answer 1108

Rusch Larygoflex Reinforced Laryngectomy tube https://www.teleflexarcatalog.com/anesthesia-respiratory/airway/product/121181080-rusch-laryngoflex-laryngectomy-tube

Answer 1109

MB can precipitate hemolysis in individuals with G6PD deficiency

Answer 1110

Aortic regurg Significant holodiastolic reversal in abdominal aorta is also a specific sign of severe AR https://www.bsecho.org/common/Uploaded%20files/Education/Protocols%20and%20guidelines/Assessment%20of%20aortic%20regurgitation.pdf

Answer 1111

a. dexmed https://www.sciencedirect.com/science/article/pii/S1743919115003684 Activates: thiopental, etomidate, ketamine, sevo, fentanyls Suppresses: benzos, N2O Variable: propofol may suppress or inhibit, morphine/hydromorphone may affect at high doses Dexmed: no evidence of suppression or activation

Answer 1112

13% Pulse pressure (difference between systolic and diastolic pressure) is directly proportional to LV stroke volume and inversely related to arterial compliance. The respiratory changes seen in LV stroke volume determine changes in the peripheral pulse pressure during the respiratory cycle Pulse pressure variation (PPV) can be expressed as a percentage using the equation PPV (%) = (PPmax − PPmin)/PPmean. Measurement of PPV can be used to predict preload non-responders in those with a PPV <13%. Also, high baseline PPV values correlate well with subsequent increase in cardiac index. In addition, the decrease in PPV after fluid therapy correlates well with the resulting increase in cardiac index. As PPV is also subject to arterial compliance, in theory patients with reduced arterial compliance (e.g. elderly patients with peripheral vascular disease), there may be a big change in pulse pressure for only a small change in LV stroke volume. BJA

Answer 1113

Same as aortic stenosis: crescendo decrescendo

Answer 1114

a. reduced splanchnic blood flow Octreotide acts on splanchnic blood flow by causing vasoconstriction via inhibition of nitric oxide synthesis and inhibition of glucagon release, both of which cause splanchnic vasodilation The resulting fall in splanchnic blood flow is felt to be responsible for reducing portal pressures and thereby reducing variceal bleeding as a bridge to more definitive therapy.

Answer 1115

c. 30 Start at peak inspiratory pressure (PIP) of 30 cm H2O for a term neonate (20-25 cm H2O preterm neonate) and positive end expiratory pressure (PEEP) of 5 cm H2O at 40-60 breaths/minute https://www.seslhd.health.nsw.gov.au/sites/default/files/documents/Neoresusdelivery20.pdf

Answer 1116

"b) thumb abduction Ulnar nerve orginate from C8/T1 Median nerve originate C5-T1 Ulnar nerve innervates: (essentially all of pinky and also adduct and flex thumb) hand muscles: ADDuctor pollicis, deep head of flexor pollics, Opponens digiti minimi and abductor digiti minii and flexor digitiminimi, 3rd and 4th lumbricals Median nerve innervates: (all of thumb action except for adduction) hand muscles: 1st and 2nd lumbricals, Oppones pollicis, abductor pollicis, flexor pollicis brevis Radial nerve - extensors of hand "

Answer 1117

Unstable angina

Answer 1118

Upper GI bleed "Glasgow-Blatchford Bleeding Score (GBS) Stratifies upper GI bleeding patients who are ""low-risk"" and candidates for outpatient management."

Answer 1119

2Kgs Neonate/infant/small paed/larg paed/ small-med-large adult 1: 2-5kg 1.5: 5-12kg 2: 10-25kg 2.5: 25-35kg 3: 30-60kg 4: 50-90kg 5: 90+kg "

Answer 1120

https://radiopaedia.org/cases/implantable-loop-recorder-device was photo

Answer 1121

Coronary Sinus + RA and RV leads + https://www.bjaed.org/article/S2058-5349%2817%2930025-2/fulltext similar to fig

Answer 1122

b) Comparison between 2 or more means

Answer 1123

Mechanism, Injury, Signs, Treatment - investigations/symptoms in there as decoys

Answer 1124

2018 BJA emergence delirium lists MALE as RF. I think N2O is answer for what is NOT a risk factor. Child "temperament" is risk factor so ASD likely contributes. occurs in 9-18% paeds - eye and ENT surgery at higher risk - higher incidence in preschool 2-5 years old (male), anxious patients, negative behaviour on induction TIVA better than Sevo in decreasing PoD https://academic.oup.com/bja/article/118/3/335/2999642 2017 review" "A slow washout with nitrous oxide after a sevoflurane anaesthetic has also been shown to decrease EA"

Answer 1125

30min as per PS03

Answer 1126

d) reduced morphine requirements Vitamin C reduces postoperative opioid requirements (N) (Level I [PRISMA] and postoperative pain compared to placebo (N) (Level IV SR [PRISMA]). APMSE

