Made Up 10 - WordPress.com · 2017-02-17 · Assembled by M Ku Mega SAQs - 1 Table of Contents Made...
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Assembled by M Ku Mega SAQs - 1 Table of Contents Made Up ......................................................................................................................... 10 Maplesons vs circle .................................................................................................................. 10 Scavenging + volatile hazards ................................................................................................... 11 Cerebral perfusion monitors..................................................................................................... 12 Substance abuse welfare policy setup ...................................................................................... 13 Substance abuse scenario management ................................................................................... 13 Colleague impaired by stress discussion ................................................................................... 14 Dealing with patient complaint ................................................................................................ 14 Sexual Harassment ................................................................................................................... 15 Palliative Care Pearls ................................................................................................................ 16 CRPS Pearls .............................................................................................................................. 16 Non-Pharm pain treatment: ..................................................................................................... 16 Carcinoid syndrome ................................................................................................................. 16 Chemotherapy info: ................................................................................................................. 16 Cardiac Drug recipe .................................................................................................................. 17 Remifentanil PCA ..................................................................................................................... 18 Phil Quinn’s SAQ session – 2016 ...................................................................................... 19 Q1 – acute porphyria ................................................................................................................ 19 Q2 – TCA overdose ................................................................................................................... 21 Q3 – Environmental impact of anaesthesia............................................................................... 21 Q4 – lung isolation discussion (repeat) ..................................................................................... 23 Q5 – thoracic paravertebral block (repeat) ............................................................................... 23 Q6 – Anorexia nervosa (repeat) ................................................................................................ 23 Q7 – PONV (repeat) .................................................................................................................. 24 Q8 – CSWS/SIADH discussion ................................................................................................... 25 Q9 – Spinal cord blood supply (repeat) ..................................................................................... 26 Q10 – PICC line discussion (repeat) ........................................................................................... 26 Eddie Coates’ SAQ session – 2016 .................................................................................... 26 Q1 – High risk extubation ......................................................................................................... 26 Q2 – Emergence delirium (repeat) ............................................................................................ 27 Q3 – Mastectomy analgesia (repeat) ........................................................................................ 27 Q4 – Bullying ............................................................................................................................ 27 Q5 – HELLP, obs emergency, difficult airway............................................................................. 28 Q6 – 3 chambered chest drain (repeat)..................................................................................... 29 Q7 – prone discussion in neurosurgery (repeat) ....................................................................... 29 Q8 – DVT prophylaxis (repeat) .................................................................................................. 29 Q9 – Paeds regional, upper limb ............................................................................................... 29 Q10 – AS periop management (repeat)..................................................................................... 30 Q11 – Anorexia nervosa (repeat) .............................................................................................. 30 Q12 – PACU requirement ......................................................................................................... 30 Q13 – ARDS (repeat)................................................................................................................. 31 Q14 – Premptive, preventative analgesia (repeaet) .................................................................. 31 Q15 - HIT .................................................................................................................................. 31 Sam Paul’s SAQ session – 2016 ........................................................................................ 32 Q1- OSA/OHS ........................................................................................................................... 32 Q2- scleroderma discussion ...................................................................................................... 34
Transcript of Made Up 10 - WordPress.com · 2017-02-17 · Assembled by M Ku Mega SAQs - 1 Table of Contents Made...
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MegaSAQs-1
TableofContents
MadeUp.........................................................................................................................10Maplesonsvscircle..................................................................................................................10Scavenging+volatilehazards...................................................................................................11Cerebralperfusionmonitors.....................................................................................................12Substanceabusewelfarepolicysetup......................................................................................13Substanceabusescenariomanagement...................................................................................13Colleagueimpairedbystressdiscussion...................................................................................14Dealingwithpatientcomplaint................................................................................................14SexualHarassment...................................................................................................................15PalliativeCarePearls................................................................................................................16CRPSPearls..............................................................................................................................16Non-Pharmpaintreatment:.....................................................................................................16Carcinoidsyndrome.................................................................................................................16Chemotherapyinfo:.................................................................................................................16CardiacDrugrecipe..................................................................................................................17RemifentanilPCA.....................................................................................................................18
PhilQuinn’sSAQsession–2016......................................................................................19Q1–acuteporphyria................................................................................................................19Q2–TCAoverdose...................................................................................................................21Q3–Environmentalimpactofanaesthesia...............................................................................21Q4–lungisolationdiscussion(repeat).....................................................................................23Q5–thoracicparavertebralblock(repeat)...............................................................................23Q6–Anorexianervosa(repeat)................................................................................................23Q7–PONV(repeat)..................................................................................................................24Q8–CSWS/SIADHdiscussion...................................................................................................25Q9–Spinalcordbloodsupply(repeat).....................................................................................26Q10–PICClinediscussion(repeat)...........................................................................................26
EddieCoates’SAQsession–2016....................................................................................26Q1–Highriskextubation.........................................................................................................26Q2–Emergencedelirium(repeat)............................................................................................27Q3–Mastectomyanalgesia(repeat)........................................................................................27Q4–Bullying............................................................................................................................27Q5–HELLP,obsemergency,difficultairway.............................................................................28Q6–3chamberedchestdrain(repeat).....................................................................................29Q7–pronediscussioninneurosurgery(repeat).......................................................................29Q8–DVTprophylaxis(repeat)..................................................................................................29Q9–Paedsregional,upperlimb...............................................................................................29Q10–ASperiopmanagement(repeat).....................................................................................30Q11–Anorexianervosa(repeat)..............................................................................................30Q12–PACUrequirement.........................................................................................................30Q13–ARDS(repeat).................................................................................................................31Q14–Premptive,preventativeanalgesia(repeaet)..................................................................31Q15-HIT..................................................................................................................................31
SamPaul’sSAQsession–2016........................................................................................32Q1-OSA/OHS...........................................................................................................................32Q2-sclerodermadiscussion......................................................................................................34
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MegaSAQs-2
Q3-Paediatricgeneralmanagementplanning(repeat).............................................................36Q4-nutritionassessment.........................................................................................................36Q5-IABPdiscussion(repeat)....................................................................................................37Q6-MyastheniaGravisdiscussion(repeat)...............................................................................37Q7-premeddiscussion(repeat)................................................................................................38Q8-pacemakerdiscussion(repeat)...........................................................................................38Q9-Venousairembolism(repeat)............................................................................................38Q10-POCD(repeat)..................................................................................................................38Q11-Fatigue.............................................................................................................................38Q12-Unexpecteddeathmanagement......................................................................................39Q13-postpartumheadache......................................................................................................40Q14-brainstemdeathphysiologicalimplication(repeat)..........................................................40Q15-post-hearttransplantissues(repeat)...............................................................................40
April-2016,57.7%............................................................................................................40Q1-weaknessafterTKJR,spinal,FNB(repeat),71%.................................................................40Q2-myotonicdystrophydiscussion(repeat),65%....................................................................40Q3-safetyfeatureofanaestheticmachine(repeat),65%.........................................................40Q4-LungisolationtechniqueinL/pneumonectomy(repeat),66%............................................41Q5-remifentanildiscussion(repeat),66%................................................................................41Q6-spinalcordischaemiainEVAR(repeat),68%......................................................................41Q7-braininjuryissuesandriskminimization(repeat),72%......................................................41Q8-pyloricstenosis(repeat),80%............................................................................................41Q9-oxygendeliverydevice(repeat),62%.................................................................................41Q10-pulmHTNdiscussion(repeat),77%..................................................................................41Q11-smokingcessationstrategy,79%......................................................................................42Q12-Brainstemdeathphysiology,25%....................................................................................42Q13-ECTphysiology(repeat),58%...........................................................................................42Q14-hypertensionmanagement(repeat),80%........................................................................43Q15-preopanaemiamanagement(repeat),67%.....................................................................43
October-2015,61.4%.......................................................................................................43Q1–upperlimbregional..........................................................................................................43Q2–hearttransplant...............................................................................................................44Q3–bloodconservation..........................................................................................................46Q4–TrigeminalNeuralgia........................................................................................................47Q5-awareness.........................................................................................................................48Q6–OSAinPaedAsTs..............................................................................................................49Q7–intraarterialinjectionmanagement..................................................................................50Q8-anaphylaxis.......................................................................................................................52Q9=CVLaccess........................................................................................................................52Q10–NIMtubeinparathyroidectomy.....................................................................................53Q11–Postendarterectomycomplication.................................................................................54Q12–chronicalcoholism.........................................................................................................55Q13-ERAS...............................................................................................................................55Q14–Hyperkalaemiainburn...................................................................................................57Q15–Tranexamicacid.............................................................................................................58
April-2015,71.9%............................................................................................................59Q1–Thoracicparavertebralblock,66.3%.................................................................................59Q2–PONV,58.5%....................................................................................................................61Q3–Pericardialeffusionmanagement,82.9%..........................................................................62Q4–sepsismanagement,38.3%..............................................................................................62
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MegaSAQs-3
Q5–Statistics,trialdesign,98.4%............................................................................................64Q6–collapsepostNVD,71.5%.................................................................................................65Q7–ChronicPainmanagementpostop,(repeat)74.6%...........................................................66Q8–penetratingeyeinjurymanagement,56.5%.....................................................................67Q9–Prolongedunconsciousnesspostop,83.4%.......................................................................68Q10–Parkinsonsmanagement,69.9%.....................................................................................70Q11–difficultairwayANZCAPD,77%......................................................................................72Q12–VTE/DVTprophylaxis,83.4%..........................................................................................73Q13–advanceddirectives,ethics,78.8%.................................................................................74Q14–spinalcordtraumamanagement,34.7%.........................................................................75Q15–preoxygenation;highFiO2usejustification,83.4%.........................................................76
Oct-2014,35.9%..............................................................................................................77Q1–Neonatalmanagementpolicy,45.8%...............................................................................77Q2–TBI,ICPmanagement,86.1%............................................................................................78Q3–prolongedTrendelenburg,59%........................................................................................79Q4–Dabigatranmanagement,53%.........................................................................................80Q5–CPETprinciple,48.5%.......................................................................................................81Q6–Fatembolism,31.9%........................................................................................................82Q7–EVARrenalprotection(repeat),42.2%.............................................................................83Q8–CHD,Fontancirculation,31.9%........................................................................................83Q9–MyastheniaGravis,69.9%................................................................................................85Q10–desaturationinPACU,43.4%..........................................................................................87Q11–Statistics,RCT,60.2%......................................................................................................88Q12–hypomagnesaemia,55.4%..............................................................................................88Q13–3chamberUWSD,9%.....................................................................................................90Q14–Lasersafety+notesonlaser,80.7%...............................................................................91Q15–FNB,69.3%.....................................................................................................................92
May-2014,53.1%.............................................................................................................93Q1-DiscussionofT-pieceJRmodification(repeat),23.3%........................................................93Q2–cardiacelectrophysiologyanaesthesia,55.3%..................................................................93Q3-QAtoimproveefficiencyinOT,65.8%...............................................................................93Q4-AFbridging,60.3%.............................................................................................................93Q5-Bariatricsurgeryairway,hypoxiaminimisation,87.2%......................................................94Q6-postopMIdiscussion,57.1%..............................................................................................94Q7-CVL,CLABbundlediscussion,43.4%...................................................................................94Q8-Thoracicepiduraldiscussion,71.2%...................................................................................95Q9-issueofpneumoperitoneum,96.8%...................................................................................95Q10-bloodproductmanagementinOT,55.7%........................................................................95Q11-Freeflapcirculationdiscussion,61.6%.............................................................................95Q12-Beachchariposition(repeat),44.3%................................................................................96Q13-acromegalydiscussion,77.2%..........................................................................................96Q14-acid/baseanalysis,discussion,59.4%...............................................................................96Q15-persistentpostsurgicalpain(repeat),85.8%....................................................................96
Oct-2013,36.6%..............................................................................................................96Q1-PeriopmxofACEi+metformin,68.1%...............................................................................96Q2-stats,definitions,26.9%.....................................................................................................97Q3-SVVdiscussion,42.9%........................................................................................................97Q4-QAtominimizeintraopdrugerrors,81.9%........................................................................97Q5-Anatomyofforearm,wrist,57.7%.....................................................................................98Q6-ABGdiscussioninvascularsurgery,71.4%.........................................................................99
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MegaSAQs-4
Q7-tourniquetdiscussion,33.5%.............................................................................................99Q8-Mediastinoscopyformediastinalmass,72.4%...................................................................99Q9-penetratingeyeinjurydiscussion,IOP,46.2%..................................................................100Q10-cerebralpalsydiscussion(repeat),57.7%.......................................................................100Q11-tramadoldiscussion,24.7%............................................................................................100Q12-POCD,46.7%..................................................................................................................100Q13-PETdiscussion,69.2%....................................................................................................102Q14-VAPdiscussion,28%......................................................................................................102Q15-C5-6quadriplegiadiscussion,75.3%...............................................................................102
May-2013,50%..............................................................................................................102Q1-MILIofneckdiscussion,68.3%.........................................................................................102Q2-Safetyfeatureofgasdeliveryinmachine(repeat),28.3%................................................103Q3-arteriallinediscussion,69.3%..........................................................................................103Q4-airwayneuroanatomy,nasalintubation85.1%................................................................103Q5-epilepsy,53.5%................................................................................................................104Q6-managementof‘unknownsevereallergy’,37.1%............................................................105Q7-morbidobesityobstetriccare,52%..................................................................................105Q8-acuteneuropathicpain,75.2%.........................................................................................105Q9–evidencebasedmedicine,53%.......................................................................................105Q10-hypothermiaprevention,66.8%.....................................................................................106Q11-systolicmurmurassessment,52.5%...............................................................................106Q12-pronediscussion(repeat),37.6%...................................................................................106Q13-hypoxaemiainOLV(repeat),71.8%...............................................................................106Q14-LAST,67.3%...................................................................................................................106Q15-preopanaemiamanagement,66.8%..............................................................................107
Oct-2012,27.5%............................................................................................................107Q1-painmanagementinelderlydementia(repeat),37.6%....................................................107Q2-DAPTandDESdiscussion,63.8%......................................................................................108Q3-weaningfromcardiopulmonarybypass,59.1%................................................................108Q4-aorticstenosis,49.7%......................................................................................................108Q5-strabismussurgeydiscussionindaysurgery,74.5%.........................................................108Q6-surgicalsafetychecklist,43.6%........................................................................................109Q7-TPNdiscussion,34.9%......................................................................................................110Q8-generalconsentdiscussion,51%......................................................................................110Q9-MRIissuesindevelopmentalldelayedpt,63.1%..............................................................110Q10-traumainducedcoagulopathy,63.8%............................................................................110Q11-peripartumcardiomyopathydiscussion,13.4%..............................................................110Q12-TAPregionalblockdiscussion(repeat),30.2%................................................................110Q13-issuesoflargetonsillarmass,69.8%...............................................................................111Q14-statisticsdefinition(repeat),53%...................................................................................111Q15-awarenessandBIS,50.3%..............................................................................................111
April-2012,61.5%..........................................................................................................112Q1-serotoninsyndrome,59.9%.............................................................................................112Q2–Beachchairposition(repeat),50.5%...............................................................................112Q3–Oliguria,72%..................................................................................................................112Q4-Ethicsinincompetentpatient,79.1%...............................................................................113Q5-spinalblockdiscussion,63.2%..........................................................................................114Q6-Bronchopleuralfistulamanagement,59.9%.....................................................................114Q7–ICPassessment/monitor,64.8%...................................................................................115Q8-thyroiddisease,thyroidstormmanagement,84.1%........................................................116
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MegaSAQs-5
Q9–Paediatricairwayobstruction,72.5%.............................................................................117Q10-ARDSdiscussion(repeat),70.9%....................................................................................118Q11-PCAservicesettingup,59.9%........................................................................................119Q12-epiduralanatomy,64.8%...............................................................................................120Q13-strokeminimization,61.5%............................................................................................121Q14-universalprecautions(repeat),76.4%............................................................................122Q15-oxygendeliverydevice,32.4%.......................................................................................123
Oct-2011,24%...............................................................................................................124Q1-oxygendeliverydevice,5%..............................................................................................124Q2-CriticalappraisalofRCT(repeat),65%.............................................................................124Q3-RBCsalvagediscussion,55%............................................................................................125Q4–Duralpuncture,60%.......................................................................................................126Q5–CVLinsertionavoidingtamponade,46%.........................................................................127Q6–HighICPanaesthesiamanagement,59%........................................................................127Q7–visuallosscomplication,62%.........................................................................................128Q8-URTIpaediatric,76%........................................................................................................129Q9–ALI,26%.........................................................................................................................130Q10-buprenorphinepatch,33%.............................................................................................131Q11-qualityassurance,57%...................................................................................................132Q12-regionalfortibialplateaufracture,73%.........................................................................133Q13-hypernatreaemiamanagement,40%.............................................................................133Q14-MImanagement,39%....................................................................................................135Q15–VTEprophylaxis(repeat),30%......................................................................................136
April-2011,32%.............................................................................................................136Q1-dexamethasonediscussion,90%......................................................................................136Q2-pulmonaryfibrosisdiscussion,46%..................................................................................137Q3-professionalattributesofananaesthetist,26%...............................................................137Q4-albumindiscussion,11%..................................................................................................138Q5-post-LSCSnumbness,77%................................................................................................139Q6-VFmanagement(repeat),55%.........................................................................................140Q7–VAEmanagement,53%..................................................................................................141Q8-cricothyroidotomydiscussion,55%..................................................................................141Q9-paediatricmurmurdiscussion(repeat),67%....................................................................142Q10-AKIdiscussion,52%........................................................................................................143Q11-Codeinediscussion,50%................................................................................................144Q12–residualNMBcomplication/assessment,55%.............................................................144Q13-Systemipreventionofpowerfailure,35%......................................................................145Q14-QTprolong,31%............................................................................................................146Q15-ANSneuropathyindiabetes(repeat),47%.....................................................................147
Oct-2010,51.8%............................................................................................................147Q1-hypothermiaconsequenceandmanagement,74.1%.......................................................147Q2-Spinalcordbloodsupply;ischaemiariskminimization,67.6%..........................................148Q3-chronicliverdisease/alcoholismdiscussion,71.2%........................................................149Q4-suprglotticairwayobstructionmanagement,64.7%........................................................149Q5-Paediatricdehydration,fluidmanagement,65.5%...........................................................150Q6-criticalappraisalofresearch,23%....................................................................................152Q7-pacemakerdiscussion,90.6%...........................................................................................153Q8-ACLSinpregnancy,55.4%................................................................................................154Q9–persistentpostoppain(repeat),54.7%...........................................................................154Q10-dentaldamagecomplication,79.9%...............................................................................155
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MegaSAQs-6
Q11-mitralregurge,pulmHTNdiscussion,57.6%...................................................................156Q12-GALAforcarotidendarterectomy,75.5%.......................................................................157Q13-Diabeticketoacidosismanagement,75.5%....................................................................158Q14-anaestheticassistantresponsibilities,40.3%..................................................................158Q15-pulmonaryfunctiontest,flowvolumeloop,EtCO2discussion,51.8%............................159
April-2010,50%.............................................................................................................159Q1-tourniquetusediscussion,66.3%.....................................................................................159Q2–Proneposition(repeat),22.9%.......................................................................................160Q3–Morbidobesitylaparoscopy,63.3%................................................................................160Q4-anaemia,transfusiontriggerdiscussion,42.2%................................................................161Q5-Myotonicdystrophydiscussion,52.4%.............................................................................161Q6-HOCMdiscussion,67.5%..................................................................................................163Q7–SAHmanagementcoiling,62.7%....................................................................................164Q8-subtenonblockdiscussion,83.7%....................................................................................165Q9-emergenceagitationdiscussion,61.4%............................................................................166Q10-inhalationalinjurydiscussion(repeat),34.3%................................................................167Q11-opioiddependence,chronicpainmanagement,76.5%...................................................168Q12-qualityassuranceprogram(repeat),51.2%....................................................................169Q13-Universalprecautionsdiscussion(repeat),65.7%...........................................................169Q14-WPW/VFdiscussion,84.9%............................................................................................169Q15–preoxygenation(repeat),56.6%...................................................................................169Q1-clopidogrelandstentdiscussion,32.9%...........................................................................170Q2-glycaemiaccontroldiscussion,69.6%...............................................................................171Q3–SOBinPACUdifferential;residualNMB,24.8%..............................................................171Q4-CPRmetabolicconsequencediscussion,59%...................................................................172Q5-Analgesiapregnancysafety,65.8%..................................................................................173Q6CXRstructure,36%............................................................................................................174Q7-Remifentanilinfusiondiscussion,37.3%...........................................................................175Q8-oxygenfluxfactorsdiscussion,62.7%...............................................................................176Q9-Endocarditisprophylaxis(repeat),60.9%.........................................................................177Q10-defibrillationphysiology,47.8%.....................................................................................177Q11-Ethics,researchreview,46.6%.......................................................................................178Q12-ImportantPaedsairwayconsiderations,54.7%..............................................................179Q13-morbidobesityobstetricdiscussion,49.1%....................................................................180Q14-smokingcessation,49.1%..............................................................................................180Q15–Neuroprotectioninheadinjury,64.6%.........................................................................181
April-2009,30.2%..........................................................................................................181Q1-Universalprecautionandapplication(repeat)36.1%.......................................................181Q2-requirementforsafegasdelivery,48%............................................................................181Q3–MalignantHyperthermia,81.2%.....................................................................................182Q4-Axillaryblockdiscussion,40.1%.......................................................................................183Q5-Parkinsonsmanagement(repeat),63.9%.........................................................................184Q6–Pneumoperitoneumphysiology,62.4%..........................................................................184Q7-coagulopathyinliverrupture,trauma,MTP&management,35.1%................................185Q8-amnioticfluidembolismmanagement,86.6%..................................................................186Q9–periopbetablockerinitiation,43.1%...............................................................................186Q10-BronchialanatomyforDLTplacement,70.8%................................................................187Q11-SAHclippingmanagement,56.4%..................................................................................187Q12-respiratorydistresspostthyroidsurgery,63.4%.............................................................188
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MegaSAQs-7
Q13-establishingpaedssurgeryserviceinlocalhospital,13.9%.............................................189Q14-chronicpain,methadoneconversion,35.6%..................................................................189Q15-statistics,samplesizediscussion,65.8%.........................................................................190
Oct-2008,50%...............................................................................................................191Q1-safetyfeatureofvaporizer,43%......................................................................................191Q2-lowerantwallregionalblock(repeat),57%.....................................................................192Q3–venousairembolism(repeat),91%................................................................................194Q4-safehandovertocolleague,63%.....................................................................................194Q5–PeriopVTEprophylaxis(repeat),45%.............................................................................195Q6-meningococcalsepsismanagement,71%.........................................................................195Q7-cerebralpalsymanagement(repeat),31.5%....................................................................195Q8-preeclampsiamanagement,61%.....................................................................................196Q9-peribulbarblock,78%......................................................................................................196Q10-cerebralvasospasmmanagement,66.7%.......................................................................197Q11-chronicpaindevelopment,53%.....................................................................................198Q12–IABPdiscussion,59%....................................................................................................199Q13-statistics,definitions,53%..............................................................................................200Q14-impairedcolleague(repeat),69%...................................................................................201Q15-OSAmanagement,86%..................................................................................................202
May-2008,47%..............................................................................................................202Q1-Oxygenstorageanddeliverydescription,52%.................................................................202Q2–RAarteriallineevaluation,complication,69%................................................................203Q3-interscaleneregional,49%...............................................................................................204Q4-Fatembolismsyndrome,73%..........................................................................................205Q5-intrathecalmorphinediscussioninTKJR,48%..................................................................205Q6-hyponatreaemiamanagement,53%................................................................................206Q7-antplacentapraeviamanagement,59%..........................................................................207Q8-neonatalresus,56%.........................................................................................................207Q9-laserairwaysurgery(repeat),70%...................................................................................208Q10–AICD/Biventpacingmanagement,62%........................................................................209Q11-murmurinchilddiscussion(repeat),67%.......................................................................209Q12-transphenoidalsurgeryforacromegaly(repeat),52%....................................................209Q13-Gabapentinasanalgesia,32%........................................................................................209Q14-Multi-centeredtrialdiscussion,61%..............................................................................210Q15-MRIdiscussion,65%.......................................................................................................211
Sep-2007,45%...............................................................................................................212Q1-macroshockprevention,40%...........................................................................................212Q2-chestdraindiscussion,88%.............................................................................................213Q3-guidelineforepiduralabscessriskminimisation,64%.....................................................214Q4-blunttraumatoheart,72%.............................................................................................214Q5-beachchairdiscussion,36%.............................................................................................215Q6-shockdiscussion,61%......................................................................................................216Q7-asthmaventilationstrategy,75%.....................................................................................216Q8-labourepiduralmanagement,73%.................................................................................217Q9-aprotinindiscussion,28%................................................................................................217Q10-SCbloodsupplyanddeterminants(repeat),21%...........................................................218Q11-Daysurgerydentalmanagement,84%...........................................................................218Q12-pyloricstenosisdiscussion,64%....................................................................................219Q13-regionalpoplitealblockforfoot/ankle,67%..................................................................220Q14-ethicsofplacebo,38%...................................................................................................220
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MegaSAQs-8
Q15-flowvolumeloopinairwayobstruction,47%................................................................221
May-2007,52%..............................................................................................................221Q1-ARDSventilationstrategies(repeat),82%........................................................................221Q2-regionalforinguinalherniarepair,34%...........................................................................221Q3-sodalimediscussion,42%...............................................................................................221Q4-paedburnpain/fluidmanagement,58%.........................................................................222Q5-SvO2discussion,36%......................................................................................................224Q6-NMTdiscussion,77%......................................................................................................225Q7-riskevaluationforpneumonectomy,69%.......................................................................225Q8-ECGuseinIHDmonitor,55%...........................................................................................226Q9-T-piecediscussion,68%....................................................................................................227Q10–Trifascicularblock,completeheartblock,53%.............................................................228Q11-Informedconsent,52%..................................................................................................228Q12–bedsideairwayassessment,77%..................................................................................229Q13-ACLS,VF(repeat)59%.....................................................................................................230Q14-flowoptimizationinmicrovascularsurgery,34%...........................................................230Q15-braindeathdiagnosis,72%............................................................................................231
Sep-2006,42%...............................................................................................................232Q1–LMAinlaparoscopy,81%...............................................................................................232Q2-paravertebralblock,55%.................................................................................................232Q3-clamping/unclampingaortamanagement,57%...............................................................233Q4-phantomlimbpain,66%..................................................................................................234Q5-LMWH&epidural,19%....................................................................................................234Q6-renalfailureelectrolytediscussion,45%..........................................................................235Q7-duralpuncturemanagement(repeat),28%......................................................................235Q8-neuroprotectionprinciples(repeat),45%.........................................................................235Q9-Nitrousoxidediscussion,68%..........................................................................................235Q10-RSIinchild,46%.............................................................................................................236Q11–periopbetablokeruse(repeat),47%............................................................................237Q12-Ketaminediscussion,56%..............................................................................................237Q13–CVLrisk,70%................................................................................................................238Q14-F7adiscussion,36%.......................................................................................................239Q15-ASAdiscussion,45%......................................................................................................239
May-2006,62%..............................................................................................................240Q1–Aspirationprophylaxis,87%...........................................................................................240Q2–IVdrugerrorprevention,39%........................................................................................240Q3-DMmanagement,75%....................................................................................................241Q4-NSAIDuse,77%...............................................................................................................242Q5-MyastheniaGravis(repeat),73%....................................................................................242Q6–smokeinhalationmanagement,57%..............................................................................242Q7–restlessinTURP,89%.....................................................................................................243Q8–pacemakermanagement(repeat),86%..........................................................................244Q9-Bupivacainetoxicity,56%................................................................................................245Q10-peribublareyeblockanatomy,33%..............................................................................245Q11-Carotidendarterectomymanagement,77%...................................................................246Q12–AFcausesandmanagementinPACU,71%....................................................................246Q13–preoxygenation(repeat),25%......................................................................................247Q14-Desfluraneuse,73%.......................................................................................................247Q15-epiduralanalgesiaconsent,62%....................................................................................248
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MegaSAQs-9
Sep-2005,62%...............................................................................................................248Q1-croup,paedsmanagement,76%.....................................................................................248Q2-Statistics,biasreduction,72%..........................................................................................249Q3-ANSneuropathymanagementinDM,36%......................................................................250Q4-CrVanatomyforLA/dental,44%.....................................................................................250Q5–LMAuseinlaparotomy,94%..........................................................................................252Q6-Anaesthesiaandthermoregulation,59%.........................................................................253Q7–Latexallergy,46%..........................................................................................................253Q8–Pneumothoraxmanagement,61%.................................................................................254Q9-Postopvisitpurpose,63%................................................................................................255Q10–Cardioversioninintraoparrhythmias,38%...................................................................255Q11–HFassessment,66%.....................................................................................................256Q12–upperlimbnerveinjury,59%........................................................................................257Q13-Ethicsre:discontinuetreatmentsupply,49%.................................................................257Q14-Ethicsre:alternativemedicineuse,52%........................................................................258Q15-ECT,70%........................................................................................................................259
May-2005,44%..............................................................................................................260Q1-Nimodipineinaneurysm,37%.........................................................................................260Q2–DVTprophylaxis(repeat),76%.......................................................................................260Q3-RIJanatomy,62%.............................................................................................................260Q4-PCAdiscussion,21%........................................................................................................261Q5-fluidoptioncomparison,48%..........................................................................................262Q6-PACvsTOEcomparison,85%...........................................................................................262Q7–failuretoemergefromGA(repeat),78%........................................................................263Q8-Circlebreathingsystem,49%...........................................................................................263Q9-Antiemetic,61%...............................................................................................................264Q10-Proneposition(repeat),47%..........................................................................................265Q11-epiduralabscessmanagement,47%...............................................................................265Q12-CasereportsinEBM,39%..............................................................................................266Q13-assessingthyroidfunctionclinically,70%.......................................................................267Q14-impairedcolleague,(repeat)63%...................................................................................267Q15-Intraopbloodsalvage(repeat),54%...............................................................................267
Sep-2004.......................................................................................................................267Q2–visuallos........................................................................................................................267Q3-Whataretheproblemsofusingthebeachchairpositionforshouldersurgery?(repeat).268Q7-Diabetesinsipidus............................................................................................................268Q8-regionalankleblock.........................................................................................................268Q9-Bier’sblockdicussion.......................................................................................................269Q11–cardiacscanutility........................................................................................................269Q12-chronicimpairedcolleague............................................................................................270
May-2004......................................................................................................................270Q1–MImanagement(repeat)...............................................................................................270Q6-Acuteherpeszoster.........................................................................................................270Q7-Pros/consofsubtenonsblock(repeat).............................................................................271Q11-renalprotectioninAAA.................................................................................................271Q12-NLS(repeat)...................................................................................................................272Q13-neonatalventilatorcharacterestics................................................................................272
Sep-2003.......................................................................................................................273Q15-DLTpositioncheck.........................................................................................................273
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Sep-2002.......................................................................................................................274Q4-Bowelprepdiscussion.....................................................................................................274Q14–MIinvestigationsdiscussion.........................................................................................275
May-2002......................................................................................................................275Q14-ECTanaestheticrisks(repeat)........................................................................................275
Sep-2001.......................................................................................................................275Q12-TBI,fixeddilatedpupilmx..............................................................................................275
May-2001......................................................................................................................276Q1–ClinicalassessmentofCHF(repeat)................................................................................276Q2–VTEprophylaxis(repeat)................................................................................................276Q3–intraoppulmoedemamanagement...............................................................................276
Aug-2000.......................................................................................................................277Q1-lungisolationmethoddiscussion.....................................................................................277Extra:Comparelungisolationmethods..................................................................................278Q2-DLTpositioncheck(repeat)..............................................................................................279Q3-hypoxaemiaunderOLV....................................................................................................279
Jul98.......................................................................................Error!Bookmarknotdefined.
Apr98............................................................................................................................280
MadeUp
Maplesonsvscircle
Whattypesofbreathingsystemwouldyouuseforapatientthathashypoxia?
• MapA=mostefficienttopreventrebreathduringSV.;
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o FGFrequired=ie~1xminuteventilation.80ml/kg/min.
o ButalsoworstwIPPV,need3xMVtoavoidrebreath.
o AlsoArarelyusednow,souseD=AwithAPL,FGFreversed.
§ DefficientinIPPV(require1MVFGF),asFGFforcesexpiredair
awayfromptsominimisesrebreathing.
NB:
ABC=APLclosetopt’send;DEF=‘Tpiecegroup’.
o ABCrarelyusednow(C=Bag/mask)
o DEFcommonlyused.
o D(Bainmodification=containadditionaltubeinsidereservoirtube,supplying
FGFtopt.)
o Potentialproblemofunrecognisedkinking/disconnectionofFGFtube.
E=Ayre’sTpiece:
o needFGF2xMVtopreventrebreathinginSV;
o min3L/minwIPPV.
o Reservoirtubeneedstobe>TVinvolumetoprevententrainmentofroomair.
F=Jackson-Reesmodification–
o mostlyusedforpaeds<20kg
o Openbagonendofcircuit(allowsIPPVbyocclusion).
o ReservoirshouldbesamevolumeasTV,asiftoosmallàentrainroomair,iftoo
largeàrebreath.
o Pros:compact,inexpensive,novalves,minimaldeadspace/resistance,portable,
BMV,simplesetup
o Cons:HighFGF.ImportantonestoknowareD,E,F,circle.
MaplesonvsCircle:Mapleson:• Disadvantge:
o NoCO2absorption
o HighFGFrequired–wasteofVA,pollution;
o Lossofptheatandmoisture;nohumidification
• Advantage:o Nounidirectionalvalvetoreduceflowresistance.
o Lightweight,inexpensiveandsimple.
Circle:o Pros:goodforitsscavenging,economy,heat/moistureconservation.
o Cons:Butnogoodforbeingcomplex(soriskofdisconnection),bulky,less
portable,reabreathingofexpiredgasifnoCO2absorber.
9components:o FGF,APL,tube,unidirectionalvalve,Y-piece,reservoirbag,vaporiser,ventilator,
CO2absorber
• Circlemaybeclosedorsemi-closed.
Scavenging+volatilehazards
Tellmeaboutscavengingsystems... • =collectionandsubsequentremovalofwastegasesfromOT
• 5componenets:
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o Exhaustport:APL/ventilator/expiratoryvalveàtransfersystem
o Transfersystem:carrywasteàreceivingsystem
o Receivingsystem:reservoir;scavengingtypicallyat80L/mintoremoveall
expiredwastedgas.
§ Hasflowindicator/controlinplace.
§ Valveincludedtopreventhigh/lowPdeveloping
o Disposalsystem:airpumptoexterior
§ Pressureregulatedsoexhaustportsdon’tgetaffected
o Exterior
• EfficientOTventilationneed15airchanges/hour,topreventaccumulation.
Extra:Hazardsofanaestheticgaspollution:
• Prevoldstudiessuggested:o ?spontaneousmiscarriage,congenitalanomalies,hepaticdx,cervicalCa,
loweredpsychomotorperformance.
o Butresultsconsideredinvalidaserroneousstudydesign.
• ASAreviewin1999:concluded‘noproofofAE’.
• ButN2Oabaddie.
o Haem,neurotoxicitylongtermexposure.
o Teratogenecityinanimalstudies;avoidusein1sttrim;
o Greenhouseeffect.
§ irreversibleoxidisationofcobaltinVitaminB12(aco-factorfor
methioninesynthetase)–inhibitionofDNAsynthesisandmyelin
formation.
• <1:1000ppm(0.1%)isok.SoproblemrarelyseeninmodernOT.
Cerebralperfusionmonitors
Evaluatemethodsformonitoringofcerebralperfusion,duringelectivecarotid
endarterectomy.
Cerebralperfusionismeasured,particularlyduringclampingof1carotidarterytoassess
cerebralcirculationismaintainedfromcollateralcirculation.Ifthereissignofcerebral
circulationcompromise,ashuntplacementshouldbeconsidered.
Techniques:• awake
• stumppmeasure
• cerebraloximetry(NIRS)
• TCD
• EEG(incldBIS/Entropy)
• Jugvenousoximetry
• SystemicBPassurrogate
• options to measure cerebral ischaemia: (Adam + Auckland notes compiled below) o TCA - monitors flow & emboli, continuous, non-invasivie; Operator dependant & can be difficult to get views, limited evidence/experience o NIRS - frontal lobe sensors, continuous, easy to use; poor +ve predictive value/sensitivity/specificty/intervention thresholds not
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established o SSEPs. Thought more sensitive & specific than EEG. GA can alter signal, intermittent nature o EEG - 16ch EEG = Gold standard; partial ones only reflects localised cortical structures.
cannot see emboli, difficult to read o Stump pressure - Specific measure of P pressure, easy/cheap; but not sensitive ie high false negative. Cannot see emboli
= Most used if pressure within range of MAP then shunt not needed o RCBF - measures CBF; invasive, time consuming, expensive o Also include awake technique = gold standard NB.
Evidenceislackingforanyofthesemethodstoactuallyimproveoutcome.
Substanceabusewelfarepolicysetup
Asanewlyappointedconsultantwithaninterestinwelfareyoufindyourtraining
departmenthasnosubstanceabusepolicy....Whataresomeofthebasictenantsofsucha
policy
• welfaredoc;Consultwelfaredoconmanagementofsubstanceabuse.
• Evidence:BasisonEvidence
o Prevention(DrugControlPolicy)
o Detection
o Intervention(PlanandTeam)
o Treatment
• Teamofinterestedpeople
o Systemmusthaveredundancy–ieaSUDInterestGroup
• Support:ExternalSupport
o CADs
o Psychiatry
o Inpatient
Substanceabusescenariomanagement
Youaretheconsultantoncallinatertiaryhospital,aregistrarhasbeenfoundinthetoiletcollapsedwithapropofolsyringeonthefloornexttothem...
Willconsultwelfareguidelineonmanagementofsubstanceabuse
• Backuptomanagecurrentclinicalsituation(whilecolleagueisimpaired,patientstill
needshelp)
• Majorsign??
• Immediateintervention:Needimmediateinterventionplan
o SuspicionandrecognitionofSUD
§ Criticalsituationrequiringimmediateaction
§ MajorandMinorsignsshouldbeconsidered–including
circumstantialevidence
o PreparationandResponse
§ Confidentiallygatherinformation.
§ Avoidprejudice
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§ Maintainpatientandcolleaguesafety
o Verification
§ CollateandDocumentinformation(Timesensitive)
• InterventionTeam
o Intervention
§ Teamapproach–HOD/Psych/SUDcommitteemember/Support
Person
§ DONOTLEAVETHEMALONE-highsuiciderisk
§ STONED
o Treatment
§ Decisionistobemadebythemembersoftheprofessionalteam
treatingthedoctor
§ Inpatientvsoutpatient;VoluntaryvsInvoluntary
o Reporting
o ReturntoWork
Colleagueimpairedbystressdiscussion
YouaresupervisingonaSaturdayMorningwhenaseniorrecoverynursereportsthatshehasconcernsaboutDrT.DrT’shandwriting–previouslylegible,isnowhardtointerpret.Herchartsareincompleteandwhenquestionedshebecameteary.Sheisoftenstressedinrecoveryaboutminorissues.Whatareyougoingtodonext?
Considerfactors:• Bio–Braintumour,physicalillness
• Psycho–depression,anxiety,drugabuse
• Social–family,fertility,relationship,money,socialproblems
Actions:Preassess,Prep,Perform,Post-meetingintervention• Preassess:
o Whatevercause,maintainconfidentialitybutnegotiatewithneedfor
statutoryreport
o privacy
• Prep:DiscusswithWelfareofficer
o Timelyapproachrequired
• Perform:STONED
o SuggesttreatmentbyGP
• Post:ArrangeforlighterworkloadforColleagueinmeantime.
o Maintaincontact
Dealingwithpatientcomplaint
AColleagueseeksyouradvice.Apatienttowhomtheygaveageneralanaesthetic2days
agoforremovalofwisdomteethasadaycase,claimsthatshewasawakeduringthe
operation.Thepatientremembershearingsomeonerefertoherasa‘fatoldcow’.Your
colleaguehasbeennotifiedthataformalcomplaintaboutthismatteristobeinvestigated
bytherelevantlegalauthority.
Q1.Discussthefactorswhichmayhavecontributedtoawarenessinthispatient.
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Q2.Giveyourrecommendationsformxofthispatient’scomplaint
Q3.Whatstrategiesmaybeusedtoassistyourcolleaguewiththestresstheymayfeel
abouttheforthcominginvestigations?
Q1–lookatmyownclassificationforawareness.
PatientMx:o Consultwelfaredoconcriticalincidentsupport
o Patientshouldreceiveapologyandtalkaboutconcerns
o ContactGP
o Document
o InformMedicalIndemnity
Colleagialsupporto Welfaredoconcriticalincidentsupport+?possiblybiggerissueof
impairment
o Expecttoencountercombinationsoffeeligns:
o Denial,anger,blame,bargaining,depression
o Identifyifthisisoneofforpartofabiggerissue
o Bewareof‘secondvictim’effect–whatsupportdoescolleaguehas?
o Recommendmentoring/counselling
o Discussionofcase,Avoidjudgement
SexualHarassment
TheSupervisorofTraininginformsyou,asHOD,thatajuniorfemaleregistrarhasfileda
sexualharassmentcomplaintagainstasenioranesthetist.
Whatarethetypicalbehaviorsofsexualharassment?
Howareyougoingtorespond?
SexualHarassment=Unwelcomeconductofasexualnaturewhichoffends,humiliates,or
intimidatesthepersontowardswhomitisdirected,regardlessofintent
o Eg.offensivejokes,displayofoffensivematerial,physicalconduct,requests
forsexualfavoursetc.
Response:o AsperANZCAWelfareguideline…
o Investigate:Obtaincomplaintdetail
o Interview:ConsultAnaesthetist+Traineeindividually
o Support:Ensuresupportfortrainee/Anaesthetist
§ Maintainconfidentialityandsafetyofbothparties
§ PsychLiaison/Counsellingforboth
o S-support
§ Seekguidanceonpolicyforsuspension,management,rehabilitation.
o T-timely,taketime
o O-outlinerole,event,management,outcome;
§ Oroutlinecomplaint,legalrequirementbyHospital/DHB;
§ Oroutlineconseuqnceiffailtocomply
o N-notify(Management,HR,Legalopinion,MedicalCouncil)orneedfor
furthermeeting/intervention?
o E-escort
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o D-Document
PalliativeCarePearls
(fromAucklandcourse)
- OralopioidtherapyconverttoSC
- 24hourmorphinepototal/2=SC24hourdosesyringedriver
- 1/6thtotalmorphinepodose=breakthroughpainprnSCdose
o (whicheffectively=1/3ofPOdose)
- OralanxiolyticconverttoSCclonazepam
- OralsteroidconverttoSCdexamathesone
- Lookathospitalguidelinesforsyringedrivermedicationcompatibilities
CRPSPearls
- SNSblock–lumbarsympathectomy
- Multimodalanalgesia
- Psychosocialsupport
- Specials:VitaminC,corticosteroids,palmidronate
Non-Pharmpaintreatment:
- Psychosocial:Relax/meditate/distract/reassurance/education/manageexpectation
- Temp:Hot/cold
- Physical:Compression,massage,splints,position
- TENS
- Otherplacebos
Carcinoidsyndrome
Tx:
•Treatmentisnormallysuppressionwithsomatostatinanalogueoctretide(SCoriv)
•200to300mcgperday,IVorsubcutaneously,in2to4divideddoses
•Aimforsymptomresolution
•‘Carcinoidcrises’areanexaggeratedformàprofoundflushing,bronchospasm,
tachycardia,andwidelyfluctuatingbloodpressure,includinghypo-andhypertension
•Treatwithivboluses20-100mcgoctreotide
•Avoidcatecholamineswhichmayincreaseserotoninrelease,butusedirectacting
ifneeded.Considervasopressin.
Chemotherapyinfo:
ClassifiedbyMoA:1Alkylatingdrug:Cyclophosphamide:pulmfibrosis,cardio
2Platinatingagents:Cisplatin:renal,electrolyte,peripheralneuropathy
3NucleicAcidsynthetaseinhibitors:Methotrexate-pulmtox-pneumonitis/fibrosis,
nephrotox
4DNAtopoisomeraseinhibitors:Doxorubicin:cardiotoxicity
5OtherDNA-damagingdrugs:Bleomycin:pulmfibrosis10%whichasscwhighmortality.
6Antimicrotubuledrugs:Vincristine:neuropathy
7Signaltransductionmodulators:Tamoxifen:DVT.
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Approachtocancerpt:-Head/neck:airway
-Cardiotoxcicity?
-Lung:lobarcollapse,SVCsyndrome
-GI:obstruction?NV,aspiration?
-Renalfailure
-MSK:Pathological#?Spinalcordcompression?
-Haem:neutropenicsepsis?Anaemia?Thrombocytopenia?
-Electoryte?HighCa?lowNa?
-General:
•chronicpain?
-Malnutrition?Can’tswallow,mucositis.
•Tumourlysissyndrome:upuricacid,urea,K,(KUU,C),highP,lowCa
Otherimmunosuppressivedrugsinorgantransplant:- cyclosporin-intransplant;SE:nephrotoxic,neurotoxic,squamouscellcarcinoma,
HTN(duetorenovasoconstriction+Naabsorp)—>CVS
- tacrolimus-intransplant;SE:nephrotox,SkinCC,NH-lymphoma+CVS/resp/CNS/liver
- azathioprine-pulmtoxicity,bonemarrowsuppression.Rarely:Hepatitis,
pancreatitis,lymphoma
DMARDcomplication:-gold-thrombocytopenia,nephroticsyndrome,goldlung(pneumonitis)
-hydroxychloroquine-Bonemarrowsuppression,agranulocytosis,aplasticanaemia,eye
-sulfasalazine-thrombocytopenia,megaloblasticanaemia,
-lefluonamide-liverdamage,lungdiseaseandimmunosuppression
-adalimumab/infliximab-seriousinfections,reactivationofinfections,demyelinatingCNS
disorders
CardiacDrugrecipe
• GTN (0.5-1mg/ml) o 0.1-5mcg/kg/min; roughly 0.5mg/ml @ 0-30ml/hr
• SNP (0.5mg/ml) o 0.01-2mcg/kg/min
• Mg o 10-20mmol; if infusion 1g/hr (Obs); watch level
• Esmolol (10mg bolus) o 0.5mg/kg loading; 25-300mcg/kg/min
• Phenyl o 0.1-1mcg/kg/min; 100mcg/ml @ 0-30ml/hr
• Ephedrine o 5-20mg/hr
• Noradr o 0.01-0.2mcg/kg/min; 100mcg/ml @ 0-30ml/hr
• Adre o 0.01-0.2mcg/kg/min; 100mcg/ml @ 0-30ml/hr
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• milrinone (200mcg/ml) o 20-50mcg/kg bolus; 0.375-0.75mcg/kg/min; 5 or 10ml/hr
• Ca o 0.035mmol/kg
• Vasopressin (V1 R) o 0.5-3unit/hour; bolus 1u if desperate
• Isoprenaline (20mcg/ml) o 0.01-0.05mcg/kg/min; bolus 10mcg if required
• Iloprost o 20mcg neb prn/Q2h for 2 days. normally Q6H.
• sildenafil o 25-50mg tds/qid
• Desmopressin o 0.3mcg/kg (max 24mcg) over 30 mins (once only)-bleed o DI dose = 100-200mcg intranasal or 0.4mcg dose IV prn
• Hypertonic saline (3%) o 3 mL/kg over 10 min or 10-20 mL 20% saline
• Salbutamol o bolus 5-15mcg/kg; infusion 5-10mcg/kg/min for 1 hour then 1-
2mcg/kg/min • Phentolamine
o 1-2mg Paeds pressor Dopamine 5-15mcg/kg/min; reasonable 1st line agent, can be used peripherally Adenosine 0.1mg/kg fast IV, max 12mg Ephedrine 10mcg/kg IV Q5min
• Dexmedetomidine o 0.5-1 mcg/kg over 15 mins loading, then 0.5-1mcg/kg/hour o IN: dexmed 2mcg/kg intranasal; elim ½ life 2hrs
bicarbonate for obstetric epidural = 1ml / 10ml of lignocaine; or 0.1ml / 10ml of bupivacaine RemifentanilPCA
• Variableboluswithnobasal(roughly~2xpotencyoffentanyl)o 0.25mcg/kg,2minlockout,increasein0.25mcg/kgincrementsatQ15min
untilVASscore<5;Upto0.75mcg/kg(IBW)
o Ifonimprovement,considerthangetovariablebasal.
• Fixedboluswithvariablebasalo Fixedbolus0.25mcg/kg;2minlockout.
o Basal0.025mcg/kg/min(10xless),increaseratein0.025mcg/kg/min
Q30minsuntilVAS<5.Upto0.1mcg/kg/min.
Max.hourlyrate=12mcg/kg/hour=0.2mcg/kg/min.
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PhilQuinn’sSAQsession–2016
Q1–acuteporphyria
Describethepathogenesisofacuteporphyrias,anditsdiagnosis?(40%)Howwouldyousafelymanageapatientwithanacuteporphyriaperioperative?(60%)
PathogenesisofPorphyria==groupofgeneticdisorders;featuringenzymedefecthenceinabilitytosynthesisHb
resultinginanaccumulationofprecursorsoxidisedtoprophyrins
• 3mainhepaticformsaffectinganaestheisa.
• autosomaldominant-butwithvariableexpression
o AIP-acuteintermittentporphyria(sweden)
o VP-variegatedporphyria(afrikaners).Dermalphotosensitivity
o HCP-hereditarycoporporphyria(rare-dermalhypersensitivity)
Diagnosis:ManagementPrinciples=minimizestressandpotentialtrigger.
• Pre
o Hx:Assesscarefully;previousattack?+veFHx?
§ MustbetreatedaspotentiallyatriskfromacuteattackwithFHx.
o Exam:presenceofneurodeficit?
o Invx:maybenormalinbetweenattacks.
§ Urine,serumfaecalporphyrins;DNAtestings.
o Manycommonlyusedmedicationshavepotentialtotriggerporphyriccrises,
thereforeimportanttoformulateperiopplanwithmedicationuseand
consultup-to-dateinformationfromestablishedmedicationreviewcentres.
o Minimisestress:
§ premedwithBDZ.Avoidprolongedfastinganduseglucose/saline
fluid.
§ Multimodalanalgesia+regional(unlessinacutecrisesasneuropathy
canhappen)
• Intra;key=obtundSNSstress+asepticpracticeasatriskofinfection.
o GAwithpropofol.MaintainwithTIVA.
o Iso/haloprobablysafe
o Bupivacaineprobsafe
o NMDprobsafe;exceptatracurium
o Fent/morphinesafe
o IfHTN/tachyàuseBB
o IfConvulsionàuseBDZ,propofol,MgSO4,don’tusethio/phenytoin.
• Post
o crisismaybedelayedforupto5d
o ICU/HDUiscrisis
Inacutecrises:• Manyprecipitants-drugs,stress,infection,alcohol,menstruation,pregnancy,
starvation,dehydration
• Symptomsincl:
o GI:Abdopain+Vomiting(maymimicacuteabdomen)
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o CNS:Motorandsensoryneuropathy
§ Autonomicdysfunction
§ Cranialnervepalsies
§ Confusion
§ Coma
§ Seizures
§ Fever
• Care:stoptrigger;help;speicla:usehaemarginate3mg/kgIVODfor4/7(inhibits
ALAsynthetasehencestopshaemproduction);BBtodecraseALAactivity;
plasmapharesis.
o Supportivecare+monitorArtline+/-CVP(ascangetlabileBPfromANS
neuropathy)+glucose(20g/hr=200ml10%/hr)
NB.
DefUnsafe Maybe ProbablySafe
Induction thio
etomidate
ketamine Propofol
Volatiles Enflurane iso
sevo
Nitrous
NMBs panc
atrac
roc
Sux
vecuronium
Reversal Atropine
Glyco
Neo
Analgesia dicofenac aspirin&
paracetamol
alfent,fent,
morphine
naloxone
LAs Ropiv Lignocaine Bupiv
Prilocaine
Sedatives nitrazepam Diazepam Midazolam
Chloralhydrate
Antiemetics metoclopramide ondansetron
Ranitidine
Droperidol
CVSDrugs Hydralazine
Nifedpine
Phenoxybenzamine
Diltiazem
verapamil
SNP
Adrenaline
α&ßagonists
Mg
ßblockers
phentolamine
Others OCP
phenytoin
Steroids
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sulfonamides
aminophylline
Q2–TCAoverdose
YoususpectapatienthastakenanoverdoseofTCA.Whataretheclinicalsignsand
investigationsthatwouldsupportthisdiagnosis(50%).Outlineyourinitialmanagementof
thispatient(50%)
Features(signs/invx)forTCAo EffectofTCA=anticholinergic,peripheralalphablockade,inhibitionofNAdr/5HT3
reuptake.
§ Feature:ManifestedmainlyinCVS,ANS,CNS
o Anticholinergic:delirium,fever,tachycardia,mydriasis,flusheddryskin,ileus,urine
retention–MR-DHB–mad,red,dry,hot,blind
o CVS:tachy,prolongedmanythings:PR,QRScomplex,QRinterval(QRSproportional
toserumTCAlevel);hencelevelusu.notmeasuredandguidedbyQRScomplex;
§ Hypotension/VT/torsades
o CNS:agitation,blindness,sedation,hallucination,seizure,coma,death
InitialMxofpatient(Stoelting)o Activatedcharcoal,gastriclavage
§ Don’tinduceemesisduetoriskofaspirationaspatientcanbecome
obtundedquicklyo Serumalkalinisation=principaltxàincproteinbounddrug,lessfreedrug;
§ GiveHCO3-orhyperventilatetopH7.45-7.55§ TitratetonarrowingofQRScomplexorceaseofarrhythmia
o ACLSifmalignantarrhythmiaoccurs+MgSO4fortorsades.o SupportABCD.o SeizurecontrolwithBDZs.o NB.Hemodialysisnoteffectiveduetohighlipidsolubility/proteinbindingofTCAs.
NB.
CEACCPsayTCAuseshouldcarewithindirectSNS(ephedrine/metaraminol)–presume
becauseofreducedreuptakeofNAdr??CanusedirectSNScarefully.
o Dryasbone,hotashare,redasbeetroot,blindasbat,madashatter.
o MR-DHB Cholinergicsyndromemneumonics:
o DUMBELLS:Diarrhoea,Urination,Miosis/Muscleweakness,
Bronchorrhea/Bradycardia/Bronchospasm,Emesis,Lacrimation,Salivation/Sweat
(don’tuseabove,asbeloweasier:oneiscommon,oneissevere)
o SLUDGE:Salivation/Sweat,Lacrimation,Urination,Defecation,GIdistress,Emesis
o KillerBs:Bradycardia/Bronchorhea/Bronchospasm
Q3–Environmentalimpactofanaesthesia
Summarisetheenvironmentalimpactofanaestheisapractice,andhowthiscanbemitigated.
Anaeestheticgas• greenhouse:Significantgreenhouseeffect,CO2emissionfromanaestheticgas
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• Globalwarmingpotentials:DES>>>>Iso>N2O>Sevo
o Mxby:usingclosedcircuit,lowflow,switchFGFoffatintubation(using
intubationbuttonfortempgasflowpauseeg.30-60secpause);automated
gasdeliverysystemswhichadjusttouseminimalflowandmaintainsetdepth
ofEtAA;circlesystems;considerRA/TIVA,avoidDes/N2Ounlessstrongly
indicatedclinically.
Recyclingofresources
• Recycling:Reusablevsdisposables;generallybetterwithreusables,benefitswith
lessenergyuse,lesscarbonfootprintandsolidwaste;atcompetitivecostwith
disposableoptions.eg.o Textiles/gowns,drapeàreusabletextileshaso Anaesthetictrayso LMA.o AvoidusingStyrofoamcups
§ Unlessitemsrequiresterilization;inwhichcasedisposablesmaybe
better:Eg.CVCkits
Bluebook:Reduce,reuse,recycle,researchandadvocate:Practicalstepsfortheanaesthetisttoreducetheirenvironmentalimpact.Reduce:
• Minimizenitrousoxideuse;lowflowanaesthesia.
• Minimisemultipledisposableitems:eg,anaesthetictrays,IVfluidbags,bearhugger
warmingblanket.
• Uselesspaper,recordinformationelectronically.Printdoublesided.
• Usefewerbatteries.Considerrechargeablebatteriesandequipment.
• Reducelightingcostwithefficientlamps.
• Turnoffthetheatreventilationandairconditioningwhennotinuse.
• Turnoffallappropriatetheatreequipmentatthemainswhenshuttingdownforthe
day.
Re-use• Considerthefinancialandenvironmentalbenefitsofreusableequipment:
o recycledpaper,rechargeablebatteries,
o considerreuseequipmentswithlowinfectionrisk:eg.SCDs,airwarming
blankets.
o Considerpurchaseproductsfromreclyclablematerials.
Recycle Segregaterecyclablematerial.
FormorjoinanOperatingSuiteEnvironmentCommittee.
Contactlocalwasterecyclingfirmsaboutrecyclingoptions.
Encouragethepurchasingofmoresustainableproducts.
Research• Encouragelifecycleanalysisandcostingofproductsusedintheoperatingsuite.
Investigatewheredecreasesinenergyandwaterconsumptioncanoccur.
Advocate • culturepromotingsustainabilitypractices
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• purchasingofsustainableproducts.
• Facilitatebikeusebyadvocatingforbikeparkingandformabicycleusers’group
(BUG).
• Advocatefortheenvironment.JoinDEA(DoctorsfortheEnvironmentAustralia),
ACF(AustralianConservationFund)orcontactapolitician.
Q4–lungisolationdiscussion(repeat)
Describethedifferenttechniquestoachievelungisolationalongwiththeirpros/cons.
Q5–thoracicparavertebralblock(repeat)
DescribetheanatomyrelevanttoperformingathoracicPVB.(50%)Listthe
pros/complicationsofperformingthisblockforapatientundergoingradicalmastectomy
(50%).
Q6–Anorexianervosa(repeat)
Describethepathophysiologicalchangesasscwanorexianervosa,andtheiranaestheticimplications.
AN=highestmortalityofanypsychdisorder=highrisk!!
• chronic,severe,multi-systemdisorder,fearofbecomingfatwithdeliberateweight
loss
• co-morbidities:majordepression,anxiety,OCD,drugmisuse-laxatives,emetics,
diuretics
Pathophys(+anaestheticimplications–domyownrestructuringinactualSAQ)CVS:
arrhythmia/bradycardia,AVblock,prolongedQT,
Myocardialimpairment:hypotension,STdepression,TWI-riskofcardiac
failureifover-filledintraop
ECGchangesinupto80%:AVblock,STdepression,TWI,prolongedQT,
arrhythmias
MVprolapse
Resp:
Decreasedcompliance;bradypnoea,
CNS:
impairedcognition,seizure
GI:delayedgastricemptying/malnutrition
Blood:
Immunosuppressionat<50%ofnormalbodyweight
Electrolyte:
↓Cl,↓Ca,↓Kmetabolicalkalosis-fromexcessivestomachfluidloss
hypothermia.
Endo:(panhypopituitarismfeatures)-hypothyroid,lossglycaemiccontrol,amenorhhoea,
adrenalinsufficiency
MANAGEMENTrehydrate
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• fixelectrolytes
• avoidre-feedingsyndrome-dangeroussoavoid
Hypophosphataemia:
• ->Myocardialimpairment+arrhythmias,cellularhypoxiaandclinicalsignsofATP
def.
• muscleweakness,rhabdomyolysis,haemolyticanaemia(rare,duetoRBC
unabletomaintaincellularintegrity);
IntraoperativeARSIBlossoflungelasticityiereducedcomliance->highAWP
o avoidhyperventilation–worsens‘hyperventilation-inducedhypocalcaemia)
Carpopedalspasm
CcautiousfluidtherapyascanprecipitatecardiacfailureEhypothermiacares
Do NMB-potentiatedif↓K&↓Ca
o avoidneostigmineifpossible-riskofarrhythmia
o PharmK/Dchanges,lowalbumin,
Ppressurecares• Randomones:asscwmitralvalveprolapse,Superficialparotitis,dentalcaries
Postop:longtowake,longtoheal
NB.
• markedelectrolytederangement(decreasesinserumpotassium,phosphate,and
magnesiumlevels)andexpansionoftheextracellu-larfluidcompartment(leadingto
increasedcardiacworkload)andtheintroductionofcarbohydratesmayleadto
increasedoxygenconsumption,increasedcarbondioxideproduction,andan
increasedrespiratoryquotient.
Q7–PONV(repeat)
ListtheriskfactorsforPONV(30%).EvaluatemethodstominimizePONV(70%)
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Q8–CSWS/SIADHdiscussion
DescribetheclinicalandbiochemicalfeaturesofCSWS,andSIADH(60%).Whatareother
commoncausesofhypotonoichyponatraemia?(40%)
NB.
Hyponatraemiaveryeasyclassification!!Hypotonichyponatraemia:
• Hypervolaemic:SIADH,heart,renal,liver,iatrogenic,pregnancy• Normovolaemic:SIADH,adrenalinsuff,hypothyroid,iatrogenic(hypotonicfluid),
thiazide,otherdrugs:PPI,antibiotics,SSRIs,AEDs,
• Hypovolaemic:CSWS,diuretics,D/V,Ketonuria,Sweats,bleed,adrenalinsuff(esp.
Addison’s),Burns,Pancreatitis,trauma
Pseudohyponatraemia(isotonicorhypertonic):• Hyperlipid,hyperprotein,severehyperglycaemia
Invx:
• Forall:Na/urineosmol,urineNa,BGL,TFT,urinedip(protein/ketone),cortisol/ACTH
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• Consider:ECG,CXR,abdoUSS,stagingCT,Echo,shortsynactentest
Q9–Spinalcordbloodsupply(repeat)
Describethebloodsupplyofthespinalcord(50%).Explainthedeterminantsofspinalcord
perfusion(50%).
Q10–PICClinediscussion(repeat)
OutlineyourproceduresforinsertionandmanagementofaPICCline.
EddieCoates’SAQsession–2016
Q1–Highriskextubation
Describeyourstrategiesforrecognizingandmanaginghighriskextubation(60%).Outline
theuseofare-intubationsystemyouarefamiliarwith(40%).
UseDASguidelineondifficultextubationStratifyriskforextubation
• difficultairway?Reintubationdifficult?
• Abilitytooxygenate?
• Anyotherriskfactors?
Optimisecondition–ABC• Patients–phys,pharm,anatomy:ABCDE–ensureadequatereversalofmuscle
relaxant–aimTOFR>0.9
• Otherfactors–location,assistant,monitor,equipment
Ask–Isitsafetoremovethetube?Ifyes,thenmayproceedtobelow:Usehighriskextubationstrategy–
• LMAexchange
• Remiextubation
• CookAEC
• Awakeextubation
Ifnot,thenneedpostponingextubationforelectiveextubationortracheostomy
Postop:considerHDU/ICUcare.
NB.
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Q2–Emergencedelirium(repeat)
A9yoisscheduledfortheirsecondENToperation.Theprevioussurgerywascomplicatedby
extremeemergencedelirium.Whatarethefeaturesofemergencedelirium?What
techniquesareemployedtominimizethiscomplication?
Q3–Mastectomyanalgesia(repeat)
Evaluatethevariousmodesofperiopanalgesiainwomenundergoingmastectomyfor
breastCa.
