1
Q
List anatomical factors that can complicate intubation.
A
- Small mouth
- Receding chin
- High arched palate
- Large tongue
- Acquired injuries (e.g., burns, tumors)
- Poor dentition (e.g., loose teeth)
- TMJ disease limiting mouth opening
- Adenotonsillar hypertrophy
2
Q
What are the principles for managing patients with a subarachnoid haemorrhage requiring endovascular coil insertion?
A
- Secure airway and maintain normoxia and normocapnia
- Maintain stable cerebral perfusion pressure
- Treat pain and seizures
3
Q
Which reflexes are tested in brainstem death testing?
A
- Pupillary light (II + III)
- Corneal (V + VII)
- Facial pain (V + VII)
- Vestibulo-ocular reflex (VIII + III/IV/VI)
- Gag reflex (IX + X)
- Cough reflex (X + X)
4
Q
What local anaesthetic blocks may be used for superficial facial surgery?
A
- Infratrochlear (eyelids, nose and conjunctivae)
- Supraorbital and supratrochlear (forehead)
- Infraorbital (lower eyelid and upper lip)
- Mental (chin and lower lip)
5
Q
Which types of operation may need facial nerve monitoring?
A
- Parotidectomy
- Middle ear surgery (e.g. mastoidectomy)
- Posterior fossa surgery (e.g. acoustic neuroma)
6
Q
How does the 2,3-DPG level change in stored blood?
A
Stored blood quickly loses 2,3-DPG and its ability to deliver oxygen.
7
Q
Briefly describe the pathophysiology of thalassemia.
A
There are four alpha globin genes on chromosome 14
- Alpha thalassemia results from mutations to 1 to 4 of these genes
There are two beta globin genes on chromosome 11
- Mutations in these genes cause beta thalassemia
- It usually manifests at 6 months of age when HbA takes over from HbF
8
Q
Which mutation causes sickle cell disease?
A
Glutamic acid is substituted for valine at position 6 of the beta globin chain.
9
Q
What is malignant hyperthermia?
A
Rare autosomal dominant (chromosome 19) condition that can be triggered by volatile agents and suxamethonium.
Incidence of 1 in 10,000.
10
Q
What are the clinical manifestations of malignant hyperthermia?
A
- Muscle rigidity
- Tachycardia
- Rising ETCO₂
- Increased oxygen requirement
- Hyperpyrexia
- Metabolic and respiratory acidosis
11
Q
Outline the pathophysiology of malignant hyperthermia.
A
Triggering agents (volatiles or suxamethonium) causes uncontrolled release of free calcium from the sarcoplasmic reticulum due to a mutation in the ryanodine receptor of the sarcoplasmic reticulum.
12
Q
What measures should be taken for a patient at risk of malignant hyperthermia?
A
- Use regional anaesthesia
- Avoid suxamethonium and volatile agents
- Implement TIVA
- Ensure a clean machine (no prior volatile use)
- Have dantrolene available
- Monitor temperature and ETCO₂ closely
13
Q
What should ETT cuff pressure be?
A
20-30 cm H2O
14
Q
Why would a mainstream gas analyser be better in an unwell neonate on NICU?
A
A mainstream analyser would add minimal dead space and be able to rapidly display changes in carbon dioxide with a high respiratory rate and small tidal volume.
A rapid response time is desired, and this is less possible with side stream capnography.
15
Q
What is the minimum monitoring for transfer as per the AAGBI guidelines?
A
- ECG
- SpO2
- NIBP
- Capnography (if airway device in place)
16
Q
What are the second line agents used in status epilepticus after two maximal doses of benzodiazepines?
A
- Levetiracetam (30-60 mg/kg over 5 minutes, maximum 3g)
- Phenytoin (20 mg/kg by slow IV infusion over 20 minutes with ECG monitoring)
- Phenobarbital (20 mg/kg IV over 5 minutes)
17
Q
How is suxamethonium apnoea tested?
A
Test involves measuring the dibucaine number:
- Patient plasma mixed with benzylcholine
- Light emission measured
- Dibucaine added (inhibits normal plasma cholinesterase)
- Reduction in light emission indicates cholinesterase activity
- Normal reduction is 80%
18
Q
What equation is used to determine the length to which the endotracheal tube should be inserted in children?
A
(age/2) + 12
19
Q
What are indications for an implantable cardiac defibrillator?
A
- Previous cardiac arrest due to VF or unstable VT
- VT with structural heart disease
- Non-ischaemic dilated cardiomyopathy
- Severely impaired ejection fraction (< 35%) despite 3 months of optimal medical management
20
Q
Which structures are pierced when performing an epidural?