Answer 1127

a) probably sural

Answer 1128

a) anterior Anterior compartment - dorsiflexion of foot and ankle Lateral compartment.- plantarflexion and eversion of foot Deep posterior compartment - plantarflexion and inversion of foot Superficial posterior compartment - plantarflexion https://www.orthobullets.com/trauma/1001/leg-compartment-syndrome

Answer 1129

Confounder

Answer 1130

Perindopril isolated hypotension is rare - most likely due to excess bradykinin, especially when bradykinin metabolism is inhibited (eg. In patients on ACEi) https://www.lifeblood.com.au/health-professionals/clinical-practice/adverse-events/hypotension "

Answer 1131

4-10 days DCI - The occurrence of focal neurological impairment … or a decrease of at least 2 points on the Glasgow Coma Scale … This should last for at least 1 hour, is not apparent immediately after aneurysm occlusion, and cannot be attributed to other causes by means of clinical assessment, CT or MRI scanning of the brain, and appropriate laboratory studies. DCI affects approximately 30% of patients who survive the initial hemorrhage. Prophylactic treatment, such as nimodipine, is typically started at admission and continued for 21 days to cover this high-risk period. cause unknown but vasospasm contributes to

Answer 1132

https://www.ahajournals.org/doi/10.1161/strokeaha.110.602888 Coil within 24hrs Treatment of ruptured aneurysms within 24 hours is associated with improved clinical outcomes compared with treatment at >24 hours. The benefit is more pronounced for coiling than clipping.

Answer 1133

e. Tetralogy of fallot Occurs with prada willi, DMD, DS https://pmc.ncbi.nlm.nih.gov/articles/PMC4454627/ and with Spina Bifida https://thorax.bmj.com/content/71/Suppl_3/A184.1

Answer 1134

Plasma https://esmed.org/citrate-toxicity-and-hypocalcemia-in-massive-transfusion/#:~:text=Table_title:%20Citrate%20content%20in%20blood%20products%20Table_content:,%7C%20Estimated%20citrate%20content%20(mmol):%201.49%20%7C Highest content Whole blood > FFP whole blood > Platelets > FFP apapharesis > pRBC apapharesis >cryo > pRBC (whole blood) FFP Plasma products and Platelets have higher Citrate than PRBC (as PRBC recons. In SAGM) When donated, whole blood has CPD added (26g/L citrate), plt apheresis has ACD added (22g/L citrate) and Plasma apheresis has straight citrate at 40g/L added Other numbers have found FFP - 20mmol/L Platelets - 15-20mmol/L Plasma - 13-15mmol/L Red cells 5-7.5mm/L Cryo 13-15mmol/L Fib conc - nil

Answer 1135

For patients requiring immediate surgery (e.g. from major trauma admission to the Emergency Department), any anaesthetic workstation can be prepared within 3 min with the use of ACFs. https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/10.1111/anae.14407

Answer 1136

b. hypocalcaemia injured muscle --> rhabdo. Rhabdomyolysis can lead to metabolic acidosis, hyperkalemia, hypocalcemia, and disseminated intravascular coagulation. Myoglobin-induced renal failure can be prevented with intravascular fluid expansion, alkalinization of the urine by intravenous administration of bicarbonate, and osmotic diuresis. (ATLS) Hypocalcaemia. https://www.acep.org/imports/clinical-and-practice-management/resources/ems-and-disaster-preparedness/disaster-preparedness-grant-projects/cdc---blast-injury/cdc-blast-injury-fact-sheets/crush-injury-and-crush-syndrome

Answer 1137

b) methylene blue

Answer 1138

d. 12hr https://rapm.bmj.com/content/early/2025/10/16/rapm-2024-105766

Answer 1139

Dabigatran (50-60% removed in 4hour run). Others have very high protein binding and difficult to dialyse off.

Answer 1140

https://litfl.com/wolff-parkinson-white-syndrome-ccc/ Likely electricity Acute unstable -> synchronised DC shock stable -> anti-arrhythmics (prolongation of accessory pathway: sotalol, amiodarone, flecanide, procanamide) drugs that shorten refractory period are contraindicated (digoxin) drugs that increase ventricular rate avoid (verapamil and lignocaine) drugs that have no effect on refractory period of accessory pathway are useless (beta-blockers)

Answer 1141

ventricular arrhythmias according to this meta-analysis https://pmc.ncbi.nlm.nih.gov/articles/PMC8990315/#:~:text=A%20total%20of%203%2C396%20studies,that%20still%20needs%20further%20confirmation.