Q4–Bullying
YouareSOTinaregionalhospital.Atraineeconfidesthatheisexperiencingbullyingfroma
particularconsultant.Definebullyinganddescribeyourdutiesandconsiderationswhen
addressingthissituation.
Bullying=repeatedunreasonablebehaviordirectedtowardsapersonorgroupthatcreatesriskto
healthandsafety
o Intimidates,offends,degrades,insultsothers(physicalorpsychological).
SOTduties/considerationstoaddresssituation• RefertoANZCApolicyondullying,discriminationandharassment
• Verifytheinformation
o Assessifbullyingisactuallynotconstructivefeedbackorpersonalconflict
o Obtaindetailedaccountofthecomplaint
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• EmployingBodymustbeinvolved
o Writtenwarningifappropriate
o Legalopinionmayberequiredespifpatientharmispossibility(asbullymay
leadtounsafeenvironmentwithpoorcommunicationamongstaff)
• Offercounselling/mentoringtotrainee
• InterventionwithConsultant:
o Meeting(+/-supportperson)–don’tuseSTONED,doesn’tfithere
- -support,taketimetolisten,outlineteamroles,notifyConsultantfor
meeting,Escort,Document.
o Bepreparedtodealwithdenial,anger,threats
o Outlinecomplaint,legalrequirementbyhospital/DHB
NB:
• S-support
§ Seekguidanceonpolicyforsuspension,management,rehabilitation.
• T-timely,taketime
• O-outlinerole,event,management,outcome;
o Oroutlinecomplaint,legalrequirementbyHospital/DHB;
o Oroutlineconseuqnceiffailtocomply
• N-notifyorneedforfurthermeeting/intervention?
• E-escort
• D-Document
Q5–HELLP,obsemergency,difficultairway
Youarecalledbyyourreg(BTY2)onobscall.Atermprimip29yowHELLPsyndrome
requirescat1EMCS.YourregisconcernedthatherairwaylookschallengingduetoBMI41
andmarginalTMD.She’shadgarde2laryngoscopyfromlapchole2yearsago.
Herplts1hourago=109.Yesterday,theywere112.
BPis170/110.Shehasheadacheandhyperreflexia.
Whatwillbeyouradvicetoyourreg?outlineandjustifyyouranaestheticmxofthis
situation.
• Issueshere:Cat1CS,PET/HELLP,cerebraloedema,highBMI,probabledifficult
airway,surgicalbleed
• AdvicetoReg=
o GethelpwhileI’mcominginimmediately
o MDT–Obs/Haem/Paeds/Midwife
o Pre–assesspt/consent,prepanaes–personnel,equipment,drugs,Surgical
concern?NeedexperiencedSurgeon,Fetalconcern?Whycat1?
§ Ifnoimmediatematernalconcern,thenwaitformetoarrivesoReg
doesn’tkillpatient;Intrauterineresus
§ Ifimmediatematernalconcern,trytooptimize,utilizeallresources
whileIcomein
§ Equipment:DItrolley/AFOI?,2xbigIV,fluidresus,
§ Drugs:GA/RSIdrugs/airwayreflexblunt,judiciousfluid,TXA,DDAVP,
MgSO4,labetalol,GTN,hydralazine,neuraxial?Mayrequired
MTP/cellsaver/level1rapifuser
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o Intra-
o Post–HDU/ICU
•
Q6–3chamberedchestdrain(repeat)
Explainthefunctionofa3chamberedchestdrainanditsemploymentinblunttraumaPTX.
Q7–pronediscussioninneurosurgery(repeat)
Onyourelectiveneurosurglistisa39yoman,BMI39forresectionofpostfossatumour.
Outlinetheissuesinpronepositioningforthiscase,andbrieflyexplainphysiologicalor
practicalbasisofeach.
Q8–DVTprophylaxis(repeat)
A23yowomanisscheduledforpelvicsurgery.ShehasFactorVLeidenandhxofDVTafter
longhaulflight2yearsago.DescribeperiopmxofVTErisk.
Q9–Paedsregional,upperlimb
4yosufferedbilatcomplicatedwrist#s(=onlyinjuries).Whatregionaltechniquemightyou
considerhere?Outlineitspros/cons(60%).Evaluateperformingregionalasleep(40%).
Axillary/infraclav/supraclavGeneralpros/consofGAvsRAPros• Bestanalgesia,avoidanceofGA–PONV,respiration,sedation,vasodilationifneruvas
repairinvolved,?reducedchronicpain
Cons• Gen:Failure,nervedamage,LAST(althoughriskreducedwithUSSuse;alsocan
achievefasteronset,highersuccessrate)
• Blockspecific:phrenicnerve,PTXetc.• Environmental:timeconsuming,needexpertise
Regionalasleep?Pros/cons• Pros
o Noevidencetosayit’smoredangerous
o NeuropraxiariskGA>?RA
o Greatertolerance,acceptance,lesspain
o Easiertoposition,lessmovement,
• Conso NeedGAsupervisionwhiledoingRA
o ?absenceofwarningfrompatientre:paresthesia/pain
Onbalance:• awakeifpatientcantolerate
• butlowthresholdtoconverttoasleepRA
• donotpersevereifdifficultRAapparent.
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Q10–ASperiopmanagement(repeat)
72yomanatAPACforinguinalherniarepair.He’sknownwithmild/modASfroecho10
yearsago.HowwillyouevaluatehisAS?60%.Howwouldyourfindingsaffectyour
approachtohismx?40%.
Q11–Anorexianervosa(repeat)
What’spathophysofanorexiaandhowdotheseimpactmxofananorexicpatientonORIF
hip#case?
Q12–PACUrequirement
WhataretherequirementsofasuitablePACU?
ReferANZCAPDGeneral
• SufficientPersonnel/Equipment:Shouldincludesufficienlevelsofequipment,staff
withappropriatetraining/experience+rostertoensureserviceprovision+
supervision.• Appropriatelocation:Designatedarea,closetoanaesthesia/sedationarea.
Emergencyplan:• Emergencycallsystem,telephonewithinternalcallsystem
• AnaesthetistsupportimmediatelyPRN
• Resus–BMV,emergencyairwaytrolley,defib,chestdrains,mechanicalventilator
• Drugs–emergencydrugs,IVaccess,fluids,analgesia,needle/sryignes
• Power:Emergencypowersupply
OtherEquipment/drugs–DAMSIP
• O2outlet,flowmeter,suction,poweroutlets,light,areastomountequipment
• Monitor–sats,NIBP,ECG,temp,stethoscope,EtCO2,12leadECG,NMT,artline,
CVL
• Warmingdevice,cupboard,refrigeratorfordrugs/blood,
• AccesstoABG,Lab,diagnosticimagingservices
• Bed-tiltablebothways,easytotilt,brakes,situp,securerails,IVpole,mattress
StaffingExperience/Training/Supervision/Ratio
• Trained,withexperience• Chargenurse• Supervisionfortraineesorunexperiencednurses• 1:1forunconsciouspatient• 1:3forstableconsciouspatient
Management• protocolised• dailycheckingofequipemnts/drugs/resustrolley• anaesthetistsupervisionwitheasycontactaccessatalltimes• dischargecriteria• Anaesthetist–instructions,prescriptionofongoingtherapies,ensurepatient’ssafe
beforeleavingPACU,authorizepatient’sdischargefromPACU.
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Designspecifics:• PartofOT/Proceduralsuite
• Easyaccesswithoutneedforscrub
• Adequateventilation(OTstandard)
• Adequatespaceforbed(9m2)
• Easyaccesstopatient’shead
• Atleast1.5spacesperOT
• Uninterruptedviewofpatients
• Nursingstation,utilityroom,storage,scrubfacilities;accesstoelectronic
managementsystemforviewingofinvestigationseg.lab,radiology
• clock
Q13–ARDS(repeat)
DescribepathophysofARDSand2possiblemechanismsinthispatient(70%);(femoral#
whenescapingfromhousefire,nowhasARDSinICU).Howwillyouventilatethispatient?
(30%)
Q14–Premptive,preventativeanalgesia(repeaet)
Explainthetermspreemptiveandpreventativeanalgesia.Giveexamplesofbothinyourclinicalpracticeandbrieflyoutlinethepresumedphysiologyinvolved.
Preventiveanalgesia:definedasanalgesiathatpersistsbeyondtheexpecteddurationofactionoftheintervention(iemorethan5.5half-livesofthemedicine)
• andmostlikelyrelyonreducingperipheralandcentralsensitization
• eg.ketamine(level1),gabapentin,LA(level1),epiduralanalgesia.
• MabewithMg,
Preemptiveanalgesia:Preoperativetreatmentismoreeffectivethantheidentical
treatmentadministeredafterincisionorduringsurgery.
• “timing”ofasingleanalgesicinterventionreduceseffectofperipheral¢ral
sensitization.
• Eg.epiduralanalgesia(level1),possiblywithketamine.
NB.
• Inclinicalpractice,preventiveanalgesiaappearstobethemostrelevantand,of
pharmacologicaloptions,holdsthemosthopeforminimisingchronicpainafter
surgeryortraumabecause itdecreasescentralsensitisationand“wind-up”.
• tomaximise thebenefitofanyanalgesicstrategyisthattheactiveintervention
shouldbecontinuedfor aslongasthesensitisingstimuluspersists(iewellintothe
postoperativeperiod)
• Centralandperipheralsensitisationaffectsboththeintensityofacutepainandthe
persistenceofpainwellintothepostoperativeperiodandbeyond.
Q15-HIT
OutlinepathophysandpresentationofHITTasitmaypertaintoavascularptinpostopperiod(60%).Describethemxofthisdiagnosis(40%).
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HIT=heparininducedthrombocytopaenia• ifconcurrentthrombosis=HITTS(thrombosissyndrome)
o (3parts):PlateletFactor-4+heparin+IgGcomplexonplateletsurface⟹
inappropriateactivationofplatelets⟹hypercoagstate⟹thrombosis
• 1-6%incidence(muchlesswithLMWH)
• present4-14daysafter2ndexposuretoheparin
• diagnoses4Ts:
o Thrombocytopaenia=>50%fall
o Timing-within5-10daysstartingheparin
o Thrombosis-venousorarterial
o nooTherexplanation• Tests:
o antibodytest-best
o plateletactivationassay
o clinicalscoringsystemsavailabletoquantifyrisk
• morefrequentwithbovinelungheparin
Features:2types:
type1(non-immune,littlesignificance)
• transient/selflimiting↓plateletsto~50
• =directheparininducedpltagglutinationienonimmunemechanism
type2(immune-highmortality!)
• platelet↓to~10&assocwiththromboembolicphenomena
• immunemediatedpltaggregationbyIgG&IgMantibodies
• developmentofantibodiestoplateletsfollowing1stheparinexposure.ieoccurson
nextexposure
• =typeIIhypersensitivityreaction–iecytotoxic
• usuallyresolvesrapidlyonstoppingheparin(canlastfor2/12)
• mustavoidUFHforever,butcanuseLMWH(withcaution)
Rx:• stopheparinimmediately
• usealtervative–lepiridinorfondapurinux
• postponewarfuntilplatelets>150(initiatewithoutloadingdose)
• monitorforthrombosis
• avoidplatelettransfusions
NB.
• Heparinaction:PotentiatesformationofAT3-2acomplex.Inhibits10,2,athighdose
also12,11,9.
• Protamine:1mg~100iu,givenomorethan50mgevery10mins,guidedbytimeof
doseforheparin+ACT.
SamPaul’sSAQsession–2016
Q1-OSA/OHS
Outlineriskfactors,causes,methodsofdiagnosingOSAandOHS(80%).Explaintheir
relationship(20%).
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OSA:• =partialorcompleteobstructionoftheupperairwayduringsleepàO2
desaturation,hypercapnia,andcorticalmicroarousalsinanattempttorestoreupper
airwaypatency.
o AsscwincrasedriskofOHS,HT,IHD,CCF,CVA,metabolicsyndrome.
Riskfators(=allpatient)
• STOPBANG–Pressure(don’tspecifynumber),age>50,Neck>40,BMI>35.
§ >3=highrisk;>5=veryhighrisk;
§ STOPbangveryspecific,butnotsensitiveenough.
• OthersasperCEACCP:o Excessalcoholintake
o Smoking
o Pregnancy
o Sedentary:Lowphysicalactivity
o A/T:Tonsillarandadenoidalhypertrophy
o Craniofacialabnormalities(e.g.PierreRobin,Down’ssyndrome,acromegaly)
o Neuromusculardisease
Diagnosis
• PSG-
• (4)EEG/ECG/EMG-chin+leg/EOG.
• (3)Sats,nasal/oralairflow,chest/abdoefforts.
• (2)Snoringvolume/videorecord
• AHI=episode/hour;>5,15,30definesmild,mod,severeOSA.
o Apnoea=>10sec
o Hypopnea=decflowby30%ordesatby4%.
OHSOHSaffectscontrolofbreathing.
• Definedasobesity+hypoxaemiaduringsleep+hypercapnoeaduringday;resulting
fromhypoventilationfromreducedventilatoryresponsetocarbondioxide.
• IncreasedriskofpulmHTN.
• Depressantdrugs,includingmanyanaestheticagentsandanalgesics,accentuate
this.
o HasdifferentpatternofPSG(consistentlylow)cf.OSA(ups/downs)
Riskfactors:
• BMI30~10%;40~20%.
OSAvsOHS:Theobesityhypoventilationsyndrome,althoughdiscreetfromOSA,isoftenfoundinthe
sameindividualswithsevereOSA(ieend-stageOSA,Aucklandcourse)
• OHSis‘end-stage’ofOSA
o CO2sensitivitynowdecreased
o BydefinitionhavechronicraisedPaCO2withraisedHCO3-
• respacidosisonABG+HCO3-raisetocompensate
• HighriskpulmHTandCHF
• Veryelevatedperioperativeriskofbadness
NB.
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• LongtermCPAPishelpful,howeverNoevidenceforshort-termpreopCPAP,but
familiarizationhelps.Alsostopsdiseasefromgettingworse(Auckland).
• OSAbyitselfisn’triskfactorforpulmHTN.ButendstageOSAieOHSis.Howeverif
HCO3isnormal,itrulesoutOHS.(NPV=97%)
• CanpreoxygenatetoET90%O2with10cmwaterCPAPfor3-5mins+25degreverse
Trendelenburg.
• PACUdccriteria:whensatsisbaselineandnodesaturationwhenleftundisturbed.Otherwisehaveamonitoredbedforcontinuoussatsmonitor.
• IfconsideringforDaysurgery??,ASAguidelinecanhelp–o ConsidersOSAseverity
o Invasivenessofsurgery
o Opioidrequirement
§ ObservedinPACUforadditional3hours;andifOSAseen,for
additional7hours.RecommendationissamefollowingRAasGA
(expertopiniononly)
Q2-sclerodermadiscussion
Outlineperiopanaestheticimplicationsofscleroderma
SystemicSclerosis(ABC-renal)• =autoimmunemediatedwidespreadcollagenousdeposition;variedseverity
• 2majortypes:
o limitedcutaneousform=commoner60%,milder:CREST:Calcinosis(calcium
depositinanysofttissue),Raynauds,Esophagealdysfunction,Sclerodacytly
(localizedthickeningandtightnessoftheskinofthefingersortoes)and
Telangiectasia
§ Limitedtoface,andskinuptoelbowwitoutchest,abdominalor
internalorgan(exceptoesophagus)
o diffusecutaneousform=systemicsclerosis;moreaggressive;widespread
skinhardening&internalorganinvolvement;highmortality
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Anaestheticimplications:• A:�mouthopening;C-spinemovement;refluxcare.
• B:Fibrosingalveolitis;RLD.• C:"Raynauds>90%
o HTN&pHTN
o myocardialfibrosis
o arrhythmias
o pericardialeffusions"
• D:atincreasedriskofchronicpain;mayhavedifficultywithusingPCA
• E:EnsurewarmtoavoidRaynauld’sexacerbation.
• Renal:"CRF
o HTNrenalcrisis"
• GI:Reflux++• Immune:strictasepsis• MSK:difficultcannulation
NB. RA (ABCD-renal-
haem) Anky Spond (ABCD-renal-eye)
SLE (clot, infection, vasculitis)
Systemic Sclerosis (ABC-renal)
Prevelance (%) 1 0.15 0.03 0.001 Airway & intubation
1 C spine unstable/AAS 2 TMJ arthritis 3 Cricoarytenoid arthritis —> Glottis stenosis/larynx obstruction or rarely: amyloid/nodules
1 TMJ arthritis 2 Occult C-spine #s / AAS 3 cricoarytenoid arthritis 4 Cx kyphosis
not usually tricky; watch for airway oedema
↓mouth opening
Resp Fibrosing alveolitis pleural effusions nodules on CXR bronchiolitis obliterans (rare) costo-chondral disease, reduced compliance.
Fixed chest wall apical fibrosis (1%) CPR difficult
LRTI PE pleuritis pulm fibrosis
Fibrosing alveolitis
CVS IHD (association), amyloid infiltration of myocardium, restrictive
pericarditis, conduction abnormalities, valve pathology (AR), Raynauds
AR (1%) MV & arrhythmias = rare
Raynauds IHD (arteritis) pericarditis endocarditis
Raynauds >90% HTN & pHTN myocardial fibrosis arrhythmias pericardial effusions
Neuro Periph neuropathy Radiculopathy Myelopathy
Cauda equina (rare) myelopathy, AAS (rare)
Cranial/Periph neuropathy (arteritis) Psychosis Seizures Stroke esp AntiPhosS
Renal mild CRF (common) amyloid glomerulonephritis CRF HTN renal crisis
GI Drug induced gastritis Drug induced reflux nonspecific abdo pain Nausea mesenteric vasculitis
Reflux ++
Haem ↓Hb - drug & disease Felty’s syndrome (splenomegaly & ↓WCC) Infection risk
↓Hb - drug & disease Antiphospholipid syndrome ↓Hb ↓platelets clot or bleed risk both likely
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Neuraxial Blocks Often difficult infection risk
Difficult- lat approach required ↑risk epidural haematoma
Check coags Infection risk
Others vasculitis; assc w Sjogrens: dry eye, scleritis
Eye: Conjunctivitis and uveitis
Skin: and joint involvement common, oral and pharyngeal ulceration
Q3-Paediatricgeneralmanagementplanning(repeat)
7montholdhavingelectiveinguinalherniarepair.Outlineandjustifyanaesthetic
management.
Q4-nutritionassessment
Howcanperiopnutritionalstatusbeassessed(30%)andhowcanitbemanagedinperiop
period(70%)?
Twokeyriskfactorsthatpredisposetoadverseperi-opoutcomesareobesityandunder-
nutrition.
• Undernutrition–increasedriskofsurgicalcomplication,infection
• Obesity–associatedwthincreasedintra-andpost-opcomplications.
Assessment:Hx
• Intake–type,frequency,quantity
o N/V,diarrhea,dysphagia?
o Weightloss?
• Surrogatemeasures–lethargy,mood,function
• Increaseddemand?–sepsis,undergoingmajorsurgery?
o PMHx:activecancer?Anorexianervosa.
o SeeingDietician?
Exam
• Obese?
• Malnutrition?–musclewasting,fragileskin,frailty,poorbalancing,cachexia?
o Featuresofanorexianervosa?–CVS,Resp..etc.
Ivx• Anaemia?
• UECr–severeelectrolyteimbalance?
• LFT–protein/albuminlevel
• Coagulopathywimpairedhepaticsynthesisoffactors?
Screeningtoolsavailablewithsomevalidity;ingeneralincludequestions:(bluebook)
• haveyoulostweightwithouttrying?
• ifyes,howmuch(kg)?
• haveyoubeeneatingpoorlybecauseofadecreasedappetite?
Periopmx:MDTinput:
• Identify‘at-risk”patients-undernourishedorobese.
• Special:
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o Considerpre-opimmune-enhancedformulasinpatientsundergoingGI
surgeryformalignancy.
• EarlyreturntoPOintakeassoonaspractical;usemultimodalPONVprophylaxis
strategies.
• EarlyinputbyDieticianfordailybalanceassessment+/-intervention.
Undernutrition:• Nutritionintervention:tailorednutritionplan(intake,expectedsurgicalinsultand
demand).
o Adequateoptimisationnotalwayspossible,howevereveninterventionas
littleas5-7daysofnutritionalsupport,topreparepatienttoenduresurgical
insultfromametabolicperspective,ishelpful.
Obesity:• Useofstrictlow-caloriedietstofacilitaterapidpre-opwithlossbecoming
commonplacedespitelackevidence
o Limitedevidenceforvery-lowcaloriedietpre-opincancersurgery-primary
concernisrapidlossofleanmusclemass.
Otherrelevantconsiderations:• ERAS(nutritionalcomponent:continueCHDdrinkuntil2hourpreop)haveleadto
improvedglycemiccontrol,loweredlevelofinsulinresistance,morerapidreturnof
bowelfunctionandreducedlengthofstay.(butleaveoutCHOloadingindiabetic
patietns)
o Considerearlyreturntoenteralintakeie<48hours.
o TrialEnwhenviableinpatentrequiringspecialisednutritionsupportpost-op.
LimitPNtopatientsunabletohaveEN.
NB.
• Controversialre:PNinmalnourishedpatientsundergoingGIsurgery(commence
pre-opfor5-7days,continuingpost-opinpatientsunabletotolerateEN)–although
recommendedbyASPEN. • ESPEN(EuropeanSocietyParenteralandEnteralNutrition)endorseuseimmune-
modulatingformulainelectiveupperGIsurgicalpatients. • arginine,omega-3-fattyacids,glutamineandotherantioxidants.
o Nutrientspositivelymodulateimmuneresponse,influencegutfunctionand
attenuateinflammatoryresponsepost-opinGIcancerpatients.
Improvementinshort-termoutcomes(reductioninpost-opinfectionand
shorterlengthofhospitalstay).
• ButcontroversialinICUpatients–worseoutcomeshownbysomestudy
Q5-IABPdiscussion(repeat)
DescribeprinciplesofusingIABP(50%).Whatareindicationsandcontraindicationstouseof
IABP(50%)?
Q6-MyastheniaGravisdiscussion(repeat)
Whatareclinicalfeaturesofmyastheniagravis?(30%).Whataretheimportantaspectsof
managementofMGduringlapcole?(70%).
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Q7-premeddiscussion(repeat)
Listindications(+eg)forpremedforsurgery(60%).Discusspros/consofsedativepremedin
daysurgery.
• Analgesia
• Anxiolytic
• Antiemetic
• Antisialogogue
• Anticholinergic–atropineespinpaedswhensuxisused
• Amnesic
• Antacid–ranitidine,Nacitrate,omeprazole
•
• DecreaseSNSresponse–BB
• Anticoagulant–clexane
• Anti-glycaemic–basalinsulinetc.
• Anti-hyperlipid–statins
Q8-pacemakerdiscussion(repeat)
Outlinepacemakerclassification(40%)andperiopmanagementofpatientwithpacemaker
(60%).
Q9-Venousairembolism(repeat)
Describefeatures(30%)andmanagementofsuspectedvenousairembolism(70%).
Features
Ifawake–dyspnea,impendingdoom
Q10-POCD(repeat)
Outlineriskfactors(40%),preventionandtreatment(60%)ofpostopcognitivedysfunction
Q11-Fatigue
Outlineguidelinestominimizefatigueinananaethetist
ANZCAwelfaredoc(primarily)+PD(simpleprinciple)
Strategies
• supports
o havementor,maintainnetwork,avoidworkisolationjoindepartmentor
privatepracticegroup,CPDforongoingnetwork.
o Recognisehighstressfulsituationandgetmoresupport
• self-care
o ABCmentalhealth:
§ Act-beactivebiospychosocially
§ Belong,joinsocialgroup
§ Committ,tohobbies,skills,volunteer,contribute
o Don’tHALT
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§ Don’tbehungery,angry,late,ortiredtowork
o Haveregularbreaks
o I’MSAFE(freefromeffectsof)
§ Illness,medication,stress,alcohol,fatigue,eating.
o Regularassessmentofinsightandtakeactionifseeingwarningsings.
o Developstressmxactivities:hobby,exercise,read…etc.
• healthcare
o makeformalappointmentstoseeGPasrequired,don’tdocorridorcare
o don’tself-careormedicateespneedfollowupofeffect
o haveaGPandhaveregularvisit;beapatient.
o Bemindfuloffamilyhistory
• workorganization
o bemindfuloflistarrangement,avoidunbalancedfrequenthighstressfullist;
befairwithcolleagues
o you’rean‘expert’onparwithanyotherspecialists;don’ttreatlikeaslave
o regularappropriatesickleave,annualleave
o maintainCPD,skill,knowledge–regularconferences,courses
• homeorganization
o ensureappropriatehomehelpasrequired
o maintainregularbreakswithfamily,withkids,withpartner(eg.‘datenight)
Needhelp?
• Colleague,mentor,SOT,Employeeassistanceprogram,DHAS(doctorhealth
advisoryservice)ANZ,DepartmentalWelfareofficer,PsychLiaison,GP.SIGWelfare.
Q12-Unexpecteddeathmanagement
Thereisanunexpecteddeathintheatre.Outlineyourmanagementofthisevent.
ANZCAwelfaredoconmanagementaftermishap…
• Majormishap=“anincidentwhichmayhave(a“NearMiss”),orhas,potentialto
produceharmtoapatient”.
• Leadsto4areasforaftermathconsideration
o Patient/relative(seeRD10)
o AnaestheticPractise/Environment
o Staffmembersinvolved(seeRD5)
o Rootcauseanalysis(RCA)
• Then…
§ Equipementinvolvedshouldbeisolatedforexamination
§ PrimaryTeaminformed,Hospitaladmininformed,ifmedico-legal
processimpliedthenmanagement,insurers,legaladvisorinformed.
§ FACTS,notopinionsshouldbedocumented–forrecords,medio-legal
defence,coroner’sexam.
§ NEVERalterexistingnotes
§ Coron’ersnotification.
• Patient/relative:interviewedbysurgeon/anaesthetist
o Opendisclosure,breakingbadnews,
• Staffmembersinvolved:supportsystemshouldbeinplace,it’sresponsibilityofall
involved;debrief,counselling,‘opendoor’policyforprofessionalsupporteg
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o GP,localwelfareofficer,mentor,friend,SOT;keepclosewatchofthose
involvedduringthistime
o Otherexamples:DoctorsHealthAdvisoryService(DHAS)ANZ,MentalHealth
Team,ANZCAWelfarerep,Lifelineetc…
• Rootcauseanalysis:byreviewingbody;identifywaystoimprovefuturecare
Q13-postpartumheadache
35yo2dayspostpartumnowhasheadache.Listyourdifferentials(30%)anddescribe
assessment/managementofapost-duralpunctureheadache(70%).
Q14-brainstemdeathphysiologicalimplication(repeat)
OutlinethephysiologicalimplicationsofbrainstemdeathfollowingSAHinapatientlisted
fororgandonation
Q15-post-hearttransplantissues(repeat)
50yowithorthotopichearttransplant10yragonowforelectivenon-cardiacsurgery.
Outlineissuesanddescribehowtheseaffectanaestheticmanagement.
April-2016,57.7%
Q1-weaknessafterTKJR,spinal,FNB(repeat),71%
A65-year-oldpatientwithtype2diabetesisunabletodorsiflexherleftfoot24hoursafter
undergoingalefttotalkneejointreplacementunderspinalanaesthesiaandaleftfemoral
nerveblock.
Discussthepossiblecausesofthisproblem.(50%)
Outlinehowyouwouldmanagethissituation.(50%)
(report)
• Knowexistenceofanaestheticandnon-anaestheticrelatedcauses.
• Hasanorderedapproachtoassessment,investigationandmanagement.
• Comment:FNBhasnothingtodowithdorsiflexion
Q2-myotonicdystrophydiscussion(repeat),65%
A30-year-oldpatientwithmyotonicdystrophyisscheduledforsurgeryforacute
appendicitis.
Outlinetheimportantfactorsinthepreoperativeassessmentofthispatient.(50%)
Describehowthispatient’smyotonicdystrophywillaffectyouranaesthetic
management.(50%)
Q3-safetyfeatureofanaestheticmachine(repeat),65%
Theanaestheticmachineisdesignedtodelivergasesandanaestheticvapourstopatients
viaabreathingcircuit.
Outlinethesafetyfeaturesofananaestheticmachine.
(report)
• featurespresentthatproduceaccurategasconcentrationsandflows.
• featurestoavoidoxygenrunningout,beinginsufficientlydeliveredandreplacingit
byalternativemeans.
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• Comment:Thiswasabigquestionbutcoreknowledgeforanesthetists.Apassrate
of65%wasdisappointing.
Q4-LungisolationtechniqueinL/pneumonectomy(repeat),66%
Youareaskedtoanaesthetiseanadultpatientforaleftpneumonectomy.
Describethedifferentmethodsforlungisolationinthispatient,includingtheadvantages
anddisadvantagesofeach.
Q5-remifentanildiscussion(repeat),66%
Outlinethepharmacologicalfeaturesofremifentanil.(50%)
Describehowthesefeaturescanbeutilisedwhenusingremifentanilinclinicalpractice.
(50%)
(report)
A-Describesclearlythenatureofshortdurationofactionandpotency/analgesiccapacity
B-clearlydescribesthebenefitsofrapidonsetandoffset.Includesdecentdiscussionofat
leastoneclinicaluse(eg.haemodynamic,coughorrespiratorycontrol)ordiscussion
touchesonmultipleclinicalaims.
Q6-spinalcordischaemiainEVAR(repeat),68%
Outlineriskfactorsforspinalcordischaemiainapatientundergoingendovascularrepairof
athoraco-abdominalaorticaneurysm.(50%)
Discussyourapproachtominimisingspinalcordischaemiainthissetting.(50%)
Q7-braininjuryissuesandriskminimization(repeat),72%
Outlinethepathophysiologicalinsultsthatexacerbateaprimarybraininjuryfollowinghead
traumaandindicatehowcantheybeminimised.
• Allaboutminimizinghypoxia,hypotension,ICP
Q8-pyloricstenosis(repeat),80%
Asix-week-oldtermbabyweighing4.0kgrequirespyloromyotomyforpyloricstenosis.How
wouldyouassessthebaby’shydrationstatus?(50%)
Detailandjustifyyourresuscitationregimen.(50%)
Q9-oxygendeliverydevice(repeat),62%
Consideringtheindicationsandlimitations,comparetherationalefortheuseof:
—Hudsonmasks
—Non-rebreathingmasks
—Nasalprongs
Q10-pulmHTNdiscussion(repeat),77%
Apatientwithknownprimarypulmonaryhypertensionisscheduledtoundergoelective
umbilicalherniarepair.
Howwillyouassesstheseverityofthispatient’spulmonaryhypertension?(50%)
Howdoesthisdiagnosisaffectyourperioperativemanagementofthispatient?(50%)
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Q11-smokingcessationstrategy,79%
Asaperioperativephysician,whatstrategiescanyouoffertoassistapatienttocease
smokingtobaccoandhowwillyoubestcommunicatethem?
ANZCAPDonsmokinginrelationtoperioperativecare
Assistingpatienttocareo AAR–
o ask-evenifanswerisknown,touseopportunitytoemphasiseimportanceof
smokingcessation,
o advice–highlightspecificperioprisks,
o refereg.Quitline,smokingcessationsupportgroups.
o Mx:Useadjunctstoassistquitprocess:o Non-pharm
§ Counselling,rapidsmokingaversivetherapy
o Pharm§ Mosteffective=Champix(Varenicline)
§ NNTslongtermabstinence
§ zyban(bupropion)=11
§ champix(varenicline)=8
§ nortriptyline=11
§ NRT:nicotinereplacementtherapy=14
Howbesttocommunicateo AAR
o Empathy,butemphasiseonbenefitofquitingonbiopsychosocialgrounds
o OffercessationadjunctssuchasNRT+infocardonquitline
http://www.saferx.co.nz/Smokefree_Pharmacotherapy.pdf
(report)
discussnon-pharm+pharmagents
Q12-Brainstemdeathphysiology,25%
Outlinethephysiologicalimplicationsofbrainstemdeathfollowingsubarachnoid
haemorrhageinapatientlistedfororgandonation.
(report)
Recogniseskeypotentialissuesthatarelikelytobeneededtobemanagedifpatientis
goingtoprovidesuitableorgansfordonation:
1.hypoperfusionofvitalorgans
2.someaspectofhypothalamicdysfunction
3.thephysiologicaleffectoftheincreaseinintra-cranialpressure
(comment)
Manycandidatesprovidedinformationonbrainstemdeathassessment,liaisingwith
relatives,consent,etc.withresultantlowscores.
Q13-ECTphysiology(repeat),58%
Describethephysiologicalresponsestoelectroconvulsivetherapy(ECT).(50%)
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DiscusshowtheseaffectyouranaestheticmanagementofapatientundergoingECT.(50%)
Q14-hypertensionmanagement(repeat),80%
Anobese55-year-oldfemalehasundergonesleevegastrectomywhichconcludedonehour
earlier.Thepostanaestheticcareunithascalledtoreportabloodpressureof190/110
mmHg.
Discussyourapproachtotheevaluationandmanagementofthehypertension.
• Assess+considerdifferential+stabilizeifsympatomatic(headache,chestpain,
dyspnea)
• Generalmanagement
Q15-preopanaemiamanagement(repeat),67%
A40-year-oldpatientwhoisscheduledforelectivetotalabdominalhysterectomyhasa
haemoglobinlevelof80g/l.
Describeyourpreoperativeassessmentandoptimisationofthispatient'sanaemia.
October-2015,61.4%
Q1–upperlimbregional
A65yearoldfemalepatientrequiresopenreductionandinternalfixation(ORIF)ofherfractureddistalradiusandulna.Shehasnootherinjuriesandisotherwisewellbutiskeentoavoidgeneralanaesthesia.a.Listtheoptionsfornerveblocktoprovideregionalanaesthesiainthispatient.(30%)b.Describetheadvantagesanddisadvantagesofeachoftheseoptions.(70%)
Needtocover:median,ulnar,radial,MSC+medialforearmcutaneousnerve
OptionsforULRA(distalforearm):brachialplexus=C5-T1(lumbar=L1-4)
• Supraclavicular
• Infraclavicular
• Axillary
• Interscalene
Pros/consofeachblocko Interscalene(blockC5-7;C8/T1hardtoblock)
o Superficialnervebundlestoblock,relativelyeasilyseenonUSS,canpossibly
relievetourniquetpain;rapidonset
o Cons:PhrenicNpalsyproblematicespifpatienthaspreexistinglungdisease;
dyspnoea
§ Horner’ssyndrome
§ RLNblock(15%)
§ Riskofintrathecal/epiduralinjection,pneumothorax,vertebralartery
puncture.
§ IncompleteblockofinferiortrunkhencemissulnarN.(15%)
o Supraclavo Rapidonset,goodefficacy;tourniquetpainrelief
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o Cons:canstillgetphrenicnerveblock,Horner’sandriskofPTX(5%),SC
arterypuncture.CanstillmissulnarN.
o Infraclavo Goodforcatheterplacement,canrelieftourniquetpain
o Deeperblock,likelymoredifficultonUSS;PTX.Butmuchlessriskofphrenic
Nblock,Horner’s;difficulttocompressarteryifpunctured.
o Axillary:o NoriskofPTXorHorner’s;easytocompressartery/veinifpunctured
o Cons:needtobeabletoabductshoulderandexternallyrotatearm.
§ Multipleinjectionstocaptureall4nerves.
§ MaynotbeenoughformedialforearmcutaneousNerveàneedLA
topup.
§ Lesshygieniclocation/infectionrisk,lessidealforcatheterplacement.
NB:
Interscalene:aim for C5 to C7; 8/T1 hard to block, can have muscle bridge b/w C7&8 ->miss C8 & T1
Digress:
GeneraladvantagesofULRA:
o possibleavoidanceofGAandassociatedrisk/complications
o minimisation/avoidanceofopioids
o post-opanalgesia
GeneraldisadvantagesofULRA:
o bleeding/infection
• nervedamage-temporaryorpermanent
• vasculardamage
• potentialforblockfailure
• LAtoxicity(espifintravascularinjection)
• residualblockpostopwithsafetyconcern;
TheserisksmanycanbereducedbyuseofUSSand/orPNS
Q2–hearttransplant
A50yearoldpatienthasreceivedanorthotopic(backtothecorrectplace)hearttransplant10yearsago.Henowpresentsforelectivenon-cardiacsurgery. OutlinetheissuesapriorhearttransplantmaypresentfortheanaesthetistANDdescribehowthesewillaffectanaestheticmanagement.Issues:
o Denervation:Heartdenervation;lossofANSresponse/baroceptorreflex
o AtrestingHR~80bpmandnobaroceptorreflexàlikelyhaemodynamic
labilityoninduction,tovolumelossandatropineisinffective.
o Pacemaker:Likelypresenceofpacemakerandarrhythmia
o Ongoingdiseaseprocess,silentMI:Likelyongoingdiseasepresentthatcausedthe
initialcardiomyopathyneedingtransplantie.CAD,amyloidosis;andmayhavesilent
MIduetodenervation.
o Immunosuppresiontherapy/complications–cyclosporine,azathioprine,steroid.
o Cardiac,resp,renal,bonemarrowdysfunction,riskofseveresepsis.
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Management:o Preop
o MDTinputwithCardiologist,TransplantTeam,cardiacPMtechnicianon
periopplanning–findoutifanyissueofrejection.
o PPM:Cardidacpacemakerassessmenttoensureoptimalfunctioning.o Optimise:Optimizeunderlyingcardiacdysfunction/chroniclungdisease/
renaldysfunction,anaemia/thrombocytopaenia,ifpresentfrom
immunosuppressiontherapy.o Establishplanforperiopuseofimmunosuppressiontherapyo Carefulairwayassessmentaspatientmayhavetrachealanastomosisis(if
heart/lungtransplantdone)Considerifintubationisrequired?Istracheal
stenosispresent?Riskoftraumatoanastomosiswithintubation?o Considersuitabilityforregionaleg.peripheralsurgery.
o Intraop:o A-Ifintubationisrequired,considershortertubesonottocontacttrachela
anastomosis.
o Maintainphysiologicalparameters:
§ Optimizepreload,contractility
§ MaintainafterloadtomaintainCoronarybloodflow.
§ HRresting~85-95bpm.
§ Usedirectactingsympathomimeticeg.phenylephrine,noradrenaline
ifrequiredtomaintainMAPwithin20%ofpatient’sbaselineBP.
o C-Ifregionalused,NABmayresultinmarkedfallinBPduetoheart
denervation–optimizepreloadandsupportMAPwithvasopressor.
o Steroidsupplementasrequired.
o Strictasepsis,antibioticprophylaxis
o Pharm:supersensitivity:adenosine,adrenaline,noradr
§ Noeffect:digoxin,atropine,noreflexHRchangestoGTN,panc,sux,
neo.
o Postopo ImpairedcoughlikelyduetophrenicN,RLNpalsiesàearlychestphysio,
mobilizationtominimizeriskofLRTI.o ClosemonitorofsilentMI.o Cangetepilepsy(?Mechanism)
NB:
Betablocker,alphablockeractasexpected.Originalfilehaslotsofexplanatorynote.
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Q3–bloodconservation
An adult patient is scheduled for a major operation during which significant blood loss is expected. Describe strategies you would consider peri-operatively when planning to minimise blood loss and transfusion requirement. Techniques rely on:
1. Optimise: increasing patients red cell mass 2. Minimis: decreasing peri-op blood loss 3. Rationale: optimising blood transfusion practices
Preop
o Inx and Rx anaemia and coagulopathies o optimise pre-op Hb
o Iron: If iron deficient and time allows (ie 2 months period before surgery) and patient tolerates: use oral iron (it time allows, and patient tolerates/is compliant). If surgery <2 weeks away, use IV infusion
o EPO: If criteria meets, consider EPO – eg. renal failure anaemia, with no other contributing causes. Consult Renal Physician.
o Time: may need to delay surgery until optimised (if appropriate) o Minimise:
o STOP Drugs: stop anti-platelet and anticoagulants if appropriate (warfarin, clopidogrel, ?NSAIDS in ortho surgery)
o Surgery: Minimally invasive surgery o Anaesthesia: TXA, good physiology control to avoid triad of doom (acidosis,
hypothermia, coagulopathy) – see below o Raionale: Pre-op autologous donation
Intraop 1. anaesthetic factors:
• regional vs GA - regional may reduce blood loss due reduced arterial and venous pressures volatile vs TIVA (?TIVA assoc with reduced blood loss)
• reduce venous ooze - avoidance of venous congestion (positioning), high intra-thoracic pressures (IPPV), hypercapnia and hypothermia
• consider permissive hypotension – but balance potential risk of ischaemic cerebral and cardiac complications. Ideally keep BP low normal for patient.
• Consider antifibrinolytics; tranexamic acid; 2. surgical factors:
• extent: quick and meticulous surgery • technique: minimally invasive surgical technique • local vasoconstriction
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• topical haemostatic agents • tourniquet use
3. autologous transfusion: which include 2 techniques: • cell-saver
o collectionandre-infusionofautologousredcellslostduringsurgery
o Considerusewhenlargevolumeshiftexpectedeg.upperGIopen
surgery,openheartsurgery.
o CI:bacterialcontaminationsurgicalfield,malignantds,presenceoffator
amnioticfluid(althoughsafetyinObstetricisincreasinglyestablished)
§ disadvantages:expensive,labour-intensive
• acutenormovolaemichaemodilution
o peri-opcollectionwholebloodwithsimultaneousinfusioncrystalloidto
maintainnormovolaemia.Re-infusedintopatientoncesurgicalbloodloss
ceased(Consultwithtransfusionspecialist+localguideline)
o advantages:notesting,minimalriskABO-incompatibletransfusion;
minimisesallogenictransfusion
o Cons:CI:LVimpairment,unstableangina,severeAS,criticalLMSds.
§ Controversialevidenceregardingitsbenefit.
Postop • Consider carefully transfusion triggers • TRICC: Hb 70 is a common target for transfusion; higher targets have not been shown to
confer additional benefit. NB: Re:cellsaver:indications:canprovideequivalentof10Ubankbloodperhour(openheart,
vascular,spinaljointreplacement,livertransplant,obstetrichaemorrhage)
o Re:haemodilutionindication:indications:(UK)potentialsurgicalbloodloss>20%ofbloodvolwithpre-opHb>100
Q4–TrigeminalNeuralgia
a.Describetheclinicalfeaturesoftrigeminalneuralgia(50%)b.Discusstheefficacyofthetreatmentmodalitiesavailableforthiscondition.(50%)
a) Trigeminalneuralgiafeatures• Pain,paroxysmsofintensestabling,lancinatingorburningpainusuallylasting
secondsinthedistributionofthetrigeminalnerve(CNV)
• commonlyunilateral,affectingthemandibular(V3)andmaxillary(V2)divisions
ofthenerve;althoughophthalmicbranch(V1)mayalsobeaffected.
• Painmayrecurmanytimesthroughoutday,withfeaturesofallodynia,
hyperalagesia.
• Higherriskofconditionif>50yo.
b) Managemetn=oftwomaintypes• Membranestabilisingagentseg.
o Carbamazepine=1stline(startat100mg/12hpo:max400mg/8hours;
o Phenytoin200-400mg/24hourspo
§ allow1-2weeksfortreatmenttotakeeffect,continuewith
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o otherantineuropathicanalgesiaeg.gabapentin,TCA,ketamine,tramadol
o othermultimodalanalgesia.Paracetamol,NSAID,opioids.
o Psychosocialinput
• Surgery
o To:peripheralnervevstrigeminalganglionornerveroot(ifcompressed
bytortuousbloodvesselsasitentersthebrainstem)
§ surgicaldecompression/ablativeprocedure
• Others:Lignocaineinfusionormagnesiuminfusionfor1-3weeks(APbook)
• spontaneousremissionmayoccur
NB:
EXTRA:oftenidiopathic,trigeminalsensoryormotordeficitsarenotdemonstrated
unlessthecauseisstructuraleginMS,vascularmalformationorcerebello-pontineangle
tumour
Q5-awareness
A61yearoldwomanisscheduledfortotallaparoscopichysterectomy.Shehashadanepisodeofawarenessunderanaesthesiaduringpreviouslaparoscopicsurgery.a.Whataretheriskfactorsforawareness?(30%)b.Howwouldyouminimisethispatient’sriskofawarenessduringheroperation?(70%)
Awareness=ie'explicitrecallofoperativeeventsduringGA'.- seriouscomplicationofanaesthesiawithlongtermpsychologicalsequelae
§ explicitandimplicitmemories:explicitmemoryisrecalledspontaneously,implicit
memorymaybeprovokedbysubsequentpost-operativeevents
§ incidence0.03%ie1:5000-1:10,000(~halfofepiduralabscess);1:500inGACS10x
lessthangeneral
CausesforawarenessunderGA• Breaksdowninto:
o Humanfactor:Accidental
§ Unrecognisedequipmentfailure
§ Reducepractitionervigilance(eg.emptyvaporiser)
o Patient:Abnormalpatientphysiology(Patient)
§ Maskedphysiologyeg.completeHB,hypothyroidism,BBuse,ANS
neuropathy
o Patient’sSNSstimulationis‘masked’fromalerting
Clinician
§ Drugresistanceeg.geneticvariability,escessiveETOH,chronicpain,
regularuseofillicitsubstances
• Also:pyrexia,hyperthyroidism,obesity,anxiety,Youngage
o HigherMACrequirement;previousawareness
§ PoorCVSreserveeg.severeASorheartfailure
o Anaesthesia:Poortechnique(Anaesthesia)
§ UnderdosingeginLSCS
§ UnexpectedDI+insufficientanaesthesia
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§ TIVA(failureofdrugdeliveryorpoorunderstandingofpharmacology,
espcombinedwithNMBD)
o Surgery:Specialcircumstances
§ Specialistsurgeryeg.cardiac,obs,paeds,rigidbronch,trauma
§ Lifethreateningemergencieseg.severebleed,septicshock,
cardiac/peri-arrest
minimiserisk• pre-operativecounsellingwithananaesthetistforprviousawarenessepisode.
o reassuranceandcounselling
o pre-medicationwithbenzo’soruseofIVatinductionreducesthe
incidenceofawarenessinthehighriskperiodafewminutesafter
induction
• intraop:
o vigilanceondepthofanaesthesiaappropriateforpatient:eg.assurance
ofMACof0.8-1.0+settingaudiovisuoalarmonMACrangeusingend-
tidalcontrol.
o onlyuseneuromuscularblockingagentswhennecessary
o useBISorentropy+audiovisualalarm.
o regularcheckingofclinicalsignseg.hypertension,tachycardia,
lacrimationandsalivation(buthaslowsensitivityandspecificity)
o Considerisolatedforearmtechnique,howeverthistechniquemaynotbe
reliableandmaybelateresponse.
• Postop:
o AssesspatientrecallusingoftheBriceQuesitonnaire
NB:
BriceQuestionnaire(Awareness)1. Whatwasthelastthingyourememberedhappeningbeforeyouwenttosleep?
2. Whatisthefirstthingyourememberedwhenyouwokeup?
3. Didyoudreamorhaveanyotherexperienceswhilstyouwereasleep?
4. Whatwastheworstthingaboutyouroperation?
5. Whatwasthesecondworstthing?
Q6–OSAinPaedAsTs
Athreeyearoldchildrequiresanadenotonsillectomyforobstructivesleepapnoea.Outlineandjustifyyourperi-operativemanagementplan.
Intro:• OSA=sleepdisorder,pausesinbreathing,orinstanecesofshallowbreathingduring
sleep.
• Issue:Periopbiggestdangerisimpairmentofrespdrive/hypoxicarousalby
sedatives;
• Aim=minimisesedationandensurevent/oxygenmaintaineduntiladequate
recover.
Management
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§ Pre–
o AssessseverityofOSA–doesitimpactondevelopment,learning,growthof
child?Poorattention,behaviouralproblem,hyperactivity,enuresis?Any
daytimesomnolence?Previoustreatment?
o Carefulairwayassessment.PaediatricOSAasscwincreasedresp
complication:desaturation,laryngospasm,anddevelopingairway
obstructionduringinduction.Needtohaveairwaymanagementstrategywell
consideredbeforehand.
o Recurrenttonsillitis?Activeinfection?
o exam:rightventricularfailure
o Invx:sleepstudy,polysomnography,polycythaemia.
§ Intra
o ConsiderCarefulpremedcarefully,asriskofsedation/respdepression.
§ MayuseketaminePO5mg/kgorsmallerdoseofmidazPO0.25mg/kg
butmonitorforrespdepressioninpreopholdingbay.
o A:preferrablySVtechnique:carefulinducewithSVtechnique,gasinduction,thenintubatewithRAEoruseLMA.
§ EMLAbeforeaimforIVinduction.Thisallowsestablishmentof
adequateanaestheticdepthrapidlyforintubation/securingairway
andrescuedrugstobegiveneffectively
o D:
§ polymodalanalgesiatoopioidspare.CanuseNSAIDwithout
increasedbleedingrisk(exceptforketorolac)
§ polymodalantiemetic(dex0.15mg/kgIV/ondas–0.1mg/kgIV)
§ Extubation:carefulsuction,left/lateralheaddownforextubation.
§ Post
o MonitorbyexperiencedPACUteam.
o Childshouldbeadmittedforovernightobservationwithcontinuouspulse
oximetry.
§ AdmissioncriteriaforOSAAs+Ts.§ age<3,
§ severeOSAieAHI>10ordesatto80%comorbidities)
o OngoignmonitorpostopinHDU/ICUmayberequireddependingonseverity
ofOSAandprogressinPACU.
NB:
Schneidermodel(validatedforchildrenabovetheageof1years);lessthan30kguseKataria,
>30kguseSchneider
Q7–intraarterialinjectionmanagement
Adrughasbeenunintentionallyadministeredthrougharadialarteriallineinanawakepatient.Describeyourmanagementofthissituation.IAinjection:
o Pain,ischaemia,thrombosis
o Dependingonthedrug–complicationsmayvaryfrompain,hyperaemia,
swelling,
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o vaso-spasm,arterialdamage,extravasationfromdamage,
o thrombosis,ischaemia,gangrene
• Aim=tomaintainperfusiondistaltothesiteofinjury+managepaintomaintain
patientcomfort.
ImmediateManagemento Identifythedruginjected
o analgesia:IVanaelgesiatokeeppatientcomfortable.E.givFentanyl
o Vasodilator(4drugs+RA)o Keepthearteriallinein-situ–allowsforintraartinjectionofpapaverine(sm
relaxantorLAorsalineflush)+o 1%lignocaine5ml+papaverine40mgflushedbyheparinsalineo iloprost-prostacyclineanaloguetovasodilateandplatelet-inhibit;o calciumchannelblockers,o SNSblockofthelimb.ConsiderStellateganglionblock(butnoevidencefor
improveoutcome)andriskofinsertionshouldbeconsideredo Venousdrainage:Elevatethearm,improvevenousandlymphaticdrainage
o Considerheparinisationoranticoagulationtokeepthearterypatentifthedrugisknowntocausethrombosis
o Otherdrugstoconsider:o aspirin/methylprednisolonetoinhibitthromboxane,
SubsequentManagement:
o plastic/vascularsurgeonsifdrugisknowntocauseseriouseffectslikethrombosis
orischaemia–thrombectomyornecrosiswashoutdebridement,repairetc.
o Ongoingobservation–forpain/paresthesia,ischaemia,infection.
Longterm:• Multimodalanagelsia,watchforpotentialCRPSo Explaintopatientbrieflywhathashappened–fullexplanationwillneedtobedone
onceacutesituationhasbeenmanaged.
o Documentevent+planforongoingcare,monitor.
o LocalWebAirsevent,QAdiscussion
NB:managementofextravasationvs.IAinjection–knowthecompare/contrast(CEACCP)
• Stop,disconnectinfusion,aspirateasmuchaspossiblefromcannula
• Leavecannulainbutlabelclearlynottouse
• Monitor:Markareaofextravasationifvisible,photo
• Elevatelimb
• Treat:(4drugs+RA)
o Salinewash
o SteroidviaIAIVtoreduceinflammation
o Hyaluronidasetohelpwithdispersingextravasate:1500unitsaredissolvedin
1–2mlofsalineandinjectedintotheareaofextravasation
o Phentolamine,5-10mgin10ml,givenbySCinjectionintoareaextravasation
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o RASNSblock
• PlasticSurgery
• Opendisclosure,QA,document
Q8-anaphylaxis
A20yearoldpatienthasbeensuccessfullyresuscitatedfromsuspectedanaphylaxis.Describeyourimmediateandlongertermpostcrisismanagement.I’drefertoANZAGGpost-resuscitationmanagementguidelineforanaphylaxis.Immediate
o HDU/ICUadmissiondependingonseverityofanaphylaxisformonitorofrecurrence.
o ~20%patientscanhavebiphasicanaphylaxiscoursewhichmaylastupto36
hours.
o Supportive:
o BC:Maintainadequateoxygenation>92%sats+MAP(within20%ofpatient’s
baselineBP)
o D:Steroid:hydrocortisone2-4mg/kgor0.1-0.4mg/kgdexamethasone.
o PO/NGantihistaminestobeconsidered.
o Investigate:Tryptaseat1hour,4hourand24hours,aswellasroutineICUblood
checks.
o Documentthoroughlyevent+reporttoWebairs.
Longertermo ReferraltoANZAAGaffiliatedAllergyTestingcentre.Testingtobedone6weekspost
eventtoallowhistaminetoreplenish.
o Patientcounsellingregardingeventandeducatere:riskminimizationstrategiesin
future:
o Listofpotentialtriggers/medicationstobegiventopatientandforfuture
medicalcarereference;untildefiniteallergytesting,potentialtriggersshould
beavoided.
o Medicalalertinpatient’smedicalrecord.Medicalbraceletforpatientonce
triggerisknown.
o Ifprolongedresus,patient’sathighriskofneurocognitivedysfunctionandshould
referforneurocognitivetestingandmonitorrecovery.
NB:
o Don’tuseIVpromethazineasmayworsenhypotension.
Q9=CVLaccess
Apatientrequiresvascularaccessforthreeweeks.A)listtheadvantagesanddisadvantagesofPICClinecomparedtoapercutaneousCVL.B)outlinethemethodsbywhichyouwouldminimisetheriskassociatedwiththeplacementofPICCPICCAdvantages:
• CanlastlongerthanCVL
• Lesscatheterocclusion
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• Lowerriskofpneumothorax
• Lowerriskofarterialdamage(arterialpuncture,arterialdilation)c/fwithCVLinthe
internaljugularvein;ordamagetonervesnearbyeg.IJ-RLN,vagalN,brachialplexus.
• LowerriskofCLABSI
Disadvantages:• HigherincidenceofDVTinlongtermuse
• Wrongroute:Cathetercanentersubclavianorneckveins
• InfectionriskwouldbelowerthaniffemoralCVLbutPICCassociatedCVLinfection
canstilloccur
• LesslumenthanCVL.
RiskminimizationEnviromentofinsertion:
• OT/PACUratherthanwardwheremaintainingasepsismaybedifficultduetomore
crowdedspaceforlinetrolley.
CLABbundle:ANZCAendorsedguideline:ANZICSonCVLinsertionandmaintenance:
• strictaseptictechnique(gown,gloves,mask,largesteriledrapeandmaintaining
sterilityfromnearbyequipment)
• considerusingchlorheximpregnantedpatch(goodevidenceforitseffect)Avoidriskofarterialpuncture:
• ConsiderusingUSSifveinnotreadilyvisible.• ifsuspectedofarterialpuncture,checkbloodgasresult.
Avoidcardiaccomplication/arrhythmia,tamponade.
o measuredepthofinsertion.
o Avoidinsertingcatheterbeyondestimateddepth.
o Avoidforcefulinsertionofcatheter.
Maintenanceoflinefunction:
• Cleanthoroughlythenapplycleardressing.
• ConfirmplacementofPICCwithCXRtoensuretipingoodposition:inSVCparallelto
vesselwallandnopneumothoraxorpericardialenlargement.
• Dailysitecheckandmaintainsterility.
• AseptictechniquewhenusingPICCline.
• Considerhepsalinelockifprolongedinactivityexpectedtominimizethrombosis.
• removePICCassoonasit’snolongerrequired
Facility’sskillmaintenance:staffinvolvedincaringofpatient’swithCVLshouldhave
educationonit’scare
Q10–NIMtubeinparathyroidectomy
AtsurgeonsrequestyouhaveplacedaNerveIntegrityMonitortubeformonitoringrecurrentlaryngealnervefunction.ThesurgeonisunabletoelicitaresponsefromthemonitorwhenstimulatingtheRLN.
• ExplainhowtheNIMtubemonitorsnervefunction(30%)• Outlinethepossiblecausesofbeingunabletoelicitaresponseandhowyouwould
managethem.NIM• = specialised ETT which allows monitoring for laryngeal nerve injury during surgical dissection • EMG system • useful for identifying RLN
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• placed that colour coded contact band is placed between vocal cords • complete circuit made with electrodes on skin above sternum • small current 0.5-2mA electrical current with sterile probe placed on anatomical site in question.
If in contact with nerve: • depolarisation of nerve ⟹ motor function, vocal cords contract à movement sensed
by NIM ETT à audiovisual display of response. Causesfornoresponseandmanagement:equipment issues:
o incorrect placement of NIM - sensing coloured band part; or dislodged during position change
o dislodged electrode pad on sternum. o Lead disconnection: monitor, surgical probe, NIM tue. o Equipment failure due to poor maintenance. o Power failure
§ Managed by preop check of integrity of equipment parts § Regular maintenance of equipment § Systemic check of all parts to ensure connection and correct placement of
ETT (using FOI or VL) nerve transmission:
• NM blockade will ↓ or prevent sensing: • Lignocaine gel lubrication to ETT used. • nebulised or trans-tracheal lignocaine • superior LN blocks • NDNMBs given - • DNMBs eg sux which hasn’t been metabolised yet
o Clear communication with anaesthetic assistant regarding use of NIM tube and avoidance of lignocaine to airway.
o Avoid SLN block. o May use NMBD initially, but monitor recovery with NMT to ensure
TOFR>0.9 o Obtund airway reflex with remifentanil during case.
• the RLN may have already been transected ⟹ prevent transmission of signal to muscles governing action of vocal cords nothing will be sensed
meticulous technique and vigilance by Surgeon throughout case. Q11–PostendarterectomycomplicationDescribe the complications that can occur post carotid endarterectomy and how these
may present in the post anaesthesia care unit (PACU):
ComplicationsSpecific to CEA:
o Airway compromise: oedema due to dissection close to airway. o Present as: SOB, resp distress, stridor, wheeze, desats, agitation, resp arrest.
o Bleed – haematoma (5-10%) o Present as swelling over wound site (can be concealed too), airway compromise,
tachycardia, hypotension (although less likely due to small compartment in neck, would see other changes earlier – eg. airway compromise)
o CVA – from ischaemic stroke
o Present as neuro deficit (sensory/motor/speech/visual disturbance), LOC, dyscoordination.
o Hyperperfusion syndrome can present as haemorrhagic stroke. Other General complications
o B: desaturation from resp depression, atelectasis o CVS instability: present with tachycardia, hyper/hypotension, cardiac ischaemia. o D: emergence agitation
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o PONV, pain
Q12–chronicalcoholism
A47yearoldmanpresentstotheemergencydepartmentwithacuteabdominalpainrequiringalaparotomy.Heisknowntohavechronichighintakeofalcohol.Describehowchronicalcoholmisusewillaffectyourperioperativemanagementofthispatient.Issuesofchronicalcoholism
o Associationwithchronicliverdisease,cirrhosis,alcoholicketoacidosis,malnutrition,
hypoglycaemia.
o IncreasedMAC.
o Riskofwithdrawalperiop,riskofseizureduetolowerthreshold
o Othercomorbiditieseg.IHD,ETOHcardiomyopathy,delayedgastricemptying,
anaemia.Coagulopathy(malnutrition,chronicliverdisease)
o Ifintoxicatedwillnotbeabletoconsentproperly.
PeriopmanagementPre
o Carefulassessmentforcomorbiditiesasmentionedabove.o Routineimportantassessment–AMPLEhistory,airwayassessment.
Intrao A:RSI
o Ifcardiomyopathy,needcardiacstableinduction:ketamine,fentanyl,
vasopressor(butbalanceriskofemergenceagitationwithketamine)
o BC:Thenmaintainoxygenation>90%,MAPtowithin20%ofbaseline.
o Monitorbleed+coagulopathy
o D:monitoradequatedepthofanaesthesia:clinically-HR,BP,pupil,lacrimation+with
BISto<60;
o Maintainanaesthesiawithatrac(organicindependentmetabolism),des
(minimizehepaticmetabolism)
o Monitor:artline(andmonitorelectrolyte/BGL)+CVL.
o Sepsiscare:Maintaingoodhygienecaretominimizesepsis,antibioticprophylaxis.
o Extubatewhenfullyawake.
Posto x2-5�edriskofpostopcomplications
o considerneedforICU/HDUpostopespifsepticwithliverfailure.
o monitorforalcoholwithdrawal&potentialseizures&delirium;useCIWAmonitor
chartbenzosasperlocalprotocol
o Bvitamins-topreventWernickesEncephalopathy
o Multimodalanalgesia:
o reduceddoseparacetamol,opioidsasperliver/renalfunction.
Q13-ERAS
a.Describetheprinciplesbehindan“EnhancedRecoveryAfterSurgery(ERAS)”programmeforcolorectalsurgery.(50%)b.Outlinethekeystepsyouwouldtakeinsettingupthisprogrammeinyourhospital.
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AprincipleofERASincolorectalsurgery:§ Definition:Fast-tracksurgery/ERASisamultimodal,evidencebased,perioperative
careprotocolisedpathwaydesignedtoachieveearlyrecoveryforpatients
undergoingmajorsurgery.
o =involvingMDTandcomprehensiveplanningofpatientcarethroughout
perioperativeallstages.
o Showntoreducepostoperativecomplicationsbyupto50%
§ Keyanaestheticgoalsincludeddetailed:o Preop:(3)
§ patientassessment,education,optimization
§ avoidanceofpreopdehydration+/-useofcarbohydratedrinks;
§ bowelprepisincreasinglydiscouraged
o Intraop:(3)§ drain,NGTavoidedwhenpossible;
§ minimalinvasivesurgicaltechniqueutilized;
§ GDFT-
o Postop:(3)§ multimodalanalgesia/antiemetic;closecollaborationwithAPMS;
§ earlyenteralfeed;
§ mobilization/PTinput.
B. key steps in setting up ERAS programme
Settingupprogrammerequires:
§ tight,coordinatedteamworkinperioperativecare.
§ activeinvolvementofthemanagement/clinicalteam
Multi-disciplinaryteamsneedtobeestablishedandwillinclude:
§ administrators/managers
§ ProjectLeader/EducatorsontheERASpathwaytoMDTteam:
o doctors,nurses,PT,OT,SW,
o setprojecttargetsandsettimeline
§ qualityassurancepersonnel
o tomaintainaninteractiveauditsystem,
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o overseeingofpatientpreopassessment,periopmanagement,
outcome,andcostofhealthcare.