A
- Skin
- Subcutaneous tissue
- Supraspinous ligament
- Interspinous ligament
- Ligamentum flavum
- Epidural space
21
Q
What are some features of TCA overdose?
A
Anticholinergic effects – dry mouth, dry nose, blurred vision, constipation, urinary retention, sweating, increased body temperature.
CNS effects – drowsiness, confusion, myoclonus, seizure, coma.
Cardiovascular effects - tachycardia, arrhythmias, hypotension, transient hypertension, VT, VF and prolonged QT interval.
22
Q
Which specific complication is associated with interscalene blocks?
A
Phrenic nerve palsy
The phrenic nerve runs on the anterior aspect of the anterior scalene.
23
Q
List the main blocks in order of decreasing incidence of local anaesthetic toxicity.
A
Intercostal space > caudal > epidural > brachial plexus > femoral > subcutaneous
24
Q
State the periods of omission for antiplatelet agents before neuraxial blockade.
A
- Aspirin, NSAIDs, dipyridamole: continue
- Clopidogrel, Prasugrel: 7 days
- Ticagrelor: 5 days
- Tirofiban, Eptifibatide: 8 hours
- Abciximab: 48 hours
NOTE: Restart 6 hours after catheter removal.
25
What are the clinical manifestations of **lithium toxicity**?
* Nausea/vomiting
* Coarse tremor
* Oliguria
* Ataxia
* Hyperreflexia
* Nystagmus
* Convulsions/coma.
26
What are the **ways** heat is lost on the operating table?
* **Radiation**: 40%
* **Convection**: 30%
* **Evaporation**: 20%
* **Respiratory losses**: 5-10%
* **Conduction**: 5%
27
What are the **AAGBI guidelines** regarding proceeding with surgery in patients who are hypertensive on the day of an elective operation?
Patients admitted for elective surgery should have a BP **below 160/100 mm Hg** in primary care.
On the day of surgery, you can proceed if blood pressure is **below 180/110 mm Hg**.
28
Why are paediatric patients **more prone** to bradycardia during anaesthesia than adults?
Due to the increased parasympathetic tone in children compared to adults, they are prone to significant bradycardia under vagal stimulation.
29
What are the **effects** of a delay between collecting a blood gas sample and analyzing it?
* Low PaO₂
* High PaCO₂
* Low pH
* High [H+]
30
What are the targets of an **axillary block**?
Median, ulnar, radial and musculocutaneous nerves at the level of the axillary artery.
The musculocutaneous nerve lies separately between corocobrachialis and biceps brachii, and needs significant redirection of the needle to anaesthetise it.
31
What **level of block** is usually needed when delivering an epidural for a Caesarean section?
T4-5
32
How often should BMs be monitored intraoperatively for a **diabetic patient**?
At least hourly
33
# Define:
oesophageal barrier pressure
Oesophageal barrier pressure = lower oesophageal sphincter pressure – intragastric pressure.
34
Describe the **landmarks** used to perform a Stellate ganglion block.
Needle contacts the anterior tubercle of C6.
| (Chassaignac's tubercle)
## Footnote
NOTE: The stellate ganglion lies at C7 formed by the fusion of the inferior cervical and T1 ganglia.
35
At what **level** is a tracheostomy formed?
Between the second and third tracheal cartilage rings.
36
Which **joint** is particularly concerning in airway management for patients with rheumatoid arthritis affecting the **neck**?
**Atlantoaxial instability**: involves the **Atlas (C1)** and **Axis (C2)**.
37
Why does carbon monoxide poisoning give a **falsely high saturation reading** on pulse oximetry?
Carboxyhaemoglobin has a similar absorption spectrum to oxyhaemoglobin (good absorption at 940 nm).
This leads to an overestimation via spectrophotometric methods of SpO2.
38
State the **Parkland formula**.
The fluid requirement in the first 24 hours is equal to
4ml x weight (kg) x %burns
Half of this is given in the first 8 hours, and the remainder in the remaining 16 hours.
39
How is an **interscalene block** performed?
Involves injecting local anaesthetic around the TRUNKS of the brachial plexus as it passes through the groove between the anterior and middle scalene muscle at the level of the cricoid cartilage.
40
What is the recommended stimulating catheter needle length for an **axillary block**?
35-50 mm
41
What is the recommended stimulating catheter needle length for a **femoral nerve block**?
50 mm
42
What is the recommended stimulating catheter needle length for a **psoas compartment block**?
80-150 mm
43
What is the recommended stimulating catheter needle length for a **sciatic nerve block**?
80-120 mm
44
Describe the sizing of **laryngeal masks**.