Answer 1142

c) reduced time to motor/sensory onset USS: reduced the proportion of participants who required additional analgesia or anaesthesia when compared with electrical stimulation alone reduced the proportion of patients experiencing pain during needle manipulation reduced the time to the onset of sensory block reduced the proportion of patients with accidental vascular puncture https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/10.1111/anae.13098

Answer 1143

c. septic shock Conditions where PPV is less reliable: False +ve - spont breathing - cardiac arrhythmias - increased intra abdominal pressure - RV dysfunction False -ve - Low vT - low lung compliance - very high resp rate https://www.atsjournals.org/doi/10.1164/rccm.201801-0088CI

Answer 1144

d. Withdraw ETT 1-2cm "Anesthesiology 2019 (https://pubs.asahq.org/anesthesiology/article/131/3/666/17826/Lung-Pulse-with-PneumothoraxExamine-the-Thoracic): The lung pulse, is the rhythmic movement of the pleura in synchrony with the cardiac rhythm. Its presence indicates that the parietal and visceral pleura oppose one another; its presence rules out a pneumothorax." Ddx no lung sliding = PTX (-ve if lung pulse present), atelectasis, prior pneumonectomy, one-lung ventilation on opposite side (intentional or unintentional primary bronchus intubation), large consolidation.

Answer 1145

a. Hb IO samples show a good correlation with venous samples for: Hemoglobin / haematocrit Chloride Glucose Urea Creatinine Albumin IO samples poorly correlate with venous samples for: WBCs Platelets Serum CO2 Sodium Potassium Calcium

Answer 1146

Carbamazepine APMSE: Topiramate is as effective as carbamazepine at 1 mth after treatment commencement and slightly more effective at the 2 mth endpoint in trigeminal neuralgia (RR 1.20; 95%CI 1.04 to 1.39) (Wang 2011 Level I, 6 RCTs, n=354). All included RCTs were of poor methodological quality; this is also an issue for carbamazepine trials, which show probable effectiveness over placebo (Wiffen 2014 Level I [Cochrane], 10 RCTs, n=480). Duloxetine has been shown to have an effect in trigeminal neuralgia https://www.bjanaesthesia.org/article/S0007-0912(19)30430-1/pdf

Answer 1147

2:1 block? (cant say if its mobitz 1 or 2 in 2:1 block...)

Answer 1148

Multisite pacing

Answer 1149

b) cardioversion

Answer 1150

Amiodarone

Answer 1151

defibrillate as per ACLS you do also switch them to BMV to confirm can ventilate manually but would not delay defibrillation with 3 stacked shocks firs

Answer 1152

a) IV insulin/dextrose Calcium (if ecg changes) - onset <3mins, duration - 30mins Insulin/dextrose - onset 15mins, peak 60mins, duration 2-3hrs Renal association Salbutamol - onset 30 mins, peak 120mins duration 2-3hrs Bicarb (in acidosis) - onset 30-60mins, duration 2-3hrs Resonium - onset 60mins (PR) and 4hrs (PO), duration variable (remember via CIS-BR 3-15-30-30/60 min onset; 30 for calcium, 2-3hrs for middle 3)"

Answer 1153

a) mixing studies When an initial PTT is prolonged, a second PTT test is performed by mixing the person’s plasma with pooled normal plasma (a collection of plasma from a number of normal donors). If the PTT time returns to normal (“corrects”), it suggests a deficiency of one or more of the coagulation factors in the person’s plasma. If the time remains prolonged, then the problem may be due to the presence of an abnormal factor-specific factor inhibitor (autoantibody) or nonspecific inhibitor, such as lupus anticoagulant. https://www.testing.com/tests/partial-thromboplastin-time-ptt-aptt/#:~:text=To%20detect%20nonspecific%20autoantibodies%20(antiphospholipid,be%20used%20for%20this%20purpose.

Answer 1154

c) variable extrathoracic - if inspiration affected -> extrathoracic - if expiration affected -> intrathoracic - if both affected -> large airway obstruction Flow-volume loops "

Answer 1155

Factor 8 4 factor Beriplex - 2, 7, 9, 10, protein C and S Excipients Antithrombin III (human), albumin (human), Heparin sodium (porcine), Sodium+ Phosphate+ Citrate+ Chloride+ (Present as sodium citrate, sodium phosphate and sodium chloride)

Answer 1156

VA ECMO Femoral and preserved cardiac function Blood is drained from the inferior vena cava, passes through the oxygenator and is then returned to the descending aorta in a retrograde fashion. In peripheral V-A ECMO any residual native cardiac output passes through the patient’s lungs. If the lungs are badly affected by pathology or mechanical ventilation is inadequate the blood of the residual cardiac output may remain significantly hypoxic as it enters the systemic circulation. Anatomically, this blood is preferentially delivered to the circulation of the heart, head and neck and right arm. Therefore, when there is residual native cardiac output and the lungs are not ventilated normally, potential exists for delivery of hypoxic blood to the coronary, cerebral and right arm circulations. This is termed differential hypoxia or harlequin syndrome. https://ecmo.icu/va-ecmo-differential-hypoxia/

Answer 1157

Type 3 always ineffective https://www.rch.org.au/clinicalguide/guideline_index/Von_Willebrand_Disease_vWD/ DDAVP for type 1 (relative deficiency) and 2a (qualitative problem). vWF and FVIII (Biostate) replacement for Type 2b and Type 3 (absolute deficiency). Platelets - second line option if ongoing bleeding https://www.uptodate.com/contents/von-willebrand-disease-vwd-treatment-of-major-bleeding-and-major-surgery#H3081086338 "