Q14–Hyperkalaemiainburn
A65yearoldfemalepatientistwohoursintodebridementandskingraftingfora40%burntoherthoraxandlegs.Sheisintubatedandparalysed.Anarterialbloodgasnowshows: pH7.12 PaO2150PaCO245HCO315K6.3 a.Outlinethepotentialcausesforthispatient’shyperkalaemia.b.Describeyourmanagementofthishyperkalaemia.Answer:(seeCEACCParticleAnaesthesiaandintensivecareformajorburns)
Apotentialcausesinclude• IncreasedKfrom:haemolysisfromsignificantburn;rhabdo,compartment
syndrome,useofsux
• Reducedexcretion:renalimpairment,espduetorhabdomyolysis,
SIRS/shock/dehydration
• Increasedcellularexchange:metabolicacidosis,K/Hexchange;2ndtorenal
impairment,potentiallacticacidosisduetohypoperfusioninstateof
hypermetabolism/SIRS/dehydrationfromburn;
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o Carbonmonoxidetoxicityleadtohypoxia,lacticacidosis,H/Kexchange.
BHyperKmanagement:• General:Ca,insulin,salbutamol,frusemide
• TriggerformanagementshouldbeguidedbyKlevel+associated
ECG/haemodynamicchanges:
o TimelytreatmentifK>6.5orurgenttxifECGchangesegwidenedQRSseen;
o CaCl10%10ml+10Uactrapidwith50ml50%dextroseover30mins.
• Sourcecontrol:
o ExcessiveKrelease:rhabdo-ensurefluidreplacement/euvolaemia,
compartmentsyndromeàfasciotomy
§ ifrhabdo,aimUO1-2ml/kg/hrandconsidermannitol(0.25-0.5g/kg)
o renalimpairment:euvolemia;considerrenal-replacementtherapyifhigh
graderenalimpairmenthasoccurred
o CVSinstability/metabolicacidosis
§ fluidresususingParkland,+/-vasopressor
§ shockwithSIRSmayrequirevasopressortomaintainperfusion
pressure.
§ oxygentherapyforCOHbtoxicity
§ considerhyperbarictherapy,espinpregnancyorcomatosepatient
Q15–Tranexamicacid
Evaluatetheroleoftranexamicacidinprimaryhiparthroplasty.
TXA:§ =syntheticlysineanaloguewhichinhibitsfibrinolysis,promotesclotstability,helps
inachievinghaemostasis;
§ howeverbenefitisbalancedwithpotentialriskofincreasedthromboembolism
(whichisn’tstronglyevidencebased)
Inprimaryhiparthroplasty,literaturereviewhasshown:(ceaccpUsesoftranexamicacid)§ Meta-analysesoftotalhipandkneearthroplastysurgeryconcludedthattranexamic
acidreducesbothbloodlossandtransfusionrequirementsandisnotassociated
withanincreaseinthromboembolicevents.
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§ Tranexamicacidappearstoshowasimilarbenefitinadultandpaediatricpatients
undergoingspinalsurgery.Thereisalsoevidencethatbothoral(e.g.1.5g8-hourly
beforeoperation)andintra-articular(e.g.50mgkg21attheendofprocedure)
administrationmayconferabenefit.
April-2015,71.9%
Q1–Thoracicparavertebralblock,66.3%
Describetheanatomyrelevanttoperformingathoracicparavertebralblock.(50%)Listtheadvantagesandcomplicationsofperformingthisblockforapatientundergoingradicalmastectomy.(50%)
AnatomyThoracic paravertebral space = wedge-shaped area, either side of the vertebral column. Bordered by:
• anterolaterally:parietalpleura;• medially:thevertebralbody,intervertebraldisk,andintervertebralforamen;and
• posteriorly:thesuperiorcostotransverseligament.
spacecontains:spinalnerve,whiteandgreyramicommunicantestothesympatheticchain,
intercostalvessels,andfat.
o Spacecontinuouswiththeintercostalspacelaterally,epiduralspace
medially,andcontralateralparavertebralspaceviatheprevertebralfascia.
(Drawparavertebralspace)
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Performingblock• directly on the spinal nerve, • lateral extension à intercostal nerves and • medial extension à epidural space through the intervertebral foramina. • Technique: Needs insertion point is 2.5cm lateral to the cephalic aspect of the
spinous process at the desired block level; contact transvere processes, walk up until no resistance felt then aim for LOR to indicate reaching paravertebral space; but not deeper than 1cm beyond TP.
Pros/consforradicalmastectomyGeneral:
• Mastectomy:Incrasedriskofpersistentpostoppain,wherebenefitofRAiswell
demonstratedtoreducerisk.
• LikelybenefitinbreastCalongtermsurvivaland?lessCarecurrencerate.
• unilateral analgesia (targeted) • can place catheter for ongoing analgesia • opioid spare (less sedation, nausea, vomiting, and constipation)
Cf. to epidural: • efficacy comparable to epidural • relatively easy to learn and perform (cf thoracic epidural); • lower risk of neurological complications • less haemodynamic instability (less SNS blockade) • less urinary retention Disadvantages:
o side effects: epidural spread, sympathetic block o complications: infection, haematoma, nerve injury, pneumothorax, LA toxicity,
intravascular injection o intraforaminal needle passage -> risk spinal cord injury or subarachnoid
injection (total spinal)
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NB: Block will cover 2 levels above and below insertion point. (OHA: up to 3-5 levels) Q2–PONV,58.5%
Listtheriskfactorsforpostoperativenauseaandvomiting(PONV)(30%)EvaluatemethodstominimisePONV(70%)BasedonANZCAendorsedguidelineonPONVassessment/managementRiskfactors
• Pt(4)o Female,hxofPONV/motionsickness,non-smoking,youngerage(<50),o Paeds:hxofPOV/PONVinrelative,>3yo,
• Aneasthesia(4)o GAvsRA,volatileandN2O,postopopioids,durationofanaesthesia(>1hr)
• Surgeryo Typeofsurgeryeg.cholecystectomy,laparoscopic,gynaesurgery,strabismus
surgery,ENTsurgery,Neuroetc.Riskminimization:
• Stratify:Basedonriskstratificationtoformulatemanagementstrategy.• Apfel:CombinedwithusingApfel’sscoretoguidemanagement.
o Lowrisk=0-1RFàconsider0-1tx.(10-20%incidence)o Med=2RFà1-2tx(40%)o High=3RFà2tx(60%)
• Methods:o Modifyriskfactors:minimizeGAexpose,N2O(useTIVA),opioidspare,
adequatehydration.o MultimodalantiemeticuseforPONVprophylaxis:(7optinos)
§ Ondansetron(5HT3antagonist),4mgIV,NNT~5• Balanceriskofheadache,constipation,potentialQT
prolongation§ Dexamethasone,4mgIV,NNT5;
• butbalanceriskwithpotentialimmunosuppression,
hyperglycaemiaespinDM.§ Droperdiol(D2antagonist),0.625-1.25mgIV,NNT5
• FDAblackboxwarningforpotentialQTprolongation,EPS,
hypoension(alphablockade)butconsideredunlikelyatsuch
lowdose.§ PropofolTIVA,showntobeaseffectiveasondansetron.
§ Cyclizine(H1antagonist),25-50mgIV,• NotavailableinAustralia;riskoftachycardia,sedation.
§ Scopolaminepatch(anticholinergic),NNT6• Sloweronset2-4hours;riskofanticholinergicsideeffect
§ Aprepitant(NK1Rantagonist),40-80mg• Limitedclinicalexperience.
o Non-pharmacological(combineswithpharmapproachworksbest)
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§ P6stimulation§ Preopginger
Q3–Pericardialeffusionmanagement,82.9%
Apatientwhois6weekspostcardiacsurgeryhasapericardialeffusionrequiringtreatment.Outlinethesymptomsandsignsofthiscondition.(70%) Whichofthesefeatureswouldtriggeranurgentintervention?(30%)Pericardialeffusion=maycausecardiactamponade,whenpressureofthefluid
accumulationinthepericardialspaceimpairscardiacfilling.
S/Sofconditiondependsonsizeofaccumulation+acutevschronicAcute=lesswelltolerated
• If small, may be asymptomatic • if large and acute, may cause worsening impairment on cardiac filling,
eventually tamponade à o haemodynamic instability à obstructive shock
• Other physical signs (insensitive and nonspecific): o increasedCVP
o Kussmal’sSign-distensionofjugularveinsduringinspiration
o pulsusparadoxus(decreaseinSBP>10mmHgduringinspiration
o Beck’sTriad-muffledheartsounds,increasedjugularvenouspressure,
hypotension
• DecreasedvoltageonECG.
Chronic=bettertoleratedthanacute,aspericardialmembranecanstretch.• Ifsevere,willstilldevelopsymptom,oftensinustachy,SOB,jugularvenous
distension,hepatomegaly,peripheraloedema,fatigue
Indicationforurgentintervention• =acuteand/orseveretamponade:
• prolongedandsevere/resistanthypotension
• cardiovascularcollapse
• bradycardia(vagalreflexevokedbyincreasedintrapericardialpressure)
• suddenonsetsymptoms(dyspnea,chestpain,hypotension,markedlyelevatedJVP)
NB:• K-sign&PP=dyssynchronyoropposingresponsesofRandLventricletofilling
duringtherespiratorycycle(akaventriculardiscordance).
• electricalalternansonECG(cyclicbeat-to-beatshiftinQRSaxisinlimband
precordialleads)
Q4–sepsismanagement,38.3%
A40-year-old100kgpatientpresentswithsepticaemiaofunknowncause.Afterreceivingtwolitresof0.9%NaCl(NormalSaline)asinitialresuscitationthepatienthasthefollowingobservations:HR126bpm BP80/40mmHgOutlineyourinitialresuscitationgoals.(30%) Evaluateoptionsforongoingfluidresuscitationatthistime.(70%)
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Intro: • Patienthassepticshock(severesepsisplushypotensionnotreversedwithfluid
resuscitation)whichisamedicalemergencywithhighriskofmortality,requiring
timelysourcecontrol+resuscitation.
o Obtainbloodculturesasapwithoutdelayingtimelybroadspectrum
antibiotic,whichshouldbegiven<1hourofrecognitionofsepticshock
Initialresusgoal• ThewellknownSurvivingSepsisGuidelinesmandatesearlysourcecontroland
intensivecare.
• However,morerecentinvestigationsonsepsismanagementfromtheARISE/
PROCESS/PROMISEtrialsshowedthatresuscitationtargetingCVPandSCVO2made
nodifferencetopatient’soutcome.
• MyinitialresusgoalwouldthenbemaintainingMAP>65mmHgwithvasopressor,
oxygenation>90%andpreventingworseningofmetabolicacidosis.
• Ifongoingsignofpoorperfusionieworseningacidosis,thenconsidernon-invasive
COmonitorandaimforCI>2.5
• Useofvasopressorisbalancedwithregularfluidresponsivenessassessments–
passivelegraisebyelevatinglegto45degree–ifimprovedBP/HRisseen;would
considersmallvolumebolus(eg.500mlofP148).
Ongoingfluidresusoptionevaluation• Type of fluid: balanced fluids eg Hartmanns or P148. Avoid large volume NaCl
and assc hyperchloraemic acidosis. • Volume of fluid: guided by evidence of fluid responsiveness, based on ECHO,
passive leg raise, arterial line pressure monitoring. o However, should combine with vasopressor use and avoid large
positive fluid balance; eg. noradr via CVL. o Consider albumin (although SAFE trial showed no difference)
• Fluid responsiveness should be reassessed regularly as volume status is dynamic and course of septic shock.
• In this patient, fluid responsivenss should be assessed in order to decide if further bolus should be given or to commence vasopressor.
NB:
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Q5–Statistics,trialdesign,98.4%
Youareplanningatrialtoevaluatetheefficacyofanewdrugonreducingpost-laparotomypain.Describepotentialsourcesofbiasandindicatehowthesecanbeminimised.Bias:Systematicdiscrepancybetweenameasurementandthetrue
valueàadverselyaffecttestresults.
Potentialsourceofbias(6) =selection,intervention,followup,recall,information,analysis
• Selectionbias:
o sampleunrepresentativeofpopulation
o controlsnotcomparablewithstudygroup
• Interventionbias:
o patientsreceivingmoreattentionbecauseoftheirtreatmentgroup(ie
Hawthorneeffect)
o espifunblindedcomparison.
§ Blinding,ensurerandomization.
• Follow-upbias:
o whenpatientsarelosttothestudyitmaybeduetoconfoundingeffecteg.
lesscapabletocontinuewithstudyduetoillness
§ minimizeeffectbyusingintention-to-treatanalysis
• Recallbias:
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o patientmistakenrecollectioneg.abilitytodescribepainwhenveryunwell
post-laparotomy
§ questionnaire/interviewconductedintimelymanner,whenpatient
clinicallysstable.Useobjectiveassessmentincombinationto
subjective.
• Measurement/informationbias:
o exaggerationofeffect:
§ egitiswellknownthatpatientsincludedintrialsoftendobetterthan
thosenotincluded,thepatientsincludedinthetrialwillhavebetter
analgesiathanthosenotincluded
• minimizebycarefulstudydesigntoensureappropriate
definitionofinclusion+exclusionstudycriteria.Referto
alreadypublishedhighqualitystudyduringstudydesign.
§ inaccurateoruncalibratedinstruments
• minimizebyensureworking,calibratedequipmentbefore
studytakeplace.
• Analysisbias
o withdrawalsordesignviolations
• minimizebysample-sizecalculationwithQualifiedStatistician
Consultanddedicatedresearchteamtofollowuppatient.
Q6–collapsepostNVD,71.5%
Youarecalledtoseea30-year-oldwomanwhohascollapsed2hourspostnormalvaginaldelivery.Whatisthedifferentialdiagnosis?(30%)Outlinetheclinicalfeaturesandinvestigationsthatwouldsupportadiagnosisofpostpartumhaemorrhage.(70%)Differentialsofpostpartumcollapse(NVD)4H4T–incontextofpregnancy
• Hypovolaemia
o Bleeding–tone,tissue,tear,thrombocytopenia
§ Uterinerupture,abruption,placentapraevia/accrete,HELLP
syndrome
o Dehydration,compoundedbyepidural
o Sepsis
o Anaphylaxis
• Hypoxia
o Cardiacevents:peripartumcardiomyopathy,myocardialinfarction,aortic
dissection.
• Hypoglycaemia
• Hypothermia
• Thromboembolism
o Amnioticfluidembolus,pulmonaryembolus,airembolus,myocardial
infarction;
o CVAorintracranialhaemorrhage
• Toxicity
o LA,magnesium,Eclampsiaandpre-eclampsia;drugerrorwithopioids.
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• TensionPTX/Tamponade
DeterminationofPPHasdiagnosis–clinical/invxHistory:
• Obstetrichistory:
o pregnancycomplicationsincreasingPPHrisk?
§ PET,bleedingdiatheses(suchasthrombocytopenia),foetal
macrosomia,obesity,twinpregnancy,lowlyingplacenta,uterine
malformationegfibroids,
o Labourcomplication?
§ VBAC?Uterinerupture?prolongedlabour,instrumentaldelivery,
historyoftraumatobirthcanal,incompleteplacenta,ecbolicsgiven
post-partum
• PMH:inheritedcoagulationabnormalitiesegvonwillebrandsdisease,factorVIIIor
IXdeficiency
• Meds:anyanti-coagulantadministration
Examination:• Haemodynamicinstability?Tachycardia,hypotension,pallor,increasedworkof
breathing,presyncope.
• Observedbloodlosspostpartum:onbed,onfloor(maybeconcealed)
o PPH=EBL>500mL(OHA);or1000mlofbloodlossinthefirst24hours
followingdelivery.
• fundus:firmandcentral?
• evidenceofclottingabnormality:bleedingfromIVlinesites;petechiae/purpura?
Investigations:• FBC:anaemia,plateletcount
• U&E:renalimpairmentandorderangedliverprofileconsistentwithpre-eclampsia
orHELLP.(haemolysischeckedbyhaptoglobulin,LDH.
• Uricacid:suggestiveofpre-eclampsia
• Coagulationprofile:includingfibrinogenlevelsandfibrindegradationproducts
Q7–ChronicPainmanagementpostop,(repeat)74.6%
Anelderlypatientisscheduledfortotalhipreplacementandhasbeentakingoxycodone40mgtwicedailyinthelastsixmonthsforseverehippain.Whatissuesdoyouanticipatewithregardtoheroxycodoneuse?(50%)Howdotheseissuesinfluenceyourpostoperativemanagement?(50%)
(Sam’sanswer)
Issues:Regularopioidusehasanumberofpsychosocial/pphysiologicalconsequences:
• Psychosocial:addiction=continuedusedespitecausingharmandbehavioural
alteraction;dependence:withdrawalsymptomswhenbaselineconsumptionnot
maintained.
o Drugseekingbevaiourmustbedistinguishedfromgenuinerequirementof
analgesia
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• Physiological:increaseddoserequirementtoachieveanalgesiceffectietolerance.
• Othersideeffectsneedtobemonitored:nausea,constipation,sedation,resp
depression.
• Periopanalgesiamaybedifficulttocontroldueto‘opioidusehyperalgesia,wound
upphenomenon’.
Mx:• Goodpreopassessmentneeded:
• ContinueregularanalgesiaperioperativelyincludingonDOS.
• Multimodalanalgesiaapproach
• Regionalwhenappropriate
• Postopopioidrequirementsmaybeupto400%increasedoverbaselineand
prolongedrequirementmaybeexpected.
o Howeverweaningofopioidsmustbeaimedforandplannedforwhen
appropriate
• Settingmanagementgoaltogetherwithpatient–unrealisticgoalofnopainis
avoided,insteadtargettingpainleveltowherereasonablefunctionisunrestricted,is
morerealistic.
• Consideropioidrotation.
(report)
Candidateswereexpectedtomentionthefollowing
• Recognisetheissuesofchronichighdoseopioiduseincludingtolerance,
dependence,addictionandsideeffects
• Mentiontheneedforanincreasedopioidrequirement,monitoringandweaningof
opioidtherapyandidentifyproblemsassociatedwithopioidtoleranceand
withdrawal.
Q8–penetratingeyeinjurymanagement,56.5%
Athirty-year-oldmanhassustainedapenetratingeyeinjuryrequiringsurgery.Whatarethekeyanaestheticissues?(30%)Outlineyourplanofperioperativemanagementandjustifyyourchoices.(70%)
Keyanaestheticissues:Specialpointinpenetratingeyeinjury:
• elevatedIOPperi-operativelyrisksextrusionofthevitreous,haemorrhageandlens
prolapse
o intra-ocularpressureneedstobecarefullymanagedandavoidfurtherrise.
Periopmx:Preop(patient/anaesthetic/surgery):
• IOPfactors:Preventvomiting,coughing,crying,breathholding,eyerubbing,
screaming,allofwhichwillincreaseIOP
o Reassurepatient,considerpremed(balanceagainstriskofsedationif
potentiallyunfasted)
o AssessPONVriskandminimisationstrategies:ieconsiderTIVA,multimodal
analgesiatoopioidspare.
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o ConsiderLAifappropriate.Isitadequacyforsurgicalanaesthesia?ispatient’s
indistress?Patientabletolieflatforsurgery?
§ Usuneedtoassessvisionpostop,communicatewSurgeon
• urgencyofsurgery?(OHAsaysmaybeabletowait);maintainpositionslightheadup
ifpossible.
• RoutineimportantAMPLEhistory/airwayassessmenttobedone.
Intraop:• Airway-avoidsuxoragentsthatcouldincreaseIOP
o Ifunfasted,thenperformmodifiedRSIwithadequateairwayreflexblunt:use
prop/remi/roc;avoidcoughing;maintainstablehaemodynamicswithuseof
vasopressor.
• Breathing:keepnormocapnoea;avoidhypercapnoeawhichincreasesIOP;avoid
excessivePEEP/airwaypressuretooptimisevenousdrainage.
• Circulation–maintainBPto<20%ofbaseline.
• Drug:adequateantiemetics/analgesic;normoglycaemic,normothermic.
o ConsidermannitoltocontrolIOPifrequestedbySurgeon.
o AvoidN2O
Postop:maintainadequateoxygenation/perfusiontoavoidsecondaryischaemicinjuryto
eye
NBonIOPcontrolPinglobe,10-20mmHg
Diurnalvariation,upatnight.
Determinants:- acqueousvol(product,absorp)
- choroidalbloodvolumeasscleralayerisnon-compliant:upvolupIOP.
- externalP:extraocularmuscletone.
Control:- acqeous:producedbyciliarybody,absorbedviatrabecularmeshwork,viaCanalof
Schlemm.DowndrainageinupvenousP,cough,strain,mydriasis.Updraininhead
up,miosis,negativeITP.
- choroidvolume:PaCO2vasodilate,MAP.
- extraocular:blink,
- Drugs:mannitol,down.amiloride,downproduction.
Re:Suxuse:(OHA:butbalancewithriskofaspiration,ifindoubt,usesuxfollowingalarge
doseofinductionagentwhichlowersIOPandreducethetransientIOPupbysux;reportdiscouragesusingsux);avoidN2O;
Q9–Prolongedunconsciousnesspostop,83.4%
Fortyminutesafteralaparoscopicappendicectomyhasbeencompleted,a55yearoldpatienthasfailedtoregainconsciousness.Listthepotentialcauses.(30%)Describeyourmanagement(70%)ListcausesAnaestheticfactors(iedrugs-anaesthetics,NMB,opioids-sedatives,error)
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• Excesssedationfrom:
o Benzodiazepines:
o Opioid
o Anticholinergiceg.scopolamine
o Alpha2agonisteg.clonidine
o Antihistamineeg.cyclizine
§ Especiallyifmultipleagetnsusedwithsedativepotential.
• Ongoingneuromuscularblockade:
o inadequatereversal
o plasmacholinesterasedeficiencywithsuxameethoniumuse.
• ProlongedeffectfromanaestheticsafterlongdurationofGAwithhighlipidsoluble
agent.Eg.isoflurane(althoughlesslikelyincontextoflapappendicectomy)
- Centralanti-cholinergicsyndrome
o Anti-Parkinsonian,antidepressantandantihistaminedrugscancausecentral
anticholinergicsyndrome
Patientfactors• Pharm:
o increasedsensitivitytosedatives,eg.OSA,encephalopathy,idiosyncrasy
o reducedeliminationofsedativeseg.Renalfailure;hepaticfailure,elderly
patient(whichpatientisnot)
• Pathophys:4H4T)
o MI,CVA,hypothermia,hyper/hypoglycaemia,hyper/hypo-kalaemia,
tamponade,tensionpneumothorax.
o Otherelectrolytedisturbance:hyper/hypo-natraemia,Uraemia,
Hypothyroidism
Management- simultaneousassess+manage- Ptexam(chart)+monitorvitals- assessABC–maintainoxygenation>90%+MAPwithin20%ofbaseline- assessGCS;- drugsassessNMT–givereversalagentifTOFR<0.9andreassurepatient.- reviewanaestheticchartandconsidercauses
o anypotentialcausativeagentsthatcanbesafelyreversed?Eg.naloxone,
flumazenil,doxapram,physostigmine.- BGLandtreatifloworveryhighsuggestingHHSorDKA.- Tempensurenormothermia.- ABGandelectrolytes:correctanysignificantderangedlevels.- FBC,UECr,TFT–foranaemiaanduremia,orthyroidderangement.- Focusedneuroexamfor?neurodeficit,pupilsandconsiderCThead- ConsultICUTeamforfurtherassessmentandadmissionifongoingLOC.
NB:
• MACawakeisconsistentlyandapproximately30%ofMAC.
• IVanaesthesiaagent:
o Typically,areductionof80%intheeffect-siteconcentrationisrequiredfor
emergence.
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Q10–Parkinsonsmanagement,69.9%
A68year-oldmalewithsevereParkinson'sDiseasepresentsforelectiverighthemicolectomy.Currentmedicationsincludelevodopa/benserazideandselegiline(monoamineoxidaseinhibitor).WhatclinicalfeaturesofParkinson’sdiseaseaffectanaesthesia?(50%)Justifyyourperioperativedrugmanagementplan.(50%)
Parkinson’sDisease(PD)isamultisystemdisorder.- Imbalanceofmutuallyantagonisticdopaminergicandcholinergicsystemsofbasal
ganglia.
- Substatianigrapigmentedcellsarelostàreduceddopaminergicactivity.
Clinicalfeatures• Cardinal=Tremor(pillrolling),leadpiperigidity,bradykinesiaandANSinstability.
o Monitortricky:CanaffectBP,ECG,oximetrymonitorwithtremor
o Positioning:Rigidityàdifficultwithpositioning.
• A:mayhaveflexiondeformityofneckàdifficultairway
• B–bulbardysfunctionàaspirationriskandunderlyingLRTI.
• C:Autonomicinstabilityàhaemodynamicinstabilityesponinduction/emergence.
• Neuropsychiatric–Anxiety,depressionarecommonàwatchforpolypharmacyand
interaction.
o Dementiainseveredisease–Consent,maydevelopacutedeliriumin
perioperativesetting.
• GI–delayedGIclearanceàaspirationrisk
PeriopdrugmanagementPreoperative–
• AssessseverityofParkinson’saswellasroutineimportantAMPLEhistory,ABC
examination.
• MDT:InseverecasesofParkinson,MDTinputwithNeurologist/Geriatrician.
• PtPrep:Continueantiparkinsonregimensisimportantwithasminimaldisruptionas
possible.
Intraoperative:- A:considermodifiedRSIifriskofGORDhighorAFOI/VLifdifficultintubation
anticipated
o Eg.prop/fent/roc/phenylephrine/.
- CMaintainCVSstabilitywithuseoffluid+vasopressoresp.oninduction/emergence.
• Pharmconsiderations:o MinimisePONV,considerTIVA+appropriateuseofantiemeticseg.
ondansetron,dexamethasone.
o AvoiddrugswhichmayprecipitateEPS–dopamineRantagonisteg.
metoclopramide,droperidol.
o Avoidpotentialdruginteractionwithantiparkinsonismtreatment:
§ Tramadol/pethidinevsSelegiline(MAOi)àserotoninsyndromeand
hypertensivecrisis.
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o Vasopressoruse:MAOicanpotentiatetheeffectsofbothdirectandindirect
actingagents.Directactingagentpreferred,usewithcare.Eg.
phenylephrine.
o Ifprolongpostopfasting,considerNJ/NGtocontinueantiparkisontreatment.
(Levodopa,MAOiareabsorbedinproximalsmallbowel).
o Ifenteralrouteimpossible,considerApoMorphine;ieIVdopamineagonist,
afterconsultingneurologist.
Postoperative:• MultimodalanalgesiaandantiemetictoaimforearlyE+D,rehabilitation/mobility.
• ConsiderNursecontrolledanaelgesiaifpatientcannotusePCAduetotremor.
• Ongoingmonitorofadequateoxygenation+haemodynamics(ANSmaycause
instability–espepiduralused.
• MayrequireHDUifseverelydependant
NB:GeneralpharmacologyfromOHA:
• Dopaminergics
o L-dopaàdecarboxylaseàdopamineinbrain
o Decarboxylaseinhibitors(benserazide,carbidopa)toreduceperipheral
conversion
o MAO-Binhibitors(selegiline),reduceCNSbreakdownofdopamine;hasfewer
druginteractionsthannon-specificMAOi,butstillwatchoutforHTN
crises/dangerousCNSexcitabilitywSSRI/TCA.
o 2ndline:Ergotderivativeseg.Bromocriptine,cabergoline,lisuride,pergolide,
directdopamine-Rstimulator.
§ Watchforposturalhypotension
o Entacapone:adjuvantagentusedtoreducedoseofL-dopa/increase
duration.
o Otherdopaminergicadjunctsincluded:ropinirole,pramipexole,amantadine,
apomorphine,tolcapone.
• Anticholinergic:benzatropine,orphenadrineetc.mainlyfortremor,rigidity,
sialorrhoeaetc.Ordrug-inducedparkinsonism/dystonias.Bradykinesia/tardive
dyskinesiawon’tbeimproved.
• DruginteractionsfromOHA
Class Interaction Notes
Pethidine Hypertension/rigidityw
selegiline
MH-likesigns
Syntheticopioidsegfentanyl Musclerigidity Esphighdose
Inhalational PotentiateL-dopainduced
arrhythmias
Avoidhalothane
Antiemetics EPsideeffects/worsen
parkinsonian
Use
domperidone/ondansetron
Antipsychoticseg EPsideeffects/worsen
parkinsonian
Preferfornewerantipsych:
risperidone,olanzapineetc
TCS/SSRI Carewithselegiline;L-dopa
inducedarrthymias.
AntiHTN MarkedBPdrop Espclonidine
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Q11–difficultairwayANZCAPD,77%
Listtheessentialequipmentcurrentlyrecommendedtomanageadifficultairwayinanadultpatient.(50%)Justifysupplementaryitemsyouwouldrecommend.(50%)RefertoANZCAprofessionaldocumentondifficultairwayequipment.ADULT:
• Basic:
o -OPA3,4,5,6
o -NPA6,7,8
o -LMA3,4,5
• -Macintoshlaryngoscopesize3,4
o -alternativebladesuchasstraightblade,McCoy,Kesselblade
o -twocompatiblehandlesincludingshorthandle
• Intubationadjunct:
o selectionofETT.
o introducerwithaCoudetipof35degreessuchasFrovaintroducer
o bougie
o malleablebluntatraumaticsylet
o intubatingLMAsize3,4,5withdedicatedtubesandstabilisingrodssuchas
LMAFastrach
o -selectionofspecialisedtubessuchasmicrolaryngealtube,parkertip,nasal
RAE
• Extubation:longairwayexchangecatheter
• Emergencycricothyroidotomy
o surgicalkitincludingscalpelwith#10blade,trachealhook,dilator,size6mm
ETTandtracheostomytubes
o kinkresistantcricothyroidotomycannulaof14Gorhigher
o rapiflowO2deviceforoxygenationthroughcannla
o Manujetforoxygenationthroughcannula.
• oesophagealintubationdetectoreg.oesophagealsyringe
• meanstoimmediatelydetectCO2
CHILDRENisessentiallythesamejustchildsized!
Additionalequipmentwhichshouldbekeptonthedifficultairwaytrolley
ForFOI:
• -aflexibleintubatingbronchoscope
• -intubatingcathetersuchasanAintree
• -sparelightsource
• -anti-fogsolution
• -lignocaineandnasalvasoconstrictors
• -biteblock
• -wire
• -endoscopymasks
OtherSupplementaryequipment:optionalequipmentdepartmentalpreference
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- Egopticalstylet,videolaryngoscope–knowncapableofimprovingDLviewand
shouldcomplementDL.
- Retrogradeintubationkit–infacialbleed,airwaybleedbutwithsparingofneck.
- Rigidventilatingbronchoscopes(oftenlargesofttissueswellingcanbeovercome)
- ContactphonenumberforoncallENTSurgeontoallowtimelyENThelpaccess
duringemergencyfortracheostomy.
- Grab-bagwithessentialequipmentsforremoteassistanceofairwaymanagement.
Q12–VTE/DVTprophylaxis,83.4%
Inpreadmissionclinicyouareassessingapatientwhoisconcernedabouttheriskofdevelopingvenousthromboembolism(VTE)perioperatively.OutlinethepatientfactorsthatincreasetheriskofVTE.(50%)DescribemeasuresthatmayreducetheriskofperioperativeVTE(50%)Patientriskfactorsincategoriesof:
- Venousstasis/endothelialinjury;
- Prolongedtravel
- Varicoseveins
- thrombophilias;
- e.g.ProteinC/Sdeficiency,FactorVLeiden,antithrombin3deficiency)
- othermedicalconditions/increasedage
- Malignancy
- Pregnancy/post-partum
- MI,CVA,CHF:likelytobebed-bound.
- Obesity
- PrevhxorFHxofVTE
- drugs/smoking
i. OCPorHRTChemotherapy
Riskminimization1.Srugery:
• Surgerytechniqueaimingforminimaldurationandtrauma
Patientfactors:
3.Non-pharmacological:
- SCDs+TEDS:calfcompressivedevicethroughouthospitalstay-àaidVR.
§ Evaluation:non-invasiveandsimpleapplication,minimalside-effects.
Moreexpensiveandstillrequirepharmacologicalregimeforhighrisk
surgery/patient.
§ requireaccuratemeasurementandfittingandCIinPVD,peripheral
neuropathy,lymphedema,skinbreakdownetc.
- Goodhydrationperi-operatively
- Earlymobilisation(physio)
§ Evaluation:low-cost,commonsense,butneedactiveprophylaxis.
4.Pharmacological:
LMWH:
o SCclexaneoncedailydosing(20-40mg)
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§ Cfunfractionatedheparin:
§ preferableunlesscontra-indicated(HITTS)
§ nomonitoringrequired;morepredictabledose-response
§ lessbleedrisk
§ howevernoteasytoreverseasheparin(only~50%
reversibility)
Heparin,5000unitsBDdosing-inconvenient
§ requiresmonitorwithAPTT,maycauseHIT,hashigher
bleedriskthanclexane,butisreversible.
2.Anaesthetictechnique:
- Neuraxial:Spinalorepidural.
§ Evaluation:associatedwithlessVTE,howevernotasbeneficialasfor
hip/kneearthroplasty;andeffectmaybelessnowwithuseofpharm
DVTprophylaxis.
NB:
Listaboveiscomprehensive.OnlyotherfactormentionedinCEACCP=surgery,esp
abdo/pelvic/orthosurgery,majortrauma,burns.
Q13–advanceddirectives,ethics,78.8%
Anelderlypatienthascollapsedwithableedintoaknownbraintumourandisunabletocommunicate.Anadvancehealthdirectivehasbeenproducedstatingshewouldnotwishtoreceivetreatmentifthemostlikelyoutcomewasasignificantpermanentneurologicaldeficit.Defineadvancehealthdirective,includingitsscopeandlegalstatus(50%)Howwouldthisadvancehealthdirectiveinfluencedecisionmakingaroundtreatmentoptions.(50%)
PARTA–definition,scope,legalstatusAnadvancedirective
• CodeofHDCRight(HealthandDisabilityConsumers)
• competentconsumermakesachoiceaboutapossiblefuturehealthcareprocedure
• effectiveonlywhenheorsheisnotcompetenttomakedecisionforthemselves,due
tophysicalormentalillness”.
• islegalbinding“writtenororaldirective;
PARTB–howADinfluenceclinicaldecisionmaking• doctorsmustactinpatient’sbestinterests.
o Informedadvancedecision,shouldbetakenintoaccountwhendeciding
whatisintheindividualpatient’sbestinterests.
o risksandbenefitsoftreatmentoptionsmustbecarefullyevaluated.Ifrisks
outweighthebenefitsthensurgerymaynotbeadvisable.
• Treatmentoptionsshouldbecomprehensive:wishtoproceedwithactivetreatment
thatcouldpotentiallybelife-saving;ornottoproceedtotreatmentthatisunlikely
toresultinimprovedqualityoflife,orresuscitationplanintheeventofcardiac
arrest.
• Alsoalthoughadvancerequestsorauthorisationofspecifictreatmentcanbe
helpful,theylacklegalweightifcliniciansassessthattreatmenttobeinappropriate”
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NB:NZMA:
A. “Patientscannotdemandorrefuseanythinginadvancethattheycannot
demandorrefusewhenconsciousandcompetent.Therefore,patients
cannotrefuseinadvancecompulsorytreatmentprovidedunderthemental
healthlegislationordemandeuthanasia.B. Alsoalthoughadvancerequestsorauthorisationofspecifictreatmentcanbe
helpful,theylacklegalweightifcliniciansassessthattreatmenttobe
inappropriate”
Q14–spinalcordtraumamanagement,34.7%
40yorequireslaparotomy10daysafteranisolatedtraumaticspinalcordtransectionatC6.Outlinekeyanaestheticissues(50%),howwouldtheseinfluenceyouranaestheticmanagement?(50%)Keyanaestheticissues
o A.possibleunstableC-spine,difficultintubationwithlimitedC-spinemovement,
pharyngealoedema;orifinexternalfixationdevice.
o B-respiraotryfailurelikelywithintercostalparalysisbelowC6(althoughdiaphragm
C3-5shouldbeintact).
o Subsequentcomplicationseg.LRTI/atelectasis,hypoxiaemicinsultlikely.
o C.initialneurogenicshocklikelyresolvedby10daysnow,expecttoseereturnof
SNStone+reflexes;butbepreparedforpotentialunopposedvagaltoneàcardiac
instability
o Bloodlosspoorlytolerated
o D.spinalshockpresentupto4/52likelywithneurodeficit
o Drugs:avoidsux(>72hr=CI)
o E.alteredthermoregulation,pronetohypothermia
o I.HigherriskofVTE/pressuresore,nerveinjuryduetoprolongedimmobility
Issuesre:laparotomy
o Fastingstatus,acuteabdomen?Septic?Metabolic/electrolytederangement?
HowitinfluencesManagement
o A.carefulairwayassessment+imagereview.MILIformodifiedRSIusingVL/bougie
tominimizeC-spinemovementanduserocuronium1mg/kg;considerSEPto
monitorspinalcordintegrityabovelesion;usingC5astestingpointie
shoulder/elbowflexion)o Ifdifficultairwayanticipated,considerAFOIorawaketrachy.
o Maintainoptimalspinalcordperfusionpressuretolimitsecondaryischaemicinsulto Normocarbia,adequateoxygenationusinglungprotectiveventstrategy,o Ifhaemodynacmiunstable,useIABP+CVLtoguidemanagement+fluid
responsiveness.MaintainpreloadandandMAP>65mmHg(orwithin20%of
baseline);withsmallfluidboluses+vasopressor.o Pretreatrestingbradycardia/unopposedvagaltonewithglycopyrrolateIV
200-400mcg.o Maintainnormothermia,normoglycaemia
o MultimodalDVTprophylaxiswithSCDs+pharmaieclexane
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o Optimizepatientre:metabolic/electrolytederangementasmuchaspossiblewithin
limitedtimepreop.
Postop:
o MultimodalanalgesiatofacilitateearlychestphysioandmonitorforLRTIwithtimely
antibiotic.
Q15–preoxygenation;highFiO2usejustification,83.4%
Describethephysiologicalprinciplesunderlyingpreoxygenationpriortotheinductionofanaesthesia.(50%)Discusstheadvantagesanddisadvantagesofusingahighinspiredoxygenconcentration(>80%)duringmaintenanceofanaesthesia.(50%)Intro/Principle:
o Pre-oxygenation=Pre-oxygenation=denitrogenationofthelungbybreathing80-
100%oxygenàincreaseoxygencontentinFRC
Physiology:
o FRC=2.1Lin70kgman(30ml/kg) Partialpressureofoxygeninlungbreathingair=
~100mmHgOxygencontent=100/760x2.1L=276ml
o PO2inlungbreathingO2=~660mmHg(alveolargasequation) Oxygencontentin
lungatFRC=660/760x2.1L=1.8L
o Providedpatienthasoxygenconsumptionrateof250ml/minapnoeicperiod
canbeprolonged(fromjustover1minuteto7mins)withoutdeveloping
hypoxaemia.
o Allowsmoretimetointubatewithouthypoxaemia. Iffailedtointubateand
ventilate=allowspatienttowakeupwithoutsignificantoutcome.
o Hyperventilationcanspeedprocessup(increasesrateofnitrogenwashout)ievital
capacitybreath.
Pros/consofhighFiO2.• avoids/preventshyperaemia
• usefulincasesofairembolismwhenneedtodenitrogenate
• ?augmentsantimicrobialandpro-inflammatoryresponseinalveolarmacrophages
o reducedincidenceofsurgicalwoundinfectionincolorectalresectionpatients
Disadvantages:• resorptionatelectasis->shuntandimpairedgasexchange
• increasesreactiveO2species->causesinflammationandsecondarytissue
injury/apoptosis-.leadingtocellularinjury/death
• contributestoCO2retentioninsomeCOPDpatients
• acuteO2toxicity->causesalteredmood,vertigo,LOC,convulsions.
• LITFL>60%Causestrachealirritation,sorethroat,pulmonarycongestion,drymouth
andnose
NB.• With100%O2forseveralminutes(2-3),alveolargasequationpredictsmaximal
pO2(alveolar)of660mmHg
o =[FiO2*(760-47)]-40/0.8
• OtherICUpoints:hyperoxiaasscwworsemortalityincardiacarrest,TBI,stroke
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causesunknown,butlikelyduetoROS(reactiveoxygenspeciesegegsuperoxideanion,
hydroxylradical,hydrogenperoxide)+hyperoxia-inducedvasoconstriction(directand
indirect)
Oct-2014,35.9%
Q1–Neonatalmanagementpolicy,45.8%
An8weekoldbabyisscheduledforaninguinalherniarepaironyourlistatalocalgeneralhospitaltomorrow.a)Outlinetheimportantissueswhenprovidinganaesthesiacareforthisbaby.(70%)b)Justifyyourdecisiontoproceedwithsurgeryatthelocalgeneralhospital.(30%)
ANZCAPD
PARTA:
Neonatalmanagementrequiresspecialattention.Issuesinclude:Overcappingissues:(mentionedinreport)
• Questionofdoesfacilityhasthefacilities/equipment/staff/experiencetoprovidecareforneonate?
o anaesthetist,anaesthesiaassistant,surgeon,nurses,neonatalteam?And
dependonhowillthebabyis,PICU?
o Ifnotequippedwithabove,thentransfertoatertiarycentreshouldbe
considered.
• Routine/importantAMPLEHistory–isbabynormallyhealthy?Pre-termbaby,what’s
baby’spost-conceptualage?
o herniasarecommoninpre-terminfants
o prematurityassociatedwithotherconditionssuchaslungdisease
o Prembaby(born<37/40)andpostconceptualage<52weeksieifpremature,
shouldbereferredtertiarycentre.
Generalconsiderationsofinfantpaediatricpatient:Patient:
• alteredrespiratoryanatomy&physiology–o duediligencegiventomanagepaediatricairway+lessreservetocopewith
apnoea,especiallyinex-prembabywithchroniclungdisease
• cvsdifferenceso smallventricleswithlesscompliance
o COisratedependent
• Fasting:ideally1stinlistsotominimisedelayinreturntofeeding.
Anaestheticfactor• A.Probablegasinductionwith/withoutparentalpresence;completefocusshouldbe
oncareofbaby.
• B.UseofT-piece/highflowtominimiserebreathingforsmallbabywithsmallTVon
induction,thenswitchtopaediatriccirclecircuit.
• D.havehigherMAC,maintainageadjustedMACof1;eg.EtSevo2.4-2.6.
• E.pronetohypothermiainbaby,keepwarm!
M.fullpaediatricsizedmonitor
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Justifydecisiontoproceedatlocalhospital:• ShouldrefertoANZCAPDonpaediatricmanagementconsiderations+local
guideline.• Eligibilityforlocalcareshouldinclude:• Adequate Staff training and experience
o Anaesthetist, anaesthetic assistant, nursing staff, surgeon, surgical nursing staff. • Equipment and Facilities
o Equipment – monitor, anaesthetic & surgical equipment, theatre set up with temperature control to maintain thermal neutral zone for paeds patient,
Worthtomention:• Ifproceed,considertoinvolveanotherspecialistanaesthetisttoassistand
• ensureallappropriateequipmentandstaffis/areavailablebeforeproceedingwith
thecase.
NB.Alteredanatomy/physiology
Anatomy
o eg.largeocciput
o small/narrowairway
o obligatenasalbreathers
o largefloppyepiglottis
o narrowestpointofairwayissub-glottic
Phys
o eg.ventilationessentiallydiaphragmatic
o lowerproportiontype1musclefibre(intercostalmuscles)-pronetofatigue
o closingvolumeoccurswithintidalbreathinginneonates-pronetoairways
collapse
o higherresistanceduenarrowerairway
o particularlypronetorespdepressanteffectsofvolatiles
Indicationfor3rdcenterinclude:• neonates(<28daysold)
• Prembaby(born<37/40)andpostconceptualage<52weeksieifpremature,
o Also=indicationforovernightstayinDSU;therotherbeingterminfacnt
<6/52old.
• Comorbidities:
o apnoeicepisodes.
o unusualand/orcomplexmedicalorsurgicalproblemsclassifiedasASA3or
greater.• liaison with specialist paediatric facility so that authorative advice available
Q2–TBI,ICPmanagement,86.1%
A25yearoldmanwithahistoryofblunttraumatotherightsideofhisheadhasafixedanddilatedrightpupil.HehasbeenintubatedandventilatedintheemergencydepartmentafteraninitialGlasgowComaScore(GCS)of15onadmissionhadfallento3.Evaluatethepharmacologicalandnon-pharmacologicalmethodstomanipulatethispatient’sintracranialpressure?
Answerintro:
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• -NormalICP5-15mmHg
• -Themunroe-kellydoctrinedescribes,ICPchangewhenvolumeinsdiethefixedskull
changes.
- Content=brain,bloodandCSF;whenanyoftheseincreaseinvolumetoa
criticalpoint,beyondcompensatorymechanism,ICPrisessteeply
• -CPP=MAP–(ICP+venouspressure),usuallyVPiszerothereforeCPP=MAP-ICP
Pharmacological• -Brain/lesion(fromOHA):
o mannitol0.25-1mg/kgover15mins,
o Frusemide0.25-1mg/kg,
o hypertonicsaline(3%)3mL/kgover10minor10-20mL20%salin;titrateto
targetofNa150-155.
o EnsuremaintenanceofCPP+oxygenationtominimisefurtherischaemic
insultandsubsequentinfarct/oedema.ConsidertransfusiontokeepHb
>70g/L.
• Blood:
o considermusclerelaxationwillpreventcoughing,strainingandallow
controlledventilationi.e./reducingtheamountofPEEPandPIP
• reducethecerebralmetabolicrateo propofolorthiopentoneinfusions;reduceCBFàreduceICP.
o advantageousinrelativemaintenanceofautoregulation+anticonvulsant
effect.
§ volatilesagents=relativeuncouplemetabolismespMAC>1à
vasodilatoryeffectmayinceaseCBFandICP.
o Adequateanalgesia
o treatseizuresifoccurswithphenytoin20mg/kgormidazolam0.5mg/kg
o avoidpyrexia–usepharm+non-pharmantipyrexialmeasures.
Non-pharmacologicalBlood:
• avoidhypercarbia&hypoxia,orhypertensionUseIPPVtocontrolPaC02to35mmHg
andensuregoodoxygenation>92%.Avoidincreasingvenouspressure
• headupto30deg
• neutralheadposition
• ensureETTtienotobstructingvenousdrainage.Considerusingtapeinstead.
• IfC-spineimmobilizationrequired,usesandbag/taperatherthanneckcollar
restrictingvenousdrain.
Surgical:• Externalventriculardrain
• Decompressivecraniectomy
NB.(reportdoesn’tactuallyinclude‘evaluate–cf.worthiness…etc’.
• braintissue(1500ml),blood(150ml)orCSF(150ml)
Q3–prolongedTrendelenburg,59%
Apatientisscheduledtoundergoprolongedsteephead-downsurgery.a.Outlinethepotentialanaestheticimplicationsofthispositioninthissituation.(50%)
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b.Describehowyouwouldmodifyyouranaestheticplantominimisethese.(50%)
Anaestheticimplications• A.ETTcanmigratetobecomeendobronchialduringpositionchange.
• B:reductioninFRC,increasedatelectasis,increasedV/Qmismatch,dereased
compliance.Mayneedpermissivehypercarbia.
• C:incVRèCO/MAPàpotentialCHF;
• D:increasedcerebralvenouspressureandreducedCSFdrainageàlikelyincICP
o oedemaofface,peri-orbital;incIOPàblurryvision
• Riskoffallingofftable,armfallenoffàbrachialplexusinjuryifnotposition/secured
properly.
• RiskofDVT(report)
Riskminimization:Pre-operative:
• Appropriatepatientselection.Patientswithmorbidobesitywithsignificantrestrictivelungdisease,poorventricularfunction,increasedICP,IOPisn’tsuitableforsteepTrendelenburgposition.
• CVS:poorventricularfunctionwhereincreasedVRcanàHF
• D:eg.glaucoma,benignintracranialhypertension,spaceoccupyinglesions
Intraop:• A:vigilantassessETTpositionregularlythroughoutcaseespwithpositionchange.
• B:PCV+PEEPtocontrolPeakPandreduceatelectasis.
• Circulation:vigilanceonMAP,espeachtimewithpositioncheck;alsotransducer
height.
• position:-riskofslippingofthebed:strappingrequired
• VTEprophylaxis:SCDs+/-clexane.
Postop:
• Monitorpotentialairwayswelling.
• Assesspatientforblurredvision,headacheorconfusion,facialoedema.
Q4–Dabigatranmanagement,53%
Apatientscheduledfortransurethralresectionoftheprostateisseeninthepre-admissionclinic.Hehasnon-valvularatrialfibrillationandwascommencedondabigatran150mgbdwhenhehadaminorstrokethreemonthsago.a)Outlinebrieflytheadvantagesanddisadvantagesofdabigatranascomparedtowarfarinforstrokepreventioninelectivesurgicalpatients.(30%)b)Describeandjustifyyourplanfortheperioperativemanagementofthispatient’santicoagulation.(70%)
Dabigatrin=directthrombininhibitor,reversiblyinhibitsbothfreeandclot-bound
thrombin.
• half-life12-14hours,longerwimpairedrenalfunction.
• 80%ofthedrugisexcretedunchangedbythekidneys,relativecontraindicatedin
patientswithrenalfailure
Pros/ConsofdabigatranvswarfarinforCVAprophylaxisPros:
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• -noroutinemonitoringrequired
• –kineticsdependantonrenalclearance
• -predictablepharmacokineticsinnormalrenalfunction
Cons
• Unpredictablehalflifewithrenalimpairment.
• Routinecoagulationtestsareunreliableinquantifyingitsdegreeofanticoagulation;
thrombintimeislikelymorereliable.
• dabagatrinassociatedbleedingisatpresentverydifficulttotreat,althoughthismay
beimprovedonceidarucuzimabbecomesmoreavailable.
o warfarincanbemoreeasilyreversedbyeg.PromXorFFP.
Managementofdabigatranperiop
o needtobalanceriskofperioperativebleedingversusarterial/venous
thromboembolism–CHA2DS2VAScscoreshouldbecalculatedtoriskstratifyand
surgicalbleedconsidered
o prostatesurgeryasscwithsignificantbleed.
o RecentBRIDGEstudysuggestednoworseoutcomewithtemporarilystopping
anticoagulationwithoutbridgingtherapy;
§ Riskofthromboembolism=0.3%incontrolandinterventiongroupsin
study.
o However,theCHADS2scoreinstudywaslow(mean
2.3)andonly3%ofpatientshadscoresof5or6
o ThereforeI’dstopdabigatran5dayspriorsurgerytorestorationofsurgical
haemostasis
o Thisisespeciallyifneuraxialanaesthesiaischosen.
o othrewiseifnormalRF,48hourswindowpreopmaybeadequate.
Q5–CPETprinciple,48.5%
a)Outlinetheprinciplesofcardiopulmonaryexercisetesting(50%)b)Evaluatetheroleofcardiopulmonaryexercisetestinginapatientwhoisscheduledforoesophagectomy(50%)
Priniciples• Cardiopulmonaryexercisetesting(CPET)=non-invasivemethodofquantitative
assessmentoffunctionalcapacity(report)
• Requires:
o -exercisemachine(usuallyabicycle)
o -acomputercontrolledincrementalincreaseinworkload
o -acalibratedpnuemotachographtomeasuregasflowandcomposition
o -continuous12-leadECG
o -Trainedpersontoconductandinterpretresults
• -parametersobtainedsuchaspeakO2consumption,anaerobicthresholdarehelpful
inriskstratification.
o AT=pointofoxygenconsumptionatwhichanaerobicmetabolismstarts
§ notalteredbypatienteffort.
§ Usefulforriskstratification:
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• >11mlO2/min/kg+testECGnoischaemia=mortality0%
• <11ml02/min/kg+testECGWITHischaemia=mortality43%
(OHA/ceaccp)
• PeakVO2:
o correlatesbestwithpostoperativecardiopulmonarycomplicationrateafter
oesophagectomy,
o studieshaveshown>800mlmin2m2beingrequiredtosafelyundertakethis
extensivesurgery.
o PeakVO2<15ml/kg/min=increasedrisk;
PartBroleinriskstratificationinoesophagectomyoesophagectomy=majorsurgeryinvolvingdoubleintra-cavitysurgery(thoracotomyand
midlinelaparotomy),longsurgery,significantcardipulmstress.
• CPETcanhelpinriskstratificationandinformeddecisionmakingbasedonindividual
estimationofperioperativesurvival,asoutlinedabove.
o Alsohelpsin:
§ -diagnosisandquantificationofrespiratoryandcardiacdisease
§ toallowforpreopoptimisationbyguidinginterventionsbefore,
duringandaftersurgery
§ anddecisionmakingonHDU/ICUrequirements
NB.
• AAAsurgery,peakVO2<20mlkg21min21,lowAT,asscwithpostoperative
complicationsand30daymortality.
• hepatictransplantation:hasdemonstratedthatpeakVO2<60%predictedandAT
<50%ofpredictedpeakVO2arebothassociatedwith100daymortality.
• Alsoshownpooreroutcomeinthoracotomy.PeakVO2<15ml/kg/min=increased
risk;<10,mortalityinthoracotomy=50%;>20=noincrasedrisk
Q6–Fatembolism,31.9%
Youarecalledtoseea30yearoldmanwithbilateralfracturedfemurs.HehasbeendiagnosedwithFatEmbolismSyndrome.a.OutlinethepathophysiologyofFatEmbolismSyndrome? (50%) b.DescribetheprinciplesofmanagementofFatEmbolismSyndrome?(50%)
Intro:o FatembolismSyndrome(FES)isarare(incidence1%),multisystemdisorder,variable
presentation;typically24-72hoursaftertrauma/longbonefractures
o Featuresinclude:classictriadinCNS/Resp/Haemsystem:confusion,alteredlevelof
consciousness,tachypneaandhypoxia,coagulopathy/petechial/DIC.
o significantmortalityis5-15%.
Pathophys:Exactpathogenesisisuncertain;twotheoriesexist.
o Mechanicaltheory:
o fatemboligaindirectentryintobloodstreamviavenulesfromdisrupted
adiposetissueorbonemarrowàdepositinpulmcirculation
o Biochemicaltheoryofpathogenesis:
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o productionoftoxicintermediariesoffatfromfatglobulesenteringplasma
(globlueshydrolysedintofreefattyacidsthattriggerscascadeofsystemic
inflammationàARDS,pulmHTN,coagulopathy,DIC.
B–ManagementprinciplesPreventativeStrategiesSurgicaltechnique:
o Earlyimmobilizationoffracture(<24hr)
o reduceintraosseouspressureduringothropaedicsurgerybydrillingventingholefor
drainageofintramedullarycavity
o Cementlessfixationifpossible
Mainstayoftreatmentissupportive.o Earlyresuscitationandstablilisation.
o Resp:EarlyoxygentherapymaypreventonsetofFES.
o Supporthaemodynamicsasappropriate.
o Haematological:Bloodproductsasneeded(espforanaemia/thrombocytopaenia
coagulopathy)
o VTEprophylaxis,considerIVCfilterinhighriskpatient(mayalsoreducesizeoffat
globulesreachingheart)
NB:
• embolizationfatoccursfrequently,butsyndromeisrare(1%).
• FEShasmajor(triad)+minordiagnosticcriteria(others).
• Knowdifferencebetween:
o Fat:pulmHTN/pulmoedema,CNS,rash
o Cementimplant:similartoFAT,butmoreCVSfeature;similartoanaphylaxis
+pulmHTN/RHF
o Air:CO2,hypotension,tachycardia,JVP,rightheartfailure.
o Amnioticfluid:anaphylactoid
• BCIS=whencementused;althoughmechanismofthiscouldbefatembolism;butair
embolismordirectfromcementalsopossible–hypoxia;hypotensiontograde3
severity=CVScollapse.
o Preventby:suctiontobonecavity,ridofair/fatwheninsertingcement.
o Preloading;upFiO2;stopN2O.
• Steoroiduseiscontroversial
o FESresolvesin~7days;mostpatientswillrecoverfully(seriouslongterm
complicationsareuncommon).
Q7–EVARrenalprotection(repeat),42.2%
An80yearoldmanisscheduledforendovascularabdominalaorticaneurysmrepair(EVAR). a.Whatarethelikelyriskfactorsforacutekidneyinjuryinthissetting?(30%) b.Describeandevaluatethemethodsavailabletopreservehisrenalfunctionintheperioperativeperiod.(70%)Q8–CHD,Fontancirculation,31.9%
A25yearoldwomanwhois30weekspregnanthasbeenreferredtoyourtertiaryhighriskobstetricclinic.
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ShehascomplexcyanoticcongenitalheartdiseaseandnowfunctionswithaFontancirculation.a)Howwouldyoustratifythecardiovascularrisk?(30%)b)Whataretheissuesrelevanttoanaestheticcarethatwillneedtobemanagedforthispatient?(70%)
Intro:thesepatientsareatincreasedrisk,whichincludeHFanddeath;greatestriskisduringlabourandimmediatelypostpartumduetostress,painandautotransfusionà
volumeload.
a)cardiovascularriskstratifyHx
• HxofCHD,ischaemia,surgery;currenttreatment;effect;
• Hxoffailure;orunexplainedpresyncope
• Functionalcapacity,NYHAgrading?
• Pregnancyprogressandimpactonpatient?Placenta,singletonpregnancy?
• Otherrelevants:GORD,allergy,accesstoregionals,venousaccess.
• ClinicallettersfromCardiothoracicsurgeon/Cardiologist.
Exam
• Vitalsigns:includingSats(highriskifsats<85%onair),RR,HR(arrhythmias?),BP.
• Satswithexertion?
• Cyanosis?
Investigation
• Echo,evidenceofventriculardysfunction?,ECG,CXR,labs(polycythaemiaHCT
>60%),pregnancyUSS-babygrowth.
• Appreciatethecirculation(Aucklandcourse)-residuallesion?PulmHTN?
Arrhythmia?
b)issuesrelevanttoanaestheticcarePreop(pre-deliveryplanning):
• MDT:Cardiology/Obstetric,midwiferyTeamconsult/+/-intensivistre:antenatal
plan;deliveryplanandpost-deliveryplan.
• Patientwillrequireadditionalmonitorduringantenatalperiod
o Considerelectivedeliverywithepiduralanalgesiaorgradualonsetanaesthesia;
anaesthesiawillalsorequireadditionalmonitorwitharterialline+/-CVP.
Othersystemicpatientconsidrations:
• InductionforGAneedstobedonewithextremecare.
• Breathing:
o MaintainSV;ifGAused,IPPVcanresultinfallinCOandpoorpulmperfusion;
reduceinspiratorytimeorlimitairwaypressure
• Circulation:
o Labourpain,stressàcatecholaminesàLVF;
§ àepiduralanalgesiaearlytohelp.
o SystemicVENOUSpressuredependantforpulmonaryflow
§ Maintainpreload;contractility
§ AvoidincreaseinPVR–CO2,O2,acid/base.
o Riskofbleed
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§ Duetocyanosisassociatedthrombocytopenia
§ AlsoduetohigherCVPwhichthesepatientsdependantonforpulm
circ.
o Riskofairembolismandparadoxicalairembolism;meticulousairwith
IVF/druginfusiontoensureminimalairbubbles.
o ConsidermonitorCVPusingfemoralvenousroute.
• Drugs:
o Synto–vasodilate,dropinSVRrisk
o Ergo–vasoconstrict;potentiallyworsenPVR;carboprostisespecially
dangerous.
o Patient’swithfontancir.Maybeanticoagulated,MDTperipartumplanon
anticoagulationmustbediscussed.
Post-delivery:willrequireHDUlevelcareorabove;Conversely,autotransfusionpost-
partumputspatientatriskofheartfailure,pulmoedema.
NB.
OHAnote:
• cyanosisresultinpolycythaemia,increasedbloodvolume,viscosity,impairedtissue
perfusion,There’softenthrombocytopeniaandfibrinogendeficiency:
FromMCQ:inEisenmenger’ssyndrome:A.animportantgoalistomaintainanoptimalshunt,bypreventingchangestopulmonary
vascularresistance(PVR)orsystemicvascularresistance(SVR)-true:
B.thepatient'shighhaemoglobinshouldbemaintainedandbloodlossmonitoredclosely
C.agaseousinductionwithsevofluranepresentsaneffectivemethodforanaesthesiaand
avoidscardiovascularcompromise
• Inductionofanesthesiawithavolatileanestheticsuchassevofluraneisacceptable
butmustbeaccomplishedwithcaution;mustmaintainSVR:PVRratiotoavoid
hypercyanoticattacks.
D.ifgeneralanaesthesiaisrequired,ketamineisanappropriatechoiceofdrug
• InductionofanesthesiainpatientswithtetralogyofFallotisoftenaccomplished
withketamine(3to4mg/kgIMor1to2mg/kgIV).SNSstimulationwithketamine
helpstomaintainSVR;(IthinkthistendstooffsetincinPVRbyketamine)
E.carefulattentiontointravenousinfusionsanddrugadministrationisneededtoprevent
paradoxicalairembolism
Q9–MyastheniaGravis,69.9%
A30yearoldpatientwithmyastheniagravispresentsfororthopaedicprocedureandrefusesaregionalanaesthetictechnique Whatarethesignsandsymptomsofmyastheniagravis?(30%) Howdoesthediseaseaffectyouranaestheticmanagement?(70%)
A
Intro:MyastheniaGravis(MG)=autoimmunediseasecharacterizedbypresenceofanti-nicotinic
Achreceptorantibodiesàdestructionofpost-synapticAchRatNMJàspectrumof
skeletalmuscularweakness.
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Clinicalfeatures:• skeletalmuscleweaknessàworsewithexercise=fatigabilityandimproveswrest.
2types:localvs.generalised
• Diseaseconfinedtoeyesonlyin15%ofMG–ptosis,diplopia
• Other85%have(systemic)ocular,facial,bulbarandmildrespmuscleweakness
• Severerespmuscleweaknessleadingtomechanicalventilation=myastheniacrisis
o Morecommoninyoungfemalesoroldman–‘sleazycouple’.
AssociatedwithMGinclude:• Thymushyperplasia(thymoma)in15%pts;
• Otherautoimmune:Scleroderma,RA,Perniciousanaemia,hypo/hyperthyroidism,
SLE
B:Howdoesitaffectyouranaestheticmanagement?Preop:
• Carefulriskstratification,inparticularriskofriskfailureoraspiration–severity
gradingscoreavailable:1-5(1=eyeonly,5=crisis,2,3,4=mild/mod/severe)
• Considerriskfactors(6)forrequirementofpostopmechanicalventilation:
o Duration>6years
o Pyridostigminedose>750mg
o Co-existingdisease:pulmonarydiseasesuchasCOPD
o Bulbardysfunction
o FVC<2.9L
o Surgeryofmajorbodycavity
• Severecase:considerpreopplasmaexchangeorreferralforthymectomy.MDTinput
withImmunology
• Routine/importantAMPLEhistoryandairway,cardiorespexam;esp.ifcomorbidities
suchasrheumatoid,largethymomapresent(affectairway+SVCobstruction).
• Considersuitabilityofregionalanaesthesia.
Intraop:• A.IfGAused,modifiedRSIifbulbarweaknestominimizesaspirationrisk;
o considerroc/suggamadex
o Glycopyrrolatetoreducesecretionsifbulbardysfunction.
o GORDprophylaxiswithranitidine,Nacitrate.
o Ifnobulbardysfunction,volatilealonemaybeenoughtoprovidegood
intubationcondition.
• DrugseffectonNMJneedtobeconsidredo ConsiderTIVAinseverecasestoavoidvolatileeffectonNMJ(asrapid
emergencevs.clearend-point)
o IfneedNDMR,usesmallerdose~30-40%ofusual.(or1/10asgivenin
anotherSAQ)
o Ifsuxamethoniumisused–mayneedanincreaseddoseofthis(eg
1.5mg/kg),watchforphase2block.CheckNMT.
o CanprolongNDMR:BB(esppropranolol),phenytoin,Mg,aminoglycoside.