1 – < 5 kg
1.5 – 5-10 kg
2 – 10-20 kg
2.5 – 20-30 kg
3 – 30-50 kg
4 – 50-70 kg
5 – 70-100 kg
6 – 100 kg
45
What are some immediate, delayed and late complications of **tracheostomies**?
**Immediate** – failure, haemorrhage, tube misplacement, occlusion of tube by herniated cuff, occlusion of tube by tracheal wall.
**Delayed** – blockage with clot or secretions, overinflation of cuff leading to mucosal ulceration.
**Late** – granuloma formation, persistent sinus, scar formation, tracheal dilatation.
46
What **equation** should be used to estimate the weight of a child?
Weight = (age+4) x2
47
What is the **anaphylaxis dose** of adrenaline in a child aged 6-12 years?
300 mcg intramuscularly
## Footnote
In the theatre setting, 1 mcg/kg IV can be given (10 mcg/mL can be achieved with 1 in 100,000 adrenaline).
48
What does the **ratio** when describing adrenaline mean (e.g. 1 in 1000)?
* 1 gram of adrenaline in 1000 mL (e.g. 1 mg/mL)
* 1 in 10,000 = 100 mcg/mL
* 1 in 100,000 = 10 mcg/mL
49
What **energy** should be administered for a **shockable rhythm** in a child?
4 J/kg
50
What are some of the **benefits** of a supraglottic airway device compared to an ETT?
* Don't need laryngoscopy
* Improved cardiovascular stability (whereas you get hypertension with laryngoscopy)
* Less rise in intra-ocular pressure
* Decreased coughing on emergency
51
What is the **benefit** of citrate-adenine-phosphate-dextrose as a preservation solution for red cells?
Adenine is able to increase red cell ATP levels, thereby increasing red cell survival to 35 days
52
What is the survival of red cells in **citrate-phosphate-dextrose**?
28 days
53
What is the survival of red cells in **acid-citrate-dextrose**?
21 days
54
What is the benefit of **SAGM** (saline, adenine, glucose, mannitol) as preservative for red cells?
Allows a greater volume of plasma to be removed from the blood in order to use FFP as a source of coagulation factors.
55
What is the **equation** for tube sizing in children?
**CUFFED**: (age/4) + 3.5
**UNCUFFED**: (age/4) + 4
56
What are some **risk factors** for local anaesthetic toxicity?
* High volume (e.g. Bier's block, FIB, epidural)
* Increased vascularity (e.g. paravertebral)
57
How is the length of **epidural catheters** marked?
One single mark at the tip so that it may be identified on removal.
They have 5 single markings at 1 cm intervals from 5-9 cm, a double marking at 10cm, 1cm intervals from 10-14cm, a triple marking at 15cm and then quadruple markings at 20cm.
58
What are the five classes of **pulmonary hypertension**?
1. idiopathic
2. secondary to left sided heart disease
3. secondary to chronic hypoxia or lung disease
4. secondary to chronic thromboembolism
5. rarer causes
59
Which **anaesthetic drugs** should be avoided in **porphyria**?
* Thiopentone
* Sevoflurane
* Ketamine
* Oxycodone
* Ephedrine
* Phenytoin
* Valproate
60
What is the **best nerve** to stimulate when monitoring neuromuscular blockade?
Ulnar nerve
## Footnote
Innervates adductor pollicis and is easily accessible during surgery.
It is also more sensitive to NMBs than the diaphragm and larynx meaning that its recovery suggests that more critical muscles have likely recovered fully.
61
What **factors** can cause spurious pH results in a blood gas sample?
* Excess heparin (acidic)
* Old blood (anaerobic metabolism lowers pH)
62
What is **heparin-induced thrombocytopenia**?
Immune mediated process that takes around 5 days to develop after starting heparin therapy.
Caused by production of IgG antibodies to heparin once it has bound to platelet factor 4 (PF4). The antibodies attach themselves to the heparin-PF4 complex and activate other platelets leading to thrombosis and a fall in platelet count.
63
What **scoring system** determines the probability of **heparin-induced thrombocytopenia**?
4Ts score:
* **Magnitude** of platelet fall
* **Timing** of platelet fall
* **Thrombosis** or other sequelae
* **Other** potential causes of thrombocytopenia
64
What **changes** occur in stored blood?
* Increased K⁺ (from cell death)
* Decreased pH (from cell death)
* Decreased 2,3-DPG causes left shift in oxyhemoglobin curve.
65
Why might **mannitol** be dangerous in certain cases of traumatic brain injury?
When the blood-brain barrier is intact mannitol is unable to cross.
If this membrane is disrupted by trauma then mannitol may cross making cerebral oedema much worse. For this reason it should only be given under the advice of a neurosurgeon.
66
How should a patient taking **once-daily long-acting insulin** in the morning be managed perioperatively?