Answer 1158

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

Answer 1159

a) Severity of air leak

Answer 1160

50mg When using both agents together, follow this approach: Calculate the fraction of maximum dose for each drug: Lidocaine fraction = (actual dose used ÷ maximum dose) Bupivacaine fraction = (actual dose used ÷ maximum dose) Add these fractions together: Ensure the total fraction does not exceed 1 (100%) So given lignocaine = 100 ÷ 200 = 0.5 can give 0.5 of bupe dose = 50mg

Answer 1161

90mg 30mg oxy IV = 30mg morphine IV 30mg morphine IV = 90mg morphine PO

Answer 1162

SGLT2 inhibitor inhibiting glucose reabsorption within the proximal renal tubules, resulting in glucosuria, modest weight loss, and blood pressure reduction.

Answer 1163

RUL "Bronchopulmonary segments: 3/2/5, 4/4 3 RUL: Apical, Posterior, Anterior 2 RML: Lateral, Medial 5 RLL: Superior, Medial, Anterior, Lateral, Posterior 4 LUL: Apicoposterior, Superior, Inferior, Anterior (lingula italicised) 4 LLL: Anteromedial, Lateral, Posterior, Superior RL: A PALM Seed Makes Another Little Plam LL: ASIA ALPS"

Answer 1164

"b) Long throacic The shoulder receives sensory innervation from the cervical (C3,4) and brachial plexuses (C5,6). Shoulder nerve supply: - Major sensation (motor & sensory) = **suprascapular** nerve (upper trunk of the brachial plexus) and **axillary nerve** (posterior cord of the brachial plexus). - Minor sensation = SLaM: **subscapular, lateral pectoral, musculocutaneous** - Rotator cuffs are supplied by: axillary, suprascapular & subscapular nerves SA-SLaM the scapula (supra and sub)" other option has been supraclav which innervates skin of upper chest/shoulder

Answer 1165

110 Brain trauma foundation guidelines: - SBP>100 for ages 50-69, - SBP>110 for ages 15-49 and above 70 years https://emcrit.org/ibcc/tbi/ TBI guideline for everything"

Answer 1166

b. intrahepatic cholestsasis of pregnancy www.ranzcog.edu.au/wp-content/uploads/Management-Obesity-Pregnancy.pdf

Answer 1167

PECS 1 - between pecs major and pecs minor - blocks lateral and medial pectoral nerves Stenum innervated by interocostal nerves. All 3 options belwo can be used for sternal fracture PECS 2 - between pecs minor and serratous ant - blocks intercostal brachial, long throacic, intercostal III - VI nerve Subpectoral interfascial plane block - between pec major and interocstal Transverus thoracic plane block = parasternal plane block "

Answer 1168

"MELD-Na score components: (BICS) Bilirubin INR Creatinine Sodium (serum) estimates survival over next 3 months >15 - listed for deceased donor transplant "

Answer 1169

1 - Buccal/intranasal Midaz 0.3mg/kg (max 10mg) if no IV access OR IV/IM midazolam 0.15mg/kg (max 10mg) 2 - IV/IO midaz 0.15mg/kg 3 - Levetiracetam 40-60mg/kg (over 5mins; max 4.5g) or phenytoin 20mg/kg (over 20mins) - provided pt NOT taking that med 4 - Give whichever was not given or phenobarbitone 5 - RSI Each step preceded by 5 mins (1 -> 5 mins after seizure onset, 2/3 = after midaz given, 4/5 = after infusion finished"

Answer 1170

"IQR For skewed data: dispersion/spread/variability: interquartile range (or other percentile-based ranges). Measure central tendency=median. For normal distributed data: dispersion = standard deviation central tendency = mean. " Measures of central tendency = mean, median, mode

Answer 1171

d) norad > 0.25mcg/kg/min for at least 4 hours For adults with septic shock and an ongoing requirement for vasopressor therapy, we suggest using IV corticosteroids. Quality of evidence: Moderate The typical corticosteroid used in adults with septic shock is IV hydrocortisone at a dose of 200 mg/d given as 50 mg intravenously every 6 hours or as a continuous infusion. It is suggested that this is commenced at a dose of norepinephrine or epinephrine ≥ 0.25 mcg/kg/min at least 4 hours after initiation. https://www.sccm.org/clinical-resources/guidelines/guidelines/surviving-sepsis-guidelines-2021

Answer 1172

Non-inferior

Answer 1173

S/C phentolamine https://www.rch.org.au/clinicalguide/guideline_index/Peripheral_extravasation_injuries__Initial_management_and_washout_procedure/

Answer 1174

c. major haemorrhage The most common causes of perioperative cardiac arrest were major haemorrhage (17%), bradyarrhythmia (9.4%) and cardiac ischaemia (7.3%) but varied by surgical specialty. Anaphylaxis was likely overestimated as a cause of cardiac arrest in our survey of anaesthetists

Answer 1175

Grimacing "1) Eye opening 2) Eyes - conjugate gaze 3) Facial grimace 4) Laryngeal stimulation test +ve 5) Low ET anaesthetic concentration <0.2% sevo, <1% des and <0.15% isoflurane 6) Movement (except coughing) 6) Movement - purposeful 7) SpO2 >97% Preop (baseline) target if cyanotic congenital heart disease 8) TV >5mL/kg"

Answer 1176

Metoprolol Results in unopposed alpha stimulation - unopposed vasoconstriction. Worsen HTN, coronary spasm, ischaemia.