• OtherPharmconsiderations:
o steroidsupplementsifonlongtermsteroid
Postoperative:
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• ExtubateifmildMG.
• AssessNMT,andreversewithappropriateagent(sugammadexorneo)
o standarddoseworksfine,butwatchforpotentialcholinergiccrisiswneo.
• Continueallregulartreatment;replacepyridowithneoifnoenteralroutepossible
(20:1ratio).
• AdmitHDU–closemonitoringofSPO2,respfunctionmonitoringneeded–monitor
hourlyFVC
• polymodalanalgesiatoopioidspare,aspatientsensitivetosedative.
NB.
Aside:Eaton-Lambertsyndrome:
• =Myasthenicsyndrome=proximalmuscleweakness;asscwcancerespSCClung.
• Likely2ndtoreducedAchrelease(Presynapticfailure);
• Notreversedbyanticholinesterase
• Exercisehelpsimprovemusclestrength
• Dysautonomiamayoccur:drymouth,blurredvisionetc.
• UnlikeMG;ELSptssensitivetobothNDMRandDMR.
1-eye;2-mild,3-severewrespdysfunction;4-crisis
Donotrespondtosteroidorplasmapheresis.
Q10–desaturationinPACU,43.4%
Astheon-dutyspecialistanaesthetist,youareaskedtoseeapreviouslywell64year-oldmaninthePACUwithSpO2of85%twohoursafterlaparoscopicrightpartialnephrectomyduringwhichhelost1litreofblood. a)Listthelikelycausesofthedesaturation?(30%) b)Outlineyourapproachtomanagingthepatient’shypoxaemia.(70%)
Likelycauses
• InadequateO2supplement
• Airway–obstruction?
• Vent/Lungs
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o Hypoventilation,lowerrespdrive,MSKimpair
• Drugeffect:opioid,BDZ,residualNMBD
o Deadspace,shunt,V/Qmismatch
o Atelectasis,pulmoedema,aspiration,PE,pneumothorax
• Circulation–poorperfusion,shock,pooroxygenflux;
o anaemiafrombloodloss.MI,decompensatedheartfailure
• Tissueuptake–hypermetabolism:
o sepsis,thyroid,MH
• monitorerror
Management:o I’dsupportoxygenationandmaintainMAPwhilesimultaneouslyassessforcauses.
o ABCDapproach,
o Openairway.UseLMAorETTifnotmaintainingairway.
o 100%O2,supportventilationwithBMVasrequired+PEEPfor
pulmoedema.
o Ruleouthypotension–supportwithfluid/vasopressorif
hypotensive.
o Ispatientconscious?IfalteredsensoriumegGCS<8,would
intubatetoprotectairway.
o considerdifferentialsandtreataccordingly;
o assessanaesthetic/PACUrecordforpotentialcausativeagents?Reversal
appropriate?
o Opioid–naloxone
o BDZ–flumazenil
o NDMR–neostigmine/sugammadex
o Doxapram?
o Exam:
o Auscultatechest–bronchospasm?Pulmoedema?PTX?
o Bleeding?Drainoutput?
o Invx:CXRtoassessforHF,pneumonia,aspiration.
o ECGtoruleoutcardiacischaemia.
o Bloodgasassessiftype2respfailure?Andhblevel.
o Ifafterdifferentialsconsideredandpatientstillhypoxaemic,considerICUinput
withongoingassessment,managementinICU.
o InformSurgicalTeamofprogress.
Q11–Statistics,RCT,60.2%
DefinationandrelevanceofstatisticaltermsinrelationtoresultsofaRCT
Q12–hypomagnesaemia,55.4%A 55 year old patient is undergoing emergency laparotomy for acute bowel
obstruction. Intraoperative blood tests include the following result: Serum Mg++ 0.40 mmol/L
(Normal 0.70 – 1.00 mmol/L) a) Outline the potential causes for this result and the effects it may produce. (70%) b) Describe the management of this abnormality. (30%)
Causes:
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a. likely acute or chronic (need trend to be sure): • ↓intake:
o malnutrition o alcoholism o PN - poorly dosed o malabsorption - chronic pancreatitis, prev bypass surgery, IBD
• ↑ed loss (GI or Renal or binder) o GI eg vomiting, diarrhoea o ↑ed renal tubular flow:
§ diuretics - osmotic or loops o renal tubular dysfunction:
§ ATN o ↑Ca (Mg antagonist) o hyperaldosteronism (too much Na/K exchange, so low K, low Mg)
• Other: o burns o acute pancreatitis
Clinicalsigns:(mainlyCVS/CNS)• symptomsgenerallywhen<0.5mmol/L
• CNS:
o neuromuscularirritability
o generalisedweakness
o verticalnystagmus
o myoclonus,stridor,dysphagia,orabdominalpain.Seizureslate.
• CVS:
o arrhythmiasesptorsardes-resistanttocardioversion
o ECGsimilarto↓K
o digtoxicity
• Metabolic:
o resistant↓Ca,↓K(shouldalwaysreplaceMgfirst)
o PTHreistance
o vitDdeficiency
Managmeent:Resuscitateandstabilizecardio/resp/CNSsystemiifmanifestationseen.
Maintainoxygenation,perfusionandsinusrhythm.
Replacementvia:
• IVMgsupplements:
o 10mmolor5mls49.3%MgSO4givenover20mins.
§ Carewithbradycardia,hypotension,arrhythmia.
§ postadministrationshouldre-checklevels.
Seekandtreatunderlyingcause
NB.LITFLECGchangesinhypokalaemia
ChangesappearwhenK+<2.7mmol/l
- IncreasedamplitudeandwidthofthePwave
- ProlongationofthePRinterval
- Twaveflatteningandinversion
- STdepression
- ProminentUwaves(bestseenintheprecordialleads)
- ApparentlongQTintervalduetofusionoftheTandUwaves(=longQUinterval)
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Cf.hyperKchanges:
Pwaveflatten/widen,PRlonger,QRSwiden,AVblock,sinus,asystole.
Q13–3chamberUWSD,9%
a.Describethefunctionofathree-chamberunderwatersealchestdrainagesystem.(adiagrammaybeuseful)(50%)b.Evaluatetheuseofthissysteminthemanagementofhaemopneumothoraxsecondarytobluntchesttrauma?(50%)
3majorparts:
o Drainage/collectionbottle
o underwaterseal
o applicationofcontrollednegativepressure
o functionistoallowcontrolledvariablenegativepressuretobeappliedto
chestdrain
Mxofhaemopneumothorax.
§ ifbronchopleuralfistulaorlargeairleak
o useofsuctiontominimizerecollectionofPTX
o variabilityallows‘weaning’fromchestdrainasleakresolves
o suctionindependentofamountofdrainageincollectionbottle=advantage
oversinglebottlecollection/suctionsystem.
§ Haemothorax:
o Collectionofbloodintrapbottle
o Allowsmeasurementofoutputandmonitorofprogress
§ If>100ml/hourcontinuouslythenindicationforsurgery.
§ safetyfeatures:
o volumecapacityofdraintubeshouldexceedhalfofptsmaxinspiratory
volumetopreventsuckingbackbottlecontent.
o volumeofH2OinbottleBshouldexceedhalfptsmaxinspvolumetoprevent
airindrawing
o drainshouldstay45cmbelowpt;nottilted
o clampdrainwhenmoving
§ complications:
o kinking
o occlusion
o retrogradeflowoffluidifcollectionchamberisraisedabovelevelofpatient
o anyclampingmaycanusetensionPTX
o breakageofglassbottles
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Q14–Lasersafety+notesonlaser,80.7%
Apatientpresentsforamicrolaryngoscopyandlaserofa5mmnoduleonhisleftvocalcord.(a)Outlinetherisksassociatedwiththeuseoflasersinairwaysurgery.(50%)(b)Discusstheprecautionsthatshouldbetakentomanagethese.(50%)
Risksoflaserinairwaysurgeryairwayfire-0.4%
damagetohealthytissue:
o lasersmokeinlungs
o directthermaldamage
injurytotheatrestaffandpatient.
o eyes
o vaporisationofcancersgas
Riskminimisationo allstafffamiliarwithlasersurgeryandlocalsafetypolicies
o laserofficer,warningsignoutsidetheatre‘Lasweron’,opaquewindowcover,
o protectionofstaff+patient.
o eyeprotection
o specialfacemasks-papillomascanseedvirusladenparticlesacrossroom
o suctiontoremovesmoke.
Fireprevention:
o anaestheticprecautionstopreventfire:(fuel,ignitionsource,combustible
gas/oxidizinggas)
o ensureantisepticisdriedbeforelaser;nopoolingondrape,bodysurface,
floor.
o avoidhighFiO2-use~21%;avoidnitrousoxide,
o airwayoptions:
§ uselaserresistantETT(lowflammabilityindex,metalcoating)-
• resistdamage&dissipateenergyoflaser⟹↓riskoffire&
adjacenttissuedamage
• filldoublecuffwithsterilesaline&methyleneblue
§ highfrequencyjetventilationviaStolzsuspensionbronchoscopy
(avoidsusingcuff&tube)
§ apneicventilationtechniqueviaO2flow.
o firedrill:
o turnofflaser
o pre-filled50mlsyringeof0.9%salineavailablereadytofloodfield
o wetgauzesforeyes
o suspendventilation,disconnectcircuit,floodairwaysitewithsaline,remove
ETTimmediately(checkfordamage)
o removeallotherflammablematerial–drape,gauze
o iffirepersists,useCO2extinguisher
o postfireextinguished:
§ ventilatewith21%&BMV
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§ bronchoscopytoassessendothelialdamage,fragments/debrisin
airway
§ considerbronchiallavage&steroids+reintubationearly.
§ +/-ICUbed
NB.
Examplesofmedicallasers:
o Pulseddyelaser–targetsRBC;treatingportwineskinlesions;minimalepidermal
scar.Postoppainlikelyrequireopioids.
• Carbondioxidelaser–outsideofvisiblespectrum;usedmainlyinENTairwaylesions
oraestheticfacialsurgery;lineofsightviamicroscopeandsurgicallaryngoscope.
o Longwavelength,dissipatesuperficially.
• Nd-YAG–outsidevisiblerange;multipleusesegairway,vascularmalformations,
ophthamlmicsurgery;ascanbedirecteddownanopticalfibreplacedthroughthe
workingchannelofafibrescope.
• KTP(potassiumtitanylphosphate(KTP)laserisalsofocusedthroughanopticfibre
butphoto-ablatesmuchmoresuperficially,socanbeusedintheairwaywithlocal
anaesthesia+/-sedation,potentiallyinanoutpatientsetting.
o Differenttopulsed-dyelaser
Q15–FNB,69.3%
a.Describetheanatomyrelevanttoperformingafemoralnerveblockattheleveloftheinguinalligament(50%) b.Outlinetheadvantagesanddisadvantagesofperformingafemoralnerveblockatthissiteaspartofananalgesiaplanforapatientundergoingtotalkneearthroplasty.(50%) A.
atlevelofinguinalligament,FNliesbeneathfascialata/iliacus,lateraltovein/artery,
separatedbyfascialayer.
B.PosandconsforanalgesiainTKJRAdvantages:
o highsuccessrare
o lowcomplicationtechnique
o singleshot20mls0.5%bupivcanprovideanalgesiatoantkneeforupto12
hours.
o Reliatvelyeasy,andsuperficialtoperforminsupine
disadvantages:• spreadofLAisunreliabletocoverobturatorN.
• Notprovidinganalgesiatoposteriorpartofknee
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o -femoralnerve(antjointcapsule&antskin)
• profoundmotorblocktoquadricepspreventingearlymobilisation
o useofnervecathetercan↓motorblockwhilegaininganalgesiabyusing
lowconcentrationswithslowinfusion
• standardnerveblockrisks:
o infection
o nervedamage
o LAST
althoughwithsteriletechnique&USguidance=exceptionallyrare
May-2014,53.1%
Q1-DiscussionofT-pieceJRmodification(repeat),23.3%
Outlinetheadvantagesanddisadvantagesofusingthepaediatriccirclesystemandthe
Jackson-ReesmodificationofAyre’sT-piece(MaplesonF)foranaesthesiaina15kgchild.
(report)
Keycomponents;shouldmention:Resistance–valves;Deadspace;Freshgasflows
Bettercandidatewillmention:Humidification,scavenging,weight/bulk,providemoreand
pointoutthereislessdifferencebetweencontemporarysystems.
Q2–cardiacelectrophysiologyanaesthesia,55.3%
Anotherwisewell35-year-oldwomanisscheduledforablationofanaccessoryatrio-
ventricularpathwayintheCardiacElectrophysiologylaboratory.
Whataretheimplicationsforanaesthesiaandhowwouldyoumanagethem?
(report)
Keycomponents,asaminimum,mentionoflikelydurationofprocedure,location[isolated]
andpossibleintra-andpost-procedurallifethreateningcomplicationswasexpected.
Q3-QAtoimproveefficiencyinOT,65.8%
Operatingtheatresstartinglatehavebeenidentifiedasaprobleminyourhospital.
Howwouldyoudesignandimplementaqualityimprovementprogramtoassessand
improveoperatingtheatrestartingtimesinyourhospital?
(report)
Keycomponents–planning,implementation,reviewandstandardsettingwithrelevanceto
latestarttimes.
Q4-AFbridging,60.3%
Apatientwithchronicatrialfibrillationonwarfarinisscheduledforelectivesurgery.Outline
howyoudecideifbridgingtherapyisneeded?(70%)
Describehowyouwouldbridgeanticoagulationifnecessary.(30%)
(report)
balancingriskofthrombosisversusbleeding,thereforeshould:
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1.Mentionpatientandsurgicalfactors:
Underpatientfactors
AFintheabsenceofotherco-morbiditiesislowriskforbridging(AHA/ACC
guidelines) CHADS2
Undersurgicalfactors–mentionhigh/intermediate/lowrisks
2.PrinciplesofBridging
Ceasewarfarin5dayspre-op
UsuallybridgewithLMWH–mentiondoserangefromprophylactictotherapeuticIfusing
therapeuticdose–cease24hourspre-operatively
Ifusingprophylacticdose–cease12hourspre-operatively
Q5-Bariatricsurgeryairway,hypoxiaminimisation,87.2%
A40year-oldmaleisscheduledforelectivebariatricsurgery.Forthispatient:
Listtheimportantfeaturesofhistoryandexaminationthatmayidentifyapotentially
difficultairway.(30%).Howcouldyoumodifyyouranaesthetictechniquetominimise
hypoxiaatinduction.(70%).
(report)
Asaminimum,answersshouldmention:
-historicalissueslikepreviousanaestheticproblems,symptomssuggestiveofOSA,
neckcircumferenceandmallampatiscore
-Theroleofawakeintubationifconcerned,positioningandpreoxygenation[ET
O2>80]bettercandidateswillsayETO2>90isspecificforbariatricsurgery?
Q6-postopMIdiscussion,57.1%
Apatientiscomplainingofcentralchestpaininthepostanaesthesiacareunit(PACU)
followingfemoro-poplitealarterybypasssurgery.
OutlinethediagnosticcriteriaforacutemyocardialischaemiaonanECG?(30%)Describe
yourmanagementofacutemyocardialischemiainPACUinthispatient.(70%)
(report)
-adescriptionofECGchangesofischaemiaandNOTinfarction
-adescriptionofimmediate“standardmanagement”ofinfarctionaswellasmanaging
issuesspecifictothispatient[settingofvascularsurgery,heparinisation,“normal”BPetc]
Q7-CVL,CLABbundlediscussion,43.4%
Youareinsertingacentralvenousline(CVL)aspartofyouranaestheticmanagementfora
laparotomy.
Outlinetheperioperativemeasuresyoushouldconsidertominimisecentralvenousline
sepsis.
(report)
-mentionofrisks/benefits,ofusingacentrallineatall
-discussionofaseptictechnique
-followingagreedprotocolsfortheinsertionprocedure
-complyingwithhandhygienerecommendations
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-useofadequateskinantiseptic
-choosingthebestCVCinsertionsite
-useofadequateportdisinfectionprioritouse
-educationofmedicalandnursingstaff
-removalofCVCassoonasitisnotneeded.
Q8-Thoracicepiduraldiscussion,71.2%
Apatienthasamid-thoracicepiduralinsertedpreoperativelypriortoanaesthesiaforopen
AAArepair.
Describetherelevantanatomyincludingsurfacelandmarksforinsertionofamid-thoracic
epidural.Useofdiagram(s)maybehelpful.(50%)
Listreasonsforpersistentlegweakness4hoursafteremergencefromanaesthesiainthis
case.(50%)
(report)
-demonstraterecognitionofsurfacelandmarksrelatingtothoracicspinalcordlevels
-outlininglayersbetweenskinandepiduralspace
-mentionofcontentsoftheepiduralspace
-reasonsforlegweaknessincluded
• spinalcordinjuryrelatedtoepidural–haematoma/trauma
• persistentnerveblockade
• spinalcordischaemia
Q9-issueofpneumoperitoneum,96.8%
Anotherwisewellpatientpresentsforalaparoscopicrighthemicolectomy.Whatarethe
issuesrelatedtothecarbondioxidepneumoperitoneum?Howwouldyourintraoperative
managementaddresstheseissues?
Q10-bloodproductmanagementinOT,55.7%
Outlinethestepstoensurethesafestorage,handlingandadministrationofbloodtoa
patientoncethepackedredbloodcells(RBC’s)havearrivedinthetheatresuite.
(report)
Processestoensuretherightpatientreceivedtherightpackoftherightproductandthatit
wasstoredsafely.Aspectsofadministrationincludingfilteringandnonmixingofinfusions.
Q11-Freeflapcirculationdiscussion,61.6%
Outlinethephysiologicaldeterminantsofbloodflowthroughamyocutaneousfreeflap?
(50%).Evaluatetheuseofvasoconstrictorsforsupportofbloodpressurefollowing
reanastamosisofamyocutaneousfreeflap?(50%).
(report)acknowledgingthatvasoconstrictorshadaroletoplaybutshouldbeconsidered
afterotherparametershadbeenoptimised.
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Q12-Beachchariposition(repeat),44.3%
Apatientisscheduledonyourlistforarthroscopicshouldersurgery.Thesurgeryistobe
performedinthebeachchairposition.
Listtheproblemsassociatedwiththispositionanddescribehowyoucouldminimisethem.
Q13-acromegalydiscussion,77.2%
A53year-oldmanwithacromegalypresentsforatransphenoidalresectionofhispituitary
tumour.Outlinethefeaturesofacromegaly.(50%)
Howdoesthisdiagnosisinfluenceyouranaestheticmanagement?(50%)
Q14-acid/baseanalysis,discussion,59.4%
Apatient’sarterialbloodgasesinclude
pH7.1,pCO227,HCO3<15.
A.Whatistheacid-basestatusofthispatientandbrieflyjustifyyourdifferentialdiagnosis
list.
B.Describehowotherbiochemicalparameterswouldhelpidentifythecause
Q15-persistentpostsurgicalpain(repeat),85.8%
Definepersistentpostsurgicalpain
Outlinetheinterventionsthatareefficaciousinreducingthetransitionofacutepost
surgicalpaintopersistentpostsurgicalpain
(report)
Keycomponentsofananswerforthisquestion:
-AdefinitionofPPSP
Chronicpain=painpersistdespitehavingrecoveredfrominitialtissueinjury.Ie
persistentpain>12weeks.
-Mustdevelopaftersurgicalprocedure
-Painofatleast2monthsduration
-Othercauseshavebeenexcluded
-Thepossibilitythatthepainisfromapreexistingconditionhasbeenexcluded
Oct-2013,36.6%
Q1-PeriopmxofACEi+metformin,68.1%
A68-year-oldmanisscheduledfortotalkneereplacementnextweek.Hehashypertension,
forwhichheisprescribedenalapril,andtype2diabetes,forwhichheisprescribed
metformin.
Justifyyourperioperativemanagementofhismedications.
(report)
Periopriskstratification
Maintainphysiological“normality”forpatient
Makinguseofguidelines/recommendations
Risk/benefitcalculationofstoppingvscontinuingagents
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Q2-stats,definitions,26.9%
Inalargeclinicaltrial,patientswererandomisedintotwogroupstostudytheimpactofBIS
monitoringontheincidenceofawareness.Thetableshowstheresults.
Groups SampleSize No.ofcasesofawareness
BIS 1250 2
Routine 1250 11
Dataanalysisfoundthatthedifferenceintheincidenceofawarenesshadapvalueof0.022.
ThestudyreportedthatBISguidedanaesthesiareducedtheriskofawarenessby82%(95%
CI17-98%)withanoddsratioof0.2andaNNTof140.
Definethefollowingtermsandexplaintheirmeaninginrelationtothisstudy:
• Pvalue
• Riskreduction
• Confidenceinterval
• Oddsratio
• Numberneededtotreat
Q3-SVVdiscussion,42.9%
a.Outlinetheprinciplesofstrokevolumevariation(SVV)measurement.(50%)
b.DescribehowSVVmeasurementcanbeusedtoassisthaemodynamicoptimisationina
patientundergoingmajorelectiveabdominalsurgery.(50%)
(report)
a.AbilitytorecognizethatthechangeinSVorpulsepressureduringtherespiratorycycleis
measuredbeforeandafterafluidchallengeanditsresponseassessedandinterpretthe
change.
b.RecognisetheuseofSVVtooptimizepreloadanduseittoassistindecidingbetween
fluidsand/orinotropes.
Betterresponsesacknowledgedsomelimitations,andthedescribedgoalofavoidingtissue
hypoperfusion.
Q4-QAtominimizeintraopdrugerrors,81.9%
Outlinemethodsavailabletominimiseintraoperativedrugerrors
- drug error incidence = 1/135 anaesthetic - significant harm to patients - need to recognise and adopt techniques to minimise such events
ANZCAPDdoconinjectabledruginanaesthesia
Individualaction• write legibly • good communication • minimise distraction when drawing up • adequate light
Priortodrawingupandadmin
• Readlabels(checkname/dose)
• Regularcheckingforexpireddrugs
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• Drawup1drugatatimeandlabel
• Ifuncertainofdrugdrawnupàdiscard
• Checkdrugbeforeadminwith2ndpersonorautomateddeviceespintrathecaldrugs
• 1ampouleto1patient.Dn’tshareampoule.
Labels
• Colourcodedbydrugclasspre-printedlabels
Storageduringanaesthesia
1. trayforemergencydrugvstrayforroutinedurg.
2. Differentroutesstoredseparatelyeg.epiduralvs.IV
Storage
• Tidy,organized,standardized,appropriatetrays
• Emergencydrugdrawer
• Storeapartlook-alikeampoules
System
• Avoidlook-a-likepackaging
• Changeofpackagingmustbewidelycommunicated
• Standardizeconcentrationofdrug
• Usepredilutedformulation;avoidneedfordilutionesphighriskdrugseg.insulin.
• Inventoryshouldminimizedrugerror–don’tmakeampouleslooklike
Infuiondrugs
- Standardizeddrugconcentration.
- Labelpatientendofinfusionline.
- Onewayvalvetoavoidsiphoningofinfuseddrug.
(report)Recognisingthatdrugisabroadtermandcouldmeanwrongdrug,dose,patient
etc.Somementionofthevariousstrategiessuchas:
• Recognisemultiplefactorsinvolved-targetthesetominimiseerrors
• Druglabellingoptions
• Checkingprocedures
• Minimaldistractionswhendrawingupdrugs
• Drugstorageoptions
• Pharmacyinvolvement
• Documentation
• Policies
• Audit
Q5-Anatomyofforearm,wrist,57.7%
Anadultpatientisscheduledforformationofanarterio-venousfistulaatthewrist.
a.Describethenervesupplyrelevanttothissurgery.(30%)
b.Discussthesuitabilityofaninterscaleneblockinthissituation.(70%)
(report)
Theneedto:
• demonstratethatthisoperationusuallyinvolvescreatingafistulabetweentheradial
arteryandcephalicveinatthewrist.
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• communicateanunderstandingthattheC5-6dermatomesneedtobeblocked,AND
thatthemusculocutaneousnerveistherelevantperipheralnerve.
• communicatethattoadequatelycoveratourniquetwillrequiresomething
else/extra(althoughuseoftourniquetinfrequent).
Theneedto:
• definewhataninterscaleneblockis
• notethatasuccessfulinterscaleneblockwillcoverC5-6asrequired
• makesomecommentonhowtomanageatourniquet
• discussthesuitabilityoftheblockwithreferencetoothersensibleanaesthetic
optionforthisoperation(GA,localanaestheticatthewrist,axillaryblock)
Q6-ABGdiscussioninvascularsurgery,71.4%
Apatientisundergoingfemoro-poplitealarterybypassgraftingforintermittentclaudication
underspinalanaesthesiawithnosedation.
Discussthispatient’sintraoperativearterialbloodgasresult.
FiO2 0.5
Patienttemperature 35.6
pH 7.235
PaO2 145
PaCO2 50
HCO3− 15
BaseExcess -6
Lactate 3.5
(report)
Diagnosingamixedrespiratoryandmetabolicacidosis;themildA-agradient,the
respiratoryhypoventilation;withthebetterresponsesdiscussingpossibleaetiologiesion
thedescribedpatient.
Q7-tourniquetdiscussion,33.5%
Discussthesafeuseofarterialtourniquetsfororthopaedicprocedures.
(report)
• Discussionofthesizeofthetourniquetanditsrelevance.
• Mentioningthattherearesomecontraindicationstotheuseoftourniquetsand
includeAVfistulasandseverePVDinthis.
• Discussionofthepotentialcomplicationsfromtourniquetuse:Systemicand
localised.
Q8-Mediastinoscopyformediastinalmass,72.4%
Youareaskedtoevaluatea35-year-oldpatientwhohasbeenscheduledfor
mediastinoscopytobiopsyasymptomaticanteriormediastinalmass
a.Discussthefeaturesspecifictothisconditionthatneedtobeconsideredwhenplanning
ananaestheticforthispatient.(50%)
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b.Describehowyoumayneedtoadaptyouranaestheticplaninresponsetoeachofthese
features.(50%)
(report)
Keycomponents:
Discussingsymptoms,signsandinvestigationsofthefeaturesthatare
a.attributedtomasseffectscausedbythetumour,
b.thoseattributedtopathologicprocessthatmaybeunrelatedtothetumourmass,for
examplemyastheniagraviswiththymomawith,orhaematologicchangeswithlymphoma.
Esp.mentionfeatureswhichcanbepotentialylifethreateningwasconsideredimportant
Thesecondpartoftheanswerrequiredacleararticulationthatthebiggestconcernis
collapseatinduction,eithercardiovascularorrespiratoryobstruction,andthatthismaybe
attributedtolossofspontaneousventilation.Inadditiontheyneedtodiscusstherisksof
paralysis,howthiscanbemanagedandsalvageplans.Theneedtoensurepre-opcondition
isoptimized,andforinvasivemonitoringwasalsorequired.
Q9-penetratingeyeinjurydiscussion,IOP,46.2%(repest)
A25-year-oldboilermakerisscheduledforrepairofapenetratingeyeinjuryonthe
emergencylist.
a.Listthedeterminantsofintraocularpressureingeneral.(30%)
b.Discusstheperioperativemeasuresavailabletominimiseincreasesinintraocular
pressureinthispatient.(70%)
Q10-cerebralpalsydiscussion(repeat),57.7%
A7-year-oldnonverbalgirlwithseverespasticcerebralpalsyisscheduledforcystoscopy.
a.Describetheimportantfeaturesofcerebralpalsyrelevanttoplanninganaesthesiaforthis
procedure.(70%)
b.Whataretheadvantagesanddisadvantagesofinhalationalinductioninthischild?(30%)
Q11-tramadoldiscussion,24.7%
Evaluatetheroleoftramadolinacuteandchronicpainmanagement.
Q12-POCD,46.7%
Threedaysafterapatienthasundergonehemiarthroplastyundergeneralanaesthesia,his
relativesasktoseeyoubecauseofconcernsthatthepatientdoesnotrecognisefamily
members.Thiswasnotpresentpreoperatively.
a.Whatfeatureswoulddistinguishbetweendeliriumanddysfunctioninthissetting?(50%)
b.Whatyouwouldadvisethefamilytobetheexpectedoutcome?(50%)
FeaturesdistinguishingdeliriumandPOCDDelirium
• =acute,fluctuatingseverityofmentaldisturbanceandinattention;
o Pattern:eitherhypoactive/hyperactive,showswax/wanepatternthroughout
day
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o Otherfeatures=distress,anxiety,hallucination,dissociationfromreality
senseoftime/place/people
o Time:Onsetusu.<3dayspostop
• Cause=multifactorial
o Patient–
§ preexistingcognitiveimpairment,elderly,sensoryimpairment
(audiovisuo);
• Druguse:ETOH,substancewithdrawal,BDZ/opioids,steroid,
anticholinergicetc(thiazidediuretics,digoxinalsohavemild
anticholinergiceffect)
§ AcutePhysicalillness:hypoxia/LRTI,hypotension,increasedICP,
CVA/TIA,hypothermia,electrolytedisturbance,UTI,liverfailure,
thyroiddx,pain
• Diagnosis:clinicalfeature+diagnostictoolseg.CAMquestionnaire–confusion
assessmentmethod.
POCD:
• =reducedmemoryandabilitytohandleintellectualchallenges(report),inparticular
thoserequirehigherlevelexecutivefunctioningseg.learningnewtasks,multi-
tasking.
o Tendstobesloweronsetthandelirium,fromdaystoweekspostop.
o Mayimproveovertime,howevermaytakelongtimeandreducedfunction
maybelong-lasting.
• Causes:
o Patient–increasingage,preexistingcognitiveimpairment,physicalinsult:
LRTI,infection.
o Anaesthesia–GAratherthanRA,longduration.
o Surgery:durationofsurgery,degreeofsurgicaltrauma;higherriskwith
majorvascular,orthopaedicandcardiacsurgery+CPBuse.
• Diagnosis:clinical+neuropsychologicaltesting.
Currentsetting:
• Patientisatriskforbothdelirium+POCD.
o commonriskfactorshereinclude:postop,physicalinsultofhipfracture,GA,
opioids+patientlikelyiselderlywhohassuffered#NOF,withpreexisting
cognitiveimpairment.
• Acuteonset,disorientationwithoutapparentsymptomsofdelirium,suggests
patienthasPOCD,howeverfurtherassessmentwithdiagnosticquestionnairewill
helptoconfirmworkingdiagnosis.
Txadvice(report):• Largelyexpectant,supportive;
o Likelyneedincreasedlevelofcarepostopuntilreasonablerecoveryof
cognitivedysfunction
• chanceofrecoveryarereasonable,particularlyofmemoryrelatedissues,butthat
someriskofoverallreducedfunction
• recoverycantakealongtime–manymonths.
• MedicationsareNOTindicated.
NB.CEACCP:
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• RiskofprolongedPOCD~10%aftermajorsurgeryin>60yo;incidcencemaybeupto
1/3in>80yo.
• ProlongedPOCD(months)tendstobepredisposedbyhigherageonly.OtherPOCD
riskfactorsareimplicatedmainlyin‘earlyPOCD’.
Q13-PETdiscussion,69.2%
Youareaskedtoassessa35-year-oldwomanonlabourward.Shehasuncontrolled
hypertensionat34weeks’gestation.Herbloodpressureis180/110mmHgandurinalysis
shows3+ofprotein.
Herobstetricianwantstodeliverherbycaesareansectionassoonasfeasible.Outlineyour
managementtooptimiseherstatuspriortotransfertotheatre.
Q14-VAPdiscussion,28%
Intensivecarepatientsmaybeatriskofventilator-associatedpneumonia(VAP).
a.Describethelikelyaetiologyof,andriskfactorsfor,VAP.(50%)
b.OutlinepreventionstrategiesthatreducetheincidenceofVAP.(50%)
(report)
b.Discussionofroleofaspiratingcolonisedsecretionsinaetilogy
c.Mechanicalventilation/ETTiscentral&mentionofimportantpatientfactorsandICU
factors.
d.Inpreventionstrategies
i.ImportanceofAvoiding/minimisingintubation
ii.Importanceofcommon,dailyICUpracticesinmanagingventilatedpatients
1.Positioning
2.Medicationstrategies
3.GeneralICUprotocols[handhygene,equipmentcare]
Q15-C5-6quadriplegiadiscussion,75.3%
A25-year-oldfemalewithlongstandingC5-6quadriplegiarequiresuretericstentinsertion.
Outlinetheimplicationsforanaesthesia.
(report)
issuestocoverwithclearanaestheticimplicationsincludenatureoftheinitialinjury,
implicationsofinjuryonrespiratoryfunction,autonomicdysreflexiaanditsimplications
peri-operatievly,temperatureregulationissues,musculoskeletalandpositioning,issues
relatedtoDVTprophylaxisandpressurecareandassociationoftreatmentofthecondition
[highincidenceoflatexallergywithrepeatIDC].Discussionofdrug/techniquechoice
especiallyuseofsuxemethoniumwouldbeexpected.
May-2013,50%
Q1-MILIofneckdiscussion,68.3%
a.Howistheneedformanualin-linestabilisationoftheneckdetermined?(50%)
b.Whataretheimplicationsofinlinestabilisationforendotrachealintubationofthe
airway(50%).
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(report)
Discussionoftheneedtousethehistory,physicalexaminationandinvestigationswhen
determiningtheneedformanualinlinestabilisation(MILS).
AcknowledgingthatMILSwasnecessaryforpatientsrequiringendotrachealintubation
wherethereisconcernofinstabilityofthecervicalspineandpotentialspinalcordinjury
duetoneckmovementduringintubation.
mentioningtheneedforMILSinclinicalsituationsotherthetraumaandmentionedcriteria
forclearingthecervicalspineintraumasituationssuchasNEXUSandtheCanadianC-spine
rule.Itwasconsideredimpressiveifacandidatehadenoughtimetowriteaverybrief
discussionofthecontroversysurroundingMRIversusCTscantoclearthecervicalspinein
theobtundedpatient.
b.Acknowledgmentofdifficultyinassessingtheairway,thetechnicalincreaseindifficulty
andthelogisticsoftheneedforadditionalstaffandpotentiallyequipment,alongwith
managementofcollarwereconsideredimportant
Q2-Safetyfeatureofgasdeliveryinmachine(repeat),28.3%
Outlinethefeaturesoftheanaestheticmachinethatensuresafegasdeliverytothepatient.
(report)
-Supplyofgastothemachineandcircuit
-Ensuringsafepressuresdeliveredtothemachineandinthepatientcircuit
-Monitoringofgascontent
Q3-arteriallinediscussion,69.3%
Anelderlypatientistoundergooperativefixationofafracturedneckoffemur.Aradial
arteriallineisinsertedpriortoinduction,andwhentransduced,thetraceappearsdamped
a.Whatarethepossiblecausesforthetracetoappeardampedinthispatient?(50%)b.
Outlinethestepsyouwouldtaketoensuretheaccuracyofyourarterialline(50%)
(report)
a.Possiblecausesfordamptrace
-Actuallydampedandcauses
-Inaccuratereading
-Accuratereadingbutclinicalconditioncausingappearance
b.Stepstoensureaccuracyofreading
-Excludedamping
-Checkcalibration
-ComparearteriallineandNIBP
-Clinicallyassessingthepatient
Q4-airwayneuroanatomy,nasalintubation85.1%
a.Describethesensoryinnervationoftherespiratorypassagefromthenostrilsto,and
including,thevocalcords(50%).
b.Listtheindicationsandcontraindicationsfornasalintubation(50%).
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Q5-epilepsy,53.5%
Whataretheperioperativeconcernsfortheanaesthetistmanagingapatientwithepilepsy?
Ref:OHA
PeriopConcerns:
Pre–assess+preparePatientfactor:
• Controlexplored(natureofseizure,timing,frequency,historyofstatusepilepticus
requiringICUadmissionpreviously?;usualtreatmentregimen)
• MDT:ifunstableorwithcomplexhistory,willneedconsultationwithNeurologist
• Systemiceffects:othersystemiceffectsfromanticonvulsantsexploredeg.
o Hyponatremiafromcarbamazepine,
o posturalhypotension,arrhythmiariskfromphenytoinetc;
• Electrolytes/glucoselevelsinvestigated,asthesecouldalterseizurethreshold
• Hepaticenzymeinducingorinhibiting
o Depthofanaesthesiamonitoringuseful–BIS,NMT.
o Musclerelaxant:consideratracwhichhasorganindependentmetabolism
o Mayhaveincreasedanalgesiadoserequirementtoachieveeffect.
Anaesthetic/surgicalfactor
• Seizuretriggerperiopneedstobeminimized:
o Stress:periopstresscouldpotentiallytriggerseizure;
o Analgesia/PONV:importanttohaveadequateanalgesiaandantiemetics–
alsohelptoreducePONVandensuretimelyreturntoantiepileptictreatment
postop
• Avoiddrugswhichlowerseizurethreshold:
o tramadol,haloperidol,pethidine,enflurane,etc.
• Dystoniascare:
o Sonottoconfusewithseizure:eg.metoclopramide,droperidol,
prochlorperazineetc.(evenpropofolcandothis,howeverabnormal
movementsasscwpropofolusehasn’tbeenshowntobeepilepticactivity;
considerco-inductionwBenzoifthere’sconcernwithabnormalmovementw
propofol).
• Fasting,ifprolongedàdisruption
o Minimizedisruption;continueregular+earlyreturntoPOintake,ifnot
practical,NGpostoporIV+monitorbloodlevel
• Regionaltechnique,ifappropriate,mayassistinearlyreturntooralintake.
• Breathing:avoidhypocapnoeaaslowersseizurethreshold.
Intraop:Watchforseizureunderanaesthesia,espifmasked:
breakthroughseizuremaybedifficulttodetectifpatient’sparalysed.EEG/BISmonitor,high
indexofsuspicionwithsuddenincreasedHR,BP,pupildilation,increasedEtCO2,muscle
tone,oxygenconsumption,couldindicateseizureactivity.
• Propofol/thiopentoneareusefulanaestheticmedicationswithanticonvulsant
activity.
Postop:patientneedstohaveadequatepostopmonitoringtomonitor
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53.5%ofcandidatespassedthisquestion.
Keycomponentsofananswerforthisquestionrelatedto
• -knowingthatepilepsyisacommonconditionand
• -indicationofknowledgeofimportanceofmaintaininganti-epilepticmedications
peri-operatively
• -awarenessofriskfactorsforhavingaseizurerelatedtoanaesthesia
• -awarenessthatanaesthesiaanddrugsusedinassociationwithanaesthesiacan
modulateseizurethreshold
• -knowledgethattreatmentwithantiepilepticdrugscaneffectenzymeactivity,drug
metabolismandanaestheticdrugrequirements
• -awarenessofsomecommonassociatedmedicalconditions
• -indicationofamanagementplanifaseizureoccurs
Q6-managementof‘unknownsevereallergy’,37.1%
Afit37-year-oldfemalepresentsforlaparoscopicappendicectomy.Shereportsa“severe
allergicreaction”duringheralaparoscopy5yearsago.Therewerenotestsperformedand
therecordsarenotavailable.
a.Outlineyourstrategyformanagingthiscase.(70%)
b.Listtheinvestigationsthatarerecommendedfollowinganysuspectedanaphylaxisand
whentheyshouldbeperformed.(30%)
(report)
• Historyofpreviousepisode;allergicrisk/tendency;discusswithsurgeon;inform
patientoflikelyrisks;makelowriskplanforthiscaseincludingdrugchoice’s;
monitoringandcontingencyplansifproblems.
• b.serumlevelsofreaction/anaphylaxismarkers[histamine;tryptase];skintesting
andtimingofall.
Q7-morbidobesityobstetriccare,52%
A25yearoldwomanat28weeksgestation,withabodymassindex(BMI)of45attendsthe
highriskobstetricclinic
Outlinethepathophysiologyofmorbidobesityaffectingpregnancyanddescribethe
implicationsforobstetricanaestheticcare.
Q8-acuteneuropathicpain,75.2%
a.Inapatientwhocomplainsofpostoperativepain,whichfeaturesofthehistoryand
examinationsuggestadiagnosisofacuteneuropathicpain?(50%)
b.Howwouldthediagnosisaffectyourpostoperativepainmanagementplan?(50%)
Q9–evidencebasedmedicine,53%
a.Whatisevidencebasedmedicine.(30%)
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b.Describethefeaturesofasystematicreview,indicatinghowitmayinfluenceyour
practiceofanaesthesia.(70%)
(report)
a.definingEBMasaprocessofidentifyingaclinicalpractice;reviewingtheevidencefor
clinicalpracticerobustlyandthenmodifyingpracticeasaresultofthereview.
b.featuresofsystematicreview–framingquestion;identifyingrelevantwork;assessing
qualityofstudies;summarizingevidence;interpretingfindings/drawingconclusions.Role
inchangingpractice:developmentofguidelinesbasedonbestcareandevidenceand
revieweffectivenessofsame.
Q10-hypothermiaprevention,66.8%
Listmethodstopreventhypothermiainpaediatricpatientsduringanaesthesiaandsurgery,
commentingontheeffectivenessofeach.
(report)
Forcedairwarming
Insulatinglayer
WarmingOR
Circulatingwatermattress
IVfluidwarming
Humidificationofgases
Preopwarming
Radiantheaters
Q11-systolicmurmurassessment,52.5%
A25-year-oldmalescheduledforelectivesurgeryisfoundtohaveasystolicmurmuronthe
dayofsurgery
a.WhataretheclinicalfeaturesandECGfindingsinthispatientthatwouldpromptyouto
postponethecasetoallowfurtherinvestigation?(70%)
b.Whatarethelikelycausesofthismurmur?(30%)
Q12-pronediscussion(repeat),37.6%
Whatarethehazardsofthepronepositionforpatientsundergeneralanaesthesiaandhow
cantheybeminimized?
Q13-hypoxaemiainOLV(repeat),71.8%
a.Whycanhypoxaemiaoccurafterchangingfromtwolungtoonelungventilation?50%b.
Describethetreatmentofhypoxaemiainonelungventilation(50%)
Q14-LAST,67.3%
Youperformmultipleintercostalblocksusing300mgropivavcaineforflailchest
a.Whatfeatureswouldmakeyoususpectsystemiclocalanaesthetictoxicity?(50%)b.How
wouldyoumanagethesituation?(50%)
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Q15-preopanaemiamanagement,66.8%
Afemalepatientscheduledrequiringatotalkneereplacementisseeninclinic.Adatehas
notyetbeenscheduledforsurgery.
Oninvestigationshehasahaemoglobinof105g/L
1.Whatarethemostlikelycausesofthisresult,andhowwouldconfirmthis?(50%)
2.Whatpreoperativetreatmentwouldyouundertakeandwhy?Whatadvicewouldyou
giveforschedulingtimeofsurgery?(50%)
Oct-2012,27.5%
Q1-painmanagementinelderlydementia(repeat),37.6%
Youareaskedtoanaesthetisean80-year-oldladywithdementiaandafracturedneckof
femur.Sheisonnoothermedication.
1.Whataretheissuesinassessingpaininthispatient?(50%)
2.Whatwouldyouprescribeforpostoperativeanalgesiaandwhy?(50%)
(fromAucklandcourse)
Issuesofassessingpaininelderlypatientwithdementia:- Difficultyinassessmentduetolikelynon-verbalisingpatient
- Patientlikelywillunderreportpainduetodementia
- Patientlikelyexperiencingcomplicationsthatexacerbatecognitivedysfunctioneg.
UTI,MI,dehydration.
Assementtshouldinclude:- Collateralinfofromcaregiver/familyisvaluable–forbaselinephysical/cognitive
function;severityofdementia;painlevel
§ Familiarfacesalsohelpstabilizepatient/engagementofcare
- Objectiveassessmentrequiredeg.FLACCorPAINAD(painassessmentinadvanced
dementia);tailorassessmenttooltodegreeofdementia+allowtime!
§ PAINAD=Breathing,vocalization,facialexpression,bodylanguage,
consolability.
§ VAS
§ Wong-BakerFACESpainratingscale.
Mxshouldinclude:- Treatcomplications->forgeneralwell-beingofpatient+helpswithassessment
- ConsidereffectsofagingonPkandPd.
o Pk–lowerTBW,higheradiposetissue,reducedmetabolism,excretion.
§ Hencemorphinemayhaveinitialhigherplasmaconcdueto
hydrophilic;fentanylmayhaveprolongedhalf-lifeduetolipophilia.
§ Principle=‘startlow,goslow’+opioidsparewheneverpossible.
- Analgesiatherefore=
o Regional–spinal(3ml0.5%bup+50mcgmorphine);toopioidspare.
o Timelyreductionof#->expectreducedpainpostreduction.
o Regularpostoppainreview(subjectvie+objective)eg.Q6Handtitrate
analgesiarequirement
o Multimodalanalgesia,PO.Para15mg/kgqid+forbreakthroughpain:
§ Oxynorm2.5mgprn/Q4H+lactulose10mlbd.
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§ Ifongoingpain,consideraddingin2daycourseoflowdoseNSAID
providingnoabsolutecontraindication;butbalancethiswithrisks.
o Eg.etoricoxib90mgodwithPPI.
§ NB.Wouldavoidtramadol,gabapentin,ketamineindementiadueto
riskofincreasingpostopconfusion.
NB.
Livermassdecby40%byageof80;CrCldecby40%byageof80.
Q2-DAPTandDESdiscussion,63.8%
A75-year-oldmanpresentsforrighthemicolectomyforanobstructinglesionofthe
ascendingcolonthathasfailedtosettlewithconservativemanagement.Hehadadrug-
elutingstentplacedeightmonthsago,andiscurrentlyonclopidogrelandaspirin.Discuss
andjustifyyourplanforperioperativemanagementofhisantiplatelettherapy?
Q3-weaningfromcardiopulmonarybypass,59.1%
1.Whataretheprerequisitesforseparationfromstandardcardiopulmonarybypassafter
uneventfulcoronaryarterybypasssurgery?(50%)
2.Whatarethelikelycausesofhypotensionintheimmediatepost-separationperiod?
(50%)
Q4-aorticstenosis,49.7%
1.Whatisthenaturalhistoryofaorticstenosis?(30%)
2.Whatarethekeyechocardiographicfeaturesinhaemodynamicallysignificantaortic
stenosis?(70%)
Q5-strabismussurgeydiscussionindaysurgery,74.5%
Youareaskedtoassessa4-year-oldchildwhoisscheduledforastrabismus(squint)
correctionasadaycaseprocedure.
1.Whataretheissuesrelevanttoanaesthesia?(70%)
2.Whatwouldpreventyoufromdischargingthispatienthomeaftersurgery?(30%)
(fromAuckland)
Issues:
§ Airway
§ OCreflex
§ Emergence–TIVA/remi(BIS);clonidine
§ PONV–uptotwiceascommonasadult.
§ Analgesia–subtenons,multimodal
Preventionfromdc:
§ Safetyconcern:responsibleguardian?
§ Distantfrommedicalassessment:contact,traffic
§ SEsfromsurgery/GAeg.
o PONV,nottolerstingPOintake
o Pain,
o Excessivesedation
o Apnoea
NB.
§ Ondans/dexdose=0.15mg/kg
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§ Cyc1mg/kgupto50mg
§ Drop25mcg/kgupto0.625mg(=maximalantiemeticdose).
Q6-surgicalsafetychecklist,43.6%
YouaretheconsultantwhohasbeentaskedwithintroductionoftheWHOSSCL(surgical
safetychecklist)toyourhospital.
1.Whataretheprinciplesbehindthechecklistthatenhancepatientsafety,withreference
toeachcomponent?(70%)
2.Whatdoyouexpectthebarrierstoitseffectiveimplementationtobe?(30%)
Keycomponentsofaresponsetothisquestionrelatedto:
1)Principles
- improvedteamcommunicationandperformance
- atooltoensureteamsconsistentlyfollowasystemtominimizethemostcommon
andavoidablerisks
- aculturethatvaluespatientsafety
- adaptiontolocalpractice
- leadership
Components
- Signin
- timeout
- signout
2)Barrierstoeffectiveimplementationmayrelateto
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- “protocolfatigue”-repetitionandinattention
- complexityandalackofcommitmenttothesystembyallmembersoftheteam
- inabilitytoadapttoindividualorinstitutionalpreferencesorpractices
Q7-TPNdiscussion,34.9%
Inregardtototalparenteralnutrition:
1.Whataretheindications?(30%)
2.Whatarethecomplications?(70%)
(report)
1)Indications
- treatmentofmalnutritionduetomalabsorptionfromanycause
- preventmusclewasting
- improvedwoundhealingandclinicaloutcomes
2)Complicationsrelateto
- delivery:earlyandlatecatheterissues
- metabolicdisturbances:acidemia,hypo-andhyperglycaemia,liverdysfunction,
hypo-andhypervolaemia,
- lipaemia,immunosuppression,vitaminandtraceelementdeficiencies.
Q8-generalconsentdiscussion,51%
OutlinethekeystepsingaininginformedconsentforanaesthesiainacompetentASA1
adultundergoingminorelectivesurgery.
Q9-MRIissuesindevelopmentalldelayedpt,63.1%
Adevelopmentallydelayed,unco-operativeadultrequiresamagneticresonanceimaging
scan(MRI)forinvestigationofdeterioratingcontrolofseizures.Whatissuesdoyouforesee
intermsofprovidinggeneralanaesthesiaintheMRIsuiteforthispatient?
Q10-traumainducedcoagulopathy,63.8%
Atraumapatientpresentsthirtyminutesafterasignificantcrushinjury,withanestimated
40%bloodloss.Hewaspreviouslywell.
1.Explainthecoagulationabnormalitiesyouwouldexpectinthispatientatthisstage.(60%)
2.Discussthecurrentevidencefortreatmentoftheseabnormalities.(40%)
Q11-peripartumcardiomyopathydiscussion,13.4%
Youhavebeenaskedtoprovideanaesthesiaforaloweruterinesegmentcaesareansection
(LUSCS)inawomanat38weeksgestation.Shehasapacemaker-defibrillatorimplantedfor
aknowncardiomyopathy.Hercurrentechocardiogramdemonstratesanejectionfractionof
35%withmildtomoderateleftventricularglobalhypokinesis.Clinically,thepatientfeels
verywell.
1.Whatadditionalpreparationswithrespecttohercardiovascularsystemwouldyoumake
toensurethesafemanagementofthispatientduringherCaesareanSection?
2.Outlinetherelativebenefitsandrisksofaregionaltechniquecomparedwithgeneral
anaesthesiainthispatient.
Q12-TAPregionalblockdiscussion(repeat),30.2%
DescribetheanatomyoftheTransversusAbdominisPlane(TAP)relevanttoregional
analgesia.(70%)ListthecomplicationsassociatedwithTAPblock.(30%)
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Q13-issuesoflargetonsillarmass,69.8%
Discussthekeyareasofconcerninyourpreoperativeassessmentofapatientforexcisionof
alargetonsillarmass.
(report)
Targetedhistory,examinationandinvestigationstodeterminethethreatofthemassto
airwaypatency.Factorstoconsiderinclude
- functionalassessment
- urgencyofintervention
- pathologicalnature/acuteorchronic
- currentmedications,treatmentsandcomorbidities
- anage-appropriateapproach
Q14-statisticsdefinition(repeat),53%
TheMallampatitestisacommonlyusedbedsidescreeningtooltoassesstheprobabilityof
adifficultintubation.Explainthetermssensitivity,specificity,positivepredictivevalue,and
negativepredictivevaluewhenappliedtothistest.
Q15-awarenessandBIS,50.3%
1.Classifythepossiblecausesforpatientawarenessundergeneralanaesthesia.(70%)
2.EvaluatetheevidencefortheuseofBispectralIndexmonitoringinreducingtheriskof
awareness.(30%)
Awareness=explicitrecallofoperativeeventsduringGA(ANZCABluebookarticle2015);incidence1:500inGACS,ie10xmorethaningeneral=1:5000.(butaquestionearliersaid
1:10,000–halfofepiduralabscess)
CausesforawarenessunderGA• Breaksdowninto:
o Accidental
§ Unrecognisedequipmentfailure
§ Reducepractitionervigilance(eg.emptyvaporiser)
o Abnormalpatientphysiology(Patient)
§ Maskedphysiologyeg.completeHB,hypothyroidism,BBuse,ANS
neuropathy
o Patient’sSNSstimulationis‘masked’fromalerting
Clinician
§ Drugresistanceeg.geneticvariability,escessiveETOH,chronicpain,
regularuseofillicitsubstances
o HigherMACrequirement
§ PoorCVSreserveeg.severeASorheartfailure
o Poortechnique(Anaesthesia)
§ UnderdosingeginLSCS
§ UnexpectedDI+insufficientanaesthesia
§ TIVA(failureofdrugdeliveryorpoorunderstandingofpharmacology)
o Specialcircumstances
§ Specialistsurgeryeg.cardiac,obs,paeds,rigidbronch,trauma
§ Lifethreateningemergencieseg.severebleed,septicshock,
cardiac/peri-arrest
UseofBISevidence
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• StudiescomparingawarenessincidencewithorwithoutuseofBIShaveshown
mixedresults.
o B-awarestudy,BISuseinhighriskpatients(cardiac,LSCS,trauma,
bronchoscopy),reportedanincidence~1%andBISreducedincidenceby
80%;NNT138.
o However,B-unawarestudysubsequently,BISinhighriskpatient,concluded
BISnobetterthanETgasanalysis.Studyshowedtherewasnoawarenessif
BIS<50andMAC>1.0.
§ Althoughthisstudyisunderpowered
o Themostrecent,BAG-RECALLtrial,attemptedtoaddresstheissueof
underpowerfrompreviousstudy,againshowedBISwasnotassociatedwith
lowerawareness.
o Currently,superiorityofBISisnotestablished.
o However,BISmaystillbebeneficialinprovidingimprovedanaesthetics
deliveryintermsofreducinganaestheticconsumption/requirementsand
improvedrecoveryprofiles.
§ there’sobservationalevidencecorrelatingcumulativedeephypnotic
time(BIS<40)withincreasedmortalityandmorbidity;BALANCEtrial
isinvestigatingthis.
Onbalance:untilfurtherclarificationonevidence,itmaybeprudenttouseBISas
supplementary,butnotthesole,assessmentfordepthofanaesthesia.Vigilanceisrequired.
• UseofBISisnotsuitableforketaminebasedanaesthesia,paediatric<1year,
hypothermia,etc.
• BISdoesnotchangewithOpioidsnorN2O.Evidenceisparticularlylackingforuseof
BISinTIVA.
NB.(TablebelowfromAlanMcLintics)
April-2012,61.5%
Q1-serotoninsyndrome,59.9%
Inregardtoserotoninsyndrome
a.Whataretheriskfactors?(20%)
b.Whataretheclinicalmanifestations?(40%)
c.Whatisthetreatmentforanacuteepisodeofserotoninsyndrome?(40%)
(report)
-specifictreatmentwithcyproheptadineorchlorpromazine
Q2–Beachchairposition(repeat),50.5%
65yomanonlistforarthroscopicacromioplastythatistobeperformedinthebeachchairposition.A.listthecomplicationsasscwthisposition(30%),b.describehowriskofthesecomplicationscanbeminimized(70%)–seeChang’senvironmentalhazardp.4Q3–Oliguria,72%
A60yomanisadmittedtotheHDUfollowinglaparotomyforlargebowelobstruction.HehasaIDUC.3hourslaterhe’soliguric.A.defineoliguria(10%),b.whatarethepotential
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causesofoliguriainthispatient?(40%),c.howwouldyoudifferentiatebetweenthesecauses?(50%).a.Oliguria=UO<0.5ml/kg/hr
b.causesinthispatient
• Pre-renal
o Decreasedrenalperfusion/ischaemia:hypovolaemia,SIRS/sepsis,MI,
compartmentsyndrome.
o DecreasedO2flux:hypoxaemia,anaemia.
• Intra-renal
o Stressresponse,asincreasedSNSoutflow,RAAresponseàADH
o Preexistingrenaldx,worsenedbysepsis,nephrotoxins–NSAID/ACEi,excess
colloiduseetc.
• Post-renal
o Uretericobstructioneg.abdocompartmentsyndrome
o IDUCobstruction
c.differentiate:
• History
o Preexistingrenaldisease?DM?prostatic
o Cardiacdisease?
o MedicationssuchasACEiorNSAID?
o Significantintraopeventsuchaslargevolumebloodloss,desaturation,
hypotension.
• Exam
o Oxygenationstatus?Desaturation?
o Cardiacexam–patientmaintainingMAP?Requiringhighdose
vasopressor/inotrope?
o Fluidbalanceexam?Patienthypovolaemic?
o Septic?Febrile,tachycardic,shocked,highleukocytosis?
• Invx
o FBC–anaemic?Leukocytosis?
o UECr–renalfunction
o Urinesample–Urosepsis?
o Bladderscan-?IDUCobstruction
o RenalUSS:hydronephrosis?Peri-renalabscess?
o ConsiderassessIAPusingintracysticpressuremonitor
Q4-Ethicsinincompetentpatient,79.1%
Anelderlypatienthaspreviouslydeclinedanabovekneeamputationforagangrenousleg.Shebecomesacutelyunwell,confusedandnolongercompetenttomakedecisions.Attherequestofthefamily,thesurgeonhasapproachedyoutodiscusswhethertoproceedwithsurgeryornot.Sheislikelytodiewithoutthesurgery.Outlinetheethicalconsiderationsyouwoulddiscusswiththesurgeon.
Autonomy=Patient’srighttomakeherowndecisionandherearlierexpressedwish.
o Althoughthisdoesnotnecessarilydictatethedecisionmaking.
o Decisionshoulddependonpreviouscircumstsanceofacompetentdecisionto
decline–wasthisaninformeddecisionwithpatientknowingconsequenceof
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declination?didpatientexpresssimilarwishesinfutureevent?Wasthisclearly
documented?Isthereanadvanceddirective?
Beneficence=Principleof‘doinggood’topatient.
o Potentialoutcomefromprocedureshouldbecarefullyconsidered–wouldthisoffer
post-proceduralgoodqualityoflifeforpatient?
o Istheriskofsurgeryoutweighedbythepotentialbenefit?
Non-malevolence=Principleofdonoharm–
o theriskofcausingsufferingtopatientshouldbeavoided.
Basisoffamily’srequest
o Family’sexpectationshouldbethoroughlyexploredandreasondiscussed.
§ incontextofpatient’spriordecisiontodeclinesurgery.
o Istherewelfarepowerofattorneyinfamily?
o Family’sviewofnotoperating?
Paternalism
o =clinician’sdiscretionofpatientcareregardlessofpatient’sautonomy.
o Shouldbebasedonaltruismandbeneficence–takingintopatient’spreviousdecision
makingandClinician’sbestattemptatdecidingwhat’sinpatient’sbestinterest.
Endoflifeissues/analgesiaprovision
o Alternativemanagementshouldbeofferedandbenefit/riskcarefullyevaluated.
o PalliationshouldinvolveMDTwithPalliativeTeam,Psychologist.
o Itispatient’srighttoreceiveanalgesiaandminimizesuffering.
Q5-spinalblockdiscussion,63.2%
Ahealthy28-year-oldprimigravidaisscheduledforelectivelowersegmentcaesareansectionforbreechpresentationat39weeksgestation.Youhaveperformedaspinalanaestheticusing0.5%bupivacaine2.2mlandfentanyl15μg(totalvolume2.5ml).a.Describetheissuesinassessingadequacyoftheblockfortheplannedsurgery(50%)b.Describetheoptionsformanaginganinadequateblockrecognisedpriortocommencementofsurgery(50%)Q6-Bronchopleuralfistulamanagement,59.9%
A25-year-oldmanwithrecurrentpneumothoraxandpersistentairleakisscheduledforvideo-assistedthoracoscopicpleurodesis. a.Outlinetheconsiderationsinvolvedininductionofanaesthesiainapatientwithapersistentairleak(50%)b.Outlinethemanagementofanintraoperativedeteriorationofoxygensaturationinthispatient(50%)Issuesinanaesthesiainduction
- A.o RequirelungisolationwitheitherBBorDLT;
§ I’duseDLTunlessdifficultywithintubation;dueto• Abletoalternateisolationquickly,fasterplacement,can
suction/ventilatebothsidesreadilyandbetterdeflationof
surgicalfield.§ Ifdifficultencountered,willusestandardETTwithBB.
- B.o Potentialdifficultywithoxygenation:cannotBMVbecauseoflargeairleak;
§ Indiresituation,considerclampchestdrain,butwatchforPTX.
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o Evaluateriskbyestimatingairleakamounto EnsurefunctioningchestdrainwithUWSDo BevigilantofriskoftensionpneumothoraxwithIPPV
§ Needlungisolationquicklyo HypoxaemiainOLVneedstobemonitored/managed
- C.o CVScollapseduetotensionpneumothorax
Managementofdesaturationintraop- MostlikelydesaturationunderOLV,howeversystemiccheckofhypoxianeedstobe
considered:o Systemiccheck:ABCapproach,scanmonitor,patient’scolour,surgicalfield
o 100%O2,ventilatemanually,assessEtCO2
o presentthen
o Auscultatechest–spasms,PTX,shunt,deadspace,
o hypermetabolism?
§ Treataccordingly
• Absent:
o ETTpositions(obtxorwrongplace)
o Considerpasssuctioncatheter
o Ruleouthypotension;optimiseCOwithvasopressor/inotrope
andensureHb>70.
o checkcircuit
• checkMonitorerror
• IfduetoapparentVQmismatchunderOLV,
o CheckwithSurgeonandprovideO2/CPAPtonon-ventilatedlung5-
10cmH2O.
• Mayneedtogentlyventilatenon-ventilatelung
o RecruitventilatedlungforpotentialatelectasisandincreasePEEP(but
considereffectofworseningVQmismatch)
o PAocclusionofnon-ventlung;butbalancewriskofRVstrain
o Ifallfails,considerCPB.
Q7–ICPassessment/monitor,64.8%
a.Listthemethodsofassessingintracranialpressure(ICP)(30%)b.EvaluatetheroleofICPmonitoringinthesettingoftraumaticbraininjury(70%)Methods
• Clinical–pupils(size,reactivity),GCS,neuroexam,resppattern,CVSchanges
(CushingresponseindicatesraisedICP:HTN,bradycardia)
• Invasive
o intracranialpressuretransducer
o intraventricularcatheterwithverticalmanometer(goldstandard)
§ morereflectiveofglobalICPthansubdural/extraduralmonitors.
• Non-invasive:CT
• Cerebralperfusionassessment
o TranscranialDoppler
o NIRS
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o EEG
o SSEPchanges;MEP.
ICPmonitorroleinTBI
• Aim=maintainCPPtominimizesecondaryischaemicinsult• ICPmonitorassistsinmaintainingCPPinTBI;asICPisdynamicinTBIandlikelywill
increasein>50%cases,duetoinflammation,oedema,intracranialhaemorrhageo CPP=MAP–CVPorICPwhicheverishigher.o IfICPshowntobehigh,espifpathologicalie>20mmHg
§ MeasurestoreduceICPcanbeperformed:• MaintainCO2=35mmHg• Mannitol/concsalttotargetNa150-155• ReducemetabolismtoreduceCBF.• DrainageofCSFwithEVD.