* Unchanged dose the day before
* Reduce by 20% on morning of surgery
67
In which **groups of patients** with diabetes should a variable rate insulin infusion be considered?
* Miss more than one meal
* Type 1 diabetes who have not had their basal insulin
* Poorly controlled diabetes (HbA1c > 69 mmol/mol)
* Emergency surgery
68
How are **platelets** stored?
At room temperature for 3-5 days.
69
Outline the **Mallampati score**.
* **Class I** – soft palate, uvula, fauces and pillars visible.
* **Class II** – soft palate and fauces visible, tip of uvula obscured.
* **Class III** – soft palate and base of uvula only visible.
* **Class IV** – hard palate only.
70
Outline the **Cormack-Lehane classification**.
* **Grade I** – full view of the glottis.
* **Grade IIa** – partial view of the glottis.
* **Grade IIb** – arytenoids or posterior part of vocal cords just visible.
* **Grade III** – epiglottis only visible.
* **Grade IV** – neither epiglottis nor glottis visible.
71
Outline the **AAGBI guidance** regarding how long heparin and warfarin should be discontinued for prior to neuraxial anaesthesia.
* UFH (IV or SC, treatment or prophylaxis) – 4 hours or normal APTTR
* LMWH (prophylactic dose) – 12 hours
* LMWH (treatment dose) – 24 hours
* Warfarin – INR < 1.4
## Footnote
NOTE: Epidural catheter can be removed 12 hours after prophylactic LMWH.
72
How should a patient with **type 1 diabetes mellitus** who is well-controlled on a basal-bolus regimen be managed?
* If having surgery in the morning and expected to miss only one meal.
* Basal insulin should remain unchanged
* Morning and lunchtime short-acting insulin should be omitted
* No dose change the day before surgery
73
What is the recommended initial dose of intravenous adrenaline in **neonatal cardiac arrest**?
20 microgram/kg
74
Which **cardiopulmonary exercise testing parameter** is particularly useful in predicting postoperative complications from operations where physical demands are high (e.g. oesophagectomy)?
Peak Oxygen Consumption
| (VO2 Peak)
75
Which nerve is often missed with a **brachial plexus block**?
Intercostobrachial nerve
## Footnote
Has a T2 sensory distribution.
Needs to be blocked separately by infiltrating at the superior margin of the biceps at the anterior axillary fold to the border of the triceps.
76
How does the **ALS algorithm** for cardiac arrest change if the core temperature is < 30 degrees?
If shockable, a total of 3 x DC shocks should be administered.
If these fail, do NOT shock further until rewarmed to over 30 degrees.
## Footnote
Do NOT administer adrenaline if core temp < 30 degrees.
Increase adrenaline dosing interval to every 6-10 mins if temperature 30-34 degrees (as drug metabolism slows).
77
What **equation** is used to estimate the weight of a child aged 1-10 years?
Weight = (Age + 4) x 2
78
What is the recommended cleaning solution for **neuraxial blocks**?
0.5% chlorhexidine in 70% alcohol
79
What is the preferred intravenous anaesthetic agent for a **Bier's block**?
0.5-1% Prilocaine (max dose: 6 mg/kg)
## Footnote
NOTE: It has a shorter duration of action and lower risk of fatal complications from systemic toxicity than bupivacaine.
80
Outline the categories of **C-section**.
**Category 1** - A threat to maternal or fetal life. Decision to delivery < 30 minutes
**Category 2** - Maternal or fetal compromise that is not immediately life threatening. Decision to delivery in most circumstances < 75 minutes
**Category 3** - Requires early delivery, but not maternal or fetal compromise
**Category 4** - Elective delivery, at a time convenient to mother and maternity staff.
81
What is the recommended cleaning solution for **central line insertion**?
2% chlorhexidine in 70% alcohol for skin disinfection
82
What should be done with insulin pumps in the **perioperative period**?
Switch from insulin pump to variable rate insulin infusion during surgery.
83
What are the **components** of the STOP-BANG score?
**S**: Snoring (louder than talking or loud enough to be heard through closed doors)
**T**: Feeling tired, fatigued, or sleepy during daytime
**O**: Observed apnoeas during sleep
**P**: Hypertension
**B**: BMI more than 35 kg/m²
**A**: Age 50-years of age or greater
**N**: Neck circumference (male 17 inches / 43cm or greater and female 16 inches / 41 or greater)
**G**: Gender: Male
84
What are the clinical manifestations of **central cord syndrome**?
* Disproportionate motor weakness (arms > legs)
* Variable sensory loss
## Footnote
NOTE: Most common incomplete spinal cord lesion, usually caused by hyperextension of the neck.