Answer 1177

low frequency probe

Answer 1178

c. justice “Justice in medical ethics emphasises fair, equitable and appropriate treatment and distribution of healthcare resources, ensuring no unfair disadvantage based on socioeconomic status, location or other factors”

Answer 1179

"Ans: Salicylate toxicity ^Cl -> NAGMA Low albumin -> Masks HAGMA, (AG reduces by 1 for every drop of albumin from 4o by 4g/L) Litium & ^Ca2+-> Low AG metabolic acidosis (Extra unmeasured cations) Lithium: Low AGMA"24.1

Answer 1180

a. ibuprofen "NSAIDS/aspirin should be avoided as it displaces thyroxine from protein and subsequently increases free T3 and T4 levels. Thyroid storm General measures Cooling IVF +/- glucose Paracetamol Propranolol Specific Hydrocortisone 200 mg QID IV PTU after PTU sodium iodide/lugols iodine"

Answer 1181

"b) Nd:yag Modified Question: this question asks Greatest, old asks least Least = Er:yag (or CO2)? Most = Nd:Yag Er:yag (Erbrium-Yag) used in dermatology which is the least penetrative CO2 laser has very little penetration (~ 10micrometres), as it has a wavelength of 10 600nm. Helium-Neon laser also has very little penetration. Nd:YAG is the most powerful, with a penetration of 2-6mm, as it has a wavelength of 1064nm. Argon penetration of 0.5mm"

Answer 1182

"72 hours ANZCA Blue Book 2023 Oral naltrexone should be stopped at least 24 hours and ideally 72 hours prior to elective surgery. And there is a lack of instruction re Contrave(naltrexone/buproprion for weight loss)- so best to stop 72 hours prior. And limited evidence re low dose naltrexone for chronic pain - so for consistency blue book says 72 hours. Caution increased opioid sensitivity in patients using perioperative naltrexone."

Answer 1183

d. proprioception Anterior spinal artery syndrome usually includes tracts in the anterior two-thirds of the spinal cord, which include the CSTs, the spinothalamic tracts, and descending autonomic tracts to the sacral centers for bladder control. CST involvements produce weakness and reflex changes. A spinothalamic tract deficit produces the bilateral loss of pain and temperature sensation. Tactile, position, and vibratory sensation are normal. Urinary incontinence is usually present.

Answer 1184

"d. 1:136,000 https://www.bjanaesthesia.org/article/S0007-0912%2817%2930746-8/fulltext 1/670 E-LSCS 1/8000 with muscle relaxation 1/8600 CTS 1/8200 Volatile + neuromuscular blocking Overall 1:19000"

Answer 1185

"d) Proceed ANZCA PG07 appendix 1 - Chewing gum and boiled sweets should be discarded prior to inducing anaesthesia to avoid them being Inhaled as a foreign body but do not constitute an indication for delaying any procedure unless they have been ingested. Therefore D"

Answer 1186

c. elderly "RFs for CPSP: Preop: mod-severe pain >1mth, repeat surgery - young, female, anxiety, opioids (ineffective) Intraop: high-risk surgeries, nerve damage Postop: Acute pain (mod-severe), anxiety/depression"

Answer 1187

Titrate to pain scores alone Should use FAS https://www.anzca.edu.au/getContentAsset/136f5a83-d1d0-4f34-be72-87b62b721d14/80feb437-d24d-46b8-a858-4a2a28b9b970/PS41(G)-Acute-pain-2023.pdf

Answer 1188

"REPEAT reconsidered as Amitriptyline a) Amitriptyline By order of favourable NNT: TCAs (amitriptyline) NNT: 3.6, NNH: 9 Strong opioids NNT 4.3 NNH 11.7 Tramadol NNT: 4.7, NNH 12.6 SNRIs (duloxetine and venlafaxine) NNT 6.4, NNH 11.8 Gabapentin NNT: 7.2 NNH 25.6 Pregabalin NNT:7.7, NNH 13.9 ANZCA Pain book Treatment of chronic neuropathic pain after SCI (Guy 2016 GL). These guidelines recommend: First line: pregabalin, gabapentin and amitriptyline; Second line: tramadol and lamotrigine (in incomplete SCI); Third line: Transcranial direct current stimulation (tDCS) alone and combined with visual illusion; Fourth line: TENS, oxycodone and dorsal root entry zone lesions."