§ MAPcanbetitratedhighertomaintainCPP.• MayalsoenabledetectionofworseningICPrequiringsurgicalintervention,once
medicaltherapyisexhausted.Consinclude:
• Invasive–bleed/infectionrisk
• Errorneousmeasurement
• dislogement
• However,noevidencetodemonstrateICPmonitorchangingoutcome.Q8-thyroiddisease,thyroidstormmanagement,84.1%
A35-year-oldfemaleisbookedforthyroidectomy.Herbloodresultsareasfollows.Thyroidstimulatinghormone(TSH,thyrotropin)0.1 (N0.3–3mIU/l)TotalThyroxine(TotalT4)20 (N4–11μg/dl)FreeThyroxine(FreeT4)4 (N0.7–1.8ng/dl)FreeTri-iodothyronine(FreeT3)120 (N60–175ng/dl)a.Interpretthethyroidfunctiontests(10%)b.Justifywhenyouwouldproceedtothyroidectomyinthispatient(50%)c.Whatisthemanagementofanintraoperativethyrotoxiccrisis?(40%)a-patientisthyrotoxicwithelevatedT4,suppressedTSHb-Whentooperatedependson
o Urgencyofsugery,esp.ifmalignancyassociated.
o Ifugent,Withinthetimeavailable,I’dassess:
o Airway-anytrachealobstructionfromgoiter?
o B:isthereretrosternalgoiter?
o C:compressingSVC?
§ Obtainhistory-SOB,stridor,orthopnoea,syncope?
§ Exam-airway,goiter?Pembertonssign+cardioresp.
§ AssesswithCTneck/chest
o EndpointI’dbetargeting,controlincreasedSNStone:
§ Arrhythmiacontrolled,HR<80(OHA),BPcontrolled.
§ Tremorabsent
o Ifelectivesetting,TFTshouldbenormalizedbeforeproceeding.Consider
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o Carbimazole/propylthioruacil
o Radio-iodinetoreducevascularityofgoiter
o +thoroughassessmentoutlinedabove.
c-thyroidstormmanagement
o wouldexpecttoseemalignantHTN+tachycardia,fever.
o Mx=notifySurgeon,declaremedicalemergency,callhelp
o Simultaneoustreat+considerdifferentials:sepsis,MH,anaphylaxis(report)
o ABCDEapproachmx:
o Intubate
o 100%oxygenandventilatetomaintainCO235mmHg,compensateformet
acidosis
o cardiacsupport:
§ betablockerpropanololincrements(1mgIV)oresmololboluses->
infusion(50-100mcg/kg/min).TargetHR<90
§ IVfluid+glucose(OHA)
o E:treathyperthermia;considerphysicalcooling(icepack,coolblanket)
o OtherSpecifictherapy:
o hydrocortisone200mgIVQID
§ action:
• adrenalinsufficiency
• decreasesT4releaseandconversion
o propylthiouracil
§ 1gloadPOorviaNGTthen250mgQID
§ action:
• inhibitthyroidhormonerelease
• decreaseperipheralconversionfromT4-T3)
o thengiveiodideegLugol’siodine5-10dropsviaNGT
o Monitorwithartline,tempprobe
o Postop-admittoICUforongoingmonitoring.
NB.
-carbimazole(antithyroid)isnothelpfulinacutesetting,aslargestoreofpreformedT3/4
needstobedepletedfirst.
-don’tgiveNSAID/aspirinasdisplacesthyroxinefromproteinbindingàworse
Q9–Paediatricairwayobstruction,72.5%
3yoinEDwithrecentonsetofstridor.A.listthedifferentialdiagnosis(30%),b.Howdoyoudifferentiatebetweenthepotentialcausesofthisstridor(70%).
Differential(eachcategorybelowhavebothsupra/infraglotticcauses)
• Foreignbody
• Infection–epiglottitis,pharyngealabscessvs.tracheitis,croup(LTBronchitis)
• Trauma–laryngealhaematoma,airwayburn,inhalationalinjury
• Neuronal–headinjury,laryngealnervepalsy.
DifferentiatecausesbasedonHx,exam,invx
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• Hx
o Gagging,choking?Onsetwhileeatingorplayingwithsmallobject?
o Barkingcough?Fever,fatigue,dyspnea,sorethroat,dysphagia,drooling,
hoarsevoice?
o Hxoftrauma/headinjuryorrecentairwaysurgeries?
• Exam
o Importanttokeeppatientascalmaspossibletoavoidworseningofairway
obstruction;alsoassessdegreeofdistresssignifyingurgencyofintervention?
§ (report)eg.Bodyposition:Tripodpositioninchildorarchedbackward
ininfantsignifiyingrespdistress?
o Phaseofstridor?(fromCEACCP)
§ Insp:extrathoracicorsupraglotticeg.epiglottis
§ Exp:intrathoracicorsubglotticeg.foreignbody.
§ Biphasic:atorbelowcords:eg.croup
o Hypoxic?Septic?Facialburn?Signsofinhalationalinjury?
o (report)Responsetotherapy:adrenalineneb/steroid?suggestcroup
whereaslimitedresponsesuggestforeignbody;rapidworseningsuggest
epiglottitis
• Invx
o Imaging;unhelpfulunlessradio-opagueforeignbodyseen.Maysee
hyperinflationoflungorlungcollapse.
o Blood:leukocytosis,
o (report)ConsiderneedforGAformx/assessment:
§ airwaysecure,endoscopyassessforlevel/extentofairwayoedemaor
foreignbody,imaging,bloodtest
Q10-ARDSdiscussion(repeat),70.9%
Anadultpatientfromtheintensivecareunitwithsevereadultrespiratorydistress
syndrome(ARDS)requiresalaparotomyforanacuteabdomen.
a.WhatarethefeaturesofARDS?(30%)
b.Explainyourperioperativeventilationstrategy(70%)
ARDSfeaturesDiagnosticcriteria:
o acuteonset
o bilatinfiltratesonCXRconsistentwoedema
o clinicalabsenceofLAHTNieheartfailure/cardiogenicoedemaorfluid
overload(PAWP<18)
o PFratio<300=ALI,<100=ARDS.
ClinicalFeatures:
§ Acute/exudativephase
§ Subacute/proliferative
§ Chronic/fibrotic
Perioperativeventilationstrategy=‘Lungprotectiveventilationstrategy’
§ Aim=preventbarotrauma,volutrauma,atelectrauma,biotrauma(infection)
§ Mode:pressurecontroltoavoidbarotraumafromventilatingwithpoorlycompliant
lung;
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§ PeakPshouldbelimitedto<30cmH2O.
§ Dependingondegreeofcompliance,somedegreeofpermissive
hypercarbiamayneedtobeaccepted.
§ PEEP:5-10cmH2Oaimtoimproveoxygenationbyreducingatelectrauma;thisneeds
tobecombinedwithuseofrecruitmentintermittently;
§ Recruitmentaimtoopenclosedalveolitherebyimproveoxygenation
(andlungcompliance)andPEEPhelpstostopalveolifromcollapsing.
o TV–6ml/kgtoavoidvolutrauma;
§ Duetoheterrogenouscompliancesamonglungunits;highTVleadsto
overinflationofhealthylungsàdamage,worseningofARDS.
NB.
Othertherapiesmaybeconsidered:
§ ECMO:knowntoconfermortalitybenefitinsevereARDSwhenother
medicaltherapieshavefailed.
§ Nitricoxide:toimproveoxygenationandreducePVR.
• Maybeusedastemporizingmeasure,howevernotshownto
improveoutcome.
§ Fluids:
• Conservative>liberalintermsofreducingventilation/ICU
duration.
CausesofARDS:
§ Direct:pneumonia,aspiration,drowning,PE,contusion..etc.
§ Indirect:sepsis,transfusion,pancreatitis,trauma,burns,drugs
Q11-PCAservicesettingup,59.9%
Youareaskedtoinitiateanopioidpatient-controlledanalgesiaserviceinyourhospital.
a.Howwouldyouensurepatientsafety?(70%)
b.Whatarethekeycomponentstoincludeindesigninganorderform?(30%)
Stepstoensuringpatientsafety• ProtocolisedPCAprescription–
o In-linewithestablishedinternationalpainmedicineguidelinesonPCA
prescription
§ guidepatientindicationandcontraindication.AllowsforNCAoptionif
appropriateforeg.patientatextremesofage,cognitivedysfunction.
§ Guidemonitorlevelrequired+vitalsignslimlitationstoindicate
withholdofPCA
§ Guide1stinstanceresuscitation–ieoxygensupplement,naloxone,
emergencyteamhelpcontact.
o Standardisedprescriptionformforhospitaluse
• PainTeamservice
o EnsureadequatestaffinAPMSforongoingdailyfollowupofpatientsonPCA
+treatmentadjustment.
o Membersinpainteammusthaveadequateclinicalknowledge,experience–
PainCNSguidedbyPainSpecialistisideal.
• Pre-made,standardizedopioidsolutionwith1concentration
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o ToavoiderrorinmakingupPCAsolution,whichcanpotentiallybe
dangerous.
• Equipments
o Protocolisedequipmentsetup–dedicatedlineoruseofanti-refluxdeviceto
ensure1wayflow+unobstructedcarrierfluidtokeepveinopen.
o PCApumpwithreliable,robustfunction–allowsprogramofbolusdose,lock
outtime,hourlylimit,backgroundinfusion,locktopreventtampering,
occlusionalarm,dosinghistory+portability.
§ +regularlyserviced.
• Staffeducation
o Regulareducationsessionsforprescribers;ideallyonlydedicatedteamof
prescribers(APMS/Anaesthetists)
o RegulareducationforPACU/WardonsetupofPCA,monitorofpatienton
PCAuse.
• Patienteducation
o HowtousePCA,whatitisforieforpain,notforotherreasons,andensureit
isonlyusedbypatient,unlessit’sanNCA.
KeycompoenentsrequiredinPCAorderform• Prescriber’ssignature,date.
• Clearpatientlabel.Adversedrugreactions.Relevantclinicalhistory–indicationfor
PCAuse,whatotheconcurrentanalgesiaisprescribed,anyspecialcarerequired?Eg.
renalfailure,hepaticfailure.
• Optionstochoosestandardized,premixedanalgesiaoption–eg.eithermorphineor
fentanyl+standardizedprescriptionofbolus,lockouttime,hourlylimit.
• Guidemonitorlevelrequired+frequency,vitalsignslimlitationstoindicatewithhold
ofPCA
• Guide1stinstanceresuscitationforadverseeventseg.opioidoverdose–ieoxygen
supplement,naloxone,emergencyteamhelpcontact.
• Contactdetailsforproblemsolving.
Q12-epiduralanatomy,64.8%
a.Describetheanatomyoftheepiduralspace(50%)
b.Whataretheclinicalimplicationsoftheanatomicaldifferencesbetween
thoracicandlumbarepiduralspacesintheplacementandmanagementofepidural
analgesia?(50%)
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SuperficialàDeepBoundaries:
• Posterior:ligamentumflavum,laminae
• Lat:pedicle,intervertebralforamen
• Sup:durafusionwithperiosteumofforamenmagnum
• Inf:sacralhiatus,closedbysacrococcygealligament
§ Nb.Communicateswithparavertebralspacethroughintervertebral
foramen
Content• Areolarconnetivetissue,fat,lymphatics,arteries,extensivevenousplexus
Clinicalimplicationsofanatomicaldifferencesforepidurals• Level:lumbarL3-5(spinalcordusu.endedatL1);ThoracicT8-10(spinalcord
anteriortoneedle)• Caudallyangulated/overlappingspinousprocesses
Ø Morecaudallyangulatedinthoracicthanlumbar,makingmidlineapproach
moredifficultinthoracic• Bloodvesselpuncture(insittingposition)
Ø Morelikelywithlumbarthanthoracicduetovenouspoolingduetogravity.• Differentialblock:
Ø Thoracicmorelikelytocausesympathectomyofheart(cranialspreadto
aboveT4),henceneedstousesmallerbolusesattimetominimize
haemodynamicinstability;closerCVSmonitoringrequired,thanlumbar
whichislesslikelytospreadtohighthoraciclevels.§ Infusionrateshouldbelowerwiththoracicthanlumbar§ Eg.2-10ml/hrvs.5-15ml/hr.
Q13-strokeminimization,61.5%
a.Listtheriskfactorsforperioperativestroke(50%)
b.Describehowyouwouldminimisetheriskinahigh-riskpatienthavingmajor
orthopaedicsurgery(50%)
(ReadChang’s)
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(report)
Riskfactors
- classification(pre,intraandpostoperative)
- age,sex,co-morbidities,cerbrovasculardisease,timingofantithrombotics
- durationofsurgery,emergencysurgery,arrythmaisandhaemodymanics,fluid
balance,inflammation
Minmisingriskinthehighriskpatient
- timingofsurgeryafteranacuteneurologicalevent
- anti-thrombotic/anticoagulantmanagement
- perioperativehaemodynamicmanagement/monitoring,fluidbalancemanagement
- dysrrhythmiacontrol
- controlofCO2
- patientpositioning
- neurologicalmonitoring
Q14-universalprecautions(repeat),76.4%
a.Whatdothetermsdecontamination,disinfectionandsterilisationmean?(30%)
b.Whatmeasuresshouldbeinplacetominimisetheriskoftransmissionofinfectiontothe
respiratorytractofpatientsviaanaestheticequipment?(70%)
(PS28definitions)
Decontamination
o =removalofmicroorganisms/unwantedmaterialsfromcontaminatedmateraislor
livingtissue.
Disinfection
o =inacvtivationofnon-sporingmicroorganismsusingeitherthermal/checmialmeans
Sterilisation
o completedestructionofallmicro-organismsincludingspores.
Asepsis
o =preventionofmicrobialcontaminationoflivingtissueorsterilematerial
Measurestominimizeriskofinfectiontransmissioninresptractviamachine
RefertoPDDocon:infectioncontrolinanaesthesia
o Clinicalstaff(stillinthereport,eventhoughQisasking‘equipment’)
o Handhygiene,gloves,mask,isolationfrompatientifunwell
o Anaestheticequipments
o
o Airwayequipments
o Machine:Filtershouldbeusedbetweencircuitandpatient’sairway;this
way,circuit/componentscanbereusedbutstillchangeafterhighriskcontact
eg.TBorvisiblycontaminated
§ Otherwise,circuit,CO2absorber,ventilators,bellow,1wayvalves
shouldbedecontaminated,disinfectedregularlyorchanged.
o Airwayequipments,bydegreeofgradingofcross-infection:
§ Criticalequipmentsiepatient’sbloodcontact
• Laryngoblade,macgillsàsterilizeaftereachuseordispose
disposableeg.bougie.
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§ Semicriticaliemucosalcontact
• Facemask,bladehandleàdisinfectordisposeof(eg.mask,
guedel,ETT,FOI)
§ Non-criticaliemanualventilationbagàdisinfect/cleanaftereach
use;unlessvisiblecontaminationàchange
NB.
-OT,negativeP,lungisolationtechnique=NOTRELEVANTasperreport.
-ifequipmentusedwithcVJD,mustbedisposedoffassterilizationdoesn’tirradicatethe
pathogen.
Q15-oxygendeliverydevice,32.4%
Withregardtooxygentherapyforpatientsinageneralpostoperativeward
a.Describetheoptionsavailable(30%)
b.Whatarethejustificationsforyourchoiceforaparticularpatient?(70%)
Options+justification
• Nasalprongs
o Flowrate:0-4L/min;>4notrecommendedasnotincreasingFiO2higherand
riskofnasalmucosalbreakdownfromdrying.
o DeliversFiO2upto35%byincreasingO2fractioninnasalcavity
o Lesseffectiveifmouthbreather,rapidRR,respdistress,duetoair
entrainment.
o Howevergenerallywelltoleratedandpatientcaneat+drink.
§ Suitableformostpopulationwithoutsevererespdistress,andnot
requiringhighoxygen,includingneonate+mostpatientsonPCA
needingO2supplement.
§ notsuitableformouthbreather,respdistress,highO2requirement.
§ Maybeunsuitableaftercertainsurgeriseg.sinussurgeries,
septoplasties
• Hudsonmask
o Flowrate:4-12L/min.
o DeliversFiO2upto60%;extra1L/minO2flowincreaseFiO2by~4%
o Efficiencyalsodependsonpaaternofbreathing;highRR/TVentrainsairand
reducesFiO2;butismorereliabletomaintainFiO2thanNP.
o Candelivernebulizedmedicine
o Maybelesswelltoleratedcf.NP,espifinuncooperativepatients;prolonged
usewithouthumidificationcouldleadtodrymouth,mucosalbreakdown.
§ SuitableformostpatientsrequiringhigherFiO2thanNP,evenmouth
breathers,orrespdistressed.
§ NotsuitableforuncontrolleduseinCO2retainersduetoriskoflosing
hypoxicrespdrive.
§ Atlowflowrate,hasriskofCO2rebreath.
• Venturimask
o DeliversspecificallysetFiO2foragivenmask.
§ SuitableforpatientwhoneedsspecificFiO2eg.COPDCO2retainers.
§ However,morecmplexandlessfamiliarity
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• Non-rebreathingmask
o Deliversupto100%O2;dependingonflowrateandMV
§ Suitableforpatientswithseverehypoxaemia/highO2requirement
eg.severeasthma,pulmoedemaetc;temporizingbeforedefinite
intervention.
• BMV(ambubag)
o Deliversupto100%O2
o Allowsassistedventilationwithbaginemergencies
• Non-invasiveventilatorsupport:HFNPorBilevelviamask
o AllowsFiO2tobesetandflowrate.
o HighflowrateprovidesdegreeofPEEPeg.50L~5cmH2O;bilevelmask
allowshigherPEEPtobegiven+inspiratorysupport.
o Humidificationcanbecombined.
§ SuitableforpatientswhorequirehighO2requirement,whorequire
PEEPorinspsupport:eg.asthmaticexacerbation,pulmoedema,post-
abdosurgeriesatriskofatelectasis.
o However,availabilitymaybelessandlimitedtoHDUratherthaningeneral
postopward;
Oct-2011,24%
Q1-oxygendeliverydevice,5%
Compareandcontrastoxygendeliverybynasalprongs,simplefacemaskandVenturimask.
Q2-CriticalappraisalofRCT(repeat),65%
AnewrandomisedcontrolledtrialsuggeststherapyAisbetterthantherapyBinthe
treatmentofconditionX.
Howwouldyouevaluatethistrialbeforechangingyourclinicalpractice?
RCTis• goldstandardclinicaltrialdesigntoestablishcause/effectrelationship
• prospective,randomized,cof.2groupswithinterventionvs.control/placebo
• howevervaryingqualityofstrengthandweaknesseshencecriticalappraisalis
mandatory.
Appraisalwillinclude:- analysisoftheconductofthestudy:
o typeoftrial
o clinicalquestioninvestigatedrelevantinmypractice?
§ hypothesisstatement,
o generalizabilitytomypatientgroup?
§ location
§ inclusion/exclusioncriteria,
§ patientdemographics?
o ethics
o measurementtool
§ randomization?Blinding?
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§ Samplegroupcalculation
o Studyexecution
§ Groupseparation?
§ Adequatefollowup?
§ Treatmentofwithdrawals?
o Qualityofresult?Power,bias/conflictofinterestmanagement,
§ applicationofappropriatestatistics,
§ analysisofresults
§ adequatepower?Significantresult?
o Comparisonswithotherstudies?
§ Consistencyofresults?
§ contributionofnewknowledgeorconfirmationofpreviouswork
o Cross-examinationofstudy
§ Discussionwithcolleaguesinjournalclub
Q3-RBCsalvagediscussion,55%
Whatarethebenefitsandlimitationsofredbloodcellsalvage?(50%)Howwouldyoujustifyitsintroductionintoyourinstitution?(50%)
ProsofRBCsalvage• reduceallogenictransfusionrequirementandasscrisk
o TRALI,incompatibility/haemolyticreactions,immunemodulation,cancer
recurrence,blood-borneinfection,biochemicaldisturbance,antibody
formation
• Doesn’trequireG/H,particularlybeneficialforpatietnswithdifficultcorssmatching
duetopresenceofantibodies
• MaybeacceptedbyJehova’sWitnesspatients
• Cellsinfusedatroomtempavoidsneedforwarmingdevice+lowerriskof
hypothermia.
Cons• Expensiveequipmentcostandmaintenanceofdisposals
• Stafftrainingandcomplexdevice
• Delayinbloodcollection,processesingandcertainvolumemayberequiredbefore
processingpossible.
• Air/fatembolism
• Electrolyteimbalance,haemolysis,coagulopathyasonlyRBCcollected.
• Bacterialinfectionifbloodcontaminated
• Controversies(CEACCP)
o Obstetricvsriskofamnioticfluidembolism,rhesussensitisation(although
safetyinthiscontextisbeingincreasinglystablished)
o Casurgery:withrecurrenceormetastaticspread
o Bowelsurgery:infectionrisk.
Introductiontoinstitutionconsiderations:• Cost-effectiveandsafetyprofiletopatient:
o Costofusingcellsavgevscostofallogenictransfusion
o Potentialcomplicationsofeachtechnique.
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• Ingeneral,morefrequentuseofcellsalve,thegreaterthelikelihoodofitbeingcost-
effective.
• Indicationforcell-salvageinclude:
o caseswithanticipatedbloodloss>20ml/kgor>1L;
o preopanaemiaorriskfactorofbleed
o patietnswithrarebloodgroup/antibodies
o Jehovah’switness.
• LikelyseehigherrequirementofcellsavlageinCTS,vascular,tertiaryobscenterwith
complexobscases;orthopaedicsurgerieswithmultiplespinalsurgeries,revisionof
majorjointreplacements.
• Thereforejustificationwilldependonthecase-mixandvolumeofsuitable
operationsattheinstitution.
Q4–Duralpuncture,60%
WhileperforminganepiduralforlabouranalgesiainanotherwisehealthyprimigravidaduringthefirststageoflabouryouinadvertentlycauseaduralpuncturewiththeTuohyneedle.DiscussyourmanagementofthiscomplicationOptions
• removeneedleandrepeatatahigherlevel(butavoidhigherthanL2/3).Consider
seekinghelpfromaseniorColleague.
• Placeintrathecalcatheter
• Abandonepiduralandusealternativeanalgesia
Decisiondependson:
• Localpolicy,stafffamiliarity,anaesthetistavailability,midwife
experience/competenceandpatientpreference.
Mymanagementofduralpuncture
• placeintrathecalcatheter,nomorethan3cminintrathecalspace.
• Labelclearlythatit’sintrathecalandonlytobeusedbyAnaesthetist.
• Notifymidwife,patient,ObstetricTeamanddocumentplanforAnaesthetist
managementonlyclearly.
o MaynotbepracticalifnoAnaesthetistbackupsupportisavailable,butthis
isn’taissueinmyDepartment.
• Analgesia:1ml0.125%+2mcg/mlfentanylincrement,titratetoeffectcoverlevelof
sensoryblocktoaroundT10/L1
PDPHmanagement
• Multimodalanalgesia,hydration,bedrestbutbalancedwithriskofVTE.
• EBP:ifrequired,excludecontraindicationandobtaininformedconsentforpatient.
Generallyperformedaround48hours.
• OngoingF/Uforrecovery+phoneF/U.
Monitorforcomplication
• Meningitis,cerebralvascularevent,SDH/SAH,SOL.
• Considerobstetricdifferentialseg.PET.
NB:
• Prophybedrest,epidural/intrathecalIVfluid,epiduralbloodpatchnotuseful.
• PDPHseenin~60%ofcases;7-10days.
• curefrom1stEBPexpectedin50%ofpatients
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• 40%mayrequire2ndEBP
• checkCI:fever,sepsis,coagulopathy,patientrefusal
• performedaround48hrs
• 24-48hrshaslowersuccessrate,and<24evenlowersuccessrate
Q5–CVLinsertionavoidingtamponade,46%
InsertionofCVLmayresultincardiactamponade.A.howwouldyourecognizethiscomplication?(50%)b.howcouldyouminimizetheriskofthiscomplication?(50%)
Recognitionofproblem–Hx,exam,invx
• Hx–SOB,presyncope.
• Exam–
o tachycardia,hypotension,raisedJVP,muffledheartsound.
o respdistress,pulmoedema.
o DecreasedGCS
• Invx
o Echo:toassesspericardialeffusion
o ECG:reducedvoltage
o CXR:pneumomediastinum,widenedcardiacborder
o Signsofend-organfailure:renalfailure,worseningacidaemia.
Riskminimization
• Insertion:
o Measure/Estimatedepthofinsertion
o USSguided
o Avoidforcefulanddeepinsertionofguidewire,dilator,line.
o Securelinewithsuturefirmly,at2points
• Post-insertion
o CXRtocheckposition,tipofCVLshouldnotlieinsidethepericardial
reflection.
o IdeallyjustoutsideofRHBonCXR,or~atlevelof<2cmbelowcarina.
o Tipshouldbeparalleltovesselwall,notdiggingintowalltocauseerosion.
Q6–HighICPanaesthesiamanagement,59%
A50-year-oldpatientpresentsforurgentcraniotomyanddecompressionofasubduralhaematoma.Twodaysagohewaswell,butnowhasaGlasgowComaScalescoreof11.Heiscombativeandhaspulledouthisintravenousline.Oninspectiontherearenoobviousveinsforcannulation.a.Listtheoptionsavailableforinductionandintubation.(30%)b.Describeandjustifyyourpreferredapproach.(70%)
Listoptions• Gasinductionwithsevo
• IMketaminethenIVinduction
• IMmidazolamthenIVinduction
• IOinductionthenIV
Aim=
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• Quick/smooth/stableinductiontofacilitatecareandpatient/staffsafety
o MinimizeICPriseandfacilitateneuroprotection
• MaintenanceofoxygenationandadequateMAPandCPP
• EstablishIVtimelytocontinuewithanaesthesia
MyapproachinOT=GasinductionwithO2,Sevo,thenestablishIVforongoingTIVA.• RapidonsetandallowsSVtechnique+assistedventilationtominimizerisein
CO2/ICP.
• Sevo<1MACrelativelymaintainscerebralautoregulation.
o Mayprovideneuroprotectionthroughdecreasedmetabolism.
o Adjustmentofsevoiseasy.cs
• ImprovesIVaccesssuccessratewithvasodilation
• OnceIVestablished,I’duseremi/propofol/rocuroniumtoobtundairwayreflexwhile
intubatepatient.Phenylephrinentobalancehypotensiveeffectfrompropofol/remi.
• SevothenstoppedandTIVAcontinuedforrestofsurgery.
Q7–visuallosscomplication,62%
Fourhoursaftermulti-levellaminectomywithinstrumentation,patientcomplainsofunilateralvisualloss.A.whatisyourdifferentialdiagnosis?(40%)b.howcanyouminimizetheriskofvisualcomplicationsinthepronepatient?(60%).Differentials
• intraocularproblem–bleed,retinaldetachmentetc.
• Vasculature:Artery-centralretinalarteryocclusion
o fromeyecompressionduringprone
o atherosclerosis/thromboembolicdisease
o ischaemia/hypoperfusion/anaemia
• Nerve–Ischaemicopticneuropathy
o Ischaemia/hypoperfusiontonerve
o Asscwithdiabetes,lengthyoperation
• CNSevent–CVA/TIA,cerebraltumour
• Postopconfusion–POCD,delirium,sepsis
Riskminimization• Preop
o Optimizepremorbidcondition:diabetes,HTN,hyperlipidaemia,glaucoma,
treatment,anaemiaetc.
• Intra
o Optimalpositionofheadandprotectionofeye;ensureadequatehead
support
o Regularchecksintraop
o MaintainOcularperfusionpressure,ensureadequateMAP+venousdrainage
+avoidriseinIOP.AvoidprolongedTrendelenburg.
o Ensureadequateoxygenation+avoidanaemia.
o Avoidhypoxaemia,acidosisandexcessivehypercapnoea.
• Postop:
o continuedmaintenanceofvitalsigns+oxygendeliverymechanism.
o Vigilance+earlyrecognitionofproblem.
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Q8-URTIpaediatric,76%
Achildwithactiveupperrespiratorytractinfectionpresentsforgeneralanaesthesia.
a.Outlinethefactorsthatincreasetherateofadverserespiratoryeventsduring
anaesthesia.(50%)
b.Howcanyoureducetheriskofanadverseeventoccurring?(50%)
RiskfactorsforrespAE
• Patient:
o URTIsyndrome:fever,purulentnasalcongestion/coryza,productivesputum,
sys.Unwell,wheeze,LRTI
o Age<5yo;esp<1yo;hxofprematurity,reactiveairwaydx,snoring,passive
smoking.
• Anaesthetic
o Airway:ETT>LMA>FM
o Drug:(decreasingrisk)thio>halo>iso/des>sevo>propofol;
§ ResidualNMB
• Surgical
o Involveairway:ENT,bronchoscopy,laryngoscopy
§ Orcausebloodinairway:nasalsurgery,tonsil,adenoids.
o Otherhighrisk:cardiac,upperabdo,eyesurgeries.
Riskminimisation
• Preo:
o Thoroughriskassessmentandifmultipleriskfactorspresent,considerdelay
surgeryby2-4weeks.(unlessSurgeryindicatedtosourcecontrolinfection,
eg.recurrenttonsillitis,sinusitis)
o Considersalbutamolnebpremedespwreactiveairwaydx
• Intraop
o Avoidairwayinstrumentationifpossible
o ConsiderTIVAwithpropofol
o ConsiderlignocainespraytocordsofIVbolusduringintubation/extubation,
whichMAYreduceairwayAE.
o Dryairwaywithsuctionofbloodbeforeextubation
o Closemonitorforlaryngospasm/bronchospasm.
• Postop
o Closemonitorforlaryngospasm/bronchospasm.
NB.
• Consensus:nolongermandatorytopostpone6weeks;atleast2weeksprobably
goodenough
• inconclusion:Blanketcancellationishistorical,currentliteraturesupports
individualisedselectivedecisions.
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Q9–ALI,26%
Youarecalledtoanaesthetizea70yomanwithperforatedbowelforlaparotomy,3dayspostcolonoscopy.Outlinemeasureyou’lltaketoreducethelikelihoodofpatientdevelopingacutelunginjury
Aim:
• Sourcecontrolofinsult–sepsis,SIRSfrombowelperforation
• Preventionofsecondaryinsult–aspiration,pulmonaryoedema,barotrauma,
volumtrauma,atelectotrauma.(pressure,volume,fluid,collapse,chemical)
Pre• Establishcurrentstatus,comorbidities
o Specificallylookingforpreexistinglundisease,smokinghx,useof
inhalers/steroids,pulmonaryoedema,pneumonia,lungcollapse,or
respiratoryfailureonbloodgas.
• andoptimizewherepossibleinthelimitedtimeavailable
o salbutamolnebulizer
o antibioticuse,tocoverintraabdosepsisandpotentialpneumonia
Intra• RSItoavoidaspiration
• Lungprotectiveventilationstrategies:PEEP5-10,TV6ml/kg,avoidhighPeakP,
recuirtmentasrequired.
• Meticulousfluidmanagement–usearteriallinetomonitorhaemodynamicsand
consideruseofSVVtoguidevolumestatus.
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o DefendMAP(~65-70mmHg)usingsmallbolusoffluid+vasopressor/inotrope
asrequired.
• Considerbloodproductasrequiredforcorrectionofexcessivebleedcausing
anaemia.Avoidover-transfusiontoreduceriskofTRALI.
Postop• Extubationconsiderationfactoringinoxygen/ventilatorysupportrequirement,
haemodynamicstatusand?openabdomenrequiringsurgeryinnearfuture.
• needICU/HDUlevelcareaftermajoremergencysurgeryforpotentiallyfrail,highrisk
patient
• meticulousfluidmanagement,maintainingeuvolaemiaascloseaspossible.
• Analgesiatoenablechestphysio,mobility,incentivespirometry
Q10-buprenorphinepatch,33%
A70-year-oldpatientwearingatransdermalbuprenorphineslowreleasepatch(Norspan®)
(5μg/h)presentsforkneearthroscopy.
a.Describethemechanismofactionandpharmacokineticprofileofthispatch.(50%)
b.Whataretheimplicationsforperioperativepainmanagement?(50%)
MoA:buprenorphikne=opioidagonist–appearstohavefullagonismforanalgesiabutlesswith
respdep,constipation.
o ~60xmorepotentthanmorphine.
o Highaffinitytoopioidreceptor,anddissociateslowlyaccountinglongdurationof
analgesia.
o Duetolesskappa-receptorbinding,there’slesspsychomimetic/dysphoriceffect
PharmKofbuprenorphinepatchmcg/ho Absorbedviaskin,bypass1
stpassmet.Highbioavailability.
o 72hourstoreachpeakconcentration;patchlastsfor1week.
o Lipidsoluble.
o HepaticmetabolismCYP4503A4.
o T1/2beta~12hours
o Noactivemetabolite.Goodforpatientswithrenalfailure.
Implicationforperioppainmxo Issues:likelyhavechronicpainwithdifficultperioppainmanagement
§ Willrequirehigheropioidamountduetotolerance
§ Buprenorphinehoweverwillcompetewithotheropioidagonists,and
hasslowoffsetduetolongt1/2beta.
§ Needtoavoidwithdrawal.
o Managementwillencompass:
§ Indication–painhistory
§ Effect
§ Othertreatment?
§ Goalsetting
§ Patientassessmentre:indicationofbuprenorphinepatch,itsdose
historyandeffectfromit.
• Anyotheranalgesia?
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• Levelofpain?Poorpaincontrolleadstopoorpostoppain.
• Psychosocialissues?
• Exploreexpectationandestablishcommongoalforanalgesia–
tobaselinepainlevelorminimalincreasemanagedby
multimodalanalgesia.
§ Analgesiastrategies:
• Continuelongtermregularopioidiebuprenorphinepatch–
(carenottoapplydirectheatoverpatchascouldeffect
absorptionleadingtotoxicity)
• Multimodalanalgesia+RA.
o Expectminimaleffectwithadditionalopioid(untilday
3afterbuprenorphinecleared)–andlargedoseis
likelyrequired.
o Hence,Considerketamineinfusion,clonidine,
gabapentintoopioidspare.
• Closemonitorforpainassessmentandtitrateanalgesia.
• APMSinvolvement+PainSpecialistinput.
Q11-qualityassurance,57%
a.Definequalityassurance.(30%)
b.HowwouldyoudesignandimplementaQualityImprovementprogrammetoassess
patientsatisfactionwiththepreoperativevisit?(70%)
ANZACPDonQualityAssurance
QA=• An organized process that assesses and evaluates health services to improve practice or
quality of care • Objectiveistoensurethathighstandardsofclinicalpracticearemaintainedthrough
regularassessments.Theresultsofsuchassessmentsshouldbeevaluatedand
actionedasnecessary.
QAprogrammeimplementationPlanning
- careful design and preparation - defining topic to be evaluated patient satisfaction, which would cover:
• Communication, efficiency, anxiety alleviation, informed consent, conduct/risk explanation etc.
- data to be collected • Target population, questionnaire, anonymous/confidentiality, independent surveyor +
analyser. - methods to collect and analyse data Implementation
Involves: - Collection and analysis of the data - Review of results - Determining action to be taken
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in order to: - Monitor and evaluate quality and appropriateness of patient care - Identification of areas of deficiency or risk - Implement and monitor of changes where necessary Review ie reaudit
- Monitoring of the outcome of changes introduced from implementation with further survey in future “closing the loop”;
Setting standards
- Writing the improvements achieved into new official regulations, guidelines or standards Resources
- QA coordinator for each anaesthetic department - Sufficient rersources of people, time and support should be available for all anaesthetists and trainees to participate fully in QA programs
Q12-regionalfortibialplateaufracture,73%
a.Whichperipheralnerve/sneedtobeblockedforcompleteanalgesiafollowingrepairofa
tibialplateaufracture?(30%)
b.Describeyourtechniqueforblockadeofthesenerve/s(EXCLUDINGcentralneuraxial
blockade).(70%)
Needtoblock:femoral/saphenous/commoperoneal/tibial
CALM,SOBER,PLANS,ACTIONS
-Sedation,o2,blocktroly,knowwhereequipmentisforresus.
-PLANS-probe,local,additives,needle,stimulator
-Probe(5-12MHzHFLprobe);vs(2-5MHzcurvilinear),Local,Additives,Needle,Stimulator
(optional)
-Actions-arrange,clean,timeout,image,optimise,notevulnerable,surround
FemoralUSS:
locateimage,nerveunderneathfascialata&iliacus.aspirate,injectensurelowresistance.
infiltrate0.75%ropivacaine,10-15mlsforsurgicalanaesthesia
PoplitealfossaUSS:
-lateral,linearhighfrequencyprobe,0.75%rop,10-15mls.(watchformaximalsafedose
~30mlof0.75%ropin70kgpt)
-popfossaup,identifytibialartery,oftensuperficialandlateraltoartery.
ConsiderCathters.
USS:increaselandmarkidentificationandreduceriskofIVinjection
Q13-hypernatreaemiamanagement,40%
A50-year-oldmanpresentswithconfusionandthefollowingelectrolyteprofile:Na+155
mmol/l,
K+4mmol/l
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HCO3−15mmol/l
Creatinine120μmol/lHb200g/l
a.Whatarethepossiblecausesofthisabnormality?(30%)
b.Howcantheybedistinguished?(70%)
Causes=
waterdepletionorexcessofsolute-notenoughwaterin:
nowater,
disruptedosmoreceptor,
motordysfunction
-hypotonicfluidloss:
DI(renal/central);
diuresis(postobstruction,drug,diureticphaseofATN);
Nonrenalfluidloss:GI,skin,lungs,dialysis
toomuchsolute:toomuchNa,seadrowning,Connsyndrome/Cushings.
Distinguishingcauses(report)B.
Howthesemaybedistinguishedonthebasisof
- history(drinking/thirstresponse/fluidloss/trauma/infection/intracerebralpathology
pathology)
- examination(volumestatus,vitalsigns)
- investigations/imagingandmonitoring
- responsetoADH/DDAVP
NB.
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Txcause;correctslowly48hrs,freewaterPO,orD5W;txDIwdesmopression1-4mcg
SCIMIVdaily.
Q14-MImanagement,39%
A70-year-oldmanhasundergoneradicalprostatectomyundergeneralanaesthesia.On
emergencehehascrushingcentralchestpain,isrestless,andhascold,clammyskin.His
bloodpressureis90/50mmHg,pulserate110/minuteandSpO2is95%onoxygenviaa
Hudsonmask.
Atwelve-leadECGshowswidespreadSTsegmentelevationacrosstheanteriorchestleads.
a.Describeyourimmediatemanagement.(50%)
b.Whatarethetreatmentprioritiesforthispatient?(50%)
Immediatemx.RecognisingacuteperiopSTEMIprobably
Helpimmediately+simultaneouslymanagepatient
Monitor–ANZCA+continuousECG+12leadECGrepeats;sendbloods.
ABCDEapproach
o optimizeoxygenation–FiO2100%,Hb>80g/L,euvolemic,haemostasis.
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o Minimizecardiacworkload–cautioususeofvasopressortomaintainMAP.Consider
esmololtocontroltachycardiaifitworsensietopersistently>120bpm.
o Analgesia.
o GTN.
o D:aspirinloading.
ImmediateCardiologyconsult+considerurgentPCI.
NotifySurgicalTeam.
CCU/ICU
Priorities:o Immeidateasabove
o Revascularisation
o Thrombolysiscontraindicated;howeverurgentPCI+MDTdiscussionon
managementoption/DAPT.
o Subsequentcare:optimizemedicaltherapy:ACEi,BB,aspirin;riskofbleedwith
DAPTneedstobecarefullyconsideredbyMDT.
o Useofunfractionatedheparinwithclosemonitor+optionforreversalmay
beareasonableapproach.
Q15–VTEprophylaxis(repeat),30%
Explainyourapproachtothromboprophylaxisinthepatientundergoingtotalkneereplacement.See2015AQ12.
April-2011,32%
Q1-dexamethasonediscussion,90%
(a)Whatistheroleofdexamethasoneinthemanagementofpostoperativenauseaand
vomiting?(70%)
(b)Whatarethepotentialproblemsassociatedwithitsuse?(30%)
Dex=steroidwithonlyglucocorticoidactivity.
RoleinPONV–provenefficacyPONVprophylaxis,andhaslongdurationofaction.
• MoA=unknown,butmultipletheories:
o Centralinhibitionofprostaglandinsynthesis
• Dose0.15mg/kg–IV/PO;or4mginadult.NoadvantagewithhigherdoseforPONV.
• Givenatinduction.
• NNT=3.7=similartoondansetron/droperidol;additiveeffectifusedtogetheras
multi-modalantiemetics.
• Alsoanti-inflameffect,improvesfatigue.
• PharmK:IV,penetratesintotissue/CSF,primarymetabolismbyliver,inactive
metaboliteexcretedinurine.
Problems?
• Peri-analburningsensationonadministration
• HyperglycaemiaespinDM-?impairedwoundhealing,infectivecomplication?
o controversial
• Adrenalsuppressionwithlongtermuse
• Singleusegenerallyconsideredsafewithregardto:
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o Osteoporosis,Cushing’ssyndrome–muscularweakness,PUD,skinfragility,
Q2-pulmonaryfibrosisdiscussion,46%
Apatientwithknownidiopathicpulmonaryfibrosis(fibrosingalveolitis)presentsforan
openrighthemicolectomy.
(a)Whataretherespiratoryissuesfacingthispatientwithregardtotheirgeneral
anaesthetic?(70%)
(b)Explainyourintraoperativeventilationstrategy.(30%)
(report)
A
• establishmentofdiseaseseverity/useofoxygen
• sequelaeofthedisease(pulmonaryhypertension/infection)
• effectandside-effectsoftreatments(steroids/azathioprine)
• factorsrelatingtoabdominalsurgeryandtheirimpactonthisrespiratory
- disease(GAandmusclerelaxation/fluidshifts)
- impactofdiseaseonrespiratorysystemphysiology(lungvolumes/V-Q
mismatch/ventilationpressures/riskofbarotrauma
- postoperativeimplicationsofdisease(patientdisposal/respiratoryfailure
potential/impactofanalgesicregimens)
B
- tidalvolumes(targetranges)
- anticipatedventilatorypressures
- I/Eratios
- useofPEEP
- FiO2adjustment
Q3-professionalattributesofananaesthetist,26%
Explaintheprofessionalattributesofananaesthetistinspecialistpractice.
Healthadvocateo Maintainspersonalhealth,well-being.
o Identifyandrespondstohealthneedsofpatients,families,carersandcommunities
Professionalo Demonstratescommitmenttopatients,communityandprofessionthroughethical
andlegalpracticeofanaesthesia
§ Adherestoethicalpriniples–autonomy,beneficence,non-
malevolence,justice.
o UnderstandsandalignpracticewithANZCAprofessionalismguidelines.
o Practisewithintegrity,honestyandcompassion.
Communicatoro Helpspatients,families,otherclinicalstafftoachievegoodunderstandingof
conduct,benefit,risks,alternatives,ofanyproposedmedicaltreatment;inorderto
facilitateprovisionofhighqualityhealthcare.
o Developrapportandtrustwithpatient.
Medicalexperto Achievesexcelleneinclinicalcare
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o Recognizethatpatientsafetyisparamount
o recognizespersonallimitationandseekhelpwhereappropriate
Scholarandteachero Demonstrateslifelongcommitmenttoreflectivelearning,andcreation,
dissemination,applicationofmedicalknowledge.
o Criticallyevaluateresearchresultstoensureaccuratetranslationandapplicationto
appropriateclinicalenvironment
Collaboratoro RecognisandpractiseasamemberwithinaMDT
o MutualrespectforcolleaguesandmembersfromMDT;includingwithtrainees.
o AbletofacilitatetaskdelegationortakeontaskfromaTeamLeader.
Managero Managespersonal,departmentalissuesandclinicalpracticeeffectively
o Allocatesandusehealth-careresourcesfairly,matchingresourcetoareasof
demand.
NB.
Acronym=HealthProfessionalismCanMaintainStellarClinicalManner(7)
Codeofconduct=values/behavioursdevelopedandacceptedbymedicalprofession;in
generalincludehonesty,patience,integrity,diligence,respectfulness,professionalism
(includingconfidentiality),compassion,cooperation,toleranceandhumility,commitmentto
4principlesofbiomedicalethics(autonomy,justice,beneficience,non-malificience)and
otherdesirablevirtures
Q4-albumindiscussion,11%
Evaluatetheuseofhumanalbumininperioperativevolumereplacement.
Albumin
• 4%(isoosmolar),20%(hyperosmolar),65kDanotpermeablethroughendothelium
• containsNaCl~140mmol+smallamountK
• preppedfromhumanplasmapasteurizedat60degfor10hourstodeactivate
microorganisms.
Action:
• givenIV,staysmuchlongerthancrystalloidsinIVspaceduetocolloiod;t1/2~16
hours;getsdistributedwithECF.
• Increaseserumalbuminlevel.
• 20%albuminalsodrawsISF/ICFintoIVFtoincraseIVvolume.
Pros
• effectivevolumeexpanderwithlongerlastingeffectthancrystalloid
• lessperipheraloedema,pulmoedema,overallfluidrequirement
• verylowinfectionrisk
• increaseserumalbumin
Cons
• expensive,limitedresource,riskofallergy/anaphylaxis.
• Ifpatienthasleakycapillaryegsepsis,albuminleaksintoISFanddrawsfluidout
fromIVFàworsensoedema.
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• SAFEshowednodifferenceinoutcomeinICUpatients(salinevs.albumin)+worsens
outcomeinTBI.
Q5-post-LSCSnumbness,77%
a.howwouldyouclinicallyassessapatientc/olegnumbnessdayafterspinalforEMCS(70%)b.howwouldyoumanagethesituation?(30%)
Differentialsforlegnumbness
• Cerebralvascularevent–CVA/TIA,meningitis
• Spinalcordinjury–needle,abscess,haematoma
• Lumbosacralnervedamage
• Peripheralnerve-femoral/commonperonealnervedamagefromlithotomy
• Meralgiaparaesthetica
• Ongoingdrugeffect?–unlikelythedayafter.
Clinicallyassess
• Hx
o Onsetofsymptom,progression?Association?
§ Redflags??Rapidlyworsenedsymptom=worrying;esp.ifc/oalso
weakness,caudaequinesyndromewithperianalparesthesia,
urinary/bowelincontinence.
§ Backpain?Fever?Headache?Otherneurologicaldeficit?
o Reivewanaestheticrecord,traumaticneuraxial?Difficult,pain/paresthesia
duringinsertion,breachofepiduralvein?
o Labourhistory–prolongedobstructedlabour?ProlongedEMCS?
o Riskfactors:DM,preexistingperipheralvasculardx,meralgiaparesthetica,
previousTIA/CVA,localizedinfection,systemicsepsis,coagulopathy?
• Exam
o Neruoexam–CrN+peripheralN.
§ DistributionofnumbnessfollowperipheralNvs.lumbosacralplexus
vs.radiculopathy?
o Signsofsepsis?Tachycardia,fever,hypotension
o Spinalinsertionsite?Swelling,bruise?
• Invx:leukocytosis,inflamemarkers+imagingifredflagpresentieCVAorepidural
abscess/haematoma.
Managementdependsondiagnosis.
• Ifredflagsabsentandpurelysensorycomplaintfollowingperipheralorlumbosacral
plexusdistributionàreassureprobabletransientnature+ongoingreviewfor
symptomrecovery.
o Ifsymptompersists/worsensaftereg.2weeks,consultNeurologyandnerve
conductionstudywithongoingfollowup.PT/OTreview.
• Ifredflagpresent:needurgentCT/MRI,Neurosurgicalconsultforurgentsurgical
evacuation(shouldtakeplace<8hoursofsymptomonset)+antibiotic.Patient
needscarefulconsultationforperceivedprognosisandcloseMDTinput(PT/OT).
• Documentationofassessmentandmanagementthoroughly.Consultofmedicolegal
teamforadviceshouldpatientcomplainthappens.
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Q6-VFmanagement(repeat),55%
A60-year-oldmanisbookedforplatingofafracturedankle.Hearrestsoninduction.His
ECGshowsventricularfibrillation.
Outlinetheimmediatemanagementofhiscardiacarrestwithparticularreferenceto
currentresuscitationguidelines.
VFcardiacarrestisamedicalemergency!
Immediatemxshouldbe:
§ NotifyOT
§ Callforhelpandgetdefib,resustrolley
§ FollowACLSprinciple–DRSABCàcommenceCPRimmediatelywhileawaitingfor
defibtobegiven
§ A:keepairwaypatentwithjawthrust,chinlift;turnanaestheticoff.Primaryaimin
initialresus=defib+CPR;andintubationshouldn’tdelaythese.Onceresources
freesup,shouldconsiderintubationespifprolongedresusanticipated+protect
airwayfromaspiration.
§ B:FiO2100%;
§ C:CPR30:2ratio,100compress/min,atleast5cmdeep;(ratiocontinuesuntilETTin
place,afterwhich=continuouscompression+ventilation).
o Defibshouldbegivenwithoutdelay:biphasic,200J,unsynchronizedshock,
followedbyCPRfor2mins.
o 2minslaterreassessforrhythmandROSC,ifstillVFàdefibwith200Jthen
continueCPR+giveadrenaline(after2ndshock)1mgIV
§ Drugs:adrenalineafter2ndshock+every2
ndcycleof2minsCPR/assessment.
o Amiodaroine5mg/kgor300mggivenafter3rdshock.
§ Canconsiderlignocaine1-1.5mg/kgtheninfusion1mg/kg/hr
§ HCO3ifhyperK.
§ Applymonitors:whenpossible–ECG,pulseox,NIBP.
§ Otheradvancedadjunctonceresourcefreesup=arterialline,CVL.
§ Considerdifferentialsandtreatsource:4H+4T.
§ Post-resuscare=ICUforfurthermonitor/management+considerationofTTM
NB.
Considertargetedtemperaturemanagement
§ Postcardiacarrest(anycause)
§ ROSC<30minsfromteamarrival
§ Time<6hoursfromROSC
§ Patientiscomatose
§ MAP>=65mmHg
TTM-Contraindications
o AdvanceddirectivestipulatingDNR(absolute)
o Traumaticarrest
o Activebleeding(includingintracranial)
o Pregnancy,recentmajorsurgery,severesepsis
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Q7–VAEmanagement,53%
Apatientisscheduledforposteriorfossasurgeryinthesittingposition.(a)Outlinetheprecautionsyouwouldtaketominimisetheriskofvenousairembolism.(70%)(b)Howwouldyourecogniseanairembolismintraoperatively?(30%)VAERiskminimization
• AvoidsittingpositionifotherpositionispossibleforSurgeon
o Avoidexcessiveheadelevation
• Maintainpositivepressureatsurgicalsite+Maintaincerebralvenouspressureo Maintaineuivolaemiao UsePEEP(howeverbalancedwriskofparadoxicalairembolismifPFOis
suspected)o Vigilanceofbloodlossandvolumereplaceasindicated.o MonitorCVPo SCDs/TEDStofacilitatelowerlimbvenousreturno ConsiderJVcompressiontotemporarilyincreasevenousP.
• Minimiseairentrysiteo Bonewaxingbysurgeono Venousbleedcauterisedo Poursalineintofieldiflargeopenvenoussystemseen
• Monitortoallowearlydetectiono Artline,CVP,EtCO2o ConsideradvancedtechniquesuchasTOE,transcranialdopploer
• AlsoavoidN2O
VAEdetectiono Clinical:suddendropinEtCO2,riseinCVP,dropinMAP,arrhythmia,tachycardia
o Precordialstethoscope/Doppler–millwheelmurmur,poorsensitivity;butwidely
available.
o TOE/Doppler–mostsensitive,allowsquatitativemeasure,andassessPFO.
o TranscranialDoppler–noninvasivebutnotverysensitive.
NB.
Mx=salienflood,compression,position,suckfromCVL,fluids,avoidincreasePVR,100%
O2,rightsideup.
Q8-cricothyroidotomydiscussion,55%
(a)Describetheanatomy,includingsurfacelandmarks,relevanttoperforming
cricothyroidotomy.(50%)
(b)Whatarethecomplicationsofthisprocedure?(50%)
Cricothyroidotomy=gainingaccesstoairwayviaopeningofcricothyroidmembrane.
Anatomy
o Trapezoidshape
o Borderedby
o thyroidcartilagesuperiorly
o cricoidcartilageinferiorly(C6level)
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o cricothyroidiusmuscleslateraly
o superficially:skin,subcutaneoustissue,fascia
o Otherstructures:
o Cricothyroidartery(branchofexteralcarotidA)approachingcricothyroid
membranefromeithersideandruninupperthirdofmembrane.
o Vocalcordsliewithinthyroidcartilageabovecricothyroidmembrane
o Oesophagusdeeptothemembrane/trachea
o Performingcricothyroidotomy
o Locatethyroidcartilage(laryngealprominence),identifyinferiorborderand
cricoid,identifyspaceinbetween=cricothyroidmembrane.
o Midlineaccesstoavoidbreachingarterylaterally(with14Gneedle/cannula
orno20scalpel-horizontalincisionthroughskintillcricothyroidmembrane
incised,thenbluntdissect).
Complicationofcricothyroidotomy
o BleedespifcricothroidAbreached.
o Infection
o Desaturationduringinsertion
o Subglotticstenosis
o Creationoffalselumenandsequelaeàairwayobstruction,SCemphysema,
pneumothorax,pneumomediastinus(report)
o Injurytosurroundingstructures:
o Thyroid,vocalcord,oesophagus
Q9-paediatricmurmurdiscussion(repeat),67%
Youhearacardiacmurmurinatwo-year-oldchildpresentingforelectiveminorsurgery.(a)Whatarethefeaturesofthemurmurthatwoulddifferentiateaninnocentfromapathologicalmurmur?(50%)(b)Howwouldyouevaluatethischild’sfitnessforanaesthesiafromthecardiacperspective?(50%)
Riskfeaturesofmurmur• Innocent
o Soft,<2/6,earlySM,variationwposture,
o Eg.venoushum–softcontinuousmurmur,louderstandingquieterlying–
diminisheswithpressureofjugularvein;(=largeCBF(20%)àlargejugular
venousBFàvesselwallvibration)
§ vibratorymurmur–smallchestwall,
§ pulmflowmurmur–turbulentflowacrossrelativelyunderdeveloped
branchofPAswvigorousheartbeat–genresolveby6/12(Auckland)
§ carotidbruit=commoninkidsduetolargeCBF.
• Pathological
o Highgrade3-6/6,thrill,harshsound,novariabtionwposture,diastolic
murmur
o Eg.VSD–PSM;PDA–machinerycontinuousmurmur
Evaluationpreop• Hx
o Failuretothrive?
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o Activitylevelandanylimitation?Cyanoticepisodewithfeeding,exercise,
cry?Dyspnea/Orthopnoea/PND/syncope?
o KnownwithCHD?Congentialsyndromeeg.Down?
o Previousanaestheticproblem?
• Exm
o Syndromic?
o Pulse:bounding(PDA),rad-femdelay?(coarctation)
o Cyanosis/Clubbing?Wcyanoticlesion
o Peripheral/centralperfusion,CRT?
o IncreasedWOB?Recurrentbronchiolitis/wheeze?(Auckland)
o Praecordium:
§ Apexdisplaced?
§ Murmurfeature?–grade,thrill,diastolic?Gallop?
§ Pulmoedema/peripheraloedema?
• Invx
o Echo?ECG?
o FBC–polycythaemia?
o UECr–renalfunctions?
Summary:ifchildisasymptomatic,isnormallyactive,isgrowingwellwithnoredflagexam
findings,thenmaycontinuewsurgery.VigilancewithpreventingVAEascouldstillhave
smallASD/VSD.Otherwise,MDTapproachwithPaedsCardiologist/Surgeon.
NB.
context:innocentmurmursoccurinupto70%ofyoungerchildren
CXRas1stlineinvxisuseful(Aucklandcourse);ECGnotsomuch.
Q10-AKIdiscussion,52%
(a)Whatfactorscontributetoacutekidneyinjuryintheperioperativeperiod?(70%)
(b)Outlinetheefficacyofperioperativestrategiestoreduceacutekidneyinjury.
(30%)
ReadChang’s
(report)
Part(a)
• RIFLEcriteria
• nephrotoxins(withexamples)
• surgicalrisk:typesandrelevantdetail
• patientrisk:age/pre-existingrenaldysfunctionandco-morbidities
• anaesthesiafactorse.g.hypotension
• postoperative:e.g.hypotension/sepsis
Part(b)
• identificationofpatientat/situationofrisk
• maintenanceofperioperativerenalperfusionandoxygen
• delivery/monitoring
• avoidanceofnephrotoxins
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• evaluationofroleofdopaminergicagents/mannitol/diuretics
Q11-Codeinediscussion,50%
(a)Describetheclinicalpharmacologyofcodeineincludinganoutlineofitstherapeuticuse.
(70%)
(b)Describetheinfluenceofpharmacogeneticsonthevariabilityofpatientresponseto
codeine.(30%)
Codeine=prodrug,metabolizedtobeactive;30-60mgtds/qid.
• POform.NoIV.
• AbsorbedinGIT.LargeVd.4L/kg.Meb.ByCYP2D6intovariousmetabolites.T1/2
~6hours.ff
o C-6-glucuronide(inactive)
o Morphine(10%)=analgesiaàM3G(neuroexcitatoryeffect–seizure,
hallucination,agitation+M6G(analgesic,butaccumulateinrenalfailure)
o Potentialforaccumjlationinrenalfailure
• PharmD–opioidreceptor.Analgesia,antitussive,treatmentofdiarrhea/high
ileostomyoutput.;SE–NV,ileus/constipation,sedation,itch,retention,allergy.
• B.
o CYP2D6exhibitsgeneticvariability(10%Caucasian,2%AsianlacksCYP2D6)
andcodeineisnoteffective.
o Someareultra-rapidmetabolisers(MiddleEastern,NorthAfrican)àhigh
serummorphineconc+increasedefficacybutalsoriskoftoxicity.
Q12–residualNMBcomplication/assessment,55%
a.whatarethecomplicationsasscwithresidualneuromuscularblockade?(30%);b.evaluatethemethodsavailabletoassessresidualneuromuscularblockade?(70%).
Complications
• Airway:unabletoprotect
o Obstruction+aspiration
• Ventilation:inadequate
o Hypoxaemia,metabolicacidosis
o Hypercapnoea,respacidosis,CO2narcosis,SNSstimulationandincreased
cardiacstress
o Atelectasisandriskofpneumonia
• Awarenessofweakness
o Anxiety,distress,PTSD,patientinsatisfaction.
• Environmental
o LongerstayinPACU
Assessmentmethods.
• Clinical(crudemethod,notobjective/accurateenough)
o Headliftfor5sec
o Handgrip
o Deepbreath
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• Neuromuscularstimulator
o TOF(=4twitches,2Hzover2sec,supramaximalcurrent)
§ TwitchheightT4/T1ratioanalysedbyaccelerometerandratio>0.9
indicateadequatereversal.
§ If<0.9,needsappropriatereversalagent
§ Visual,tactileassessmentinaccurate.
o DBS(=2burstsoftetanicstimulationof3twitcheseach,750msapart)
§ T2/T1ratiomeasuredusingaccelerometerequallyreliableasTOFR
§ TactileassessmentbetterthanTOFusingtactile.
§ Morepainfulonawakepatient
o Tetanic(=sustainedstimulation50Hzfor5sec)
§ Lookforfade=residualblock.
§ Verypainfulandnotappropriateinawakepatient.
Q13-Systemipreventionofpowerfailure,35%
YouareinvolvedintheplanningofanewDaySurgeryUnit.(a)Whatsystemswouldyouputinplacetoreducethelikelihoodofapowerfailure?(50%)(b)Outlineaprotocolfordealingwithpowerfailures.(50%)
Reduceriskofpowerfailure• Designinclude2typesofpoweroutlet:
o Ordinary+
o Uninterruptedpowersupply(withbluefaceplates)=ordinaryoutlet+
connectiontoemergencypowersupplywhichactivatesiforindarypower
supplyfails
§ NOTE:red=Mainpowerbutwithdieselgeneratorbackup.
• Usedforcriticalequipments,eganaestheticmachines,
ventilator,infusionpumps,OTlights
• NeedtoknowdurationUPScansustainpowersupply
• Separatepowergeneratorwhenordinarypowerfails
• Internalbackupbatteries–foressentialequipments:machines,ventilator,
pumps.
o +knowledgeofitsduration/reliability
• ImmediateaccesstoEletricalcompany,electriciansforhighpriorityproblem
solving/restorationofpowersupply.
Protocolofmanagement• Generalinfrastructure
o Protocolkeptatfrontdesk,manager’soffice,insideemergencymanagement
protocolinallOTs,withflashlights
o Emergencymanagementcoordinatordesignation
o designatedlinesofcommunicationwithallareas(OT,coordinator,power
company,electrician)regardingtheevolution/resolutionofthepowerfailure
• OTenvironment
o Protocolforcontinuationorcancellationofsurgery–ifsafetycanbe
ensured.
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§ Ifcontinuationrequired,converttoUPSforvitalequipment+battery
poweredsurgicalequipments:diathermy,laser,drills.
o Aanaesthesia:anaestheticmanagementshouldaimtoconvertto
spontaneousventilation;considerbatterypoweredTIVA;knowledgeof
independentpowersupply/alternativestorunessentialequipment
§ Backupmanualmonitorsavailable:BP,BMV,intermittentbolusesof
drugs.
• Personnel
o educationforstaffregardingback-upcapabilitiesandessentialemergency
contacts
o intelligenceregardinginternalbatterysupply/UPSusageandavailable
supply
o
Q14-QTprolong,31%
(a)Describetheabnormalityonthiselectrocardiogram.(30%)(b)Whataretheimplicationsofthisabnormalityforanaesthesia?(70%)LongQT
Implicationso Issues:longQTcanleadtolifethreateningventriculararrhythmia(torsades,VF)if
furtherworsens
o WorseningoflongQTcanbecausedby(OHA)
o Drugs
• TCA,phenothiazine,antihistamine.
• Droperidol,ondansetron,volatileanaesthetics
o Hypothermia
o Increasedstressresponse,SNStone.
o IncreasedITP(Valsalva,excessivePEEP)
o Managementshouldbe:
o Preop:(OHA)
• CardiologyTeamconsult
• Commencebetablockade
• Ensurenormoelectrolytelevels,espMg.
• DiscontinuedursgthatprolongQTcifappropriate–
• Premedforanxiolysis
o Intraop:
• MonitorANZCA+artline.
• Resusequipment/drug(espMg)available;ifhighriskusehave
defibpadonbeforeinduction.
• AvoidsympathomemieticordrugsthatprolongQTcas
appropriate.
o BluntingofSNSstimulation(pain,laryngoscopy,
normocapnia).
• AvoidexcessivePEEP/Valsalva.
• Maintenanceofnormaltemperature.
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o Postop:ongoingmonitorofECG;considerHDU,telemetryforongoing
monitorespathighrisk(eg.suddencollapsehx,FHxofsuddendeath)
Q15-ANSneuropathyindiabetes(repeat),47%
(a)Howwouldyouidentifyapatientwithautonomicneuropathyassociatedwithdiabetes?(50%)(b)Whataretheanaestheticimplicationsfromacardiovascularperspective?(50%)Diagnosis
o ANSaffectsmultiplesystems:
o Hx
o Durationofdisease.
o Posturalhypotension?Presyncope,syncope,palpitation?
o GIgastroparesis,constipation,diarrhoea;erectiledysfunction,urinary
retention;excessivesweating?
o Knowncomplicationsofneuropathy?Previousanaestheticrecordofunstable
haemodynacmis?
o Exam
o Lying/standingBP.HR/tachy/bradyatrest?Valsalva?
o Peripheralneuropathy?
o Excessivediaphoresis.