85
Which clinical sign is an early sign of **magnesium toxicity**?
Loss of tendon reflexes
86
What is the **upper limit blood pressure** that would allow you to proceed with surgery in someone without a pre-admission history of hypertension?
< 180/110 mm Hg
87
What markers indicate that **DKA** has resolved?
Ketones < 0.6 mmol/L
Venous pH > 7.3
88
Which **blood tests** are suggestive of a diagnosis of von Willebrand disease?
* Low von Willebrand factor antigen
* Low ristocetin cofactor activity
89
What **formula** is used to prescribe maintenance fluids for paediatric cases?
**4-2-1 rule**:
* 1st 10 kg - 4 ml/kg/hr
* 2nd 10 kg - 2 ml/kg/hr
* Subsequent kg - 1 ml/kg/hr
90
What is the current recommendation for intraoperative steroid cover in patients who are **steroid-dependent**?
For those on > 5 mg prednisolone equivalent per day for 4 weeks or longer
**OPTION 1**: hydrocortisone 100 mg IV at induction, followed by continuous infusion of 200 mg hydrocortisone over 24 hours
**OPTION 2**: dexamethasone 6-8 mg IV (covers the next 24 hours)
91
What is the recommended **minimum MAP target** after ROSC to ensure adequate cerebral and coronary perfusion?
> 65 mm Hg
92
What dose of intravenous or intraosseous adrenaline is used in **paediatric cardiac arrest**?
10 mcg/kg
93
What test is used for **malignant hyperthermia**?
In vitro muscle contraction studies using caffeine and halothane.
94
Which **risk stratification system** is used to predict risk of perioperative cardiac events in patients undergoing non-cardiac surgery?
Detsky's Risk Stratification System
95
What are the clinical features of **class II haemorrhagic shock**?
* 15-30% blood loss
* Tachycardia, tachypnoea, decreased pulse pressure
* Minimal changes in systolic pressure
* Anxiety or hostility
96
Describe the mechanism underpinning **organophosphate poisoning**.
Organophosphates phosphorylate the esteratic site of AChE.
Inhibition becomes irreversible - the phosphorylated AChE reacts very slowly with water resulting in a rise in a widespread rise in synaptic ACh concentrations.
97
Outline the step-by-step management of **bronchospasm**.
1. 100% Oxygen
2. increase volatile (not desflurane)
3. Beta-2 agonist
4. magnesium, ketamine, ipratropium, hydrocortisone, aminophylline
## Footnote
NOTE: Desflurane should NOT be increased because it is an airway irritant. Furthermore, in severe bronchospasm, drug delivery is compromised so IV options should be sought.
98
Outline the **AAGBI guidance** on discontinuing DOACs before neuraxial anaesthesia.
* **Rivaroxaban** (prophylaxis): 18 hrs
* **Rivaroxaban** (treatment): 48 hrs
* **Apixaban** (prophylaxis): 24-48 hrs
* **Dabigatran**
- CrCl > 80: 48 hrs
- CrCl 50-80: 72 hrs
- CrCl 30-50: 96 hrs
## Footnote
NOTE: Next drug dose after catheter removal can be given at 6 hours.
99
How long after **thrombolytic drugs** (e.g. alteplase) can a patient have neuraxial anaesthesia?
10 days
100
How long after removal of an epidural catheter can various forms of **heparin therapy** be restarted?
* UFH SC Prophylaxis: 1 hour
* UFH IV Treatment: 4 hours
* LMWH SC Prophylaxis & Treatment: 4 hours
101
How long after **fondaparinux** can a patient have neuraxial anaesthesia?
Prophylaxis: 36-42 hours
Treatment: AVOID (consider anti-Xa levels)
## Footnote
Can be restarted 6-12 hours after catheter is removed.
102
What is the **most sensitive monitor** for detecting intra-operative venous air embolism?
Transoesophageal Doppler
| (can detect 0.02 mL/kg of air)
103
What is the normal range for **intra-ocular pressure**?
10-20 mm Hg
104
Which feature of intrathecal anaesthesia is the most important factor in determining the **duration of the block**?
Dose of the drug
105
What does in plane vs out of plane and short axis vs long axis mean in the context of **ultrasound**?
In vs Out of Plane = NEEDLE
Long vs Short Axis = Anatomy
106
How long must a child be fasted after having breast or formula milk before an **anaesthetic**?
Breast: 3-4 hours
Formula: 6 hours
## Footnote
NOTE: Ultrasonographic evidence of an empty stomach is good enough to proceed.
107
What **dose and duration** of regular prednisolone warrants specific measures to be taken in the perioperative period due to the risk of precipitating adrenal insufficiency?