Answer 1189

Dysaesthesia Ans = allodynia – normal touch = painful Dysaesthesia = normal touch or even just spontaneous pain. Unpleasant, abnormal sense of touch (e.g. burning, wetness, can be pain) Paraesthesia = abnormal sensation (or loss of sensation) Hyperalgesia = pain out of proportion Hyperaesthesia = stimulus required"

Answer 1190

e) distance from anterior margin of dense to posterior surface of anterior arch of atlas be aware of wording Normal interval <3mm adult, <5mm child Widening indicates potential instability can also measure PADI (posterior atlantodental interval) or SAC (space available for cord) . Posterior cortex of dens and anterior arch C1. normal is >15mm. Less than this - increased risk of AAI and spinal cord injury Antlantoaxial instability Loss of transverse ligament + erosion of odontoid peg → atlanto-occipital instability in ~25% of patients *Acute subluxation can cause spinal cord compression and/or compression of vertebral arteries Two main categories of cervical spine instability: Atlanto-axial subluxation *Anterior: C1 moves forward on C2 *Posterior: C1 moves backward on C2 *Vertical: odontoid process subluxes through foramen magnum *Lateral/rotatory subluxation: C1/C2 rotation Subaxial subluxation *Occurs less commonly *More likely to involve neurological symptoms

Answer 1191

"Decreased urine output (alternative is Residual sedation) - Dexmed can be a diuretic (increase GFR and UO) Loading infusion: Transient HTN (α2B receptors agonism), bradycardia, hypotension Intaop dexmed associated with PACU: ↓ PONV, shivering, cough, emergence agitation, pain scores Decreased BP (hypotension) No change bradycardia and sedation and PACU LOS No change - BSL - bradycardia/sedation/LoS PACU Decreased everything else incl. BP (PONV, shivering, cough, agitation, pain)" "BJA 2020 RCT: 24hrs post-induction dexmed reduces AKI post aortic surgery requiring CPB. No differences in HR/BP/sedation https://www.bjanaesthesia.org.uk/article/S0007-0912(20)30001-5/pdf "

Answer 1192

"Increasing MV -> avoid hypocapnoea is part of algorithm If desat >20% from baseline - check head position - ensure neutral - check ETT ties - exclude venous/arterial obstruction – Optimise O2 delivery - HR/SV/ MAP (vasopressors/ ^FiO2 (treat hypoxia), optimise ventilation (clear CO2), tranfusion if anaemic – Optimise O2 consumption - ensure adequate depth of anaesthesia, avoid hyperthermia, exclude seizures- antiepileptics

Answer 1193

" >120sec Optimal seizure duration somewhere between 10-120seconds. https://academic.oup.com/bjaed/article/10/6/192/299664

Answer 1194

a) initial sympathetic stimulation Beginning with the electrical stimulus, there is an initial parasympathetic discharge lasting 10–15 s. This can result in bradycardia, hypotension, or even asystole. A more prominent sympathetic response follows during which time cardiac arrhythmias occasionally occur. Systolic arterial pressure may increase by 30–40% and heart rate may increase by 20% or more, generally peaking at 3–5 min Left ventricular systolic and diastolic function can remain decreased up to 6 h after ECT. Cerebral oxygen consumption, blood flow, and intracranial pressure all increase https://www.bjaed.org/article/S1743-1816(17)30338-4/fulltext

Answer 1195

A) 30 day mortality MINS study n=15,065 patients. >45 y/o undergoing non cardiac surgery. Had troponins measured for 3 days post op. Elevated trop independently predicted 30 day mortality.

Answer 1196

a) Propofol for LMA + PPV alternative could be e but significance of transphenoid surgery and potential pneumocephalus... Placing cpap on this patient even with an OPA is likely going to increase risk of this. an LMA gives a better seal (and its a glorified OPA anyway). If you're able to stick an OPA in someone you can use an LMA (Answer e suggests the pt is so obtunded that they will tolerate an OPA as no suggestion of deepening with props)

Answer 1197

d. Adductor brevis "Boundaries: - Medial wall - sartorius - Posterior wall - adductor longus, adductor magnus - Anterior - vastus medialis Contents: subsartorial artery/vein, saphenous nerve and nerve to vastus medialis (both branches of femoral nerve)"

Answer 1198

a. inferotemporal The inferotemporal approach offers more physical space between the globe and the orbital walls, providing safer access away from the extraocular muscles compared with a medial or off-centered (“two thirds/one third”) inferotemporal approach.Citation8

Answer 1199

40mL/kg Massive transfusion (prevent hypothermia/acidosis/coagulopathy) Children- (pRBC) transfusion i.e. replacement of: >1 blood volume in 24hours OR >50% TBV in <3-4hours OR >10% TBV over 10 minutes (OR 40mL/kg blood) Adults - replacement of >1 blood volume in 24hours OR >50% blood volume in 4hrs 10mL/kg pRBC increases Hb 20g/L; (cGPT); 1 unit pRBC ~300mL"