ImplicationsfromCVSperspective.o Unstablehaemodynamics,esponinduction,withbleed,orlikelyexaggerated
responsetostimulationfromunopposedSNS.
§ MonitorwithArt-lineifpatient’sathighrisk;
§ MaintainadequateMAC-BrtobluntunopposedSNSresponse.
o RiskofsilentMI;henceneedvigilanceonmonitorofcardiacischaemiawith
continuousECG;use5-leadECGwithpatient’sathighriskeg.knownIHD,previous
MIs,PVD.
o Hypothermiariskfromimpairedvasomotoractivity/thermoregulation;riskof
subsequentcomplications–bleed,shock.
o Pharmacology:slowercirculationtimeformedicine.
Oct-2010,51.8%
Q1-hypothermiaconsequenceandmanagement,74.1%
(a)Whataretheclinicalconsequencesofhypothermiato340Cinadults?(50%)(b)Howcanyoumanagebodytemperatureinamulti-traumapatient?(50%)
Hypothermia=coretemp<35deg;hasmultisystemiceffect
Hypothermiaclinicalconsequenceo CVS
§ IncreasedSNStone:tachy,HTN,incO2demand,CBF;riskof
arrhythmia,heartblock,VT.JwaveonECG.
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§ Changesinregionalcirculation:vasoconstrictperipherally,splanchnic
BF.
o Resp
§ IncO2consumption,ventilatordrivetomeetdemand;increased
WOB.
§ Riskofbronchorrhea,bronchospasm.
o CNS:
§ Behavior-addingclothing,movingtoawarmerenvironmentetc
§ Possiblecerebralprotectionincertaincircumstances
o Haem:
§ Impairedimmune+plateletfunction+clottingfactors.
o MSK:
§ Shiver+increasedO2demand;difficultieswithmonitor;patient
discomfort.
o Immune:impairedwoundhealing,sepsis
o Pharm:altereddrugmetabolism(musclerelaxants)
Bodytempmanagementinmulti-traumapto Minimiseheatloss
§ Increaseambienttemp
§ Reduceunnecessaryexposure;coverwithwarmblanket/bairhugger
§ Ensurepatientisdry
o Activewarming
§ Heater,forcedairwarmer,warmblanket
§ Bladder/bodycavitylavagewithwarmsaline
o IVF+bloodthroughwarmer
o Warmed/humidifiedgasinventilation;useofHME.
Q2-Spinalcordbloodsupply;ischaemiariskminimization,67.6%
a)Describethearterialbloodsupplyofthespinalcord.(50%)(b)Whyisspinalcordfunctionatriskduringopenrepairofathoracicaorticaneurysmandwhatmeasuresareavailabletoreducethisrisk?(50%)Bloodsupply
- AnteriorspinalAo 2vertebralAàmergeatforamenmagnumàantspinalAo suppliesant2/3ofspinalcord
- PosteriorspinalAo VertebralAàPostinfcerebellarAàpostspinalAo 1oneachsideofpostcord;supplyingpost1/3ofcord
- RadicularAs(ofcervical,thoracic,iliacAs+Adamkiewicz)o Branchesfromaortatoaugmentmultiplelevelsofspinalarterieso (report)passviatheintervertebralforaminaalongnerverootswhichthey
supply.Mostofthesepairedsegmentalarteriesaresmall.
o Haslargebranch=AofAdamkiewiczfromlowthoraciclevelT9-T12in75%
population(althoughvariable,canhavehigher/lowertakeoffvariation)
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Duringrepairofthoracicaorticaneurysm,becauseofaorticclamp,radiculararteriesbelow
clampnolongeraugmentsspinalcordperfusionàriskofischaemia,espifAof
Adamkiewiczinvolved.
- Surgicalmanipulationalsomayàvasoconstriction,reducedSCbloodflow.
- Significantbloodloss,anaemia,CVSinstabilityfurthercompromisesSCperfusion
Ischaemiariskminimization(belowallfromreport)
- Minimizecordischaemiao Minimizeclamptime
o Optimizeperfusionpressure,SCPP=MAP–CSFPorSCVPwhicheveris
higher.
§ maintainMAP+considerplacelumbardraintolowerCSFpressure
(aim<10cmH2O)
o maintainsats>90%andHb>70g/L.
o LowerbodyCPBorreimplantationofsegmentalA,(ieshunt)
- Neuroprotectiono MildsystemichypothermiaorDHCA
o Epiduralcooling
o PharmmethodtodecreasemetabolicrequirementievolatileorIV
anaesthesia
- SCmonitoro Evokedpotentials–SSEPorMEP
Q3-chronicliverdisease/alcoholismdiscussion,71.2%
A45-year-oldmanwithalongstandinghistoryofalcoholismisbookedforuppergastrointestinalendoscopyandbandingofoesophagealvaricesfollowinganepisodeofhaematemesis.(a)Howistheseverityofthispatient’sliverdiseaseassessed?(50%)(b)Howdothesefindingsinfluenceyourevaluationofthispatient’sperioperativerisk?(50%)(report)
A
Inparticular,afocusedhistorythatincludespastcomplicationsandtreatmentsaswellasan
examinationelicitingsignsandsymptomsofchronicliverdisease,suchportalhypertension,
wereessentialinassessingtheseverityofthispatient’sliverdisease.Extramarkswere
awardedtocandidateswhoindicatedlookingforextra-hepaticsequelaeofadvancedliver
disease,suchashepatorenalandhepatopulmonarysyndromes.Ofparticularrelevancein
thispatientwouldbeevaluatingtheeffectsthatlongtermalcoholabuseandliverdisease
havehadonthepatient’scardiovascularsystem.
B
• CPorMELD:However,thesescoresareonlytoolstoserveaguidetotheseverityof
theliverdiseaseandinofthemselvesdonotdictatethepatient’sperioperativerisk.
• Markswerenotawardedfordescriptionsofanaestheticmanagementplans
Q4-suprglotticairwayobstructionmanagement,64.7%
A68-year-oldmaninhospitalawaitingdefinitivesurgeryforasupraglotticsquamouscellcarcinomaofthelarynxhasworseningstridoratrest.
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(a)Howmighthissymptomsbeimprovedinthepreoperativeperiod?(30%)(b)Describeyourevaluationofhisairwayandhowthiswillinfluenceyourintraoperativeairwaymanagementplan.(70%)Symptomimprovement
o Dexamethasone
o Adrenalinenebulizer
o Posturing:tripodposition
o CPAP,helioxortracheostomy
o Treatmentofinfectionifpresent
o Considerradiotherapy
Airwayassessment/managemento History–redflagsinclude:stridor,dyspnea,orthopnoea,dysphagia,hoarsevoice,
previousdocumenteddifficultywithairwayo Exam–routine/important:mouthopen,interincisordistance,MP,TMD,neck
movement,prognathism,?looseteeth,trachealdeviation?o Investigation
o NasoendoscopybyENT–assessforsize,extension,bleedofsupraglotticSC
ca.o CXR/CTneck/chest–airwaycompression?Deviation?Stageofcancer?In
lowerresptract?o MangementneedsMDTinput,andoptionsinclude:
o Awaketracheostomy–ifseveresupraglotticobstructionisseenmaking
intubationriskunacceptablyhigho AFOI/awakeVL:
§ Ifairwayobstructionisn’tsevereandETTcanbepassedthrough
cords;howeverblindpassageisdangerousthereforeAFOI/AIC
combinedwithVLvisualizationshouldbedone.§ ENTbackupforemergencytracheostomy
o AsleepSVtechniqueisasscwithhigherriskandonlyconsiderifawake
techniqueisimpossibleieuncooperative/agitatedpatient
Q5-Paediatricdehydration,fluidmanagement,65.5%
A6-month-oldboypresentswithanacuteabdomen.Heisdiagnosedwithintussusceptionandbookedforlaparotomyafterafailedattemptatreduction.Hisheartrateis160bpmandBPis75/45mmHg. Hiselectrolyteprofileisasshown:Na+132K+2.7Cl−106Urea3.3Creatinine86Lactate4.5mmol/l(a)Howwouldyoudeterminehisdegreeofdehydrationandhowsevereisitlikelytobe?(40%)(b)Describeyourperioperativefluidmanagement.(40%)(c)Whenwouldyouproceedtosurgeryandwhy?(20%)Dehydrationassessment
• Hx:intakevsoutput–feedingasnormalorreducedfeed?Diarrhea?Vomit?
o Numberofwetnappychanges?
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• Exam
o Lethargic?Non-interactive?Drowsy?
o CVS:HR,BP,skinturgor,antfontanelle?
§ AlsoRR,urineoutput,weightloss?
• Invx
o UECr
• Assessment:Forthisagegroup,HR160isslightlyincreased,BPnormal;hence
dehydrationisestimatedtobeapprxmild.Tachycardiacanbereflectionofpain.
o However,significanthyponatremia/hypokalaemia;whichmaysuggestlossof
fluid(lossofK),withcompensatorymechanismbyRAAaxisegADHholding
ontopurewatercausinghyponatremia.Riseinlactatelikelyreflectionof
ischaemicgut!!
Periopfulidmx• Aim=replacedeficit+maintainongoingneed
• Regimenthendependsonestimatedloss,butuse
• Preop:
o 10-20ml/kgofbolusthenobserveresponse;ifHRimproves,considerrepeat
10ml/kgbolus;I’dusebalancedIVFeg.P148.
o Ongoinglosseg.NG,stomaoutputshouldbereplacedml:ml.
• Intra
o Replacelossintraopfrombleed+evaporationfromlaparotomy;monitor
responseregualrly
o Maintain=4:2:1rule,forthispatientestimateweight=6kg.Hencehourly
maintenance=24ml/hr.
§ Consider1/3reductiontoaccountforacutestressresponse,souse
18-24ml/hr.
§ I’dusedextrosesaline:0.9%NaCl+5%dextrose.
• Post
o Maintainwith18-24ml/hrdextrosesaline
o Ongingmonitorofhaemodynamics+electrolytes+responsetoany
correction/replacementfluid.
Whentoproceedandwhy• Dependsonurgencyofsurgery;howeverifischaemicgut,needtooptimize/fluid
resus/replaceelectrolytewithinlimitedtimeandproceedforurgentsurgery.• I’dtransferpttoOTtofacilitateongoingclosemonitor/resus+prepareforGA.
NB.
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• 0-6mont=70SBP(neonate);RR40;HR160
• 6-1year=90SBP(infant);RR35;HR140
• >1=100SBP(smallchildren);RR20-30;HR120
• >5=likeadult(children)• systolic pressure 50-90mmHg = 80 + (age x 2) for over 1 yo; • MAP up to 6/12 = post-conceptual age • RR = 24-age/2 for over 2yo
Noplaceforisotonicsalineanymore.Don’tuse0.45%saline,use0.9%saline.
Q6-criticalappraisalofresearch,23%
Howwouldyoucriticallyappraiseapaperpublishedinajournal?
Criticalappraisalisasystematicprocessusedtoidentifythestrengthsandweaknessesofa
researcharticleinordertoassesstheusefulnessandvalidityoftheresearchfindings;which
wouldinclude:
• Qualityofstudyresult
• Relevanceofstudyquestion
Typeofarticleshouldbeconsidered;andinorderofhighesttolowestsignificance:• Systemicreview,metanalysis
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• RCT
• Non-RCTtrialseg.case-control,cohort,observational
• Casereport,series
• Expertopinions
Appraisalwillinclude:- analysisoftheconductofthestudy:
o typeoftrial
o clinicalquestioninvestigatedrelevantinmypractice?
§ hypothesisstatement,
o generalizabilitytomypatientgroup?
§ location
§ inclusion/exclusioncriteria,
§ patientdemographics?
o Ethics–potentialconflictofinterest?
o measurementtool
§ randomization?Blinding?
§ Samplegroupcalculation
o Studyexecution
§ Groupseparation?
§ Adequatefollowup?
§ Treatmentofwithdrawals?
o Qualityofresult?Power,bias/conflictofinterestmanagement,
§ applicationofappropriatestatistics,
§ analysisofresults
§ adequatepower?Significantresult?
o Comparisonswithotherstudies?
§ Consistencyofresults?
§ contributionofnewknowledgeorconfirmationofpreviouswork
o Cross-examinationofstudy
§ Discussionwithcolleaguesinjournalclub
Q7-pacemakerdiscussion,90.6%
(a)Describethecommonclassificationcodeforpermanentpacemakers.(30%)(b)Outlinetheprinciplesinvolvedintheperioperativemanagementofpatientswithapermanentpacemaker.(70%)Classification5lettersystem:
o Chamberpaced–AVDO
o Chambersensed–AVDO
o Responsetosensing–TIDO
o Ratemodulation/programmability–simple,multi,rateresponsive,none
o Antitachycardiafunction–paced,shocked,dual,none
Mx:o Preop-
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o Evaluate:indication,currentusage,underlyinrhythm,dependence?Magnet
response?
§ Ifdependent,needasynchronouspacingintraopwhenPMinhibited
bydiathermy.
§ Shoulddisablerateresponsiveness+antitachycardiafunction.
o MDTinputwithTechnician+Cardiologistifpatient’shighriskeg.requiring
cardiacresynchronizationtherapy.
o RoutineAMPLEhx,examofairway/CVS/respsystems,invxensure
electrolytesnormal
o Intraop:
o Resusequipment,isoprenaline,atropine,externalpacing,defibready;pads
onifhighrisk(farawayfromPM;usuonoppositethigh)
o Monitor-ECGonpacemakerdetectionsetting;needhaemodynamicmonitor
incaseofECGnoise–eg.pulseoxorart-line.
o Technicianinput
o PrecautiontominimizePMinterference
§ Diathermy-bipolar,padposition,>15cmdistancetoPPMofdiathermy
use,<5secburstsQ10sec;lowestfeasibleenergy.
§ Lithotripsy:shockwavetimedatR-wave.
o InCRT:lossofAVsynchronycanprecipitateheartfailure;sohavetelemetric
programmer/techniciancloseathand.
o Postop:
o ReinterrogationofPM,turnsettingbacktonormal;mandatoryesp.ifsetting
haschangedordetectedPMtriggerintraoporuseddiathermy<15cmtoPM.
NB.
HRS/HRSUKcodesforICDtype
o Shockchamber–AVDO
o Chamberwhichpacingdelivered–AVDO
o Tachycardiadetection–E(intracardiacElectrogram)vs.H(Haemodynamicmeans)
o Pacemakercapabilityofthedevice(3-5lettercodesasususal)
Q8-ACLSinpregnancy,55.4%
Howandwhyiscardiopulmonaryresuscitationmodifiedforthepregnantpatientattermcomparedwiththenon-pregnantpatient?
Q9–persistentpostoppain(repeat),54.7%
a.listthepredisposingfactorsforpainpersistingformorethan3monthspostop(50%)b.outlinetheinterventionsthathavebeendemonstratedtobeefficaciousinthepreventionofpersistentpostoppain(50%)see2014AQ15.PPP=Chronicpain=persistent:painpersistdespitehavingrecoveredfrominitialtissueinjury.Ie
persistentpain>12weeks.(reportre:PPPsays-Painofatleast2monthsduration)
-postop:Mustdevelopaftersurgicalprocedure
-notduetoothernociception:Othercauseshavebeenexcluded
• Thepossibilitythatthepainisfromapreexistingconditionhasbeenexcluded
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Predisposingfactorso Patient
o Preexistingpain,chronicpain,poorcopingstrategy,psychiatricdisorder–
anxiety,catastrophizingthinking,historyofperipheralneuropathy–DM,PVDo Anasthesia
o Poorpaincontrolperiop,acutepostoppain,nervedamagefromregional
nerveblockade.o Surgery
o Nerveinjuries,direct/ischaemic,limbamputation,thoracotomy,ICDs,
mastectomy,LSCS,hysterectomy.ManagementtopreventPPP
- Preopo Discussionofplan,reassurance,addresspsychiatricissue.o Premedanxiolytic;preemptiveanalgesia(iegivenbeforenoxioceptive
stimulation)–para,NSAID,gabapentin- Intraop
o Multimodalanalgesicstrategy+RA.§ Espformastectomy,thoracotomy,LSCS.§ Preventiveanalgesia:ketamine,clonidine,opioid.
o Preventnodamange:§ Goodsurgicaltechnique§ Minimizingtourniquettime.§ Carefulpatientpositioning§ Maintainphysiology:oxygenation,MAP,Hb.
- Postopo Goodcontrolofanyacutepostoppain.o Ongoingclosef/u,withAPMSinput.o Ongoingmultimodalanalgesia.
Q10-dentaldamagecomplication,79.9%
AnadultpatientwhowasintubatedfortonsillectomyisnotedtohaveanuppercentralincisortoothmissingintheRecoveryRoomafterextubation.(a)Listthepredisposingfactorsforperioperativedentaldamage.(50%)(b)Whatisyourmanagementofthissituation?(50%)(a)Predisposingfactorsinclude:·Patientfactors:
• Vulnerableteeth(loose,isolated,cappedteeth,veneers,crowns)
• Gumpathology;hyposalivation(egfrompreviousradiotherapy)
• Anatomycausingdifficultyinintubation(egpoormouthopeningorneckextension)
Anaesthetic/surgicalfactors
• Useofgeneralanaesthesiaandanendotrachealtube
• Poortechniqueatlaryngoscopy
• Surgicalgags/retractors
• Inadequateanaesthesiaorrelaxationallowingbiting
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• Poorcarewithsuctioningororalairway(egGuedel)use
• Postoperativeshivering
(b)Managementincludes
• Reviewtherecordstoassessthepatient’spriordentalcondition
• Reviewthecase,ifnecessarywithotherteammembers,todeterminethemost
likelytimingandcauseofthedentaldamage
• Findthetooth,withimaging(egCXR)ifnecessary
• Consultadentistforassessmentandfurthermanagement
• Documenttheeventsandfindings
• NotifymedicaldefenceorganisationandlocalQAmechanism(departmental
morbiditymeeting)
Q11-mitralregurge,pulmHTNdiscussion,57.6%
A78-year-oldfemalepresentsforfixationofadisplacedfemoralfracture.Shehaslongstandingmitralregurgitationandisknowntohaveameanpulmonaryarterypressureof60mmHg.Shereportsorthopnoeabutisnotshortofbreathatrest.(a)Whataretheissuesofconcerninyourpreoperativeassessment?(50%) (b)Howwouldyoumanagepulmonaryvascularresistanceperioperatively?(50%)Issuesinpreassessment–femoral#fixation
o Urgentsurgery-atleastmoderaterisksurgery
o Highriskpatient–elderly,MR,severepulmHTN;likelyCCF+arrhythmia+current
physicalinsult
o Periopandconsentshouldaccountforsuchhighriskandwithcarefuldecision
makinginvolveMDTwithpatient/family,ICU,GeriatricPhysician,Cardiology,
Orthopaedics
§ Ideallyleastinvasivemanagementoptiontoprovidepatientwith
meaningfulqualityoflife.
o APACshouldinclude:
§ Functionalcapacity,MRseverity,previoustreatment?
§ LV/RVfailure?Arrhythmia?
§ OthercontributorycauseofpulmHTN?Eg.COPD?
§ Echocardiogram
§ Currentstatus?Bleed,pain,haemodynamicinstabilityfromfemoral
#?Alsocompartmentsyndrome,fatembolism,neurovascular
compromise?Otherassociatedinjuryfromtrauma?
ManagemnetofPVRperiop
o Preop
§ AvoidfurtherriseinPVR–hypoxaemia,hypercapnia,acidosis
• Ensuregoodoxygenation,maintainingofMAP,Hb
• Ensureoptimizationofanyacutephysicalinsulteg.pulm
oedema,atelectasis,pain,bleed,anaemia,shock.VTE
prophylaxis.
• Avoidnitrousoxide,avoidketamine.
§ Continuationofanti-pulmHTNagentsorconsiderstartingsildenafil,
prostacyclin.
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§ ConsideradmissiontoICUformonitorandmilrinoneinfusion.
o Intrao
§ Monitor
§ Anaesthesia:RAvs.GA.I’duseRAifoncontraindication;
• GoodforMRwithSVRreduction,lessaffectonventilation,
goodanalgesiapostop,goodSNSbluntingperiop;reducesrisk
ofVTE.
§ Maintainstablehaemodynamicswithbalanceduseof
fluid/vasopressor.
• Avoidexcessivehighdoseofvasopressor(effectonPVR)
• Consideruseofvasopressinforpuresystemiccirculation
effect.
§ IfGArequired;uselungprotectiveventstrategy.EnoughPEEPbut
avoidexcessivelyhighPEEPorhighPIP(highervolume,likely
overdistendpulmvesselsandworsenPVR)
o Postop
o OngoingmonitorandmanagementinICUwithallofabove.
Q12-GALAforcarotidendarterectomy,75.5%
Whataretheadvantagesanddisadvantagesofgeneralversuslocalanaesthesiaforcarotidendarterectomy?RAcanbedoneundersuperficialcervicalplexusblockade+/-surgicalLAtopup;deepCPB
hasn’tshowntoprovideadditionalbenefit.
- Pros
o Allowsassessingpatientclinicallyinrealtime
o CerebralBFautoregulationisrelativelypreserved
o Lessuseofshunting(demonstratedinGALAtrial)
o AvoidGAandassc.Risk(sorethroat,PONV,potentialcardiorespinstability)
§ ThereforelikelybetterhaemodynamiccontrolwithRA.
- Cons
o LAST
o Failedblock,needforGA(1.5%requirementinGALAtrial)
o HighlevelofcooperationfrompatientandSurgeonrequired;may
compromisesafetyifpatientbecomeconfused/agitatedintraop
o Accesstoairwaylimitedifneedtointervene
GA
- Pros
o Controlofairway,ventilation,allowingmorecontroloverpCO2cfsedation
o PotentialneuroprotectiveeffetfromGA
o AvoidsrisksofRA:highlevelofpatientcooperation,LAST
- Cons
o Relativeuncouplingofautoregulation(althougheffectlimitedwith
TIVA/volatileMAC<1)
o Likelymorehaemodynamicinstability,complicatedbypotentialpre-existing
CVSdisease
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§ althoughcanbemanagedwithvasopressor/vasodilator
o Needextramonitoring,whichisn’tasreliableasclinical
§ SSEP,
§ EEG
§ NIRS
§ Stumppressure
§ TCA
o Sedationpostop,makingassessmentofneurofunctiondifficult.
Overall:GALAtrialshowednodifferenceinoutcome(morbidityandmortality)
Q13-Diabeticketoacidosismanagement,75.5%
Outlinetheprinciplesofaninitialmanagementplanfordiabeticketoacidosis,havingregardtothephysiologicalderangementsinvolved.
Q14-anaestheticassistantresponsibilities,40.3%
YouareontheinterviewpanelappointingnewAssistantsfortheAnaesthetist.Whataretheeducationalrequirementsandthepracticalresponsibilitiesexpectedoftheapplicants?ConsultANZCAPSonAnaestheticAssistantresponsibilitiesEducationalrequirements
• 3yearfulltimeCourseatanappropriateinstitution
§ 2yearforenrollednursesinfulltimeemployment
§ 1yearforregisterednursesinfulltimeemployment
• Mixoflectures+supervisedpracticalexperience
• Assessmentofskills/knowledgethroughexamsandassignmentsandpractical
assessments
• Contentofcourseshouldinclude:basicsciencespertinenttopractiseofanaesthesia,
clinicalanaesthesia-includingGAandRA,environmentalsafetyinOT,safedeliveryof
anaesthesia,care/use/servicingofanaesthesiadelivery
systems/monitor/equipment;infectioncontrol/universalprecautions,crisis
management.
§ OTmanagementaspects–healthandsafetyofstaff,patients.
• EvidenceofCPD–ACLS,equipmentupdates,conferences
Practicalresponsibilities• MemberofMDT
• Assistinconductofanaesthesia
§ Immediatelyavailableforinduction,emergenceandwhenassistance
isrequired.
§ PrimaryresponsibilityremainwithallocatedOTlist/Anaesthetist
• Prepareandapplicationofanaestheticmonitor
• Prepareandcheckofanaesthesiaequipment,deliverysystem
§ Level2checkbeforelist
§ Level3beforeeachcase
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• Decontamination,cleaning,sterilizationofequipmentasperANZCAguideline
• Restockingofequipment,drugs
• Ensurequalityassurance
Q15-pulmonaryfunctiontest,flowvolumeloop,EtCO2discussion,51.8%
Eachofsections(a),(b)and(c)isworthequalmarks;withineachsection,eachquestionisworthequalmarks. (a) mixtureoflectures,supervised
%
predicted
Lowerlimitof
normal
Forcedvitalcapacity–FVC 1.74litres60%
2.41litres
Forcedexpiratoryvolumein1sec
–FEV11.47litres 70% 1.82litres
FEV1/FVCratio 84.5% 68.2%
Forcedexpiratorytime-FET 9.1secs
Residualvolume-RV 0.85litres 39% 1.5litres
Totallungcapacity-TLC 2.81litres 54% 4.22litres
Diffusingcapacity-DLCO8.75
ml/min/mmHg39% 14.9ml/min/mmHg
(i)Identifyingthekeyfeatures,whatpatternofdisorderisdemonstratedbythesetests?(ii)Whatarethepossiblecauses? (b)WhataretheimplicationsofgeneralanaesthesiaforanadultpatientwithCurveBpresentingforakneearthroscopy?(=restrictivepatternonflow/volumeloop)C-(i)Describetheabnormalitiesonthiscapnograph. (ii)Whatisyourdifferentialdiagnosis? (iii)Howwouldyouidentifythelikelycauseintheintraoperativesetting?=obstructivepatternonEtCO2trace.
April-2010,50%
Q1-tourniquetusediscussion,66.3%
a.Listthecomplicationsassociatedwiththeuseoflimbtourniquetsduringsurgery.(60%)b.Howcanthesecomplicationsbeminimised?(40%)Acomplications
• Duringtourniquetapplicationo LimbischaemiaespinPVDo Skin,nerve,muscledamageespfragileskin,peripheralneuropathy,DMo Tourniquetpain–SNSresponsewithtachycardia,HTNandincreasedcardiac
workload§ Exposepatienttoriskofincreasingopioiduse,postopsedation.
o Poorvenousdrainagepriortotourniqueton:§ Increasedvenousbleed,bruise,venousstasis/DVT
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o Un-noticedarterialdamageàbleedwhentourniquetreleased• Whentourniquetreleased
o Releaseofmetabolicwasteproductàcoldblood,CO2/H/Kàhypotension,
arrhythmia,hypothermiao Venodilation/decreasedvenousreturnàhypotensiono ReactivehyperaemiaàreperfusioninjurywithO2radicalrelease,bleed.o PotentialPEfromdislodgedDVT.
Riskminimization• Application:
o Padding,approrpiratetourniquetsizing,ensurevenousdrainageprior.o LimittourniquetPto100mmHgaboveSBP(arm),100-150forthigh;or250
forarm,300forthigh.• Maintenance
o Limittourniquettimeto90mins;max120mins;monitorP.o Ensuretourniquetbreakfor15minsiflongertourniquettimeisrequiredà
removalofwasteproduct,deliveryofO2,restorationoftissueATP.• Release
o Ensurenormovolaemiaandconsiderfluidloadingwithreleaseo HyperventilatetocounterCO2rise,metabolicacidosiso ConsiderCaClforarrhythmia(probablyrelatedtohyperK)o ResusequipmentavailableforpotentialneedofACLS
Q2–Proneposition(repeat),22.9%
a.listhazardstopatientasscwithpronepositionunderGA(60%)b.howcanthesehazardsbeminimized?(40%)see2013AQ12Q3–Morbidobesitylaparoscopy,63.3%
20yofemalewithBMI48forelectivediagnosticlap,endometriosis.NootherPMH.Describepotentialproblemsasscwithanaesthetizingthispatient.Note:Examreportcomment:EsotericandexcessivemanagementsuggestionsforwhatisacommonanaestheticscenariosubtractedfromthevalueofsomeanswersIssues
• Patient
o Morbidobesityisassociatedwithfollowingissues:
o Difficultairway:intubationandBMV,needingcarefulairwayassessmentand
possibleawakeintubationtechnique.
§ Lookforotherriskfactorseg.hxofOSA,highgrademallampatior
shortthyromentaldistance.Preoxygenationmaybedifficultdueto
reducedFRC..
o Difficultventilation:asreducedrespiratorycompliance;compoundedby
pneumoperitoneum+Trendelenburg.
o CVS:compressionofIVCàhypotension.Hypercapnoeamayinduce
arrhythmiawithSNSstimulation.
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o GI:havehigherresidualgastricfluidvolume,riskofaspirationneedtobe
considered–I’dusemodifiedRSI
• Anaesthesia
o Pharmacologyconsideration–dosingbasedonLBMformostmedications
howeverexceptionsincludesuxamethonium,infusionsofpropofoletc.which
isbasedonTBW.
o Mayhavedifficultywith:
§ BPmonitor,requiringarterialline
§ IVaccess,needingUSSorevenCVL.
§ Positioningdifficulty,needingmoreassistants,airmattress.Safetyfor
patient/staffisparamount.
§ Theatretablemayneedextensions
• Surgery
o (Pneumoperitoneum+Trendelenburg)
o Surgicaldifficultyàlongerduration,likelyriskoforganicinjury,bleed.
• Postop:
o
o Prolongedrecoverylikelyiflongsurgery+useofsevofluranewithhigherfat
solubility.
o SedationriskespifunderlyingOSA,higherriskofrespcomplication,which
maynecessitateHDUlevelmonitor.
o HighriskofDVTneedingmulti-modalprophylaxis.
Q4-anaemia,transfusiontriggerdiscussion,42.2%
a.Describethepathophysiologicalchangesassociatedwithahaemoglobinof75g/L.(50%)b.Outlinethepatientfactorsthatwouldindicatetheneedforaperioperativeredbloodcelltransfusioninapatientwithahaemoglobinof75g/L.(50%)AImmediate–SNS,CO
Intermediate–RAA,ADH,volume,thirst,2,3-DPG,O2extractionbytissue
Delayed–Haemopoiesis,Hbproduction
B1transfusiontriggersarenotdefiniteendpointsbutguides
2Instead,transfusionshouldbeaimedatpreventionofend-organhypoxia,symptomatic
reliefofsymptoms,andencouragewoundhealing,especiallywhenthere’sincreased
demandandsignofdecreasedsupply
Q5-Myotonicdystrophydiscussion,52.4%
A26yearoldwomanwithsubclinicalmyotonicdystrophypresentstothehighriskobstetricclinic.Sheis25weekspregnantinherfirstpregnancyandotherwisewell.Shehopesforanormalvaginaldelivery.Describeandjustifyyourrecommendationsforthemanagementofheranalgesiaforlabourandtheperioperativemanagementofanypotentialoperativedelivery.
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Myotonicdystrophy
- =autosomaldominantdisorder
- multisystemic,characterizedbymyotoniaofskeletalmuscle,weakness.
- Systemicmanifestationsincludecardiomyopathy,respiratoryfailure,riskof
aspiration.
- Specifictoobstetrics,there’sriskofuterineatony,PPH.
Analgesiarecommendationsforlabour- Considerearlyepiduralanalgesia
§ avoidopioidandN2O->increasedsensitivitytorespdepression,
sedation.
- Usemultimodalanalgesiatoopioidspare.
Periopmanagementofpotentialoperativedelivery(=usesystemoffocusedissuemx)- Preop:thoroughassessmentofpatient’sdiseaseseverity(althoughknowntobe
subclinical),establishfunctionalcapacity,obtainAMPLEhistory,examairway,
cardio/respsystems.InvxwithECHO,andcheckTFT.Ensureeuthyroidism.Consider
steroidsupplementationifadrenalinsufficient.
§ MDTinputwithObstetrician,Cardiologist,GeneralPhysician.
- Regionalanaesthesiaispreferredforusualbenefitinobstetricanaesthesia–airway
complication,aspiration,fetalsedation,bradycardia,uterineatony,delayed
bonding.
§ Especiallyifthere’sCVS/Respimpairmentfrommyotonicdystrophy.
§ NeedlargeboreIVx2,GHandhave2unitscross-matchedcloseby.
- Preventmyotonia;aswellasdistress,mayreducesurgicalaccess
§ Continuedrugseg.phenytoin,procainamideifalreadyon.
§ Avoidhypothermia,shiver,mechanical,electricalstimulation
§ Avoidsux(generlisedcontracture);mayuseNDMR,however
neostigminemayinducecontracture;ideallyuseroc/sugammadexif
necessary.
§ UseGTNifdifficultsurgicalaccesseg.IV25-50mcgbolus.
- Preventrespfunctiondeterioration
§ Beawareofincreasedsensitivitytorespdepression.Opioidsparewith
RA,multimodalanalgesia.UsesmallerdosesofopioidPRN.titrateto
effectcarefullywithclosemonitoring.Eg.sevredol5mgPO.
- PreventCVSfunctiondeterioration
§ monitorasperANZCAguideline.I’dhavelowthresholdforartline,
dependingonpatient’scardiacfunctiononpreassessment.
- Preventaspiration
§ RanitidinePOregularduringlabour.
- Postop->OngoingmonitorofCVS/Resp/MSKfunctionsandmultimodalanalgesia.
ConsiderTAP/ilioinguinal/iliohypogastriccathetertoopioidspare.
NB.
Severity-Systemic
1airway:aspiration?
2CVS:dysrhythmia,MVprolapse,cardiomyopathy
3Resp:respfailure?
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4CNS:centralapnoeaatnight?
5GI:delayedemptying,ileus/pseudoobstruction
6Renal/GU:uterineatony,PPH
7Endo:DM,hypothyroid,adrenalinsufficiency
Femalesmaybeamenhorreicorhaveproblemswithinfertility.Menhavetesticularatrophy.
Otherrandom: Baldness,mentalretardation,Cataracts
Myotoniascanbeeitherdystrophic(myotonia+musclewasting/weakness)ornon-
dystrophic(onlymyotonia)
Q6-HOCMdiscussion,67.5%
A40yearoldmanwithhypertrophicobstructivecardiomyopathy(HOCM)presentsforelectivelaparoscopiccholecystectomy.a.Describetheprinciplesofintraoperativehaemodynamicmanagementforthispatient.(40%)b.Howwouldyoumanagehypotensionpostinductionofgeneralanaesthesiainthispatient?(60%)HOCM
o CausesdynamicLVOTobstruction+SAMduetohighvelocitybloodflow/Venturi
effect+functionalMR.
o Also,LVH,diastolicdysfunction,riskofarrhythmia
PrinciplesofintraophaemodynamicmxforHOCMo Monitor+art-line+considerTOE
o Preload–full
§ Avoidhighintraperitonealpressurethatimpairspreload;aim
<10mmHg;avoidexcessivereversetrendelenburg
o HR–avoidtachycardia;aimlownormaltomaximizediastolicfilling+coronary
perfusion.
§ avoidexcessiveSNSdrive;mayhaveAF;orathighriskofarrhythmia
ifdeveloptachycardia.
o Afterload–maintainnormalafterloadwithvasopressor.
o Contractility–aimforlownormalcontractilitytoreducedynamicLVOTobstruction.
§ Mayneednegativeinotropyeg.betablocker
Hypotensionpostinductionmxo Ifsevere,isEMEGENCY!Declarethisandgethelpwithresustrolleyimmediately.o ABCDresuscitation;discontinueanaesthetic,FiO2100%.o ConsiderdifferentialsalthoughfrequencygamblemostlylikelycauseisHOCM–
evaluatewithTOE.§ Ensuregooepreload,afterload,considerbbtoreducedynamicLVOT
obstructionesphyperdynamiccontractionseenonTOEiftachycardia
ispresent.o Otherdifferentials:
§ TransientanaestheticeffectonreducedSVR,cardiodepression–
supportivecare.§ Anaphylaxis–fluid+adrenaline(butwatchfordynamicLVOT
obstruction)§ Bleed
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§ Pneumoperitoneumetc–consideropenprocedureifpatientdoesnot
toleratepneumoperitoneumQ7–SAHmanagementcoiling,62.7%
A43yearoldfemalewithaGrade1subarachnoidhaemorrhageisscheduledforcoilingofhermiddlecerebralarteryintheradiologysuite.Discusstheimportantissuestoconsiderwhenprovidinganaesthesiaforthispatient.
Issues(arrangedbyovercappingissues,althoughmayconsiderpre,intra,post(report).
o SAH-likelyincreasedICP
o NeedtopreventriseinICP
§ TIVA/remitomaintainoptimalautoregulation
§ Ventilationtomaintainnormocarbia
§ Preventriseincerebralmetabolism:
• Avoidfever,treatseizureifoccurred,
§ Ensuregoodvenousdrainage:avoidcompressionwithtubetie;
maintainneutralheadposition.
§ ConsiderICPmonitor
o maintainCPP+manageCVSinstability
§ mayseeECGorchanges(TWI/QTprolong)
§ useartline+/-CVP+temp/NMTmonitoretc.(report)
§ maintaingoodMAP;aimeuvolaemiaandusevasopressor/inotropeas
required
§ avoidexcessivelyhighBPwhichcouldworsenbleed.
• KeepSBP<140mmHg;
• monitorcloselywithart-line.
• Useremitoobtundstimulationfromintubation.
o NeuroprotectionandminimizesecondaryinsultwithTIVA.
§ Maintainnormothermia+normoglycaemia.
o SIADH-hyponatremia–monitorandcorrectasrequiredslowly<10mmol/L
perdaywithsodiumchloride(0.9%or3%)
o Riskofrebleed;delayedneurologicaldeficit/vasospasm–
§ nimodipineprophylaxis
§ ongoingclosemonitor/neuroassessmentinICU.
§ RtreatwithHHHifvasospasmoccurred.
o RemoteareaRadiologysuite
o Familiarizeenvironment+equipment
o Maintaincontactwithassistantsforanticipatedcomplicationandobtainhelp
timely.
NB.
OHA:
-watchforcomplications:rebleed(espfirst24hrs,4%risk),delayedneurologicaldeficit,
hydrocephalus,oedema,seizures.
-ICUbook:HHH:upMAPthenwatchforneurology,thenmaintain(likelyMAP90-110)until
stable.Ifnoimprovementafter2-4hours,considerinterventionalradiology;hypervolaemia
toincreaseMAP(unlessLVF),whichwillalsoachievehaemodilution.
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-OHA:suggestedvaluesareMAP+15%,CVP>12mmHg,HCT30-35%.
-ifanyneurodeterrioration-performCTscan.
-FASTHUGcareinICU.
Q8-subtenonblockdiscussion,83.7%
a.Describetheanatomyoftheeyerelevanttoasub-Tenon’seyeblock.(40%)b.Discussthepotentialadvantagesanddisadvantagesofthistechniqueforprovidingregionalanaesthesiaforeyesurgery.(60%)STB=instilLAintoSTspace,whichispotentialspacebetweentenon’scapsule(avascular)+sclera(vascular/red)
AnatomyforSTBGlobe(superficialàdeep)
• Conjunctivaàtenon’scapsuleàsubtenonspace(potential
space)àscleraàchoroid/ciliarybody/irisàretina
Extraocularmuscles,encasingthecone-shapedorbit:
• 4recti
• SO+IO
Neuroanatomy
o SensaEontotheEye
§ CorneaandSupero-nasalconjunctivaànasociliaryN(V1)
§ TheRestàLacrimal,Frontal,Infra-orbital
o Motorsupply
§ SC,levatorpalpebral–III(upper)
§ MR,IR,IO–III(lower)
§ LR–VI(abducens)
§ SO–IV(trochlear)
Optimalblock=sensoryblockandakinesisoftheglobe(motorblock)isrequired.
• NB.ieinsidemusclecone=2,3,5,6.
• Outside=4
Globetendstositsanterior,highandlateralinorbit;henceaccessingsubtenonblockis
commonlyviainfero-nasalapproach.
Pros/cons
o Pros:qualityasgoodasRBB,avoidscomplication(retrobulbarbleed,opticN
damage,scleralperforation),minimalpain,saferinanticoagulation
o Others:canbedonewaxiallength>26mm
o Blockcanbeeasilytoppedup.
o Cons:subconjunctivalhaemorrhage,chemosis(whicharerelativelyminor),carew
scleralbuckles(mayneedmultipleinjections)
o Others:allergytohyalase
o Patientcooperation:liestillandrelativelyflatforsurgery
o Rarebutimportant:brainstemanaesthesia
o CIinprevvitrectomy(report)
o ArrhythmiaswithLApressureàvagal
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NB.
Q9-emergenceagitationdiscussion,61.4%
a.Describethefactorsthatinfluenceemergencedeliriuminchildren.(50%)b.Howwouldyoumanageemergencedeliriumina3yearoldchildhavinghadmyringotomytubesinsertedundergeneralanaesthesia?(50%)
ED=behaviouraldisturbancepostemergence:
• Psych:Inconsolable,irritable,uncooperative
• Phys:Thrashing,crying,moaningàcanresultinphysicalharmtochild,bruise,
distress,wounddehiscenceetc.
o ?lastingmemoryimpairment/maladaptivebehavior(Auckland2016)
o variableincidencereport18-80%.
EDfactors• Pt
o Age:Preschoolage,esp2-5yo
o Psych:Anxiety,pooradaptability/temperament
• Anaes
o Gas:Volatileagent,higherriskwsevo,iso,descf.halo
o Speed:Rapidwashouttimeofvolatile
o Pain
o OtherDrugs:
§ Benzodiazepineuse(report)
§ ??Anticholinergics-atropine;antidopaminergic-metoclopramide,
§ Protectivefactors:
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• Avoidrapidwashoutofsevo,eg.useofpropofolbolusatend
ofsurgery.
• Intraopuseofketamine,fent,clonidine,dexmedetomidine
mayalsobehelpful.
• UseTIVA.
• Surg
o Eye,ENTproceudres
ManagementofEDin3yopostmyriongotomyo Declare:Callforhelp,gentlyholdchild,usesoftprotectivepadseg.onbed
rails
o Ensuresafety,simultaneouslymanage+consider/treatcauses:
o OtherCauses:
§ ABCDE:hypoxia,hypotension,raisedICP,thirst/hunger,anxiety,
hypoglycaemia,hypo/hyperthermia
§ MI:bladderdistension,pain
o Actions:
§ Reducestimuli:Noise,light,handling
o Pharmtx:eg.
§ Fentanyl1mcg/kgIV;2mcg/kgIN;atendofsurgery;
§ Morphine0.05mg/kg
§ Propo:treatw0.5-1mg/kg
• bolus2-3mg/kgIVover3minsatendofsurgery
§ Clonidine1-2mcg/kgIV
§ Dexmedetomidine-0.15-1mcg/kgIVover5mins.
• Reassureparentsofself-limitingnature+goodprognosisofcondition.
NB.
• Emergenceagitationnotsameasemergencedelirium(ED).EDisasubsetofEA.No
universallyagreeddefinitionofEA.
• Prevention:propofolbolus/infusion–Katariaif<35kg;Schneiderif>35kg.
Q10-inhalationalinjurydiscussion(repeat),34.3%
a.Describethepathophysiologicaleffectsofaninhalationalinjuryfollowingahousefire.(60%)b.Whatimplicationswouldthishaveforanaesthesiaoneweekaftertheinjury?(40%)
Smoke inhalation = inhales heat and chemical smoke, can cause
• Thermal injury – airway swelling, tissue sloughing, scarring, stricture • Chemical injury – inflammation, oedema, hypoxaemia due to CO toxicity or cyanide
poisoning (methaemoglobinaemia) à leading to airway obstruction
o Lung: pulm oedema, VQ mismatch, chemical pneumonitis, bronchospasm, ARDS o SIRS: (report=key word) inflammatory cascade
Implication for anaesthesia 1 week later:
Airway o Likely still ventilated; if not, still have airway sensitivity.
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o Swelling à difficult intubation. (report: use of LMA is not appropriate) § Be very careful with transfer across beds, not to dislodge tube.
Breathing: o ARDS likely; pulm oedema, secretion. o Chest wall burn -> dec compliance; difficult ventilation. o May have VAP.
§ Use LPV strategy; may need to accept permissive hypercarbia Circulation:
o Large area burn -> large volume fluid shift; losses. o Large area debridement -> bleed + anaemia. o Narrow window of fluid therapy to avoid excessive administration which worsens oedema /
ARDS. Drug:
o Avoid sux; use NDMR if paralysis required. E:
o Meticuloustempcare;beawareofriskofhypothermiaduetolargeareasurgical
exposure.
Nutrition:largemetabolicrequirement;ideallycontinueNG/NJfeedthroughoutperiop
period(Auckland)
NB.
Feedearly<48hours;post-pyloricfeedingrecommended+minimizeinterruption;continue
NJfeedthroughoutsurgery.
Q11-opioiddependence,chronicpainmanagement,76.5%
A34yearold,opioid-dependantwomaniscomplainingofseverepainonthedayafterafirstmetatarsalosteotomy.Thenursesareconcernedsheisdrug-seeking.a.Howwouldyouassessthispatient?(60%)b.Outlineyourpainmanagementplan.(40%)
Assessment;Objectivepainassessment–consider:o Baselinepainlevel?Chronicpain?Patientreceivedhernormalpainregimens
periop?
o Currentanalgesiaregimens–isthisappropriate?Esp.incontextofchronic
painmanagement?
o Haspatientgotpersistentpostoppain?Assessforriskfactors:
§ Patient:chronicpain,anxiety,poorpaincopingstrategy?
§ Anaesthesia:severeacutepostoppain?Inadequateperioppain
regimens?
§ Surgery:intraoprecord–anydocumentationofnerveinjury?
Prolongeduseoftourniquet?
o Patient’scurrentpainfeature?Neuropathicpain?Featuresofallodynia,
hyperalgesia,nervedamage?Featureofwithdrawal?
§ Althoughunlikely,butruleoutcompartmentsyndrome.
- Obtainnursingstaffperspective–patient’sbehavioronward?Canpatientbe
distracted?Ispatientself-medicating?
Mxplan:Ifacuteonchronicpain:
- explain/reassurepatient
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- ensureoptimalmulti-modalanalgesia+opioidsparingstrategies–ketamine,
clonidine
- ensurecontinuationofpatient’snormalopioidregimens.
- rationaliseopioidusewithpatientandnursingstaff
- considerpsychliaisonifsignificantanxiety
- ruleoutsurgicalproblems-needsurgicalreviewifconcernwithtightcast,
ischaemia,compartmentsyndrome…etc.
- ongoingfollowupbypainteam.
- Contactthenominatedopioidprescribertoplandischargemanagement
NB.(comment)reluctancetogiveopioids=abadmistake.
Q12-qualityassuranceprogram(repeat),51.2%
a.Describetheaimsofaqualityassuranceprogram.(40%)b.Outlinethestepsyouwouldtaketosetupaqualityassuranceprogramforyouranaesthesiadepartment.(60%)(report)
• ThereferenceforthisquestionisANZCAProfessionalDocumentTE9:Guidelineson
QualityAssuranceinAnaesthesia
Q13-Universalprecautionsdiscussion(repeat),65.7%
a.Whatdoyouunderstandbytheterm“UniversalPrecautions”?(40%)b.Describehowyouapplytheseprecautionsinyourdailyanaesthesiapractice.(60%)
Q14-WPW/VFdiscussion,84.9%
A58yearoldmanpresentsfortonsillectomyforatonsillartumour.Hehasa2yearhistoryofintermittentpalpitations.Hiselectrocardiogramatdiagnosisshowsthefollowinga.Whatisthediagnosis?Describetheelectrocardiographicchangesthatsupportyourdiagnosis.(30%)Followingtheadministrationofneostigmineandatropineforreversalofneuromuscularblockade,youseethefollowingrhythmonyourmonitor.b.Whatisthisrhythm?Howwouldyoumanagethissituation?(70%)
WPW
o SR@70,butshortPRinterval(travellingdownaccessorypathway);deltawave
(slowerinitialQRSdepolarizationviaaccessorypathway),wideQRS,
o SecondaryST/Twavechanges.
o Alsosupportedbyhistory(intermittentpalpitation)-report
VF:
o ACLS(repeat)
Q15–preoxygenation(repeat),56.6%
a.whatisthephysiologicalbasisofpreoxygenation?(50%)b.describeyourmethodofpreoxygenationincludinghowyouassessitsadequacy(50%).See2015AQ15.
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Oct-2009,30.2%
Q1-clopidogrelandstentdiscussion,32.9%
Thereisa70-year-oldfemaleonyouremergencylistforanurgentlaparotomy.Shewasinvolvedinamotorvehicleaccidentthismorningandsustainedmultipletrauma.Hermedicationsincludeclopidogreltocovertheinsertionofbaremetalstentsintohercoronaryarteries2monthsago.1.Describethemechanismanddurationofactionofclopidogrel.(30%)2.Whatarethemajorconsiderationsfortheperioperativeperiodinviewofthepatient’sstent?(70%)
MoA+durationofclopidogrel
o ADPreceptorantagonist;irreversiblyantagonizeADPreceptoronplatete
o Nopltactivation,expressionofGIIBIIIA-R,noaggregation.
o Prodrug;activemetabolitehalf-life8hours;butirreversiblebindingsodurationisof
lifespanofplatete(5-7days)
Majorconsiderationsinperiopcareofthispatient?
o Riskofbleedwithmultipletrauma+clopidogrelwhichisn’teasilyreversed.
§ Traumainducedcoagulopathy,hypothermia,acidaemia,consumptive
coagulopathy.
o Riskofstentthrombosis,andhighmortalityrate,withoutclopidogrel.(althoughBMS
isnow>30daysandshouldberelativelyepithelializedandissafew/oclopidogrel).
ConsultCardiologist.Patientprobablyneedplateletforresusfromseveretrauma.
BevigilantofriskofMI/CVA/death.
o Riskofseveretrauma.
§ Inacutesetting,riskofbleedprobably>thrombosisrisk.
§ CarefulmonitorofperiopmajoradverseCVSeventshouldbe
monitored.
Mx;
• Hx;goodprimarysurvey;invxCT/USSandresuswithinlimitedtimebefore
emergencysurgery.
Anaestheticconsiderations:
• A-EMSTprinciple;stabilizeC-spine;RSI
• B-likelymultiplerib#s,haemopneumothorax;needICDbeforeIPPVcanbeginto
minimizeriskoftension
• C-hypovolaemicshock,coagulopathy;allowpermissivehypotension,lowvolume
resuscitationbeforedefinitehaemostasiswithsurgery.
§ Mayrequiredamage-controlsurgeryinviewofseveremultiple
trauma
• D:TBI,ICPcare.MayhavelowGCSthatrequireairwayprotection.
• E:keepwarm,butavoidfeverincontextofTBI.
• M:MayrequireMTP.
• Monitor/equipment:level1,Art-line;backupanaesthetist,2techniciansforoff-load
highleveltasks.
• Postop:
§ ICU.Cardiologist.Recommenceclopidogrelwhenconsidered
appropriatebyMDT.
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Q2-glycaemiaccontroldiscussion,69.6%
Listtheadvantagesanddisadvantagesoftightglycaemiccontrolperioperativelyinadiabeticpatientoninsulin.(30%)Howwouldyoumanagetheglycaemiccontrolforsuchapatienthavingaminorprocedureundergeneralanaesthesia?(70%)
TightPros–minimizehyperglycaemia
Cons–hypo,needclosermonitortoreduceriskandislabourintensive;assc.withworse
outcomeinmortality(NICE-SUGAR)ingeneralICUpts.
Periopmx:Assessment
Prep
Earlyonlist
Continuationoftreatmentappropriately
Monitorregimen
Planforabnormalresult–eg.250ml10%forhypothendextroseinfusion;vs.subcorrection
insulinbasedonlocalprotocol
Recommencementregimen
(report)
• Theimportantadvantagesoftightglycaemiccontrolrelatetominimisingthe
complicationsofhyperglycaemiai.e.ketosis,glycosuriaanddiuresisandriskof
infection
• Theimportantdisadvantageistheincreasedriskofpotentiallydangerous
hypoglycaemia
• Adefinitionoftightcontrol(eg4.5-6.0mmol/litre),and,forthesecondpartofthe
question,acceptablecontrolforTHISpatient(eg<10mmol/litre)
• Peri-operativemanagementshouldincludeconsiderationof
o theassessmentofthepatient’sregularpreoperativeinsulintherapyand
controlothetimingofthesurgery(i.e.earlyonthelist)
o anexplicitperi-operativeinsulinregimenthatcoversthepatient’sbasal
insulin
o requirementswhileavoidinghypoglycaemiainthefastingperiod
o amonitoringregimenwithaplanforabnormalresults
o apost-operativeplanforrecommencingregulartherapy,oradischargeplan
(comment)
• Someincorrectlyextrapolatedthestudiesfromtheintensivecaretotheoperating
theatreenvironment
• Goodanswerstailoredthecomplexityand“tightness”oftheperi-operativeregimen
tothatofthepatient’sregulartherapy
Q3–SOBinPACUdifferential;residualNMB,24.8%
a.49yowomanhasjustarrivedinthePACUfollowingaTAHunderGA.Sheisagitatedandc/odifficultybreathing.1.Listdifferentialdiagnoses(40%).2.Howwouldyou
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determineifthiswascausedbyresidualNMB?(40%).3.WhatistheroleofsugammadexinthetreatmentofresidualNMB?(20%)
1.differential
• Patient:
o Airwayobstructionàhypoxaemia
o Ventilatoryissue–atelectasis,VQmismatch,pulmoedema,preexistinglung
dx(asthma/COPDexacerbation)
o CVS:PE,MI,HF,severeanaemia
o CNS:TIA/CVA,delirium,anxiety
o Renal:urinaryretention
• Anaesthesia:residualNMB,opioidnarcosisorinadequateanalgesia.
2.determineifduetoresidualNMB
• Hx
o Reviewanaesthsiachart,timingoflastNMB,documentationofTOF
assessment?Givenreversalagent?
o Factorsforprolongedblock?Mg,gentamicinetc.
• Exam
o Clinical:headlift,handgrip,TVdepth(crudeassessment)
o NMTassessmentusingTOFratio(orDBSratio);TOFbettertolerated.Assess
T4/T1ratiousingaccelerometerandif<0.9=residualNMB.
3.roleofsugammadexintreatingresidualNMB
• =cyclodextrinthatreverseaminosteroidNMB–mosteffectivewithrocuronium,less
sowithvecuronium,notforpancuronium.
o Reliablereversalofrocuroniumandquickerthanneostigmine;alsoduration
foreffectislonger.CapableofreversingdeepNMBwithhigherdoseeg.up
to16mg/kg.
o Particularlyusefulwhenneostigminereachedits‘ceilingefect’aslikelyinthis
case.
• UnabletoreversebenzoisoquinoliniumNMBeg.atracurium.
• Expensive.Riskofanaphylaxisexists.
Q4-CPRmetabolicconsequencediscussion,59%
A70yearoldfemalehadacardiacarrestafterarrivingintheRecoveryRoomfollowingopenfixationofafemoralfracture.ThisarterialbloodgaswastakenafterintubationandseveralminutesofCPR.(report)
• Recognitionofaseveremixedrespiratoryandmetabolicacidosis
• Themostlikelycauseofthisabnormalityislacticacidosisfromhypoperfusiontothe
peripheraltissues,inconjunctionwithabsentorhypo-ventilationfrominadequate
perfusiontotherespiratorycentreofthebrainstem.Artificialventilationis
inadequateorhashadinadequatetimetoremovetheaccumulatedcarbondioxide,
andexternalcardiaccompressionhasbeentoolateorinadequatetoprevent
anaerobicmetabolismintheperipheraltissues
• Manypossiblecausesofbothrespiratoryandmetabolicacidosiswereacceptable
includingdualpathology,butanyaetiologyhadtoexplainBOTHcomponents
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Q5-Analgesiapregnancysafety,65.8%
Awomanwhois10weekspregnantpresentstotheEmergencyDepartmentwithaclosedtibialshaftfracture.1.Classifythedrugsusedinpainmanagementaccordingtotheirsafetytouseatthisstageofpregnancy.(40%)2.Whataretheoptionsavailableforperioperativepainmanagementforthispatient?(30%)3.Whatwouldyourecommend?Justifyyourchoice.(30%)
Drugsafetyclassification–asperAustralianDrugEvaluationorMedsafeNZ- A=safe,usedbylargenumberofpregnantwomenwithoutharm
- B1:usedbysmallnumberofpregnantwomenwithoutharm.Noharminanimal
studies
- B2:similartoB1.Howeveranimalstudiesisinadequateorlacking.
- B3:similartoB1.Howeveranimalstudiesshownincreasedfetaldamage.Although
significancetohumanisunknown.
- C:maycauseharmfuleffectstofetusbutwithoutmalformations.
- D:unsafe,cancauseharmfulfetalmalformation.
- X:highriskofpermanentdamage,useiscontraindicatedinpregnancy
Perioppainmanagementoption- GroupA:paracetamol,codeine,LA:bupivacaine/lignocaine
- GroupB:gabapentin
- GroupC:opioids,NSAIDs,tramadol;antidepressants-TCA,SSRI.
- GroupdD:carbamazepine,phenytoin,valproate.
- Others:
o Earlyreductionoffracture+traction/immobilization/surgery
o Regional–eg.epiduralorpoplitealnerveblock+catheter.
o Monitorforpotentialcompartmentsyndrome+timelyfasciotomy(report)
Myrecommendations–afterinformingpatienttoformulateanalgesiaplan:- Para-safe.
- Opioids–shortcourseofopioidisprobablyrequiredtoprovideeffectiveanalgesia.
Riskoffetalrespdepressionisnotanissueatthisgestationanduseofshortcourse
isn’tasscwithhighriskoftolerance.
§ AlsoallowsPCAtosetup=betteranalgesia
- Regionalwithpoplitealblock/catheterwouldgivebestanalgesia+opioidspare.Use
oflowconcLAinfusioneg.0.2%ropivacaine0-10ml/hr,willnotmaskcompartment
syndrome.
- OngoingF/UbyAPMSandweanoffopioidasearlyasappropriate.
- AvoidNSAIDduetopotentialriskofmiscarriage;wouldn’tuseepiduraldueto
potentialcompartmentsyndrome.
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Q6CXRstructure,36%
a.IdentifythestructureslabeledAtoHonthisnormalchestX-ray.(40%)1. TrachealAirColumn
2. Carina
3. 1stRib
4. Scapula
5. MinororHorizontalFissure
6. RightHemidiaphram
7. LeftHemidiaphram
8. AscendingAorta
9. Clavicle
10. SuperiorVenaCavaShadow[A]11. RegionofAzygosVein12. RightPulmonaryArtery[B]
13. LeftAtrialAppendage[G]14. BorderofRightAtrium[C]
15. InferiorVenaCava16. AorticArch[E]
17.LeftPulmonaryArtery[F]18.BorderofLeftVentricle[H]19.DescendingAorta
b.Describethearterialbloodsupplyandvenousdrainageofthemyocardium.(60%)Artery:
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• Aorta-->aorticsinuses(justaboveAV)àLCA+RCA
o LCAàLMSàLAD+LCx
§ LCx(lateralaroundLAVgroove)àmarginal
§ LAD(anteriorlybetweenIVgroove)àdiagonals
o RCA(posteriorlybetweenantAVgroove)àanastomosewLCx+branchPDA
+interventbranch
Supplies:• LCA:LA,ant/latLV,antIVS,SA(40%)+AV(20%)nodes;partofRV
• RCA:RA,RV,postLV,postIVS+SA(60%),AV(80%)notes
Venousdrain:
• 2/3:veinsaccompanyarteriesàdirectlyintoRA.
o antcardiacvein
o (4)greatcardiac,middlecardiac,smallcardiac,obliquecardiacveinsà
coronarysinus
• 1/3:smallveins(venaecordisminimae)àdirectlyintocardiaccavity
Q7-Remifentanilinfusiondiscussion,37.3%
A27yearoldmalepresentswithaglioblastomaforacraniotomy.Aspartofyouranaesthetictechnique,youdecidetousearemifentanilinfusion.1.Discussthecharacteristicsofremifentanilwithrespecttoitsuseasaninfusion.(50%)2.Whataretheadvantagesanddisadvantagesofusingeffectsitecalculationstoguideremifentanilinfusions?(50%)
Remi=phenylpiperidine;pureu-agonist.Equipotenttofentanyl.70%PPB,smallVd,rapidly
metabolizedbytissueesterasewithlargeclearance30-40ml/kg/minhenceshortt1/2.
Organ-independentmetabolism,well-preservedindiseasestates,hencereducesinter-
individualvariability.
Remicharacteristicsforuseininfusion
• dose(0.05-0.5mcg/kg/min)
• rapidonset(highlipidsolubilitycf.morphineandlowpKa),allowsforeasytitration.
• SmallVd/highCl,t1/2isshort~3mins.
• Context-insensitivethereforeregardlessofinfusionduration,t1/2remainssame
~3minsàgoodininfusionasoffsetispredictableandquickafterlongdurationof
use.
• Delayedpostoprespdepressionriskislow(unlessotheropioidused).
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• AllowsforrelativestablecontrolofhaemodynamcisduetoeffectonMAC-Bar
sparingespwhenstableeffectsiteconcentrationisreachedwithinfusion.
o IdealforcontrolBP,permissivehypotensiontoachievegoodsurgicalfieldeg.
inENT.
Pros/consofusingeffectisitetoguideremiinfusions?
• Effectsitecalculationconsidersage,LBM(height/weightcalculation),gender+
equilibrationtimebetweencentralandeffectsites(report).
o Ultimatelythisresultsinlessvariationindrugeffect,andamorepredictable
effectfromagivendose.
Cons
• Inter-individualvariabilitystillexists,hencecalculationisn’tabsoluteandtitrationto
effectshouldalwaysbedone.
• Predeterminedalgorithmbasedonsampleoffit/healthyindividuals,whommaynot
reflectpatient’sclinicalstates–eg.opioidabusers,extremeages.
• Cancauseadvsereffects:apnoea,respdepression,chestwallrigidity,
bradycardia/hypotensionmorelikelywithremi.
Q8-oxygenfluxfactorsdiscussion,62.7%
1.Outlinethefactorsthatdetermineoxygendeliverytothetissues.(30%)2.Howmightyouincreasetheoxygendeliverytothetissuesinananaesthetisedpatient.(40%)3.Howdoesahyperbaricchamberinfluenceoxygendeliverytothetissues?(30%)
A
Oxygendelivery(g/dl)=bloodflowtotissuexoxygencontent
Oxygencontent=(Hb(g/dl)xo0xygensaturationx1.34)+(0.003xPaO2(mmHg))
B
o Bloodflow/CO/vasculaturetoneetc
o Hb
o Oxygenation
C
IncO2contentdissolvedinblood
Eg.100%,1atmcontent=2g/dL;at3atm=6g/dL;espusefulineg.COormethaemoglobin
whenHblostabilitytocarryoxygen;otherwise,Hbdoesmajorityofworkanddissolved
contentevenwHCtherapydoesn’thelp.
(report)
• Part1:anequationrelatingcardiacoutput,arterialoxygensaturationand
haemoglobinconcentrationtooxygendeliverywithaccurateamountsandunits
• Part2:astructuredmethodofprovidingexamplesofhowtoincreasethevarious
componentsoftheaboveequationegcardiacoutputwithinotropicagents,
haemoglobinwithredbloodcelltransfusion
• Part3:hyperbaricoxygenimprovesdeliverypredominantlybyincreasingdissolved
oxygen
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Q9-Endocarditisprophylaxis(repeat),60.9%
1.Whataretheindicationsforprophylaxisagainstperioperativebacterialendocarditis?2.Justifyyourchoiceofantibiotics.(50%)
(report)
Indicationsforprophylaxisincludepatientfactors:
• previousendocarditisfromanycause
• prostheticvalveorotherintracardiacmaterial
• unrepairedorpalliatedcyanoticcongenitalheartdisease
• acyanoticcongentialdxwithprostheticmaterialwithin6monthsofrepairorwith
residualdefectatsiteofrepair
• cardiactransplantreciientswithvalvuloplasty
• RHDinindigenouspopulation.