Prednisolone ≥ 5 mg per day for ≥ 1 month
108
What **measures** should be taken when managing a patient who is at risk of adrenal insufficiency having major surgery?
Hydrocortisone 100 mg IV at induction.
Then continuous infusion of hydrocortisone 200 mg/24 hrs.
## Footnote
ALTERNATIVE: dexamethasone 6-8 mg IV (lasts 24 hours)
109
What is the dose conversion of **hydrocortisone to prednisolone**?
10 mg PO prednisolone = 40 mg IV or PO hydrocortisone
110
What is the dose conversion of **prednisolone to dexamethasone**?
1 mg Dexamethasone = 6.7 mg Prednisolone
111
What is the **intraoperative CBG target** in patients with diabetes and how would you manage hyperglycaemia?
* 6-10 mmol/L (< 12 tolerated if poorly controlled)
* T1DM: assumed 1 U rapid-acting SC will drop CBG by 3 mmol/L
* T2DM: 0.1 U/kg of rapid-acting SC
## Footnote
NOTE: recheck after 1 hour, up to maximum single dose of 6 units
112
What are the main clinical features of **salicylate toxicity**?
* Tinnitus
* Nausea & Vomiting
* Respiratory Alkalosis --> Metabolic Acidosis
* Hyperthermia
* Confusion, Agitation, Reduced GCS
113
Which **ECG leads** are best for:
A. Ischaemia
B. Arrhythmias?
* **V5**: ischaemia
* **II**: arrhythmia (P wave)
114
What common **ECG changes** are considered normal in children?
* Right axis deviation
* Sinus arrhythmia
* TWI V1-3
* Short PR
115
What are the **benefits** of diamorphine over fentanyl in segmental epidural analgesia?
* Less systemic absorption
* Longer duration
116
Outline the **Armitage formula** for caudal blocks in children.
* **Lumbosacral**: 0.5 mL/kg
* **Thoracolumbar**: 1 mL/kg
* **Mid-thoracic**: 1.25 mL/kg
Maximum: 20 mL
## Footnote
Recommends 0.25% bupivacaine.
117
What **mechanism** underpins transfusion associated **acute lung injury**?
Donor antibodies (usually anti-HLA or anti-neutrophil) activating recipient neutrophils in the pulmonary vasculature, leading to capillary leak and non-cardiogenic pulmonary oedema.
118
What are the features of **glycine toxicity**?
* Restlessness
* Headache
* Visual disturbances
* Confusion
* Seizures
* Bradycardia
* Renal impairment
119
Which **nail polish colours** interfere most with pulse oximeters?
* Black
* Blue
* Green
120
Which **electrode configuration** is most sensitive for detecting left ventricular ischaemia?
* CM5
* RA (red) on upper right sternum
* LA (yellow) on V5
* LL on left shoulder
121
Below what **blood pressure** should chest compressions be commenced in intra-operative anaphylaxis as per NAP6?
SBP < 50 mm Hg
122
What are the different phases of **intra-operative hypothermia**?
1. **REDISTRIBUTION**: vasodilation redistributes heat from core to periphery, rapid loss
2. **LINEAR**: ongoing slower heat loss to environment
3. **PLATEAU**: body attempts to restore thermal balance
123
Which group of surgical patients need **active warming**?
> 30 mins
124
What is the **first-line chelator** for lead poisoning?
Dimercaprol
## Footnote
Also used in arsenic, mercury and gold poisoning.
125
How should **MAO inhibitors** be managed in the perioperative period?
Reversible (e.g. moclobemide): omit on day of surgery only.
Irreversible (e.g. phenelzine, isocarboxazid): stop 2 weeks before.
## Footnote
NOTE: The main risk is profound pressor effect when administering sympathomimetics.
126
As per **AAGBI guidelines**, when is processed EEG needed?
Whenever NMBs are administered, throughout all phases of anaesthesia from before the initiation of neuromuscular blockade until recovery of train-of-four to >0.9 has been confirmed.
127
Which **antihypertensives** can be continued on the day of an operation?
All antihypertensives **EXCEPT** those that affect the renin-angiotensin-aldosterone system.
128
What needle is used for a **peribulbar block**?
25 mm, 25 G
129
What are some **causes** of increased airway pressure?
* **ANAESTHETIC**: blockage in circuit, inappropriate ventilator settings, oesophageal intubation
* **SURGICAL**: capnoperitoneum, head down positioning
* **PATIENT**: laryngospasm, bronchospasm, anaphylaxis, aspiration, pulmonary oedema, mucus
130
What are some **potential causes** of intraoperative hypertension?