Answer 1200

Aprepitant barrier contraception for 28 days https://www.merck.com/product/usa/pi_circulars/e/emend/emend_pi.pdf https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5809356/ 2 months in UK (28 days in USA) Works as a centrally acting NK1 receptor antagonist by blocking actions of Substance P - also ↑activity of dexamethasone & ondansetron (in chemo)"

Answer 1201

c. Phenoxybenzamine Phentolamine used intraop (short action/reversible cf phenoxybenzamine which is irreversible and has a lasts 3-4 days as need to make new receptors) Preop objectives: (note orthostatic hypotension and ST/T wave changes of Roizen criteria now questionable) 1) BP control (<130/80 seated): α blockade >7days (e.g. doxazosin or phenoxybenzamine, latter stopped 24-48hrs preop due to postop hypotension), +/- CCB (nicardipine SR) 2) HR/arrhythmia control: selective β1 antagonists (metoprolol/atenolol) avoids hypertensive crisis (if β2-vasodilation stopped and unopposed α vasoconstriction) 3) High Na+/fluid intake -> restores blood volume 4) Optimise myocardial function: ECG (ventricular hypertrophy, tachycarrhythmia, myocardial ischaemia). TTE mandatory (majority pts have diastolic dysfunction) Beware HOCM (MCC, due to HTN), and atypical Takutsubo 5) Reverse glucose/electrolyte disturbances (hyperglycaemia, and hypercalcaemia)"

Answer 1202

d. Basilar

Answer 1203

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

Answer 1204

a. add 0.03 VBG vs ABG pH + 0.035 PCO2 - mean difference +6mmHg; good correlation in normocapnoea (unreliable when PaCO2>45mmHg) Correlate well: HCO3-, Base Excess, Lactate - dissociation above 2mmol/L https://litfl.com/vbg-versus-abg/ "

Answer 1205

a. decreased renal blood flow Should enhance CO and increase renal blood flow

Answer 1206

"d) rocuronium (as severe) - diazepam if mild #Hyperthermia in SS - mostly mediated by muscle hyperactivity - paracetamol, dantrolene ineffective - mild: topical cooling and benzos to ↓muscle activity - severe (>41.1 degrees) -> rhabdo, metabolic acidosis, DIC -> Rx = sedation, NDMB necessary (avoid suxamethonium due to hyperkalaemia) https://www.medsafe.govt.nz/profs/PUArticles/Dec2012Neuroleptic.htm#:~:text=However%2C%20NMS%20is%20characterised%20by,are%20indicative%20of%20serotonin%20syndrome "

Answer 1207

a high frequency Frequencies above 100 kHz (and specifically in the radiofrequency range of 0.5-3 MHz) avoid causing neuromuscular stimulation and cardiac excitation, unlike lower, mains-level frequencies (50-60 Hz), which can cause ventricular fibrillation.

Answer 1208

"Cohort "Prospective: - Observational cohort studies: observes exposure, then observes the development of risk. Uses relative risk (i.e. who develops the illness) - Randomised and non-randomised (cohort) interventional controlled trials. RCTs gold standard - only study that can establish casuation by evaluating intervention https://www.bjaed.org/article/S1743-1816(17)30475-4/fulltext#seccestitle70 " Retrospective: - case reports (and case series (a collection of case reports) - cross-sectional studies/surveys: no control group, merely a large series of case reports -> e.g. can determine prevalence of a disease - case-control studies: identified risk factors assoc/ w/ outcomes. -> compare case w/ control to identify RFs or causative agents implicated in aetiology of disease -> Use odds ratios"

Answer 1209

"c - IE ratios - no recommendations (lack of evidence for a specific I:E ratio) * The ventilator should initially be set to deliver VT ≤6–8 ml kg–1 PBW and PEEP=5 cm H2O. * Individualised PEEP can prevent progressive alveolar collapse. Recruitment manoeuvres can reverse alveolar collapse, but have limited benefit without sufficient PEEP * An I:E ratio of 1:1, which has been characterised as providing a ‘balanced stress to time product’, was associated with attenuation of lung damage. Evidence for specific I:E ratio lacking -> no recommendation. (^ mean airway P but reduces peak airway P) * high ventilator driving pressure (ΔP=plateau pressure [Pplat]–PEEP) has been recognised as a significant determinant of lung injury and is linked to PPCs"

Answer 1210

"a) 1% PPV = TP / TP + FP For example For prevalence of 1:1000 the number of TP = 1 False positives = 999 x 10% FP = 99 PPV = 1 / 1+99 PPV = 1% PPV = TP / TP + FP NPV = TN/ (TN + FN) Sensitivity = TP / (TP+FN) Specificity = TN / (TN+FP)"

Answer 1211

"a) pupil constriction (horner syndrome) and reaction to light Loss of SNS, so would have relative miosis. Still has PSNS and optic nerve (CNII) intact so intact pupillary light reflex - anhidrosis (decreased sweating), enopthalmos (sunken eyeball), bloodshot conjunctiva, facial flushing on affected side Also possible: VC paralysis, RLN injury, phrenic n injury, brachial plexus injury, pneumothorax, indavertent epidural"