Proceduralfactors• dentistryinvolvingworkonthegumsorabreachintheoralcavity,orworkcloseto
theperiapicalarea
• As+Ts
• Ifprocedureisatsiteofestablishedinfection.
ChoiceofAB:
o Dependsonsensitivity+surgicalsite
o Dental/Resptract/ENT
§ Amoxicillin2gPO1hourbeforeorIV2gjustbeforesurgery
§ Ifallergythenclindamycin600mgPO1hourbeforeorIVjustbeforeover
20mins.
§ Orclarithromycin500mgPOIhourprior.
§ IfMRSA,givevancomyin25mg/kgupto1.5gIVslowinfusionbeforeprocedure.
o
Ajustificationofantibioticchoicebasedonthesensitivitiesofthemostlikelyorganisms(eg
streptococcusviridans)includingthetimingofdosingandalterationsforthosewith
penicillinallergy
Q10-defibrillationphysiology,47.8%
1.Describethedifferencesbetweenbiphasicandmonophasicmanualexternalcardiacdefibrillators.(50%)2.Whatisthe“synchronize”buttonfor?Whenwouldyouuseit?(20%)3.Listthepotentialhazardsofdefibrillation.(30%)
MonophasicvsBiphasic§ Mono=passageofdampenedwaveformacrossheartinonedirectiononly
o Requireshigherenergy360Jtoachievedefibcurrentcf.bi
§ Biphasic=sinusoidalwaveformacrosstheheartinonedirectionfollowedby
reversedpolaritywaveinoppositedirection.
o Lessenergythanmonoie200J;
§ Approx.120Jachievessamedefibcurrenttomono360J.
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o Higherefficacycfmono;andduetolowerenergy,exposepatienttoreduce
riskofelectricalinjury,myocardialdamage(seebelowunder‘hazards’)
o Other:bihasautomaticadjustmentofenergyinresponsetopatient
impedencetocurrentflow;hencedon’trequireescalatingenergylevels.
Synchronise§ =shockdeliverytimedwithRwaveofECGcomplex;inarrhythmiawithacardiac
output.Eg.AF,VT,SVT.
o ThereforepulselessVT/VFshouldbemanagedwunsynchronizedshock
§ Toavoidshockdeliveredduringrepolarization(Twave)whichcouldcauseRonTà
malignantventriculararrhythmias
Listpotentialhazardsofdefib:§ Burn->usecorrectivesizedconductivepadscorrectlyapplied
§ MSK/nervedamage
§ Lethalarrhythmias->synchroniseshockifappropriate.
§ Failuretoshock->equipmentmaintenance
§ Hazardstohealthcareworker->cleardeclarationofshockandensurenopatient
contactduringshockdelivery
Q11-Ethics,researchreview,46.6%
Whatarethekeyobjectivesofethicalreviewofaresearchproject?(report)
EthicalPrinciplesinMedicalResearchshouldfollowInternationalGuidelinessuchastheHelsinkiDeclaration.
EthicalReviewobjectivesshouldincludeassessingaspectsofresearchsuchas:• Aimshouldbeclearlydefined,thatistoaddressaclinicalquestionthatremains
unansweredinordertoimproveknowledge.
• Assessparticipantconsentprocess–shouldincludehaveinformationsheetprovided
outliningaimofstudy,whyitisdone,whatitinvolvesforparticipantandhowthe
resultwillcontributetowardsimprovingknowledge.
o Participantsshouldhaveenoughtimetoconsiderbeforeprovidingtheir
voluntaryconsent;haveallquestionsansweredandabletowithdrawfrom
studyatanytime.
• Designofstudy:
o anypotentialharmhasbeenminimized–participantsshouldnotbedenied
anyknowneffectivetreatment;trueequipoisestatusmustbeensured;
confidentialitymustbestrictlymaintained.
o methodologicalvalidity,biasminimisation–randomization,blinding,if
appropriate.
o adequatepowertodetectsignificantfindingieminimizingfalsenegative
(type2)+falsepositive(type1error).
o Ifinterimanalysisshowedpotentialharmorbenefit,theremustbeprotocol
toterminatestudyearlytominmiseharmorunnecessarywastingof
time/resource.
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Q12-ImportantPaedsairwayconsiderations,54.7%
You’regivingapracticaltutorialonpaediatricairwaymanagementtoEDregistrarsatalargehospital.Whataretheimportantaspectsofpaedsairwaymanagementthatyou’dpresenttothem?
Paedsairwaymximportantaspects:(asperreport)
• anatomy/physiologicalfeatures+mxo distinctivefeaturesofneonatal/infantairwaycfadult,covering
• largehead/occipitusà
o useshoulderroll,ensureneckneutral,useshorter
handleifbladeinsertionisdifficultduetolargehead
• smallnasalpassage,nasalbreather,largetongue&tendency
toobstructairway
o useguedeltoovercomeairwayobtxn.
• Shortneck,difficultsurgicalairwaylandmark
• Floppy,longepiglottismakemakeviewdifficult
o Considerstraightbladetoliftepiglottis
• Higherleveloflarynx(C3-4),moreacuteangleb/wtongue&
glottisopening
o Uselaryngealmanipulation+-straightblade
• Trachea=shorter;tendencytohaveEBintubation.
o Vigilanceofdepth+ascultatetoensurebilatAE.
o KnowledgeofcalculationofETTdeptheg.sizex3or
age/2+12.
o Paedsrespphysiology;
• smallerreserveandmorerapiddesaturation
• increasedriskofapneas
• increasedairwayresistance
• increasedriskofatelectasis+effectofgastricdistension+
chestwallcompliance.
• reducedefficiencyofrespmuscles
• lackofresponsetobronchodilatorsduetoabsenceof
bronchiolesmoothmuscle
• (emphasisehighriskpotentiallywithPaedsairwaymx,andcallingforAnaesthetic
helpearlyisessential!!).
• airwayassessmento congentialsyndrome
o dysmorphicfeatures:macroglossia,micrognathia,widewebbedorshort
neck,limitdmouthopening
o difficultywithusinguniversalassessmenttool:mallampati,mouthopen,neck
movement.
• Basicairwaymanoeuvres+equipmento Position,oxygen,signofairwayobtxn:strior,accessorymuscleuse,see-saw
chest/abdowallmovement
§ Andsimplemxstrategies:jawthrust,ensureheadneutral,use
guedel,useCPAP.
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o Utility,sizing,pros/consofguedel(canbeeffectivetorelieveobtxnbutneed
sedationtotolerate),NPA(bettertoleratedinlightsedationbutmaynotbe
aseffective),LMA(needtoobtundairwayreflex;notaprotectedairway).
• IntubationequipmentsandtechniqueinPaedsresuscitationo Laryngoscopetypes(MacvsMillers)
o ETT–cuffed,uncuffed+difference,sizingbyage/4+4;
§ VarietiesofETT:RAE,reinforced,microlaryngealtube,trachytube
o Fibreopticscope
o Laryngoscopytechnique+verificationmethod–clinical+EtCO2(gold
standard)
• Surgicalairwayitsindicationso Crico,mini-trach.
• Commonpaedsairwayscenarioso Stridor,Croup,epiglottidis,foreignbody,tonsillectomy/bleeds,trisomy21,
cysticfibrosis
Q13-morbidobesityobstetricdiscussion,49.1%
Youseea28-year-oldwomanatthepre-admissionclinicwhois32weekspregnant.Sheweighs150kgandhasgestationaldiabetes.Sheishopingtohaveanormalvaginaldeliveryatterm.1.Whataretheissuesyouwoulddiscusswithherduringtheappointment?(50%)2.Whatwouldyourecommendforhermanagementwhenshegoesintolabour?(50%)
Q14-smokingcessation,49.1%
Apatienthassmoked20cigarettesadayforover25years.1.Whataretheexpectedphysiologicalchangesthatwouldoccurinthefirst3monthsfollowingcessationofsmoking?Includeatimeframeforthechangesyoudescribe.(60%)2.Whataretheclinicalbenefits,withregardtoanaesthesia,ofsmokingcessationinthispatient?(40%)FromANZCAPD:(roughlyas1day,1month,2months,6months)• 1day:COHb,nicotine,O2
• 1month:Woundheal,sputuminc
• 2months:Sputumvolumenormalise,lungfunctionimprove,normalisationofopioid
requirement
• 6months:Immunefunction
Beneftis:Airway-reactivity
B–oxygenation,mucus,chestinfection,O2delivery
C–MI,CVA,arrhythmias
D–CVA,DVT/PE
Infection–improvedwoundhealing
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Q15–Neuroprotectioninheadinjury,64.6%
Describetheprinciplesofcerebralprotectioninapatientwithanisolatedclosedheadinjury.Identifyseverity+potentialsystemiccomplication
o Ptassessment–anyevidenceofraisedICP?AirwaycompromisewithlowGCS?
Neurogenicpulmoedemaorcardiacinstability,electrolytedisturbance.
§ ManagewithABCapproach,intubateifGCS<8andmaintain
oxygenation,normocarbia,adequateCPP,normoglycaemia.
o Monitor:artline,routineANZCArecommendation+ETCo2ifintubated.
o OngoingcareinICU/HDU.
MaintainCPPo maintainMAP–withfluid,vasopressor,inotropeasrequired.Euvolaemia.
o Ensurevenousdrainage,headup30deg,neutralposition,nocompressionovervein
ie.Noneckcollar,tubetie.
o ConsiderICPmonitortoguideCPPmanagement.
PreventriseinICPo PreventexcessiveriseinBP.Bluntresponsetostimulationwithanalgesia.Eg.
remifentanilusetobluntairwayreflexonintubation.o Normocarbia.o Consalt/mannitolaimforNa150-155;osmo290-300.o ConsiderEVDifworseningICP/hydrocephalus.o Ifbleedevidentoninvestigation,forsurgicalcontrol/evacuation.
Optimizeoxygendeliveryo Maintainoxygenation>90%
o MaintainHb>70g/L.
Minimisecerebralmetabolirequiremento Avoidpyrexia
o Avoidseizure;ifoccurred,treatwithphenytoin,BDZetc.
April-2009,30.2%
Q1-Universalprecautionandapplication(repeat)36.1%
Whatdothetermsdecontamination,disinfetionandsterilizationmean?Whatmeasuresshouldbeinplacetominimizetheriskoftransmissionofinfectiontotheresptractofpatietnsviaanaestheticequipment?Q2-requirementforsafegasdelivery,48%
WhatareessentialsafetyrequirementsfordeliveryofgasesviaanaestheticmachinesandtheirassociatedbreathingcircuitsinuseinANZ?(don’tincludeventilatorsorscavenginginanswer)
Dangerousgasmixture=
• Hypoxic
• HighCO2
• Eitherhighinhalationalanaestheticconc(withcardiorespdepression)orinsufficient
concputtingpatientatriskofawareness
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Safetyfeaturesforgasdeliverybymachine+circuit(excludeventilator/scavenging)
• Wallgasoutlettomachine
o Colour-codedoutletport:
§ O2-white;N2O-blue;air-black/white
o NISTforspecificgastoavoidmistake.
o Colour-codedhose
o Pressuredat4bar;gaspipelinecheckedwithPharmacist
• Gasfromcylinder
o Pin-indexed
o Visiblepressuremonitoroncylinder
• Anaestheticmachine
o Pressuremonitor/regulation
• Visibleaneroidmanometerfromwalloutlet/cylinderforeach
gas;
o flowmeters
• O2=lastgasaddedtothecommongasoutletattopof
flowmetertubes
o anti-hypoxicdevice
• minimumO2:N2Oratioregulator
• CutoffofothergasesonlossofhighpressureO2
o audiovisualalarm–disconnection,lowO2,high/lowCO2orvolatile.
• Circuit(thisisabitunclear)
o Featuresinclude:unidirectionalvalve,CO2cannister,sampletube,HMEfilter
o Pressureregulation:
• Pressuremonitorofcircuit
• AbilitytoadjustAPLvalve
• Pressurealarms(high/lowP)+disconnectionalarm(audio-
visual)
• Othergases:
o Low/highCO2monitor/alarm
o Low/highanaestheticgasconcentrationmonitor/alarm+interlocksystemi
allowingonly1vaporisertobeswitchedon)
• Infrastructure:
o Level2machinecheckbeginningofanaestheticlist
o Level3machinechecksbeginningofeverycase
Q3–MalignantHyperthermia,81.2%
Apreviouslywell80kg19-year-oldmaleisanaesthetisedforORIFof#tibandfib.HehasaRSIincludingSuxamethoniumandisintubatedandventilatedviaacirclesystemat12breathsperminuteandaTVof700mLwithaFiO2of0.5.Hehashad500mcgoffentanylandanaesthesiaismaintainedwith1.5MACSevoflurane.Hedevelopsanincreasingsinustachycardiato160/minwithfrequentventricularectopicbeatsandhisETCO2risesto60mmHgdespiteincreasinghisventilation.Thereisnorebreathingevidentofcapnography.ABGsnowpO2105mmHgpCO265mmHgpH7.12 HCO320.7mmol/LBE-10 Outlinethestepsyouwouldfollowtomanagethissituation.
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Issue:significantmixedmetabolicacidosis,respacidosisdespiteadequateIPPV.Needsto
consider/mxasMHunlessprovenotherwise.Lookforothersignseg.musclerigidity,
hyperthermia.
Managementstepsoutline• Declareemergency,gethelp,stopsugery,getMHbox+dantrolene/ice,stopvolatile
immediatelyandrunTIVA.
• JobdelegationasperANZCAendorsedguideline–ensuresmallteamtomixmultiple
dantroleneampoules
o 2.5mg/kgdoseIV,repeatQ15minstoresponse.Mayneedtomobilise
dantrolenesupplyfromPharmacy,hospitalscloseby.
o Arterialline,CVL,IDUC.
• VentilateFiO2100%;hyperventilatetolow/normalCO2;reassesswABG
• CVS:maintainMAP>65mmHg.Stabilisearrhythmia/hyperKwithCaCl10%10ml.
• CNS:paralysewithNDMR.
• Tempcontrolto<38deg:coldIVfluid,physicalcoolingmeasures(icepackto
peripheries),coldsalineirrigationofbladder,webswabsinsurgicalfieldandexpose
patient.
• Renalprotectespriskofmyoglobinuria/rhabdomyolysis.Optimisevolumestatusand
monitorUO.AimUO>1.5-2ml/hr.Avoidnephrotoxics.
• Electrolyte:hyperKtx:insulin/glucose,dialysisinseverehyperKespwithrenalfalure.
Postop:ICUandcontinuemaintenanceofvitalsignsasabove+documentationofevents
thoroughly.
Subsequently:musclebiopsy/genetictesting/caffeine+halothanetestingforpatient+
family.Clinicalalertforpatient.
NB:
• VerapamilcauseseverehyperKwithdantrolene
• Dantrolenedose>10mg/kgisunlikelytobeeffective(or35vials).24ampoulesat
least(20mgperampoule)36ampoulesiflargehospitalorisolatedhospital.
Q4-Axillaryblockdiscussion,40.1%
DrawX-sectionviewofarmataxillatoshowanatomyrelevanttobrachialplexusblockforsurgeryofforearm.Listpros/consofblockatthislevelcomparedwsupraclavicularblockProsPtx,horner’s,superficial,cancompressA/Vifpunctured,goodforhand/forearmsurgery,
excellentsurgicalcondition.
ConsLargevolume,riskofLAST,vesseinjury,lesshygienicarea,armabductionrequired,maynot
coveringmedialcutnofforearmandarm;tourniquetpainnotcovered(report)
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Q5-Parkinsonsmanagement(repeat),63.9%
70yomanwith10yrhxofParkinson’spresentsforTKJR.He’sonlevodopa/carbidopa5timesaday.Outlinethemainissuestoconsiderre:PDandperiopmanagementofthispatient
Issues• AssessmentseverityofPD;difficultywcommunicationorCVSassessmentdueto
reducedmobility
§ AbruptstopofPDdrugsmaycauseNMS
• Frailty,nutrition
• ANSinstability,gastricstasis,haemodynamics
• Drugs:avoidinteraction–avoidanti-dopaminergic
• MSK:tremor,unabletoliestill,sitstillmeansregionalmaynotbepractical
• Monitorinaccuracy
• Postopanalgesiaassessmentmaybedifficult;nedtocontinuePDregimenassoonas
practical;riskoffall,riskofDVT.
• Needorganizedhelpwithrehab.
Q6–Pneumoperitoneumphysiology,62.4%
DescribephysiologicaleffectsofpneumoperitoneumwithCO2forlaparoscopyEffects=fromincreasedintraabdopressure(IAP)+CO2absorption.
CVS,dependsonIAP:
• <10mmHg:increasedVR,SVRàincreasedCO,MAP.
• 10-20mmHg:reducedVRbalancedbyincreasedSNStoneàincreased
SVR/HR/contractilityàreducedCObutMAPmaintained.
• >20mmHg:reducedVRoutweighsincreasedSVR/HR/contractilityàlowCO/MAP
• overall,increasingIAPàincreasingmyocardialO2demand,whichisinitially
balancedbyincreasedcoronaryBF,untilhypotensiondevelops.
• Sometimesseeincreasedvagaltoneàbradycardia,hypotension.
Resp
• FallinFRC,RV,ERV,pulmcomplianceàincreasedPeakP.
• IncreasedatelectasisàVQmismatch
GI
• IncreasedGIpressure,riskofregurgitation
• DecreasedsplanchnicbloodflowfromincreasedIAP.
Renal
• Decreaserenalbloodflow/GFR
• IncreasedRAAaxis,ADHsecretionàNaandwaterconservation.
CO2absorption/hypercapnoea
• IncreasedPVR
• Respacidosis
• SNSstimulation
• Increasedcerebralbloodflow,ICP
• CO2narcosisathighlevel~80mmHg.
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Q7-coagulopathyinliverrupture,trauma,MTP&management,35.1%
Outlinecoagchangesyou’dexpectinapatientwithrupturedliverfromabluntabdotraumarequiringmassivetransfusionanddescribehowyou’dminimizethemMTP=>1blodovolumeoor>10unitsRBCin24hours.
Coagulationchanges;fromoriginalinjuryorfromMTP
o Traumainducedcoagulopathy–§ Tissuedamage,shock,glycocalyxdegrade,heparinoidsrelease,
anticoagulantexpression+profibrolyticproteins,ProtCactivation->
increasedtPA->endpointsthatworsenbleed:• hyperfibrinolysis;dysfibrinogenaemia,systemic
anticoagulation,impairedplateletso Consumptive
§ Tissuedamage,SNS,SIRS,shock,activationofcoagcascade(tissue
factorofrF7acomplexactivatecoagulationàthrombin/fibrinform);
eventuallyresultinDICo Acidaemia;dysfunctionalfactors/plateletso Hypothermia;dysfunctionalfactors/plateso Dilutional
Riskminimisation§ Prevent,treatcoagulopathy
o Controlbleedingsource–medicalmx(ifhaemodynamicstable;bleeding
likelyself-contaiing)vs.surgicalmx.
o Avoidhypothermia…
o Avoidconsumptivecoagulopathy;MTP,proactivereplacementofplasma
productswithguidancefromTEGorcoagulationprofiles.
§ HoweverRBC/FFP/Pltratioempiricallyshouldbecloseto1:1:1
§ AimINR<1.5;APTT<40,(orgive4FFP);Ca++>1mmol/L,Fib>1g/L;plt
>50(or>75forsafetymargin).
§ TXAgivenearly<3hours
§ Permissivehypotension,lowvolumeresuscitationuntildefinite
controlofhaemostasis;avoidoverzealousIVFadministration.
§ Cell-saver
§ F7aifallfails,90mg/kg.
o Avoidacidaemia…
§ Optimizeoxygenation,lownormalMAP60-65mmHg,(balancingriskof
bleed);optimizeintravascularvolume+Hb.
§ VentilatetolownormalCO2tocompensateformetabolicacidosis.
§ ConsiderHCO3ifsevereacidaemia1mmol/kg=1ml/kgof8.4%
NB.
§ TIC:=earlyendogenouscoagulopathyindependentofacidaemia/hypothermia;
Worst5-10%isseenonTEGàpoorestprognosis;Mortality4x.
o 2mediators:hypoperfusion+tissueinjur(severityofTICcorrelatedwshock/injury);
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o Catecholaminesurge,endothelialactivate,glycocalcyxdegradeà
Heparinoidsrelease;
o anticoagexpress,profibrolyticproteins,protCactivation(F5,F8inhibited,
inhibitoroftPAinhibitedàfreetPAincreasedtocausefibrinolysis)à
• dysfibrinogenaemia,systemicanticoag,impairedpltactivity,
hyperfibrinolysis(tPAactivation)
Q8-amnioticfluidembolismmanagement,86.6%
OutlinefeaturesandclinicalmanagementofamnioticfluidembolismQ9–periopbetablockerinitiation,43.1%
A65yomalepresentsinPAC.Heisscheduledforfem-popbypasssurgeryforPVDin4daystime.Hehasischaemicrestpaininhisleg.Evaluatetheusefulnessofinitiatingtherapywithbeta-blockerstoreducetheincidenceofperioperativemyocardialinfarctioninthisman.Periop MI prevention encompasses:
o risk factor optimization o arrhythmia, CHF, ACS, severe valvular disease o DM, CRF, HTN, hyperlipidaemia, smoking cessation.
Betablocker initiation is controversial o In general: continue betablockers if on already (AHA/ACC Guideline 2014)
Pro o If v high risk patient with inducible ischaemia on stress testing, o Or intermediate risk with >3 risk factors + o Moderate-high risk surgeries, o No CI, such as asthma, COPD, bradycardia, heart block, adverse reaction, then
o may be benefit to initiate >1wk prior to surgery, titrate to target HR <65, avoid hypotension.
o use longer acting agents (ie atenolol or bisoprolol > metoprolol), possibly reduce risk of periop MI by reducing cardiac oxygen demand.
§ (NB claudication is relative CI) Cons
o However, evidence is inconsistent. o Large trial (POISE) showed cardiac benefit, but showed increased overall mortality, from
increased risk of stroke + hypotension (although dosage of betablocker 100mg considered high in this trial + introduced on day of surgery)
On balance: this is a case of high-risk procedure of moderate ungency. Cardiac risk is >5%. Would potentially beneficial if there’s more time. Given only 4 days away, will NOT initiate bb. Aim for non-malevolence.
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Q10-BronchialanatomyforDLTplacement,70.8%Draw a diagram illustrating the bronchial anatomy to the level of the lobar bronchi
and describe how you’d use fibreoptic scope to correctly position a R/DLT
PositioningR/DLTwithFO:
• PlaceDLTwithR/rotationalmovementastubeisadvanced(withpatient’shead
slightlyturnedleft)
• Checkposition–170cm~29cm;10cmtallerorshortshouldadjustdeeperor
shallowerby1cm.
• Use4.2mmbronchoscope,suitableforsize35FrDLT.
Check
• Entertracheallumen,continueventilaterightside,seeprimarycarina+bronchial
lumengoingintoR/mainbronchus(ensurecuffisjustvisibleandnobronchialcuff
herniation).
CheckR/DLT
• ThenensureRULventilatingportisincorrectpositionwithRULbronchus
o EntreRULbronchusconfirmtrifurcation
• ComebackandmovedistallyseeRML+RLL+secondarycarina.
NB.
• Neonatebronchoscope=2.2mm;paed=3.2mm.
• <6yrs-electivebronchialintubationorbronchialblocker
• 6-8yrs-bronchialblocker,bronchialintubation,uninvent
• 8yrs-bronchialblocker,bronchialintubation,univent,DLT Q11-SAHclippingmanagement,56.4%A 40 yo otherwise health male presents following a sub-arachnoid haemorrhage. He is
scheduled for clipping of a middle cerebral artery aneurysm. Outline the major issues
in providing anaesthesia for this patient and describe how you would address them. Issues for anaesthesia and management
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o Patient o Grade of SAH based on WFNS?
§ Predicts severity of raised ICP? Conscious level? o CVS instability assc with SAH? o Neurogenic pulm oedema? o Electrolyte disturbance? From CSWS/SIADH/DI. o Obtain routine/important AMPLE history and airway exam.
o Anaesthesia o Airway: access limited
• Ensure good secure § Airway reflex needs to be obtuned on intubation to avoid secondary
bleed: remi/TIVA/muscle relaxation. Phenyl to counteract hypotensive effect from induction.
o Ventilation à likely have pulm oedema; use lung protected strategy with PEEP to maintain oxygenation.
§ Maintain normocarbia o Circulation: maintain MAP, ensure euvolaemia. May need to have transient drop
in BP to help with surgical bleed control + clipping. § Minimize BP changes at crucial parts: intubation, pins, incision,
extubation (= key point from report) o D:
§ Optmimise CPP; maintain oxygenation/MAP as above. Optimize venous drainage: head neutral, no compression over neck venous drainage.
§ Be vigilant of potential rupture, seizure; treat with phenytoin, BDZ if seizure occurs.
o Drug: TIVA optimally maintains cerebral autoregulation and potentially confers best neuroprotection; avoid nitrous. Consider mannitol, conc salt as required.
§ Consider ICP monitor, lumbar drain o E: maintain normothermia, normoglycaemia. o M: routine monitor as per ANZCA guideline + A-line preinduction.
o Surgery o Bleeding risk à ensure valid G/H + large IV access. o May perform temp clipping before definite clipping, ensure optimal collateral BF
by maintaining high normal MAP. Postop:
o HDU/ICU for ongoing care and neuro-assessment. o Vigilant of rebleed esp in first 24 hours. o Vigilant of vasospasm esp first 2 weeks: prophylaxis w nimodipine; HHH therapy if
vasospasm occurs. Q12-respiratorydistresspostthyroidsurgery,63.4%Describe management of patient post-total thyroidectomy who has resp distress in
PACU
Simultaneously maintain oxygenation with supplementary O2 while consider differentials. DIfferntials include:
o Tracheomalacia o HYypocalcaemia o Recurent LN injuries o Oedema of airway o Iatrogenic PTX. o D-bleeding / haematoma o Others anaesthetic differentials include:
o A. laryngospasm, aspiration, anaphylaxis o B. bronchospasm o C. MI o D. Oversedation, Residual NMB, Drug error
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Mx: o Call for help + inform Surgeon to review ?haematoma o ABCDE approach:
o A. support/maintain airway: chin lift, jaw thrust; § suction if aspiration, ?haematoma needing release of suture line § temporize measure with adrenaline neb + IV dex if not given already;
consider heliox § meanwhile assess need for re-intubation and set up equipements for
inhalational induction, SV technique; or RSI if bleeding concern, full stomach.
• ENT presence for tracheostomy back up + control of bleed. o B. FiO2 100%; nasoendoscopy to assess RLN integrity and cord positions
§ CPAP § Assess pneumothorax: neck distension, hyperinflated lung, decreased
sound; bronchospasm – wheeze? o C. maintain MAP >65; any presence of shock or ECG changes? o D. assess anaesthetic chart and consider reversibility of any sedatives/NMB? –
§ Naloxone, neostigmine/sugammadex, flumazenil, doxapram. o E. assess electrolyte, replace Ca as required, keep level >2 or ionized Ca >1. o Postop: need ICU/HDU for ongoing management and airway obstruction settles
before extubation. Q13-establishingpaedssurgeryserviceinlocalhospital,13.9%Outline steps to take to ensure safe introduction of elective paeds surgery at your
local private hospital
Consult ANZCA PD on paediatric surgery in general hospital without dedicated paeds facilities + monitoring, and airway equipment.
• Introduction of paeds surgery require MDT approach involving Surgery,
Anaesthesia, Nursing, Administrative support.
• Consult regulatory authorities: local, state and national and set up local group to
consider scope of practice which will include:
o Formulation of local protocols o Policies for patient selection (age >1yo, ASA <3, minor-intermediate surgery) o Policies for transfer: neonates, prem baby, ex-prem baby <52 post conceptual
age, hx of apnoea, or complex medical/surgical problems. o Importantly, Consult other local hospitals / Paeds specialty centre for
advice/review. • MDT approach on implementation strategies, which will require preparation of:
o Staff training for Anaesthesia, Surgery, Nursing (Ward/PACU) on management of Paeds Surgical patients + training with paeds equipment.
o Equipment purchase § Airway § Circuitry, ventilators § Cannulas, BP monitor, defib § Fluid, infusion pumps § Drugs, prescribeing guideliens § Tempcontrol in theatre, air conditioner, to ensure adequate thermo-
maintennace for paed patients o dedicated/separate ward facilities for patient and family care, interview. o + Gradual implementation of plans and ongoing formal rv/QA of the whole
undertaking. Q14-chronicpain,methadoneconversion,35.6%Healthy 28yo male has persistent pain 12 weeks after compound # to lower leg and
now on slow release oxycodone 80mg BD and oxynorm 20mg Q4h. Discuss pros/cons
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of switching opioid to methadone in this situation and how this may be achieved
safely.
Pros
- formulation of methadone has various forms: PO, IV, rectal - no active metabolite - long duration - additional efficacy with NMDA antagonism +/- redcued reuptake of SSRI/NAdr -> enhanced
descending inhibitory pathway. - Less constipation
Cons
- Less familiarity among Anaesthetists - Conversion can be difficult and ratio is a rough guide. Interindividual variability + between
dose (ie higher vs lower dose) variability exists. - Pain control may be inadequate initially and close monitoring titrating to effect is essential. - Titration is slow, should allow 72 hours for peak effect to be seen before further titration.
o Meanwhile, continue with short acting oxycodone for breakthrough pain. - Common metabolic pathway via CYP 3A4, 2D6; competition with other drugs - Long, widely variable elimination half life! - Can prolong QT, needs ECG monitor.
Switching to methadone - Pain assessment + discussion with patient regarding switch. - Safe swtich should encompass
§ Calculation of equianalgesic dose based on FPM published opioid conversion table.
§ I’d start at a lower dose, considering incomplete cross-reacitivty between opioids; ie reduce equianalgesic dose by 30%.
§ I’d divide the dose into BD regimen, then titrate up to target dose Q3 days.
§ In the meantime, use oxycodone as rescue analgesia. § Ongoing regular review by APMS for efficacy/compliance.
Q15-statistics,samplesizediscussion,65.8%How is an appropriate sample size for a clinical trial determined? What are the ethical implications of using an inappropriate sample size in a clinical trial? Sample size determination
• Consider factors such as o effect size – what’s clinically significant difference; the smaller the effect size, the
larger the required sample. o Power – usu. >80% - which describes certainty of picking up the true effect;
higher power require larger sample § Ie type 2 error (beta) set to be <0.2 to accept null hypothesis
o Significance level – which describes the limit above which false positive due to chance is considered to be unlikely, usu. 0.95; the higher the significance level, the larger the sample size.
§ Ie type 1 error (alpha) set to be 0.05 to reject null hypothesis o Variance of sample – describes the variability of study outcome within sample
(difference in means); which can be estimated from pilot studies or literature search. The larger the variance, the larger the sample required; rare events require a larger sample size.
o Drop out / withdrawals – need to be accounted for; therefore increase the calculated sample size by 10%; also allows for margin of error in estimate of variance.
Calculation
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• Computerised Statistical softwares, which formulated to calculated sample size based on factors described above.
• Published tables Ethics of an inappropriate sample size
Ethical consideration • Sample size too small
o Lacks precision to provide reliable answers (type 2 error); result may be misleading and put sujects at risk
o Wastes time and resources • Sample size too big
o Waste resources, money/time. o Potentially delaying initiation of a therapeutic benefit hence prolonging suffering
in those denied treatment. • Trials must have sample size calculation protocol (power analysis) • If adequately powered study has an unexpected large effect, it can and should be stopped
early by data/safety committee who should be overseeing the study.
Oct-2008,50%
Q1-safetyfeatureofvaporizer,43%
Outlinetheoperatingprinciplesandsafetyfeaturesofamodernvariablebypassoutofcircuitvaporiser.Safetyfeatures
• Tempcompensation• Flowcompensation
Principle:Plenum:outofcircuit,vaporiserwherealiquid/vapourphaseofVAiskeptinequilibrium,at
saturation,atthetempset,andvapouruptakedrivenbypositiveupstreamFGF.Manual
dialallowssplittingratioofbypass/vaporiserchamberstreamtobesetàallowsadjustment
ofVAconc.
SafetyfeaturesrelatedtopreventwrongVAused,minimiseVA%inaccuracy,
Tempcompenàheatsinkhighheatcapacitysolatentheatvaprapidlyequilibratedwith
container/containerwithenvironment.SochangetempminimizedinVA.
Flowadjustmentwithtempchangesie.Upflowwithdowntemp,sooverallVAconc
ismaintained;thisisachievedbybimetallicstrip/metalrod.
OrdirectadditionofknownquantityofVAtoFGF.egdesfluranedualcircuitgas
blender.
Flowcompenàensuresat,bymetalorfabricwick/stripmaxsurfaceareaàflow
independence.
Pumpingeffect(remixofvapwithFGF/backpressurefromventilator)minimisedby
pressurevalveorensurechannellengthlongenoughfromvaporiseroutlet.
• VappositionedupstreamfromO2flush,soreduceriskofsuddenincflow.
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Agentspecificvaporiser(requiredduetodifferingphys/chemProperties,hence
calibration.),colourcoded/fillingportkeyindexed/spindleO-ringtightfitfromback
bar/anti-spilldevice/Interlockingsystem/closingmechanism/visibleagentlevel/warning
systemre:lowfill.
Q2-lowerantwallregionalblock(repeat),57%
Describetheinnervationoftheloweranteriorabdominalwallfromtheumbilicustothepubicsymphysis.Describeatechniqueofperipheralnerveblock(notwoundinfiltration)toprovidepost-operativeanalgesiaforalowtransverseabdominalincision.Innervationbranchesof10th,11th,12th(subcostal)intercostalnerves
ilioinguinaln
iliohypogastricn
genitofemoraln
Anatomy:TheanteriordivisionsofT7-T11(antrami)—>intercostalspace
-enterabdominalwallbetweenIO+TAuntilreachRA—>perforateandendingas
anteriorcutaneousbranchessupplyingtheskinofthefrontoftheabdomen.
-Midwayincourse,aroundmid-axillline—>pierceEO—>lateralcutaneous
branch—>anteriorandposteriorbranchesthatsupplytheEOandlatissmusdorsi
respectively.
TheanteriorbranchofT12communicateswiththeiliohypogastric
-ItslateralcutaneousbranchperforatestheIO+EOmusclesandandsupplies
sensationtothefrontpartoftheglutealregion.
Theiliohypogastricnerve(L1)dividesbetweenIO+TAneartheiliaccrest—>lateraland
anteriorcutaneousbranches,theformersupplyingpartoftheskinoftheglutealregion
whilethelattersuppliesthehypogastricregion.
Theilioinguinalnerve(L1)communicateswiththeiliohypogastricnervebetweentheinternalobliqueandtransversusabdominisneartheanteriorpartoftheiliaccrest.
—>Itsuppliestheupperandmedialpartofthethighandpartoftheskincovering
thegenitalia.(3)
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Technique:CALM,SOBER,PLANS,A-lateral/supine
C-cleantechnique
T-timeout
I-imageprobetransverselyplacedatMAL,betweenIC+costalmarginwithHFLprobe.
O-ensure3musclelayersclearlyidentified
N-noteunderneathperitoneum
S-instillLAinbetweenIO+TA-20mlsof0.2%ropivacaineforpostopanalgesiaonbothleft
andright
inplane:needleintroducedmedially,in-linewiththeUS,untilreachesthelayer
betweeninternal
NB.
• I(twice)getlaidonFriday–iliohypo,ilioingui,genitofem,latcutner,ob,femoral
o ielumbarplexus=L1-4primarily,butwithcontributionfromT12tothetwo
‘I’nerves.
o 2fromL1–(iliohyp/ilioing)
o 2fromL2(butalso2from2spinalnerves)–genit,lat,fem
o 2fromL3(butalso2from3spinalnerves)–obt,fem
o allexcept‘I’receivesL2.
• sacralplexus=L4-S4;
o Sacralplexus;5nerves:SIPP+sciatic=L4-S3–supgluteal,infgluteal,post
cutaneous,pudendal,sciatic
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Q3–venousairembolism(repeat),91%
Whatwouldmakeyoususpectvenousgasembolismduringasurgicalprocedure?Brieflyoutlinetheprinciplesofmanagementofvenousgasembolismcausinghaemodynamiccompromise–see2011AQ7Highriskprocedures:
• Postcrafossa• Intraperitonealinsufflation• Beachchair
Mxprinciple
• Emergency,notifySurgeon,stopsurgery,callforhelp.• Airway:intubate• Ventilation:FiO2100%.StopN2Oifinuse.• CVS:asperACLS,CPR(evenifnotinarrest)mayhelptobreakupairbubbleto
smallersize,lessobstruction.o Trendelenburg/rightsideuptoreduceoutflowobstruction.o SupportRVfunction–volume,inotrope/milrinone,vasopressor;minimize
PVR.• Immediatelypreventfurtherairentrainment:
o Loweroperativefieldtobelowlevelofheart.Floodsurgicalfieldwithsaline.o Bonewaxing,occlusionofopenvein.o Jugularvenouscompressionifintracranialsurgeryo UseofPEEPcontroversial:balanceriskofparadoxicalembolithroughPFO
withpotentialbenefitofincreasevenouspressure.o CVLplacementwithtipclosetoRAtoaspirateair.
• Postop:ICU.ConsiderhyperbaricO2therapy/referral.Q4-safehandovertocolleague,63%
Inwhatcircumstancesisitpermissibletopermanentlyhandoverresponsibilityforananaesthetictoacolleagueandhowwouldyouensurethatthishandoveroccurssafely?
Handovercircumstances:Personnel
• fatigue,illness,
• otherlegitimatecommitment
• hassuitable,competentandwillingcolleaguetohandoverto
Circumstances
• ideally,patientisclinicallystable,withoutforeseeableadverseeventsorrequireany
anaestheticinterventionimminentlyeg.inductionoremergence.
Pointstoensuresafehandovershouldinclude:• allfactsrelevanttosafemanagementofpatient• Patient:Hx,exam,invx• Surgery:nature,stageofsurgery
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• Anaesthesia:airway,venttechnique,IVaccess,fluidtherapy,incidents,allergies,
drugsgiven• Thetowrapup:
o Postopplan,destinationo Ensuredocumentationuptodateo EnsureColleaguehasallquestionsansweredo Levaecontactdetailo NotifyTheatreTeam.
Q5–PeriopVTEprophylaxis(repeat),45%An otherwise well 60 yo man having radical prostatectomy. List+briefly evaluate
strategies to prevent periop thromboembolism
Q6-meningococcalsepsismanagement,71%You are covering ICU in your local district hospital when a 14-year-old boy presents to
your emergency department obtunded and hypotensive with a rash suggestive of
meningococcal sepsis.
Describe your resuscitation.
This is a medical emergency! Declare emergency to ED staff and obtain help with resus; Simultaneously assess patient + resus with ABCDE + early antibiotics!
§ AMPLE history + airway, cardio/resp exam. § A – maintain open airway with jaw thrust, chin lift; will need to consider intubation to
protect airway if patient’s LOC deteriorates eg. GCS <8; however, in the first instance, systemically cover resus until help available to provide resource for intubation
§ B – FiO2 100% + monitor sats to ensure adequate saturation > 92%; o ABG to check for adequacy of ventilation; avoid resp acidosis which complicates
metabolic acidosis leading to severe acidaemia o Will need IPPV after intubation is established; maintain low normal CO2 35mmHg
§ C – patient is hypotensive and will require fluid resus to assess response. o IV access (+ blood culture, FBC/UECr/Coags/LFT) o Give 500ml boluses increments to assess effect, continue until no longer
responsive; in which case vasopressor should be used. o In context of severe sepsis, noradr via CVL is appropriate. o Titrate to maintain CPP >60mmHg (if obtunded, likely has increased ICP; hence
aim for MAP >80mmHg). § D – antibiotics: 3rd gen cephalosporin – ceftriaxone 2g IV BD.
o Dexamethasone 8mg IV given before antibiotic providing it’s not delaying AB treatment.
§ Monitor: NIBP, ECG, Sats, temp, IDC; when resource is available, art line + CVL should be established. Admit to ICU for ongoing care.
§ Should investigate with CXR, Urine sample + consider CT scan to assess for other causes of obtunded GCS + signs of increased ICP. LP should be performed after contraindications have been ruled out: ie high ICP, coagulopathy, local infection.
§ Family meeting with diagnosis, treatment progress + consider AB prophylacsis.
Q7-cerebralpalsymanagement(repeat),31.5%A 6-year-old girl with severe spastic cerebral palsy presents for major orthopaedic
surgery to correct lower limb deformities.
Outline the implications of cerebral palsy for anaesthesia management for this
operation.
CP
- = diverse group of neuro disroders characterized by varying deg of motor, sensory,
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intellectual impairment
Anaesthesia mx for major ortho surgery
- Pre
o Thorough preassessment as ortho surgery is major, can be long, painful, involve significant bleed.
o Specifically in CP, look for: § A- TMJ dislocation due to spasticity, potential difficult airway. Fixed
flexion deformity?
§ B- Scoliosis – restrictive LD; hx of CLD from prematurity?
§ C-Cardiac complication of RLD à pulm HTN, RHF
• Will need MDT consult re: periop mx of cardiac complication. § D-Epilepsy, intellectual disability?
§ GI-GORD? – consider aspiration prophylaxis
§ MSK-spasticity? o Routine/important AMPLE history + airway, cardio/resp exam. o Invx: if known RLD, may have PFT and ECHO – assess to establish baseline
function. - Intra
o A- Protect airway in view of frequent GORD, oesophageal dismotility; if severe GORD, perform modified RSI; Sux isn’t contraindicated. If apparent difficult airway, consider asleep SV technique with FOI, or FOI through LMA.
o B- if RLD, need ventilator strategy w small Vt, higher RR +/- permissive hypercapnoea (but avoid if known pulm HTN); key = avoid barotrauma.
o C- if pulm HTN, RHF, need to careful avoidance of worsening pulm HTN (acidosis, hyperCO2, hypoxia); and may require pulm vasodilator eg. sildenafil.
o D- epilepsy care, avoid epileptogenic drugs eg. tramadol, etomidate; continue with anticonvulsant periop. Ensure PONV prophylaxis to encourage continuation of PO meds.
§ Other drug: multimodal analgesia +/- regionals should be used. o E- careful maintenance of temperature, avoid hypothermia which worsens spasm. o MSK: need continuation of anti-spastic; care with positioning which may be
difficult. - Post
o Ongoing monitor/maintenance of stable vital signs. o Analgesia options – expect high requirement, use epidural +/- opioid +/-
ketamine infusions. § Likely have increased opioid sensitivity – need close monitor.
o Ensure continuation of regular meds eg. anti-epilepsy, anti-spastic. o Consider ICU/HDU.
NB. -sux isn’t contraindicated Q8-preeclampsiamanagement,61%A 25-year-old primigravida patient presents to the delivery suite at 38 weeks
gestation complaining of a headache and difficulty with her vision. Her BP is 180/115
and she has clonus. Cardiotocograph monitoring shows no indication of foetal
distress.
Outline your initial management of her preeclampsia.
Q9-peribulbarblock,78%Describe a technique of peribulbar block for cataract surgery.
Describe how you would minimise complications of this block.
Peribulbar=instilLAintowithinorbitoutsidefibrotendinousringofextraocularrectimuscles.
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Preparation:CALM&SOBER,PLANs&ACTIONS
• Consent,assistant,line,monitor.• ConsiderSedation,oxygensupplementandhaveequipmentforresusavailable,as
required.• Needle-25G2.5cmsharpneedle,local-6-10mlsofbupivacaine0.5%+2%lignocaine
mix+hyalase15u/ml.Technique
• Arrangepatient(supine,gazeneutroal),aseptictechnique,timeout.• LAdrop:oxybuprocaine2dropstheniodine2drops• Bloodvesslesarerichinsuperonsasalquadrant(opthamlicartery/opticN);hence
approach=2injectionsclassically.(inferotemporal,midlinesuperior).
o Inferotemp:accesspoint=verticallinedownfromlateralimbustoinfborder
oforbitalrim.
§ 1mmabovethispoint,needleentryverticallyinuntilapproximately
atpostpoleofglobe(20-25mm);
§ walkoffbonecarefullyslightsuperomedially
• watcheyeforanyrotationalmovementwhichindicatessclera
contact=redirectneedleinferolateraltoavoidsclera
perforation
§ negativeaspiration,then~3-5mlsofLA.
• Stopinjectifglobebecomestense!
§ ApplygentledigitalmassageoruseHonanballoontodissipateLA.
o Midlinesuperioraccess=1mmbelowmidlineofsuperiororbit,needle
verticallyinto~postpole,negativeaspirate,LA~3-5mls.
Complications+riskminimisation:
• Stillriskofperf.(maybeevenhigherriskthanretrobulbar)
o watchforgloberotationalmovement;
o avoidinptwithaxialelgnth>26mm
• Haemorrhage
o AvoidifINR>2orcoaguopathic
o Avoidsuperonasalapproach–richinbloodvessels
• Infection–aseptictechnique
• OpticNdamage–ensureneutralgaze,avoidsuperonasalapproach
• Retrobulbarblok–watchforearlyptosisandproptosis;thenconsidersmaller
volume.
• Brainstemblockàensurenegativeaspiration/noCSForblooddrawback;anticipate
potentialriskandhaveresusequipmentavailable. Q10-cerebralvasospasmmanagement,66.7%Discuss the management of cerebral vasospasm following the coiling of a cerebral
aneurysm. Aim
o Risk stratify based on WFNS or Fisher (which predicts vasospasm+prognosis) o Prevention with nimodipine prophylaxis as soon as practical after SAH diagnosis
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o Optimal supportive measures to ABCDE – maintain oxygenation > 90%, Hb >70g/L; maintain low normocarbia, normothermia/normoglycaemia
o Manage ICP o In addition to supportive measure, perform HHH therapy and maintain CPP o Minimize rise in ICP – mannitol, conc salt, EVD drain, treat seizure/pain o Consider ICP monitor to guide CPP management o Reverse vasospasm
o Close monitor of patient’s neuro status in HDU/ICU – vasospasm risk remain elevated up to 2 weeks post SAH.
Vasospasm Management
o Nimodipine o 60mg NG Q4h or 1-2 mg/hr IV, but balance risk of hypotension
o HHH therapy o ICU book: HHH: up MAP titrate to neurology, then maintain (likely MAP 90-110 or
MAP + 15%). If no improvement after 2-4 hours, consider interventional radiology.
o hypervolaemia to increase MAP (unless LVF), which will also achieve; CVP>12mmHg
o haemodilution HCT 30-35% - decrease vascular resistance, optimize flow o Interventional radiology: consider intra-arterial vasodilator-GTN, papaverine
NB.
Q11-chronicpaindevelopment,53%
Listtheriskfactorsforthedevelopmentofchronicpainfollowingasurgicalprocedure.OutlinepossiblemechanismsfortheprogressionofacutetochronicpainChronicpain=painpersistdespitehavingrecoveredfrominitialtissueinjury.Iepersistent
pain>12weeks.
Riskfactors=usualforPPP+- Patient
- Surgery–highdegreeoftissuedestruction;postopradiation,chemotherapy.
o Highrisksurgerytype=amputation,breastsurgery,thoracotomy,inguinal
herniarepair,CABG,LSCS/hysterectomy
- anaesthesia
Mechanismsforprogressiontochronicpain
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- Peripheralsensitization/inflammation(subP,leucotrienes,calcitoningene-related
peptide)àallodynia,hyperalgesia,dysaesthesia
§ Formationofneuroma/nervespoutingmaycontributetoperipheral
sensitisation
- Centralsensitization:neuronindorsalhornsensitizedvianeurotransmitterson
NMDA-R;NK1-Ràcausealteredgeneexpression,proteinexpression,neuronal
changesatspinalcordlevelàwind-up
- ->wind-up/NMDAtrigger->centralneuralsensitization
- Othercentralchanges:
o Changesinsomatosensorycortexmayleadtodevelopmentofphantomlimb
pain
o ImpaireddescendinginhibitorypathwaypostCVA,spinalinjury
o SNSinvolvement–type1followingtissueinjury;type2followingnerve
injury.
Q12–IABPdiscussion,59%List the indications and contra-indications for the use of an intra-aortic balloon pump.
Describe how its performance is optimized
IABP – improve ventricular function by o Increase myo O2 supply o Decrease demand (decrease afterload + enhanced Windkessel effect).
Indications
o Severe/refractory systolic function impairment, failed medical treatment o Cardiogenic shock
o Post MI o Bridging to cardiac transplant o Post MVR
o Symptom control in severe CAD as bridging to imminent CABG
o Weaning from CPB o Acute MR, VSD eg from AMI
CI:
Absolute o Aortic regurgitation (>mild) o Aortic dissection o Chronic end stage heart disease with no anticipation of recovery o Aortic stents
Relative o Aortic trauma or aneurysm including AAA o T achyarrhythmia o Uncontrolled sepsis o Severe PVD o Coagulopathy
Optimise performance:
o Size of ABP, balloon volume o Positioning (3-5cm distal to L SCA) o Correct trigger = ‘counter pulsation’
o Inflat: arterial pressure trace (dicrotic notch) or ECG (T wave midpoint) o Deflat: prior to upstroke & R wave ECG
§ Use arterial / aortic trace intraop, as diathermy interferes with ECG trace! o Helium for inflation/deflation (low density) o Sinus rhythm if possible, rate controlled o Set at 1:1, 1:2, 1:4
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Q13-statistics,definitions,53%
Explainthetermssensitivity,specificity,positivepredictivevalueandnegativepredictivevaluewhenappliedtoadiagnostictest.
Sensitivity=truepositive/(truepositive+FN)
• Ierateoftruepositive(howmanytrue+veispickedupofall+ve)
• Abilityoftesttodetectdiseaseamongpatientswiththedisease
o otherwords,highsensitiveindicateslowfalsenegativerate,inwhichcascea
negativetestresultisusefulatrulingdiseaseout
Specificity=truenegative/(truenegative+FP)
• Ierateoftruenegative(howmanytrue–veispickedupofall–ve)
• Abilityoftesttoruleoutdiseaseamongparticipantswhodon’thavethedisease
o Otherwrods,highspecificindicateslowfalsepositiverate,inwhichcasea
positivetestresultisusefulatrulingdiseasein
PPV=TP/(TP+FP)• Ielikelihoodthatdiseaseiscorrectlyidentifiedbyapositivetest
NPV=TN/(TN+FN)
• Ielikelihoodthatdiseaseiscorrectlyruledoutbyanegativetest
PPV&NPVconsidersprevalenceofthedisease.
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• Ifdiseaseiscommon,thenapositivetestistrulylikelytoindicatepresenceof
disease;hencePPVwouldbehigher.
• There’sreciprocalrelationshipbetweensensitivityandspecificity
NB.
Justrememberdefinitions.Don’toverthink.
BayesTheorem:PPV=sensitivityoftestxprevalence/numberofpositivetests
Q14-impairedcolleague(repeat),69%
Whatarethesignsthatmaymakeyoususpectopioidabuseinacolleague?Ifyouhadsuspicionsofopioidabuseinacolleagueoutlinetheprinciplesthatshouldguideintervention.(followingpointsfromAucklandslide)–there’salsotheSAQpractise
BasemanagementonANZCAWelfaredocguidanceonsubstancemisuse
Patientsafetyisprioritywhileinvestigationtakesplace.Ifimmediaterisklikely,needsimmediateaction.Signsofopioidabuse/Factors
• Difficulttodetectandneedhighindexofsuspicion
• Majorsigns
- IVaccessarm,injectionmarks,swabs/needle/ampoulesseenoutside
ofclinicalenvironmenteg.changingroom/home,observationofself-
injection.
- Falsificatinoofrecord,signingoutincreasingquantities,inappropriate
highquanitityforcase,discrepanciesinrecord,
illegible/inaccurate/alteredrecordings;consistentcomplaintofpain
inpatientsoftheanaesthetist.
- Majorchangeinmood,behaviours,tremors,withdrawalsymptoms,
intoxicated.
• Minorsigns
- Bloodstainedcloth,carryingsyringes/ampoulesinclothing
- Isolation,refusingbreaks,willingtorelieveothers,volunteerformore
oncallsafterhours,seeninunusualplacesinOT,remaininginhospital
whenoff-duty
- Incrasedsickleave,unavailability,socialwithdrawal.
- Increasedaccidentsormistakes,unsatisfactoryworkrecords.
Principlesofintervention(prepare,intervene,post-intervention)• Confidentialinvestigation–involvewelfareOfficer,HOD;gatherinformation.
o Contactpreviousemployers• Planforactions• MDTapproachwithcontingencyplan
o Interventionearlyindayo Colleaguewell-beingisessentialandmustcontinuouslymonitorforsuicidal
riskthen
o Support:returntowork
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o TakeTimetolisteno Outlineteamroles–includingPsychassessmento Notify–doctorofmeeting/purpose.Needsupportperson?o Escort–atalltimes;immediateinpatientfacilityfordetoxprogram(2-3
monthstreatmenttimerecommended).o Document
• Statutoryreportingrequirements• Futureretrainingopportunities
o RegulatoryBodyrequirements–AHPRA/MCNZo Healthmonitoro Activepreventativeprograms
NB.
Statutoryreporting:
• Regulatorybodies:AHPRA/MCNZ–AustralianHealthPractitionerReg.Agency
o HPCAA2003–healthpractcompetencyassuranceact–mandatoryreport
o MandatoryreportingisgovernedbyMCNZ,notbyLaw.
§ Failuretoreportisnt’acriminalact,butmaybeabreachof
professionalobligationsetoutbyMCNZàdisciplinaryproceedings.
§ However,iffailuretoreportleadstopatientharm,patientmaysue
thepersonwhofailedtoreport.
• Law=cannotpractiseifdysfunctional;includingjudgement,skill,knowledge,
behavior,infectionrisk.
Q15-OSAmanagement,86%
Whatsymptomsandsignssuggestthepresenceofsleepapnoeainapatientpresentingforpre-operativeassessment?Howdoesthepresenceofsleepapnoeaalteryouranaestheticplan?
May-2008,47%
Q1-Oxygenstorageanddeliverydescription,52%
Outlinehowoxygenisstoredatthehospitalanddeliveredtooperatingtheatresuptoandincludingthewalloutlet.Inyouranswerincludefeaturesthatensurethesafetyofthesystem.O2=Storage
• InVIE(vacuuminsulatedevaporiser)§ Liquidat-189C(BP=-180C);pressuredat10bar;doublewalled,
vacuuminsulatedfromenvironmentaltemp;haspop-offvalvesafety
mechanismtoavoidover-pressurisation/explosionwithincreasing
pressurefromincreasingtemp.Canbeheatedtoincreaseddemand
andmaintainoperatingpressure.§ Supportedby3legsincluding1measuringweight/contentofVIE+
alarm.§ Storedawayfrommainhospitalbuilding,fenced,nosmokingin
vicinity
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§ SpecificindexedconnectorsoonlyO2canberefilledintoVIE.• Backupoxygencylinder
§ Oxygencylinder,varioussizes–eg.CinAus/AinNZ.• Pressurizedgas;fullcylinder=137bar• Amountproportionaltopressure
§ Bankofmultiplecylinders+backup.§ Fillingratiomonitoredtopreventexplosionofcylinderinextreme
tempDelivery
• VIEtoOTgasoutlet§ Safetymechanism:uniquesizefromothergaspipes,labeled,valveto
ensureunidirectionalflow,pressureregulateddownto4barin
pipeline;monitoredwithalarmwhen20%pressurechangedetected
whichshutsoffvalvesdownstreamtoeveryOTs.Heatingsystemto
maintainstabletemperatureinpipeline.§ HasconnectingvalvetobackupoxygencylindermanifoldshouldVIE
supplyfallbelow4bar.• Gasoutlet
§ 4bar§ safety:colourcoded,NIST(non-interchangeablescrew-threaded
connection),selfclosingvalves,gascheckedwithPharmacist,alarm
syteminplaceoflossofsupply.• Oxygen=white,N2O=blue,air=black/white.• +colour-codedhosestomachine.
§ Abilitytocloseoffoxygensupplytodesignatedareashould
emergencyoccureg.fire/explosionNB.
Cylinder–160000kpaà400kpa
Nitrousoxide-storedasaliquidwithvapouronthetopatapressureof4400kPa.
Q2–RAarteriallineevaluation,complication,69%
Whyistheradialarteryacommonsiteforarterialcannulation?Whatcomplicationsmayoccurfromradialarterycannulationandhowmaytheybeminimised?RAusedcommonly
• Superficialanatomy
• Dualsupplyofhandbyradial/ulnararteries,assafetyfeatureifRAoccludes
• Discretefromnerves
• Relativelycleanarea,lessriskofinfection
• CorrelatewellwithcentralBP
• Easytoaccesswrist.
Complications+riksminimization
• Haematoma/bleed
o AvoidmultipleattemptsifdifficultanduseUSSguidance
o Ensuretapclosedwhennotinuse.
• Infection
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o Aseptictechniqueoninsertion.Cleardressingoverlinetoallowearly
detection;aseptictechniqueduringsamplingfromline.
• Thrombosis
o Removearteriallineasapwhennotrequired
o Pressurizedsalinebagconnectedtoartline,intermittentflushtopreventline
occlusion.
• Ischaemiatohand
o Allen’stestpriortocannulation,howeverthishaspoorPPVandNPV.
• Inadverdentarterialinjection
o Ensureclearlabel,injectionportprotectedbyredcolouredcap,redlineon
cathetertoindicateitsarterialline.
• Inaccuratereading(bubbletrapping,disconnection,inaccuratetransducerlevel)
Q3-interscaleneregional,49%
DescribetheanatomyofthebrachialplexusrelevanttoperforminganinterscaleneblockunderUSS.Includeadrawingillustratingtherealorsonoanatomyyou’dexpecttoseeinatransverseviewofthebrachialplexusatthepointofneedleinsertion.
Anatomydescription:
• Brachialplexusbetweenant+midscalenemuscle
• C6=mainlyroots+trunks
• AdjustuntilC5-7seen;lateralapproach,ensureothervulnerablestructuresnot
injuredbyvisualizingneedletipcontiuouslyawayfromvulnerablestructures
o Vessels:carotid,jugular.àaspiratebeforeinject.
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§ Carotidsheathanttoantscalenemuscle
o PhrenicN.anteriortoantscalene.
o Thoracicduct;antmedialtoscalenemuscle
o Domepleura(inferiorthanC6)
o Vertebarteryintransverseprocess
o CervicalSNSganglioin:medialtocarotidsheath;antlattovertebralbody.
Q4-Fatembolismsyndrome,73%
DescribetheclinicalfeaturesandtreatmentofFESFES:
§ Usu.postlongbone#,1-3days(rarely<12hours).OrDM,pancreatitis,alcoholic
liverdx,bonetumourlysisetc.
Features
§ Classictriadofpetechiae,CNS/confusion->coma;Resp-dyspnoea->arrest
§ Others:fever,CVS-tachy->rightheartstrain,plmoedema,pulmHTN,
thrombocytopaenia.
Mx
§ (thisisn’trequiredbyreport)Considerdifferentials–anaphylaxis,PE,PTX,CVAetc.
§ earlyimmobilization/reductionof#.
§ largelysupportive.
§ ABCDapproach
o AvoidworseningofPVR;considerNO,sildenafil,milrinone,RVsupport.
§ Surgicalprevention:
o Avoidhighintra-medullarypressureduringrodding;venthole.
NB.Knowdifferencesbetween:
§ Fat:pulmHTN/pulmoedema,CNS,rash
§ Cementimplant:similartoFAT,butmoreCVSfeature;similartoanaphylaxis+pulm
HTN/RHF
§ Air:CO2,hypotension,tachycardia,JVP,rightheartfailure.
§ Amnioticfluid:anaphylactoid
PathogenesisofFES:(causeisstillunknown)
§ Mechanicaltheory–obstructivemicroemboli
§ Biochemtheory–degradeoffat->FFA,causinginflammation,myocardial
dysfunction.
Q5-intrathecalmorphinediscussioninTKJR,48%
A65yofemaleweighs85kgand165cmtall(BMI31)isscheduledforTKJR.Shehasnootherhealthproblems.Discusstheprosandconsofintra-thecalmorphineforpost-opanalgesiainthispatient.(salientpoints)
Pros- Prolongedaction
- Easeofadministrationwithspinalanaesthesia
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- Nomotorblock,lesssympathectomycfw
- Lesssystemiceffect
- LikelybetteranalgesiathanIV/POmorphine.
Cons- Cephaladmigrationmayleadtodelayedrespdepression;espifpatienthasOSAwith
highBMI
- Complexitywithmonitorwithadditionalopioiduseforbreakthroughpain
- Invasivewithspinalanaesthesia–bleed,infection,PDPH
- Adversereactions:itch,ileus,urineretention,reactivationofherpessimplex
Q6-hyponatreaemiamanagement,53%
Theelectrolyteherearetakenfroma38yowoman,obtunded30hoursafterabdohysterectomy.She’sotherwisehealthy.Explainhowtheseelectrolytescouldhavehappenedanddescribehowyou’dcorrectthem.Na110K3Cl80HCO325Glucose5Urea3CrnormalOsmolality225mosmol/kg
(UsesameclassificationsystemasLITFL)
Electrolyteabnormalitiesare:§ Hypoosmolar,Hyponatraemia
§ Hypochloraemia
§ Mildhypokalaemia
Causesofabnormalities:§ Hypovolaemia(losingNa+volumefromdifferentialsbelow)
o Diureticsuse:loop,thiazide
o RenalimpairmentwithRTA(unabletoretainNahencewater)
o Addison’s/adrenalinsufficiency
o Extra-renalNalosseg.diarrhea/vomit/pancreatitis
§ Euvolaemia(holdingontofreewaterduetodifferentialsbelow)
o SIADH
o VoluntaryexcessPOintakeofwater(thesecouldbeunderhypervolaemia
too)
o OveradministrationofIVF(thesecouldbeunderhypervolaemiatoo)
o Saltrestricteddiet
§ Hypervolaemia(unabletovolumeregulate,andretainingwatergreaterthansalt)
o OveradministrationofIVF,especiallyifhypotonicfluidused
o Others:HF,nephriticsyndromeorAKI
Correctionstrategies
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§ ABCapproach+considerhypertonicsalineifpatient’sacutelyhyponatreamiaor
symptomatic–obtunded,seizure.
§ Dependsonpatient’svolumestatusbasedonhx/exam.
o Ifhypovolaemic:
§ Volumeresuswith0.9%NaCl.
§ Ifadrenalinsufficiencysuspected–longtermsteroiduse+profound
shock–givemineralcorticoidreplacementeg.hydrocortisone100mg
IVTDS.
§ Ifextra-renalloss:estimatevolumeloss+replacevolumeml:ml.
o Ifeuvolaemic/hypervolaemic
§ Givehypertonicsaline3%1-2.5mls/kg/hràuntilsymptom
improvementorNa>125.
§ Withholdfreewateradministration.
§ AdmittoHDU/ICUforongoingmonitor/management.
§ Inallcases,shouldmonitorpatient’sclinicalstatus+electrolyteclosely(eghourly).