* **ANAESTHETIC**: inadequate anaesthesia, analgesia or neuromuscular blockade, drug error
* **SURGICAL**: tourniquet, vasopressor administration by surgeon
* **PATIENT**: missed antihypertensives, thyrotoxicosis, phaeochromocytoma
131
Describe how you would set the pacer output for **transcutaneous pacing**.
* Increase pacer output from 60 mA until capture (spikes align with QRS).
* Confirm both electrical AND mechanical capture (femoral pulse).
* Set pacer output at 10 mA above capture.
132
List some causes of **intraoperative bradycardia**.
* **ANAESTHETIC**: remifentanil, digoxin, high intrathoracic pressure, reflex bradycardia (metaraminol), LAST
* **SURGICAL**: capnoperitoneum
* **PATIENT**: previous medications (beta blockers, calcium channel blockers, digoxin)
133
List some causes of **intraoperative tachycardia**.
* **ANAESTHETIC**: inadequate analgesia or anaesthesia, drug error, hypovolaemia, anaphylaxis
* **SURGICAL**: intense stimulation, bleeding, circulatory embolus
* **PATIENT**: primary cardiac arrhythmia, electrolyte disturbance, malignant hyperthermia
134
List some causes of **perioperative hyperthermia**.
* **ANAESTHETIC**: excessive warming, blood transfusion
* **SURGICAL**: sepsis, surgical devices (e.g. diathermy)
* **PATIENT**: neuroleptic malignant syndrome, serotonin syndrome, thyrotoxicosis, malignant hyperthermia, alcohol withdrawal, sympathomimetic syndrome
135
What measures should be taken to actively cool a hyperthermic patient **in theatre**?
* Reduce operating room temperature
* Cooling jackets or blankets
* Ice packing in groin, axillae and anterior neck
* Bladder, gastric or peritoneal lavage with 10 mL/kg iced water
* Benzodiazepines to treat shivering and consider paralysis
* Paracetamol
136
What treatment should be **administered** if serotonin syndrome is suspected?
Chlorpromazine 25-50 mg IM
## Footnote
Because it blocks 5HT-2A receptors.
137
What are some **life-threatening complications** of intra-operative hyperthermia?
* Hyperkalaemia
* Hypoglycaemia
* Acidosis
* Hypotension
* Altered consciousness
* Convulsions
* Coagulopathy and DIC
138
What are the most common causes of **perioperative anaphylaxis**?
* **Antibiotics** (teicoplanin)
* **Muscle relaxants** (suxamethonium)
* **Chlorhexidine**
* **Patent blue dye**
## Footnote
Consider colloids.
139
When should **mast cell tryptase levels** be measured in anaphylaxis?
At onset, 1-2 hours and > 24 hours
140
What **adrenaline infusion** should be used in intraoperative anaphylaxis?
* 5 mg in 500 mL dextrose = 1:100 000, titrate to effect
* 3 mg in 50 mL saline. Start at 3 ml/h-1 (= 3 μg.min-1), titrate to maximum 40 ml/h-1(= 40 μg.min-1)
141
What are the **transfusion goals** in massive intraoperative haemorrhage?
* Hb > 80 g/L
* Platelets > 75
* PT and APTT < 1.5
* Fibrinogen > 1 g/L
## Footnote
Avoid DIC (maintain BP, treat acidosis, avoid hypothermia, treat hypocalcaemia and hyperkalaemia)
142
What are some clinical features of a **fat embolism**?
* Haemodynamic instability (hypotension, tachycardia)
* Hypoxia
* Petechial rash
* Confusion/irritability
143
Outline the management of an **intraoperative air/gas embolism**.
* Stop source of air/gas + discontinue N2O.
* Tell surgeon to flood wound with saline and cover with wet packs.
* Lower surgical field to below level of heart.
* Place patient in left lateral position.
* If CVC in situ, attempt to aspirate air.
* Volume loading and valsalva manoeuvre may help.
144
What measures should be taken to eliminate the trigger in **malignant hyperthermia**?
* Turn off vaporisers and remove from anaesthesia workstation.
* Set FGF to 100% oxygen at maximum flow.
* Hyperventilate (2-3 x minute ventilation).
* Place activated charcoal filters on both limbs of breathing circuit.
* Change soda lime and breathing circuit if feasible.
145
Describe the clinical features of a **high neuraxial block**.
**IN SEQUENCE**
* Hypotension and bradycardia
* Breathing difficulty
* Paralysis of the arms
* Impaired consciousness
* Apnoea and unconsciousness
146
What SpO2, PCO2 and temperature targets should you aim for in the context of **neuroprotection** following cardiac arrest?
SpO2 94-98%
pCO2 4.5-5.5 kPa
Temp 32-36 °C
147
What **IV fluid boluses** should be administered in intraoperative sepsis?