Answer 1212

"a) More bleeding, normal INR and APTT - also more transfusions' - INR and APTT done at room temp Mild hypothermia (<1degC) ^ blood loss by 16% & tranfusion risk by 22% Anaesthesiology 2008 effects mild periop hypothermia"

Answer 1213

Hydroxycobalamin "IV hydroxocobalamin (B12) 5mg with repeat dosing upt to 15mg sodium thiosulfate used in case series also appears affective with no AE https://www.resuscitationskills.com/library/algorithms/all-adult-als-guidelines-june-2017.pdf "

Answer 1214

"a) reduce RR HFNP - reduce RR, increase end expiratory lung volume, PEEP up to 7cmH2) with closed mouth, reduced airway surface dehydration, decrease atelectasis, improve secretion clearance, CO2 washout, reduction in anatomical dead space https://www.bjaed.org/article/S2058-5349(17)30029-X/fulltext"

Answer 1215

Sagittal, subxiphoid

Answer 1216

"a) AB group - has no plasma antibodies Plasma compatibility - should be combatible with ABO group of recipient to prevent haemolytic reaction. ANY RhD subtype can be given Pt group: A --> compatible with A, AB plasma B --> compatible with B, AB plasma AB --> compatible with AB plasma O --> compatible with all " https://www.lifeblood.com.au/health-professionals/products/component-compatibility

Answer 1217

FB BJA 2hrs if in oesophagus, or symptomatic in stomatch

Answer 1218

"90min - the lungs take 90 mins ""In Australia it is usual to stand down the DCDD process if the agonal period has exceeded 90 minutes"" https://www.donatelife.gov.au/sites/default/files/2022-01/ota_bestpracticeguidelinedcdd_02.pdf

Answer 1219

"Conitnue to breast feed as per usual. Do not need to express and discard. Monitor infant for signs of respiratory depression and drowsiness especially if multiple doses of opioids/bzd AVOID codeine in breastfeeding https://anaesthetists.org/Home/Resources-publications/Guidelines/Anaesthesia-and-sedation-in-breastfeeding-women-2020"

Answer 1220

B or D (?D misremembered) b. ocoulocephalic reflex is an inferior test compared to the vestibulo-ocular reflex (tests same nerves) and may exacerbate pre-existing spinal injury pre-conditions for test - temp >35 - normotension - exclusion of sedatieves - absence of electrolyte abnormalities/ Liver faliure - absence of NMBD a minimum 4-hour observation period prior to neurological determination of death using clinical examination alone. Throughout this observation period, all preconditions are met, the patient has a Glasgow Coma Scale of 3, with pupils nonreactive to light, absent cough/tracheal reflex and apparent apnoea on a ventilator. Following an acute hypoxic-ischaemic encephalopathy or hypothermia (<35°C) of duration greater than 6 hours, there should be a waiting period of 24 hours before determination of death using clinical examination alone.

Answer 1221

b) 1 hourly https://www.diabetessociety.com.au/wp-content/uploads/2023/03/ADS-ANZCA-Perioperative-Diabetes-and-Hyperglycaemia-Guidelines-Adults-November-2022-v2-Final.pdf Continue hourly BGL monitoring until the person leaves the recovery area. If the BGL has been stable (and within target range) while in the recovery area, BGL monitoring can be decreased to 2 hourly if type 1 diabetes, or 2-4 hourly if type 2 diabetes. If BGLs have been unstable or if VRII, hourly monitoring is required.

Answer 1222

"c) Normal Lung Normal lung = A lines (pleura) + batwing appearance + sliding" "A lines horizontal - may be normal or pneumothorax B lines vertical - can be interstitial fluid e.g. pulmonary oedema -> (After Hours, Batman is Vigilant) Pneumothorax features: - abscence of B lines & sliding (on highest point of anterior chest) - absence of lung pulse - presence of lung point"

Answer 1223

d) NAGMA non-anion gap metabolic acidosis (NAGMA), often specifically referred to as hyperchloremic metabolic acidosis.

Answer 1224

c. fibrinogen <2 https://www.bjanaesthesia.org.uk/article/S0007-0912(17)31590-8/pdf platelets < 150 Giga/L (OR 2.98, 95%CI 1.63, 5.46), fibrinogen < 4.5 g/l (OR 1.86, 95%CI 1.21, 2.87) and APTT ratio ≥ 1.1 https://www.sciencedirect.com/science/article/abs/pii/S2468784721001069

Answer 1225

"a) 6 hrs 6hr and 24hrs hypocalcaemia—ionized calcium <0.9mmol/L, total calcium (corrected for albumin) <2.2mmol/L. Trough level usually occurs at 20hr following parathyroidectomy and typically normalizes by days 2–3."

Study deck (25.2, 24, 23, 22, 21) Flashcards

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