* Adult: at least 30 mL/kg
* Child: at least 20 mL/kg
148
Which **drug therapies** support haemodynamics in **septic shock**?
* **Noradrenaline**: first choice
* **Adrenaline**: added if needed
* **Vasopressin**: 0.03 U/min to reduce NA requirement
* **Dobutamine**: up to 20 µg/kg/min if myocardial dysfunction
* **Hydrocortisone**: if haemodynamic stability not restored.
149
What is the risk of nerve damage with **neuraxial anaesthesia**?
* Temporary: 1 in 1857
* Permanent: 1 in 20,000
* Paralysis: < 1 in 80,000
150
What is the risk of awareness in **general anaesthesia**?
1 in 20,000
With NMB: 1 in 8200
66% occurred during induction or emergence
151
What are some risk factors for **accidental awareness**?
As per NAP5
* Use of NMB
* Obstetric, cardiac, thoracic surgery
* Female sex
* Younger adults (not children)
* Obesity
* Junior anaesthetist
* Emergency/out-of-hours surgery
* Previous AAGA
152
What is the **risk** of anaphylaxis in the perioperative period?
1 in 10,000
153
What is the **risk** of perioperative cardiac arrest?
As per NAP7
1 in 3000
154
What are the most common causes of **intraoperative cardiac arrest**?
* Major haemorrhage
* Bradyarrhythmia
* Cardiac ischaemia
155
What is the first step in managing **paediatric cardiac arrest**?
5 rescue breaths
Then compression-ventilation ratio of 15: 2
156
Which drugs should be given in cases of **shockable paediatric cardiac arrest**?
After 3 shocks give:
* Adrenaline IV/IO 10 µg/kg
(and every alternate cycle thereafter)
AND
* Amiodarone IV/IO 5 mg/kg
(and repeat 5 mg/kg once more only after 5th shock)
157
What are the **different types** of Lundberg waves you'd see on ICP monitoring and what are they suggestive of?
* **Lundberg A**: plateau waves, suggestive of impending herniation (Cushing's reflex)
* **Lundberg B**: rhythmic spikes every 30-120 seconds, cerebral vasospasm
* **Lundberg C**: low amplitude oscillations every 7-15 secs which represent NORMAL central venous homeostasis
158
Which airway devices are commonly used in **ENT surgery**?
* Armoured ETT (kink resistant)
* Ring-Adair-Elwyn tube (north- or south-facing)
* Laser tubes (for laser surgery)
* Flexible LMAs
159
What **measure** is most important in reducing the risk of delivering a hypoxic mixture via a cylinder of entonox?
A dip tube to the bottom of the entonox cylinder will mean the lowest % of oxygen delivered will be 20%.
160
List the **appropriate sizes** of blood pressure cuff for different groups of people.
* 3cm – infant
* 6cm – child
* 9cm – small adult
* 12cm – adult
* 15cm – large adult
161
Outline the **mechanisms** of heat loss from the body in theatre and their relative contributions.
* Radiation (40%)
* Convection (30%)
* Evaporation (15%)
* Conduction (5%)
* Respiratory losses (10%)
162
What are the components of the **Apfel score**?
1. Female sex
2. Non-smoker
3. History of PONV or motion sickness
4. Planned use of post-operative opioids
163
What are some manifestations of **cyanide toxicity**?
* Tachycardia
* Arrhythmia
* Hyperventilation
* Sweating
* Metabolic acidosis
* Rising venous oxygen saturations
164
What **type of blade** should be used to intubate a 1 year old?
Infants have a floppy V shaped epiglottis so a straight blade is advanced over the posterior aspect to lift the epiglottis.
Wisconsin is an example of a straight blade (similar to Miller).
165
What should **blood pressure** in the community be controlled to prior to having an operation?
< 160/100 mm Hg
Primary FRCA
flashcards
Decks in class (17)
# Cards
-
Anatomy for Anaesthesia223
-
Physiology: Respiratory303
-
Physiology: Cardiovascular179
-
Physiology: Renal, Hepatic & GI63
-
Physiology: Neuro, Endo, & Haem237
-
Pharmacokinetics and Pharmacodynamics213
-
Pharmacology: Inhalational & Intravenous Agents232
-
Pharmacology: Analgesics & Muscle Relaxants160
-
Pharmacology: Emergency & Miscellaneous Drugs251
-
Part 1: Physics & Equipment242
-
Part 2: Physics & Equipment227
-
Part 3: Physics & Equipment232
-
Part 4: Physics & Equipment217
-
Statistics & Evidence-Based Practice36
-
Part 1: Applied Clinical Anaesthesia165
-
Part 2: Applied Clinical Anaesthesia169
-
Part 3: Applied Clinical Anaesthesia157