LimitdailyNariseto<10mmol/day.Rapidcorrectionisdangerous!Cancausecentral
pontinemyelinolysis.RoutineANZCAmonitor+placeart-linetofacilitate
haemodynamicmx+monitoringfoelectrolytes.
Q7-antplacentapraeviamanagement,59%
A34yowomanpresentsat36weeksgestationwithananteriorplacentapraeviaandLSCSisscheduled.Shehasnointercurrenthealthproblems.Shehasahistoryof2previousLSCSunderregional.DescribeandjustifythechangesthishistorywouldmaketoyourroutinepreopandintraopmanagementplanforLSCS.
Q8-neonatalresus,56%
Youareaskedtoprovideassistancetoresuscitateababy.Oneminafterbirththebabyisapneic,grey/blueallover,floppyandunresponsivetostimulation,withapulsefeltintheumbilicalcordstumpat60/min.Whatisthisbaby’sAPGARscore?Describeyourresuscitationofthebaby.
APGARscore=BiT2CH• Appearance(colour)=0
• Pulse(HR)=1
• Grimace(tone)=0
• Activity(tone)=0
• Resprate(breath)=0
APGAR=1
NLSdescription
• Callforhelp,monitoron,resuscitarewarm,dry/stimulateifnotproperlydone
already;assessBTCH/satsQ30sec,equipmentreadyforlikelyintubation+drugs–
dex,adrenaline,fluid,HCO3;establishIVviaumbilicalvein,orconsiderIO.
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o Hxofhighriskdeliveriesshouldbeobtained-?diabetes,substanceabuse,
opioiduse?Prematuriy?Twinpregnancywithriskofanaemia?
Chorioamnioitis?• Keepbabywarm
• A-open
o Chinlift/jawthrust,avoidoverextension/flexion.Suctionifmeconiumseen.
o Aim=oxygenationandshouldassessoverallstatusofABCratherthan
fixatingonintubation.Howeverconsidertrachealintubationatseveralsteps
• B-givennotbreathing,willgiveinsufflationbreathx5;withRA–(2-3secat30-40cm
water)+ventilatefor30sec(20-30cmwater,RR40-60bpm,dependingonpost-
conceptualage).
o Ifnochestexpansion,repositionairway/bettermaskseal,considersuction,
OPAorincreasedPinsp
• C-30secslater,assessrespeffort+HR(auscultate)
o IfHR>100+goodrespeffort,givefreeflowO2thengraduallyweanifable
o HR60-100,continuewithventilation+Q30secreassess
o IfHR<60,performchestcompressionwithBMVwithratioof3:1(100/min);
reassessQ30sec;40%FiO2,then100%ifnoimprovement.
§ IfongoingHR<60,considerdrugs:
• Adrenaline:10mcg/kgIVorETT100mcg/kg.
• Dex:10%,2ml/kg
• Fluid(normalsaline)10ml/kg
• HCO3:4.2%1ml/kg
• +considerintubation=size3.5ETTneonateof3ifprem;
depth=9.5cminneonate.
• Sendcordbloodgas+refertoSCBUforongoingcareifanysignofincreasedWOB.
NB.
Q9-laserairwaysurgery(repeat),70%
A25yomanistohavelasersurgeryforavocalcordpapilloma.Whatarethehazardsassocwiththeuseofalaserinthissituationandhowcantheybeminimized?
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Q10–AICD/Biventpacingmanagement,62%A patient with an AICD with biventricular pacing presents for elective surgery.
Describe how the presence of this device influences your perioperative management
of this patient
Bivent pacing AICD o = pacing of R + L ventricles o usu for management of severe CHF, hence must ensure optimisation in elective setting. o Risk vs benefit carefully assessed o Consider referral to Cardilogist if any sign of CHF.
Periop mx: Pre:
o Hx/exam look for symptom/signs of CHF o Echo: Cardiac function o ECG: pacemaker dependence? o AICD/PM technician recent revision report?
o by local policy, eg. >6/12, then may need referral for technicican interrogation. o Setting? Battery life? Magnetic placement? Dependence? Underlying rhythm?
o AICD reprograme preop o Disable rate responsiveness, anti-tachycardia fxn by technician or magnet o Maintain bivent pacing o Consider asynchronous PM if dependent + diathermy use near PPM
o Availability of electrophysiology service on DOS. Intraop:
o Resus drugs ready eg. isoprenaline, atropine, external pacing device, defib pad applied prior to surgery
o Monitor: routine ANZCA guideline + art line + CVP due to high cardiac risk + 5 lead ECG pace-maker detection on
o Minimise EM interference: o Bipolar > unipolar o pad placement far away from PPM o avoid diathermy <15cm of PPM. o 1 sec burst Q10sec to avoid repeated asystole
o having technician service close at hand in case event of haemodnamic compromise from loss of AV synchrony/bivent synchrony.
Postop: o re-interrogation of PPM, back to preop setting. o PM check if abnormal ECG indicating PM seen, cardioversion/defib occurred, or diathermy
use <15cm of PPM. Q11-murmurinchilddiscussion(repeat),67%You are the anaesthetist at a children’s hospital. A 3yo child scheduled for dental
restoration and extractions is found to have a systolic murmur during your preop
assessment on the day of surgery. They have been on a waiting list for 6 months and
have had a dental abscess that settled with antibiotics. Describe hwo you would
evaluate the significance of this murmur and how this evaluation would affect your
decision to proceed or not with surgery.
Q12-transphenoidalsurgeryforacromegaly(repeat),52%Outline the issues involved in the pre-operative assessment of the patient presenting
for transphenoidal surgery for acromegaly – see 2014A Q13-Gabapentinasanalgesia,32%Evaluate the role of gabapentin in acute and chronic post surgical pain management
Gabapentin
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= anticonvulsant, structurally similar to GABA. - Has analgesic property, acts on A2D subunit of VGCC at CNS (spinal cord) level reducing
pain transmission. Role in acute post surgical pain
- Investigated and analysed in meta-analysis to show: - Efficacy in analgesia and opioid sparing effect – decreased vomit, pruritus
- Preventative analgesia property (Auckland) - Efficacy in reducing neuropathic pain - Anti-allodynia, anti-hyperalgesia
- Also, anxiolytic effect. § However, dose variation widely across studies, hence effective dose
difficult to derive; but likely in range of >300mg. § Also limited by increased sedation, esp when used concurrently with
opioid. § Only PO formulation available. § Although possible, but hasn’t been proven to decrease chronic pain
development. Role in chronic post surgical pain
- Treatment of neuropathic component of chronic pain, esp: in diabetic neuropathy, phantom limb pain, post-herpetic neuralgia, pain following spinal cord injury.
- Also used as part of multimodal chronic pain treatment. § Equal efficacy to TCA and has safer side effect profile than TCA.
Q14-Multi-centeredtrialdiscussion,61%Describe the advantages and disadvantages of multi-centered clinical trials in
anaesthesia research.
(report) Advantages
Study validity: • Can undertake studies that are not feasible at single institution • Greater stats power, esp for rare events eg. death • Recruitment of large numbers of patients • Quicker patient recruitment • Wider range of patients and clinical settings, therefore better generalizability of results than
a single site study Research collaboration / network
• New researchers develop skills and beneficial relationships with experienced investigators. • Develops relationships for future trials and research collaboration.
Clinical • Patients have benefit of closer supervision than in usual standard of care.
Disadvantages
Complexity of Multicentre trials • Logistics of managing many centres and staff at remote locations (ie main investigator, site
investigator, patients) • Supervision, reliability, honesty and protocol ompliance of remote investigator • Burden of ensuring data quality, data queries and data cleanup • Need to develop method of remote data submission • Data analysis more complicated than single centre study; as it needs to adjust for effect of
centres (ie cannot pool all patients as if similar). Resource intensive
• Expensive. Need to source large funds usu. from competitive grants • Some sites may not recruit adequately, and not offset set-up costs • Additional cost of central administration • Need 24 hr support for troubleshooting; esp. between different time zones. • May have industry sponsorship that may bias protocol and outcome.
Applicability of protocol
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• Protocol must be applicable and approvable at all centres • Protocol must conform with local standards and practices, and ethics. • Logistics of getting protocol through different ethics comittees. Variable standards, but this
is being streamlined through single ethical review; o However local review of multicenter studies is a burden for local ethics
committee. • Studies of procedures depend on level of skill at each centre • Little ability for an individual site to change or influence protocol • Approval of international studies has possible problems of variable national standards,
practices, consent, ethics. Accredibliity of result
• Control of data analysis, writing of paper and publication relinquished to another body. Q15-MRIdiscussion,65%Outline problems of providing GA in MRI suite for adult.
Environmental
o Foregin, remote, limited access to help and resus drugs/equipment. § Similar consideration for recovering patient in a remote location.
o Transfer issue before/after under GA? Alternatively, likely require Transfer before and after MRI under GA eg back/forth from ICU or OT/PACU
Anaesthetic equipment precaution
o MRI compatible equipment: Requirement for MRI compatible machine/ventilator/monitor § Airway equipment – laryngoscope, need to be outside of MRI room § ECG: Wires should not have coils to avoid electromagnetic heat induction
causing burn; Pad placed between ECG lead and skin. § If machine incompatible, will need to be placed outside of MRI room.
o Long anaesthetic circuit, IV infusion lines required with significant deadspace and potential inaccuracy with sampling of gas mixture, spirometry; or delayed infor
o Auditory alarm of machine not reliable in MRI suite due to noise § Place machine/infuser outside of MRI room so alarm can be heard.
Patient safety
o Limited Access: to patient limited during scan o MRI indication + Standard AMPLE/ABC exam
o Implication of GA in adult patient? Confused, septic, unstable, claustrophobic, intellectual disability? à careful assessment.
o Mandatory MRI safety assessment to ensure no ferromagnetic substance/contraindications: § Jewellery, hearing aids. § Important safety considerations incdlue:
• Heart: generally safe: endothelialised/fixed by fibrous tissue eg. stents (unless recent), prosthetic heart valves, sternal wires
§ other ones not endotheliailsied = not safe: PPM/ICD
• Brain/eyes/ear: aneurysm, neurosurg clips, intraocular metallic foreign body, cochlear implants - not safe; unless they’re titanium clips
• Orthopaedic Joint replacements: generally safe, but evaluate each individually
§ Noise levels protection as level >85decibels
Staff safety
o Repeated MRI field exposure effect unknown – ideally all staff should vacate MRI room during scanning.
o Emergency helium gas release/quenching à hypoxic environment, during MRI shut down § Familiarize with emergency procedure to evacuate/manage this § Have working O2 sensor in scanning room.
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Sep-2007,45%
Q1-macroshockprevention,40%
Explainthefeaturesoftheelectricalpowersupplytooperatingtheatresthatprotectpatientsfrommarcoshock.
Macroshock=o whenpersoncompletesanelectricalcircuitbetweenactive/neutralwireandearth
§ 5mA=pain
§ 10mA=sustainedmusclecontraction
§ 50mA=respparalysis
§ 100mA=VF
o muchlargercurrent,thanmicroshock(=50uAdirectlytotheheart)
Patientsareconnectedtomultiplemonitors(ECG,oesophagealtempprobes,CVLin
theatre),whichpotentiallyexposestomoreleakycurrents,faultyequipmentsoraccidental
earthing,withsubsueqentriskofbothmacro/microshock.
Robustprotectivemechanismsmustbeinplacetoensurepatient/staffsafety:
ProtectivefeaturesofpowersupplyinOT
• Isolatedpowersupply
o Externalpowersupplyisisolatedtotheatresupplybyuseofelectromagnetic
induction
§ Hencewhenpatientcomeintocontact,preventscircuit
completion/macroshock
• Earthingofcasing+fusesorRCD(ieClassIequipment)
§ Henceiflivewirebecomesfaultyandtouchescasing,currentflows
downearthwhichmeltsfuses/tripsRCDtodisruptcircuitandraise
alarmoffault.
• RCD(circuitbreaker/safetyswitch)
§ Detectscurrentfromactiveandneutral;ifdiscrepanciesinflow
occurs(iepresenceofleakingcurrent,aslowas10mA)àtripsRCD
whichbreakscircuit<50mspreventingmacroshock
• Thereforenotidealifcontinuitysupplyisessentialforlife
savingrequirement;howeverthisisgenerallynotaproblemin
bodyprotectedareas.
• LIM(lineisolationmonitor):
§ Monitorsleakingcurrentcontinuously;alrmswhencurrentsensed.
§ Doesn’tbreakcircuit,butallowsfaultyequipmenttobeidentifiedto
preventmacroshock
• Equipotentialdevice
§ =mechanismwherecasingsofalltheequipmentinOTareearthedto
samepotentialsonopotentialdifferencebetween2livecasings
hencenopotentialsourceformacro/microshock.
• Regularmaintenanceandcheckingofelectricalsupplyandequipments
• Othersmechanisms:
o Class2equipemtns-Doubleinsulationofallparts
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o Class3–safetyextralowvoltage(SELV)tominimizepotentialcurrentflowto
levelsthatwon’tcausemacro/microshock(differentlevelsasdefinedby
Bodyprotectedorcardiacprotectedequipments)
o Non-conductingflooring/bedding
Q2-chestdraindiscussion,88%
A60yearoldmandevelopsalargehaemo/pneumothoraxfollowingattemptedinsertionofahaemodialysiscatheterviatheleftsubclavianroute.Describeyourtechniqueofchesttubeinsertiontodrainthisandthefeaturesofthepleuraldrainagesystemyouwouldconnecttoit.
TechniqueforICDplacementtodrianL/haemoPTX.• Prep-CALM&SOBER.
• Surgicalopinions.
• Execution:ACTIONS(modifiedfromregionalacronym)–arrangepatient,
clean/asepticapproach–(fullpreplikeinneuraxial),timeout,notevulnerable
structures,placeICD.
§ AcquireLandmark=midaxillaryline;5thintercostalspace
§ Insertion:LA,bluntdissectover6thrib,walkuprib,identify5
thIC
space,bluntdissectICmuscletopleura,thenpleuralspace;largetube
clampedinserted(post/superiorly,30Frtodrainblood),secure
dressing–suture/ties/tightsealdressing.
§ ConnecttoUWSDlowerthanpatient;thenunclampthetubetostart
drainingblood.
FeaturesofUWSD• Placedlowerthanpatient;atleast45cmbelowtoavoidre-breathingoffluid
drained.
• 3bottlesystem.
o 1st=collection
§ drainofblood+evaluationofvolumecollected
§ tubeiswidetoreduceresistance+large>1/2ofpatient’smax.insp
volumetoavoidfluidre-enteringchest
o 2nd=UWSD
§ preventsentrainmentofairintopleuralcavity
§ volumeofwaterinbottleshoult>1/2ofpatient’smax.inspvolumeto
avoidindrawingofair
o 3rd=suctionbottle
§ weight/heightofwaterabovetubeisproportionaltodegreeof
suctionapplied.
• Othersafetynotes:
o Clampdrainwhenmoving;unclampwhenmovingfinishes;orevenbetter
useaHeimlichvalveduringtransport.
o Ifsuctionifoff,thentubingshouldbeunpluggedtoallowair/fluiddrainingto
avoidPTX.
o Avoidsuctionpostpneumonectomy.
• Complications:
o Kinking,occlusion,
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o Retrogradeflowoffluid
o PTX(espwithprolongedclamping!)
o Bottlescanbreak(ifmadeofglass)
o Drainsmustbeuprighttomaintainseal
Q3-guidelineforepiduralabscessriskminimisation,64%
Outlineguidelinesyouthinkshouldbeinplaceforreducingboththeincidenceandthemorbidityofepiduralspaceinfectionsasacomplicationofepiduralanalgesia.Patientselection
Aseptictechnique
Handlingofcatheter
Post-placementFU
Post-dischargeeducation
Managementifinfectionsuspected
Q4-blunttraumatoheart,72%
A40-year-oldwomanpresentshavingbeentrampledonbyahorse.Shehasacompoundfractureofherarmrequiringsurgeryandbruisingoverthecentreofthechestwithafracturedsternum.Listtheinjuriestotheheartthatmaybecausedbythisblunttrauma.Ifshehadnosignsorsymptomsofcardiacinjurylistandjustifyanyscreeninginvestigationsforcardiacinjuryyouwouldperformpriortoanaesthesia.Heartinjurylist
§ Myocardialcontusion,arrhythmia(RV>LV>RA)
§ Ruptureofventricles,VSD
§ Coronaryinjury,ischaemia
§ Pericardialeffusion,tamponade
§ Valvulardamage,acuteincompetence
§ Aorticdissection;aroticvalveincompetence
Screeninginvestigations
§ Bloods:TnT–verysensitive,takeatimmediate,6hour,thendailyformonitor
§ CXR–screenofmediastinum,lung,pleuralspace,heart.
o Readilyavailable,providesmultipleinformation
§ ECG
o Forsignsofischaemia,
o Tamponade(reducedvoltage)
o Arrhythmia
§ Notspecific,butreadilyavailableandusefulscreeningtool
§ Echo–ifsignsofcardiacinjury,orifcardiacunstable,thenintraopTOEismost
useful;alsoassessmajorvesselinjury,pericardialeffusion,RWMA,valves;
ventricularrupture.
§ CTchest–indicatedforbestdetailedscreenofbluntchesttraumaespwith#
sternum(betterthanCXR)+allowsforC-spineassessmentatsametime.
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Q5-beachchairdiscussion,36%
A50yearold,110kgbuilderisonyourlistforanarthroscopicacromioplastywhichistobeperformedinthebeachchairposition.Listtheproblemsassociatedwiththispositionanddescribehowyoucouldminimisethem.PositioningofpatientintobeachchairpositionshouldbedonebybothSurgicaland
AnaestheticTeam,ensuringsafetythroughoutthecase.Regularcheckingshouldbedone.
(report)
Problems:
Environmental
o Limitedaccesstopatientduringsurgery;airway,circuit,IV
§ Ensureairwaysecuredwithbothtapeandtie.
o Circuitdisconnectionduringpositionchangeàensuresecurejoints
o Lossofmonitoringduringpositionchangeàsecuremonitortobodywithtape;
vigilanceduringpositioning.
Patient
o C:Hypotension,cerebralischaemia/infarct;opticischemicneuropathy;MI.
§ VigilancewithmaintainingadequateMAP/CPPthroughout
§ cerebralperfusionpressureneedstobecarefullymaintained.BPto
brainlikely15-20mmHglowerthanthatmeasuredonarm,therefore
takeintoaccount.avoidexcessivecompressionoverjugularvein.
§ Gentleinduction,slowattainmentofposition,fluid/pressor,
compressionstocking
§ IfusingArtline,leveltransducerwithtragustoreflectCPPdirectly.
§ Avoidhypocapnoea.
§ Ensurenocompressionovereyes.
§ Consider5leadECG,espifknownwithIHD.
§ considercerebraloximetry-suddenreductionmayindicatereduced
cerebralperfusion,espknwnwithCVA.
o Venousairembolism
§ Avoidnitrous,hypovolaemi;sealoffopenvenoussinuseswithcautery
orbonywax,vigilancetohaemodynamicchanges.
• (Althoughusunotaprobleminarthroscopywithirrigation
fluidspresent)
o Positionrelatedinjury:
o Headmalposition,C-spineinjury,brachialplexusinjury,occipitalnerve
compression;fromvigorousmovement
§ Headwellsecuredwithheadsupport/tape
§ Ensureneutralhead/neckposition/padded
§ Vigilanceandregularcheckthroughoutcase.
o Arm:ulnarN,auricularN,armfallingofftable.
§ Ensurearm/elbow/wristwellsupported/padded
§ preventbyavoidstretch+appropriatepadding
§ vigilanceandregularcheckthroughoutcase.
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o Hip:Sciaticnerve—>avoidstretchbyflexkneeslightly
o sacral,vascularcompression—>appropriatepadding,protection
Q6-shockdiscussion,61%
Definecirculatoryshock.Categorisethecausesofcirculatoryshockandgiveanexampleineachcategory.
Circulatoryshock=inadequatetissueperfusion,O2deliverytomeetdemandàendorgan
dysfunction,lacticacidosis,death.
Categories+example
§ Cardiogenic=failureofcardiacfunctiontopumpbloodtomeetdemand
o Eg.postMI,postCABGwithmyocardialstunning.
§ Hypovolaemic=insufficientvolume/preloadtoprovideadequatebloodcirculation
o Eg.multi-systemictrauma,postAAArupture
§ Obstructive=obstructionofcardiacoutflowtracthenceunabletoprovideblood
circulation
o Eg.pneumothorax,cardiactamponade
§ Distributive=reductionofvolumefromvascularsystemàperipheraloedema,pulm
oedema;henceunabletoprovidesufficientpreload/CO/circulation.
o Eg.anaphylaxis,septicshock
Q7-asthmaventilationstrategy,75%
A25yearold,65kgwomanwithacutesevereasthmarequiresintubationandventilation.Explaintheproblemsassociatedwithinitiatingventilatorysupportinthispatientanddescribehowyouwouldovercomethem.(reportonlymentionsinvasiveventilation;don’tworryaboutnon-invasive)
Severeasthma=life-threatening!Riskof§ Highairwaypressure,resistanceduetobronchospasm,inflammationàobstructive
airwaydiseasewithriskofairtrapping,breathstackingàobstructiveshockà
death!
Problemsforsevereasthmaventilation+managementstrategiesPre-induction:
§ Patientassessmentcanbedifficultduetodifficultytoverbaliseduetodyspnea+
needforemergencymanagement;collateralhistoryisessential,AMPLEshouldbe
obtainedwhilesimultaneouslyprovidetreatment.
§ Remotelocation:PatientmaybetoounstabletomovetoOTandintubation
requiredinED–remote,foreignenvironmenet,limitedhelp.
§ Ensurepresenceofairway/anaestheticassistant+equipment–drug,
airway-ETT,laryngoscope,BMV,oxygen,suction.
§ Patientdistressintripodpositionandunabletolieflatanddifficulttopreoxygenate.
§ ProvideFiO2100%throughnon-rebreather+ensureassistantsto
positionpatientsafelyuponinductionofGA.
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§ However,expectlowreservetocopewithapnoeaandrapid
desaturation!Ensureadequatepreparation+clearcommunicationof
plansA-Dforairwaymanagmene.t
Induction:
§ RSIrequiredasprobablenotstarved+needtominimizeapnoeatime.
§ Bronchospasmlikelyworsenswithintubation.
o Wouldusepropofol+ketamine,sux+vasopressorPRN(balancedinductionto
minimizehaemodynamiccompromisefrompropofol.Propofolhowever
helpstoobtundairwayreflexandketaminehelpswithitsbronchodilator
effect)
§ CVSinstabilitywithinductionespifhighintrathoracicpressurereducingVR/preload
o Ensurefluidrunning+useofvasopressor
o Patientlikelyquitetachycardicwithbronchodilatortherapy,ifexcessive
tachycardiamayleadtocirculatoryarrest.Beaware!
o performACLSifcirculatoryarresthappens
Post-induction+ongoingventilation
§ expecthighairwaypressure+riskofbreathstacking/intrinsicPEEP:
o ensureongoingbronchodilatortherapy:regularsalb,ipratropium,
prednisone,MgSO4,propofolinfusions.+/-antibioticsifconcurrentLRTI.
o Ventsetting:IEratiolow(atleast1:2,likelymoreeg1:3);reducedRR(to
allowadequateexpirationtime)
o Aim=oxygenation.
o MVneedtobebalancedwithhypercarbiaandmayrequirepermissive
hypercarbia.
o AssessintrinsicPEEP;mayrequiredecompressionintermittently(ie
disconnectcircuittoallowdeflationoflungs).
o Bevigilantofbarotrauma,pneumothoraxàICDplacementifpneumothorax.
o AdmitICUforongoingcare.
Q8-labourepiduralmanagement,73%
Youareaskedtoprovideepiduralpainreliefforawomaninlabour.Sheishavingprimigravida,andis3cmdilated.Describeandjustifybothyouchoiceofdrugsforandthemodeofadministrationofepiduralanalgesiainthissituation.Q9-aprotinindiscussion,28%"It's no longer justifiable to use aprotinin during cardiac surgical procedures".
Discuss.
Cardiac surgeries often involve CPB, assc with increased bleeding risk due to
- Coagulopathy (dilution, consumption) - Thrombocytopaenia (plt destruction, consumption) - Heparin effect - Hypothermia - CPB insult – coagulopathy, thrombocytopaenia/dysfunction, fibrinolysis. - Therefore antifibrinolytic is used to limit bleeding.
Aprotinin = serine protease inhibitor (anti-fibrinolytic), previously used to reduce blood loss complicated by hyperfibrinolysis.
- An important study (BART trial) however showed that using aprotinin, cf with tranexamic acid, led to doubling risk of renal failure requiring dialysis, MI, HF, CVA; therefore
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aprotinin has been withdrawn from the market. - I agree therefore its use is not justified in cardiac surgical procedure. - I’d continue to use tranexamic acid (lysine-analogue in treating bleeding due to
hyperfibrinolysis. Q10-SCbloodsupplyanddeterminants(repeat),21%Describe the blood supply to the spinal cord. Explain the determinants of spinal cord
perfusion.
SC perfusion determinants:
• = MAP - venous p or CSF p whichever is greater • MAP determinants • Venous P determinants – SVC/IVC pressures, avoid obstruction, abdominal/thoracic
pressure, PEEP, pneumoperitoneum etc. • CSF pressure – drainage
Drugs: vasoppresor vasoconstrict and limit perfusion, but maintains MAP to drive forward flow which is more important. Surgery: direct x-clamp of aorta, esp above artery of Adamkiewicz Q11-Daysurgerydentalmanagement,84%An 18 year old otherwise healthy female is to have 2 impacted wisdom teeth
surgically removed as a day stay patient.
Describe and justify features of your anaesthetic technique that may help prevent the
common postoperative problems you would anticipate in this patient.
Issue:
• Day stay • Dental procedure with bleeding, pain • Potential high anxious patient (age group, reason for needing anaesthesia) • Problems of GA: sore throat, sedation, PONV • Rare but important: blood aspiration, laryngospasm (but Q ask ‘common’); focus on
‘Common only’ (report) Anaesthetic management:
• Preop o PONV-Risk stratify PONV (Apfel’s score) and consider TIVA if high risk. o Anxiety-Premed for anxiolysis as required, but care with potential sedation postop
and preferably use shorter agent eg. midaz o Discuss with Surgeon/patient: Is LA technique with sedation possible for this
patient? – avoids risk of GA. • Intraop
o Avoid N2O. Use multimodal antiemetics eg. dex + ondans; avoid using neostigmine if possible; ie ultra-short acting muscle relaxant and remifentanil.
o Pain-multimodal analgesia+LA infiltration/dental block by Surgeon to opioid spare – less PONV, sedation.
o Bleed- ensure good intraop haemostasis; consider throat pack to reduce residual blood in airway (but need clear management protocol to ensure safety)
• Postop o PONV-Use rescue antiemetics as required eg. droperidol, but care with sedation. o Pain-rescue analgesia eg. morphine; has supplies of simple analgesia for ongoing
management at home (paracetamol, ibuprofen +/- tramadol/antiemetic) o Monitor of ongoing bleed.
Dishcarge criteria
• When vital signs stable and patient comfortable and not feeling nauseous; without surgical bleed; +/- able to drink.
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NB. PS on Day procedure: Patient factor - ABCDE - no unstable medical condition - patient/caregiver able to care for themselves after discharge - side effects controlled, pain/N.V and adequate hydration - clear instruction on analgesia plan, contact plan if any concern and travel arrangement for medical assessment - clear instruction on driving, drinking alcohol and legal decision making not to be done until 18 hours later Social: - responsible caregiver understand plan - travel, phone arrangement - phone follow up (ideally) arranged.
Q12-pyloricstenosisdiscussion,64%A 3 week old male infant who was born by uncomplicated vaginal delivery at term
presents with projectile vomiting for 2 weeks. His weight is now 2.8 kg from a birth
weight of 3.1kg. His presumed diagnosis is pyloric stenosis. His blood chemistry
results are:
Measured Normal Range Na 129 mmol/L 135-145 mmol/L K 3.0 mmol/L 3.5-5.5 mmol/L Cl 84 mmol/L 95-110 mmol/L HCO3 36 mmol/L 18-25 mmol/L Creatinine 69 μmol/L 20-75 mmol/L Glucose 3.0 mmol/L 2.5-5.5 mmol/L Explain how these abnormal results come about. Describe an appropriate fluid
resuscitation regime for this infant.
List the laboratory criteria by which you would consider him sufficiently resuscitated
for surgery.
Pyloric stenosis
• Repetitive vomiting à o losing HCl, Na, K, water à increase in HCO3- initially o metabolic alkalosis, hypoCl, Na, dehydration
§ Hypovolaemic/hypoNa stimulates SNS, RAA, ADH release à Na, H2O reabsorbed by renal tubule;
• however this is at expense of H/K further lost due to Na/H, Na/K exchanger à worsening of metabolic alkalosis/HypoK
o K/H exchanger then compensates for hypoK, at expense of losing H and further alkalosis
§ HypoCl: leads to increased renal reabsorption of HCO3 to maintain neutrality à causing futher alkalosis.
Fluid resus regime
• Aim = to replace volume, Na, K, Cl; which will lead to correction of alkalosis + maintain ongoing need
o Assess volume status: Hx, Exam, Invx: weight, fontanelle, skin turgor, haemodynacmis/RR/activity
o Initially resus volume with 0.9% NaCl, 20ml/kg boluses, then reassess; repeat w 10ml/kg boluses if responsive.
o Replacement with NG loss should be – ml:ml with 0.9% NaCl.
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o Maintenance should be with 0.9% NaCl + 5% dextrose + 20mmol/L KCl; § 6ml/kg/hr ie 12ml/hr (as per Starship)
• NB. Not exactly the usual 4:2:1 rule + consider 1/3 reduction due to surgical stress response/ADH release; but this is as per Starhip 2009 Pyloric Stenosis regimen.
o Replace K, at 20 mmol/L concentration with maintenance fluid (not added to resus fluid; Starship only started replacing K after resus; in maintenance fluid).
§ If higher conc is required, then should be given via CVL with ECG monitor.
Lab criteria indicating sufficient resuscitation for surgery
Ideally: • Cl >105 • Na >135
• K >3.5
• HCO3 <26
NB. Priority however is given to correction of volume, acid/base/Cl value; (Cl needs to be >105mmol/litre for the vast majority of infants to have no residual alkalosis) Mention of urine chloride greater than 20mmol/litre = extra mark. Paeds: IV K max dose = 0.4mmol/kg/hr Q13-regionalpoplitealblockforfoot/ankle,67%Describe a technique of neural blockade in the popliteal fossa for surgery on the foot
and ankle including a description of the relevant anatomy.
Popliteal fossa formed by
Uppper medial: Semimembranous and semitendinosus m. Upper lateral: biceps femoris Lower borders: gastrocnemius
Technique: CALM, SOBER, PLANS,
A-lateral or prone C-clean T-time out I-image-transveresely above crease in popliteal fossa, identify pop A, vein; identify CP/T. N; (tneds to be lateral to A)
• move superiorly to see Ns fuse —> sciatic N • out of plane approach watching needle tip on screen then gradually deepen needle angle to
reach N. O-optimise N-watch for pop A. V S-15-20 mls of 0.75% ropivacaine; negative asp, 5ml aliquots, watch spread of LA on US. Wait for ~20 mins for effect. Q14-ethicsofplacebo,38%A clinical trail is planned to evaluate a new analgesic. Discuss the ethical
considerations in having a placebo group in the trial.
Placebo = used to compare with drug to determine true effect or side effect. Commonly used in RCT to reduce bias. Ethical considerations
- Informed consent from patient to participate in study is required; which should consider these…
- Analgesia = basic human right; hence using placebo to manage pain soley is unethical;
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instead it should be used as part of ultimodal analgesia. § To work around this issue, the new drug may be compared to itself in a
lower dose or to other established analgesic regimen. - Equipoise for this new drug needs to be carefully considered and evaluated by Ethics
Committee. § International Document exist to guide consideration: eg. Helsinki
Agreement or American Pain Society Research Ethics guideline. - On the other hand, bias in research should be carefully considered and prevented in
methodology design. Biased study with invalid result is a cost to time and human resource and potentially delays introduction of an effective drug, which is unethical in itself.
- Finally, patient withdrawal from study should be allowed at any time.
Q15-flowvolumeloopinairwayobstruction,47%Draw flow volume loops associated with
a) Fixed upper airway obstruction
b) Variable extrathoracic airway obstruction
c) Variable intrathoracic airway obstruction
Explain briefly the physiological reasons for the shape of these loops.
May-2007,52%
Q1-ARDSventilationstrategies(repeat),82%
Whataretheprinciplesofventilatorymanagementofpatientswithacuterespiratory
distresssyndrome(ARDS)?
Q2-regionalforinguinalherniarepair,34%
Describetherelevantanatomyandtechniqueforfieldblockforinguinalherniarepair.
Anatomy:
• Needtoblockilio-hypogastric,ilio-inguinalandgenitalbranchofgenitofemoral
nerver.ThesenervesareformedbyT12andL1nerves.
• TravelantmedbetweenIOandTA.
• T12suplataspectofinguinalligament
• IliohypogasN–traversesIOinfrontofASIS;runsdeeptoEO;suppliessuprapubic
skin
• IlioinguinalN–traversesIOandenteringuinalcanal,suppliesskinofscrotum.
Technique
• Iliohypogastric–22g5cmneedleispassedthroughtheskinatapoint2cmmedial
and2cminferiortotheASISaimingtowardsthepubisatanangleof45-60degrees.
Thepassageofneedletipthroughtheexternalobliqueaponeurosiscanbe
appreciatedasa„pop‟.LAisinjected~10ml.
• Ilioinguinal:Theneedleisthenpassedafurther1-2cmthroughthesofterresistance
ofinternalobliquemuscle.Further10mlinjected.
• Fan-wiseSCinfiltrationsuperficialtoaponeurosiswillblockthecutaneoussupply
fromlowerintercostalsandsubcostalnerves.
Q3-sodalimediscussion,42%
Howdoessodalimework?Listthehazardsassociatedwithitsuse.
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Sodalimeo Calciumhydroxide,Ca(OH)2(about94%)
o Sodiumhydroxide,NaOH(about5%)
o Potassiumhydroxide,KOH(about1%)
o pHindicator:ethylviolet.Turnspurplewhenexhausted.
o Silicatoremovemoisture
H2O+CO2→H2CO3
H2CO3(aq)+2NaOH→Na2CO3+H2O+heat
Na2CO3+Ca(OH)2→CaCO3+2NaOH
Hazardso Heatenoughtocausefire
o Dustinhalation
o Increasedresistance
o Skinirritationtostaff
o Leakanddisconnection
o Interation
o Sevoflurane
§ Moreinteractionwithbaralymethansodalime
§ FormscompoundA-E
§ CompoundAproducedingreatesamount
§ Nephrotoxicinrats,butathigherdosesthanclinicaluse
• Notoxicityinhumanreported
§ Factorsthatinfluenceproduction
• ↓FGF→↑production
• DehydrationofBaralyme→↑production
• DehydrationofSodalyme→↓production
• ↑temperature→↑Production
o Des>Enf>Isoflurane
§ Allcontaindifluomethyl(-CHF2)compound
§ FormsCarbonMonoxide
§ Canbeupto30%
§ ↑Temp;Dry;↓FGFallleadsto↑production
Q4-paedburnpain/fluidmanagement,58%
A2yearoldchildhasburnstolowerbodyfromimmersionintoahotbath.Describeyourassessmentandmanagementofpainandfluidrequirementsinthefirst2hoursfollowinginjury.(report)
observationassessmentofpain+titrationofopiatesinapotentiallyshockedchild.
Painassessment/mx§ Hx:Severityofinjury?MIST-Durationofimmersion,watertemp,otherinjuries,
treatmentsofar?OtheimportantAMPLEhistory
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§ Exam:o burnassessmentwhichgivesindicationofseverityofpain:
§ extent,usingruleofnineforchildren:§ Thiskidhaslowerbody,sopotentiallyinvolve:
• ½anttrunk=9%• ½backtrunk=9%• legs=13.5%eachside
o sototal=27%+18%=45%!!Significant!§ Degreeofburn–1/2/3.
o Painassessment–likelysignificant§ Subjectivereportby2yearoldchildmaybepossible§ Parentalreport§ Objective:FLACC–face,limbs,activity,consolability,cry
§ Management(asperCCDHBPaedsprotocol)
o Multimodalanalgesia–para,• NSAID(notifrhabdo)-neurofen5-10mg/kgQ6H,• tramadol(1mg/kgIV/POQ6H),• opioid(0.2mg/kgPO,Q4H).
§ NCAvs.(morphine10mcg/kg/mlbolus,1mlbolus,5minlockout.§ Infusion–10mcg/kg/ml–0-2ml/hour;under3/12,0-4mlover3
month.§ MonitorRR+sedationhourly.§ Monitorpainscore2hourlyinitially,4hourlywhenpainstably
controlled.o Considerketamineinfusion
§ 0.1mg/kg/ml–at0-2ml/hr;for>3/12only.o Excessivepain,considercompartmentsyndrome.o Non-pharm:distraction,dressingwithbiosyntheticdressing.o DressingchangewilllikelyrequireGA.Ifhowevertolereablecanconsider
Entonoxorketaminesedation.Fluidrequirementsassessment/mx
§ Hx:drinkingstill?Passingurine?Wetnappies?§ Exam:CVS/RS/CNSexam-volumestatusforsubsequentfluidmx.
o UOshouldbemonitoredcloselyandformspartofongoingresuscitationgoal.§ Invx:electrolytemonitorduetolargevolumefluidshiftfromsignificantburn.§ Management:
o Parkland’sformulatoguidefluidmx:§ children3-4ml/kg/%,Hartmanns.§ first½in8hourssinceinjury,2
nd½overnext16hours+maintenance
(withdextrosesaline).§ UO:aimfor1ml/kg/hour
o Needtoconsidernutritionduetoincreasedmetabolism§ ConsiderNJfeedearlyby24hours,ifnotmaintainingPOintake.
o WillneedreferraltoBurncentreduetosignificantburnextent,extremeof
age,andspecialareaoverperineum.NB.
PainassessmentinPaeds:(actuallyverysimilartogeriatric)
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§ Wong-BakerFACESPainscore,usufor>3yo
§ Numericratingscale
§ Behaviouralscale-FLACC
Q5-SvO2discussion,36%
Discusstheusefulnessofthecontinuousmeasurementofmixedvenousoxygensaturationintheintensivecarepatient?SvO2=mixedvenousbloodsaturation,frompulmAsampledwithPAC–canbemeasured
continuously.
§ Providesanindicationofglobaloxygenationstatus,andnormallevelis~70%.
§ AlsousedassurrogatemeasureofCO.
§ HoweverSvO2shouldbecorrelatedwithpatient’sclinicalstatus,withother
measurementseg.acid/basestatus,lactatevalue,
UtilityofSvO2inICU–providesadditionalinformationregardingoxygenation/perfusionstatus;
§ IncreasedSvO2(If>70%)
o couldindicateperipheralhypoxiaandinabilitytoextractoxygen.
§ Cyanidetoxicity,mitochondrialdisorder,sepsis
o Ordecreasedoxygendemand:hypothermia,sedation
o Orreassuranceofadequateoxygenationprovidedpatient’sclinicalstatus
remainstable.
§ DecreasedSvO2(If<70%)o couldindicateincreasedoxygenationextraction,hypoperfusion.Anaemia,
hypoxaemia.
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o IncreasedO2consumptioneg.pyrexia,pain,shiver,seizure,MH.
§ BonusfeaturesofPAC:canalsoprovideCVP,PAP,PCWP–diagnosepulmHTN.Diagnosticaidhenceguidessubsequentmanagement;
§ bleed/anaemia:considertransfusionkeepHb>70g/L§ hypoperfusion:considerfluidchallengethenassessresponse
Limitations:§ requiresPACwhichisinvasiveandhaspotentialrisk:CLAB,cardiactamponade,
arrhythmia,PArupture,pneumothorax.§ NoproventrialsindicatingimprovementinoutcomewithuseofPAC/SvO2alone.
Therefore,giveninvasivenatureofPAC,IwouldnotroutinelyusePAC/SvO2tomanageICU
patient.Ifused,thenshouldcorrelatewithotherclinicalmeasuresoutlinedabove.Q6-NMTdiscussion,77%
Listthepatternsofperipheralnervestimulationthatmaybeusedtomonitornon-depolarisingneuromuscularblockadeduringanaesthesiaanddescribehoweachisusedinclinicalpractice.
• Singletwitch
o Needbaselinetwitchheightforcomparison
o Notveryusefulcfothermodalities
• TOF;4stimulations,2Hx
o Count:4thtwitchreduction=75%,3=90%blockade,1=95%;notwitch=
complete.
o TOFR:70%=weakperiphery/cough;>90%=safeextubationcondition
o Needaccelerometer/EMG,manualisinaccurate.
• DBS:2burstsoftetanicstimulation(50Hz),750msapart
o Ratio>90%indicatessafeextubationcondition
o BettercfTOFwithmanualdetection
• Tetanus:5secondsoftetanicstimulation
o Fade=MostsensitiveforNMBeffect
• PTC
o Tetanicstimulation,3secpausethensingletwitchesat1Hz
o Twitchiscounted
o 10twitchequivalentto1twitchinTOF
o usedwhenTOFis0,monitorsdeepNMB
NB.
Iesee1count,then<15minsforallexceptpanc;see2count,then<10minforalltoseefirst
T1count
Q7-riskevaluationforpneumonectomy,69%
A65yearoldmanwitha40packayearhistoryofsmokingisscheduledforrightpneumonectomyforcarcinoma.Describeyourpreoperativeevaluationofhisrespiratorysystemtodecidehiscapacitytoundergothisoperation.Preopevaluationofrespsystemforfitnessofsurgery
• Hx
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o Presence/severityofsymptom?–dyspnea,PND,Roizenscore,cough,
haemoptysis
o Systemiceffect?–SIADH,Eaton-Lambert,Horner’s?
o Functional,nutritionstatus
o Currenttreatment+respoptimization.
o OtherAMPLEhistory?Smokinghx?COPD,asthma,pulmHTN/RHF?
o Previoussurgery,anaestheticrecord
• Exam
o Airwayassessment
o CVS/Respexams–presenceofpulmHTN/RHF?
o SignsofSVCobstruction?Mediastinalmasseffect?
• Invx
o Stagingscans
o Fitnessforsurgery=3leve:
o 1ststage
§ PFT,spirometry
o FEV1>1.5suitableforlobectomy;
o FEV1>2suitableforpneumonectomyor>80%
predicted
o 2ndstage(ifnotmeetingcriteriain1
ststage)…
§ Quantitativelungscan
o %ppoFEV1>40%?AND
o %ppoDLCO>40%?(musthaveboth)
o 3rdstage(ifnotmeetingcriteriain2
ndstage)
§ Exercisetesting/CPET=mostaccurate
o VO2max>15ml/kg/min?
o Ifnot,considerotheroptions;as<15=highrisk
NB.Othernumbers:
• DLCO>60%hasreducedmortality;>80%hareducedpulmcomplications
• Othersurrogatesofexercisetesting:
o Stairclimbing->2FOS(20steps,15cm/step)?Ifnot=highrisk
o 6minwalk–if<300m=highrisk(correlatewVO2<10);600m~VO2of
15ml/kg/min.
§ dropinsatsduringexercise>4%=highriskor<90%
o InCPET:
§ VO2>20ml/kg/min=noincreasedriskforcomplication/death
§ VO2<10=mortalityrateof~50%.
§ AT>11ml/kg/minisreassuringformajorsurgery.
Q8-ECGuseinIHDmonitor,55%Describe how the ECG should be used to monitor for intraoperative myocardial ischemia
in a patient with ischemic heart disease.
ECG: noninvasive, continuous monitor of myocardial electrical activity, characterized by rate/rhythm/axis/interval/morphology
o May see changes assc w MI, although can be non-specific. However PPV increases in patients with higher risk of cardiac event. Like in current patient with IHD.
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Technical:
o Correct lead placement o Good quality lead, contact (may need to shave skin; over bony prominence) and minimize
interference (movement or diathermy) o 5 lead ECG allows monitor from more leads: II, V5 + other limb leads & augmented leads o V5 tends to be most sensitive for MI (80% of all detection). o Trend monitor used; o ST segment analysis used (ie diagnostic mode, not monitor mode) o Auditory + visual alarms
Watch for o ST segment changes: ST elevation, ST depression, T wave inversion, new LBBB o (from report) o Highest sensitivity when a combination of leads is used. Ideally an inferior lead (III) and a 2
praecordial leads o (V3 and V5, or V4 and V5). When only one praecordial lead can be utilized (common
clinically) the most isoelectric lead of V3, V4 or V5 should be used o upsloping ST segment : 2 mm depression, 80 msec after J point o horizontal ST segment : 1 mm depression, 60-80 msec after J point o downsloping ST segment: >1 mm from top of curve to PQ junction
Q9-T-piecediscussion,68%The T-Piece is obsolete in modern anaesthesia practice. Discuss.
T-piece aka Mapleson E
• = open systemi circuit • Inflow limb (FGF) à patient à exp limb for exhalation (no valves in system)
Pros
• Simple, light weight. • Low dead space, low resistance
• Fast wash in
• Modification allows controlled manual ventilation ie Jackson-Ree’s/Mapleson F by occluding open end bag
o Also able to assess compliance/TV with hand BMV (which is more subtle in circle) • Miniises risk of inadverdently switching to machine ventilator with potentially dangerous
settings. Cons
• Inefficient, needs high FGF to minimize rebreathe (2x of MV in SV) or >3L/min w IPPV; reservoir tube needs to have volume = TV to prevent entrainment of air (if too small) or rebreathe (if too big)
o risk of rebreathing if low FGF, high MV, high CO2 production • non-humidified
• volatile no scavenged, pollution of theatre
• decreasing familiarity with T-piece among non-paeds anaesthetists
Alternative circuit: closed-paeds circle circuit with CO2 absorber, unidirectional valves
• has low-resistance, low dead space
• allows low flow anaesthesia; less FGF/volatile use/pollution + volatile scavenged
• rebreathing minimized due to one way valve
• controlled manual ventilation also allowed with APL/reservoir bag
• humidification/warming of gas
• Cons:
o heavy/bulky/not easily portable
Summary
• T-piece still has role esp in paeds patients, where MV/TV is small, although the increasing efficiency of low resistance, low dead space paeds circle system has minimized this benefit.
• However, T-piece is simpler, reliable, more portable esp useful in remote location and is still commonly used by many paed anaesthetists. It’s therefore not ‘obsolete’.
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Q10–Trifascicularblock,completeheartblock,53%
A56yearolddiabeticisscheduledforlaparoscopicnephrectomy.Thisishispre-operative12leadECG(Chang’sAnaesthesiacomplicationp.18).TenminutesintotheprocedurehisBPis70/30andhisECGlead2monitorlookslikethis.WhatdoesECG1show?WhatDoesECG2show?OutlineyourmanagementofthesituationassociatedwithECG2.ECG1=trifascicularblock
ECG2=completeheartblock,slowventrate
ManagementofcompleteHB.
• Differentialneedtobeconsideredsimultaneouslyasmx:
o Vagalstimulation(pneumoperitoneum,organstimulation)
o Drugerror(eg.b-blockerinadverdentlygiven).
o MI,electrolytedisturbance,hypoxaemia,hypercarbia.
• Mx:
o DeclareemergencyascompleteHBwithhaemodynamiccompromise.
§ Removevagalstimulation–pneumoperitoneumandstopsurgery.
o Gethelp,needexternalpace-makerimmediately
§ Titratecurrentupuntilcaptures,thenincreaseafurther10mA.
o ABCapproach:
§ Maintainoxygenation.
§ Supporthaemodynamicswithfluid+atropine600mcg(repeatupto
3mg),adrenaline5-10mcgincrementsandsetupisoprenaline
infusion0.01-0.05mcg/kg/min.
o Investigateelectrolyte,UECr,Mg/Ca/P,Trop+12leadECG?ischaemia+
ECHOtoassessforRWMA.
o WillneedHDU/ICUpostopwithCardiologymanagement.Patientlikelywill
requiretransvenouspacingorPPM.
Q11-Informedconsent,52%
Whyisconsentforamedicalprocedurenecessary?Whatmakesconsentforamedicalprocedurevalid?
Whyconsent?o Ethical–
o rightofpatienttohaveconductofprocedureandrisksexplained+
alternativesandopportunitiesforquestions.
o showsrespectforpatientautonomyandacknowledgespatient’srightof
decisionmaking.
o Medicolegal–detailingriskandbenefitsmayprovideprotectionagainstclaimsfor
negligenceshouldadiscussedcomplicationarise,despitetheprocedurebeing
carriedoutcompetently.
Conditionsforavalidconsento Preassess:Patient->competenttoconsent,appropriateage,nomental/cognitive
illness,nosedation.
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o Intermsoflanguagethatpatientcanunderstand–usequalifiedinterpretor
forpatientwhodoesnotspeak/understandEnglish.
o Prepare:Time,environment->private,quiet,unrushed,enoughtimeforpatientto
consideroptions
o Perform:
o Consentinganaesthetist;PARQ
o Idealyperformedbytheproceduralanaesthetist,whohasadequate
knowledge/experienceofperson
responsible/conduct/benefit/risks/alternatives.
• Defineswhatrisksareimportanttodiscuss.
o Rarebutsignificant
o Commonbutrelativelyminor
o IfdetailedconsentwasdonebyanotherAnaesthetist,theprocedural
anaesthetistshouldstilldiscusswithpatientbeforeoperationforany
unansweredquestions,issues.
o Consentbypatient
o Givenvoluntarilywithoutcoercion
o Informedintermsofknowledgeofconduct,benefit,risks+alternatives+
implicationofnotdoingtheprocedure.
• Ifpatientfirmlyrefusestoknowaboutrisksinvolved,should
notenforceandshoulddocumentthis.
o Patienthasrighttorefusetoconsentorwithdrawconsentatalltimes.
o Document+signaturefromanaesthetist/patient.
NB.
o Ifconsentimpossibleeg.inseveretrauma,unconsciouspatient,thentreatment
withoutconsentmayproceedprovidedthatit’sinpatient’sbestinterestand
attempttoascertaincollateralinformationhasbeenmade.
Q12–bedsideairwayassessment,77%How do you assess an otherwise well patient with regard to difficulty of intubation at the
bedside? How accurate is this assessment?
DI definition: occurs there’s difficulty in aligning mouth opening to laryngeal inlet to obtain Cormack Lehane view of 1 or 2; can be due to:
• limited mouth opening, • oral cavity factors, • limited neck movement or obstruction.
History • history of difficult intubation – from patient report, patient bracelet or previous
documentation. • comorbidities such as morbid obesity, OSA, RA/AS, C-spine fusion, Ex-Fix device, or other
congenital abnormalities: Down’s, Pierre Robin, Klippel-Feil syndromes. • previous laryngeal surgery, radiotherapy to head/neck, dental wiring.
Exam • Mouth opening
o Trismus = dangerous sign! o Interincisor distance: <3cm = intubation tricky; <2.5cm LMA tricky = reliable sign.
• Prognathism o If lower incisor cannot reach beyond upper incisor, intubation likely difficult =
moderately accurate sign. • Mallampati
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o 1/2 likely easy; but small false negative rate o 3/4 likely difficult (but false positive rate high)
• Oral cavity lesions? o Loose teeth, crowded teeth, prominent front teeth; reliable sign of potential difficulty
due to loose object or teeth obstructing space for laryngoscopy o Enlarged tongue, oral tumour, abscess; = good accurate warning sign of difficulty o High arched palate (report); assc with likely difficulty o Gaps in dentition may trap laryngoscope
Neck movement o Inability to perform atlanto-occipital extension or assume sniffing air position =
accurate warning sign of difficulty due to malalignment of view, especially severe limitation present.
• Thyroimental distance o <7cm likely difficult, the shorter the distance the higher predictability of difficulty, but
measurement often done inaccurately; § combined with Malampati would give higher PPV, but lower sensitivity.
• Neck circumference o >40cm assc with difficulty with intubation, more reliable than Malampati alone.
• other factors: o large breast likely will obstruct space for laryngoscopy o morbid obesity: due to association with other risk factors
On balance, individual test isn’t as good and combined test tends to give better indication of potential difficulty. Q13-ACLS,VF(repeat)59%Ambulance officers performing CPR with bag and mask ventilation. She has been rescued
from a swimming pool.
Describe how basic life support should be provided in the emergency department. She
has no pulse and her ECG shows ventricular fibrillation. Outline the advanced life support
algorithm you would now follow.
BLS part:
§ ACLS principle § DRSABCDE § Danger include: wet patient, floor which can cause electrocution of patient/staff à needs
thorough drying. § Check response + signs of life (respiration/pulse) § Open airway § If no pulse à chest compression + BMV at 30:2 ratio.
2
nd part:
§ VF à CPR + defib in earliest instance possible providing patient is thoroughly dried. Q14-flowoptimizationinmicrovascularsurgery,34%An otherwise fit 30 yr old man is having microvascular reimplantation of his forearm.
Describe methods available to optimise the perfusion of the reimplanted limb in the post-
operative period.
Optimise oxygen delivery and perfusion (postop period)
- B: maintain oxygenation > 90% + Hb > 70g/L
o Avoid excessive high Hb as increased viscosityàdecreased flow, aim Hct ~0.3
o
- C: maintain perfusion pressure (MAP – venous P) o Maintain MAP within 20% of baseline or >65mmHg (70mmHg if known HTN/renal
dx)
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o Maintain euvolaemia and manage hypotension with modest dose of vasopressor/inotrope.
§ Avoid excessive vasoconstrictor as it may compromise flow through anastomosis
§ Multimodal analgesia to reduce stress response. o Enhance venous drainage:
§ Avoid tight dressing
§ Maintain modest degree of arm elevation (close to level of right atrium) - Monitor distal perfusion closely postop – doppler + clinical assessment of CWMS (colour,
warmth, motor/sensation) o Early detection and reexploration in OT if perfusion compromised.
NB. OHA said dextran may help maintain graft patency., depending on surgical preference. However, 2015 review discouraged use of dextran (1b) as associated with increased systemic complications and flap failure; if anticoagulation is desired, use LMWH prophylaxis.
- Intraop factors: - Anaesthesia: consider regional – SNS blockade, vasodilate + best analgesia. - Surgery: Ensure good anastomoses and check perfusion
Q15-braindeathdiagnosis,72%Outline the steps necessary to diagnose brain death in a 38 year old woman who is
comatose following a subarachnoid haemorrhage.
Brain death diagnosis steps
o Precondition = having a diagnosis to suggest brain death (24 hour after TTM; >4 hour after coma before testing commences)
o Exclusion:
o Adequate MAP
o No drug effect, ETOH. o Not hypothermic; no severe electrolyte/metabolic/endocrine disturbances
o MSK: intact MSK function. o Examinable: Able to perform apnoea test, brainstem test (at least 1 eye, 1 ear) o Clinical testing
o by 2 independent medical specialist trained in ICU. o Procedure = o Apnoea test: absence of breathing despite PaCO2 >60. Ensure tube patent. o Fixed dilated pupils
o No brainstem reflexes: corneal, gag, cough, vestibule-ocular reflex. o No motor response to moxious stimuli (face/trunks/limbs)
o Other test:
o If cannot test: do cerebral angiography (absence of flow to brain) = gold standard; EEG/SSEP not considered valid.
NB. Not compatible with brain death
o Decorticate/decerebrate posture o Seizure
Spinal reflex can be compatible with brain death. Vestibulocular reflex:
o cranial nerves III, IV, VI, VIII o Inspect the auditory canal with an otoscope to confirm that the eardrum is visible. If not
visible the ear canal must be cleared before testing can begin. o Elevate to 30 degrees to place the semilunar canal in a horizontal position. Instil 50mL of ice
cold water into the ear canal using a syringe. Hold the eyelids open and observe for a minimum of 60 seconds.
o Response – no movement. ANY movement precludes brain death.
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Q1–LMAinlaparoscopy,81%
DiscussriskandbenefitsasscwithIPPVthroughprosealLMAforlaparoscopiccholecystectomy
Proseal
Laparoscopicchole–dependsoncontext;likelyacutelyunwellwithdelayedgastric
emptyingandbowelobstruction,thereforeprosealLMAuseisn’tappropriate.
Riskwithproseal:
• notsecureairway
• ventilationmaybedifficult
o duetoairleakaroundcuffathighpressureeg.pneumoperitoneum,obesity
(althoughreverseTrendelenburgmaylessencomplianceproblem)
o gastricinsufflationàaspirationriskwithanunprotectedairway
o issueofunderventilation,hypercpanoea,SNSstimulation,increasedICP/CBF,
CO2narcosis
Benefitwithproseal:
• maybeeasierinsertionandlowerfailureratethanintubation.
• Lessinvasive,avoidsairwaytrauma,haemodynamicinstabilityduetolaryngoscopy
(althoughLMAinsertionmaytolesserextentstillcauseairwaytrauma)
o AllowFOIthroughLMA.
• MayallowfastertheatreturnoveraspatientmaybetransferredtoPACUwith
workingLMAin-situ.
• Prosealcf.classic:
o Highersealpressure,duetodorsalcuff(maywithstandpressureupto
30cmH2O)
o Separateoesophageallumenallowingdrainageofregurgitant/NGinsertion
o Integratedbiteblock.
Onbalance:I’dintubateandprotectairwayforpatientunderoinglaparoscopic
cholecystectomy.
Q2-paravertebralblock,55%
Describeyourtechniqueforperformingacontinuousparavertebralblockina50yearoldmanwithfractured5th–10thleftribs.Includepossiblecomplicationsandrelevantanatomy.
AnatomyParavertebralspaceislocatedjustanteriortotransverseprocessandbordersare:
- Medial:vertebralbodyandpedicle
- Posterior:Transverseprocessandcostotransverseligament
- Lateral:ribsandcostotransversejoint
- Anterior:costovertebraljoint
Containsspinalnerveofcorrespondinglevel
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Technique
- 2levelsaboveandbelow;T7insertion.
- 2-2.5cmlateraltospinousprocess,lignocaine,18Gtuohy,LOR,contactT.process,
walkoffabove,insert<1.5cmdeeper;mayfeelLOR.
- Infusion5-15ml/hrof0.2%ropivacaine.
Q3-clamping/unclampingaortamanagement,57%
Describethecardiovascularchangeswhichoccurduringclampingandunclampingofthesupra-renalaortaduringrepairofanabdominalaorticaneurysminapatientwithnormalventricularfunctionandoutlineyourstrategiestomaintaincriticalorganperfusionduringtheseClamping(intermsofclinicalparameters)
- haemodynamicchange:Hypotensiondistaltoclamp;hypertensionproximalto
clamp(upinSVR/SVCflow/SNSresponse)- HR:reflexbradycardia,althoughmayseetachycardiaduetoSNSstimulation+
increasedSVCflowàBainbridgereflexo Changedependsonbalanceofthesefactors
- Cardiacworkload:o Suddenincreaseinafterloadàincreasedcardiacwork
§ Usu.balancedbyincreasedCBF/O2supply,butmaycauseMIif
demand>supply- RegionalBF:
o Cerebralbloodflowmaintainedbyautoregulationandnotdisruptedby
clampo SC/RBF/splanchnicBFreducedespdistaltoclamp
Management- Minimizehaemodynamicchange;
o counteractafterloadincreasewithvasodilatros,eg.deepenanaesthesia,use
GTN,hydralazine,phentolamine,
o ifepiduralin-situ,considerloadepidural,butbalanceriskwithhypotension.
o ReleaseclampifLVfailureapparent(ECGchange,hypotension)anduse
gradualclamp.
- Minimiseincreaseincardiacworkload
o Asabovetominimizeincreaseinafterload.
o Also,consideresmolol.
- MinimizeregionalBFischaemia
o Minimizeclamptime
o OptimalsupportivemeasuretomaintainABCDE:normovolaemia,
oxygenation,haemotocrit.
o Considerdistalperfusionwithshunt,orotherspecials:eg.forSCperfusion:
lumbardrain,coolsalineviaepidural,hypothermia.
- Monitor
o Cardiacischaemia–ECG,artline,CVP
o End-organischaemia–UO,SSEP,MEP
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Unclamping- Haemodynamicchange;dropinBP/coronaryBFwith
o Suddendropinafterload(decreaseby70-80%)
o ReducedVR
o Venodilation/cardiacdepressionfrommetabolicwaste(acid,K,CO2)
o arrhythmia
- Management:
o Minimizehaeodynamicchange
§ Reclampifseverehypotensionandgradualunclamping,sequential
iliacunclamping
§ Maintainhighnormovolaemiaprior
§ Lownormocarbiatocompensateforacidosis,CO2wasteproduct.
§ Vasopressor/inotropetomaintainMAP
§ Treatarrhythmiawcalcium
§ ConsiderHCO3-
Q4-phantomlimbpain,66%
Describethefeaturesandmanagementofphantomlimbpain.
(Auckland)
Features- Noxioussenseationinmissinglimbs;atypeofneuropathicpain.
- Incidence30-80%
- Immediateordelayed,intermittent;variableintensity,buttendstoresemblepre-
amputationpain.
- Risks:
§ Pre-amputaitonpain,postopstumppain,poorpaincopingstrategy,
psychiatricdisorder.
Mx- MDTinput.
Pharmtx:
- calcitoninusefulinacutephantomlimbpain
- epidural,ketamine=maybeeffective;espusedaspreemptiveanalgesia.
- nervesheathcatheter,opioid,gabapentin=treatacutepain,althoughnoevidence
orpreventingchronicphantomlimbpaindeveloping.
- Multimodalanalgesiatotreatacutepain.
Non-pharm:
- mirrorbox,motorimagerytreatment=effective(iesensorydiscriminationtraining)
- Psychosocialsupport:distraction,reassurance,education,expectationmanagement.
- Physiotherapy:massage,ensurecorrectprosthesisfitting,stumpsupport.
- TENS
Q5-LMWH&epidural,19%
Describeandjustifyanappropriatestrategyfortheuseoflowmolecularweightheparininapatientundergoingkneereplacementsurgerywithanepiduralblock.
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AAGBI:-LMWHtx:notrecommended
-prophy:withcaution
Strategy:Lastdoesofclexanebeforeepiduralinsertionorcatheterremoval–12-24hours
Nextdoseofclexaneafterepiduralinsertionorcatheterremoval–4-6horus
- Wcautionforprophyandnotrecommendedwithtx.
Henceintxclexane;I’drecommendalternativeanalgesiaduetohighriskofepidural
haematoma.
Ongoingcare–regularreview,dailyreview,monitorforproblem,considerXalevel
(althoughtAndrewCameronsayit’suseless).
Q6-renalfailureelectrolytediscussion,45%
Listandexplainthetypicalelectrolyteabnormalitiesofchronicrenalfailure.
• Na–normal–excretionmaintained+volumeregulationintact
• Cl–normal–followsNatomaintainneutrality
• K–high–reducedexcretion
• Mg–high–reducedexcretion
• Ca–low–lowproductionVitD,reducedCareabsorptionfromGI/Kidney
• P–high–reducedPexcretion
§ 2ndhyperparathyroidism
• H–high–reducedexcretion
• HCO3–low
Q7-duralpuncturemanagement(repeat),28%
WhileperforminganepiduralforlabouranalgesiainanotherwisehealthyprimigravidainfirststageyouinadvertentlycauseaduralpuncturewiththeTouhyneedle.Describeandjustifyyourmanagementofthiscomplication.
Q8-neuroprotectionprinciples(repeat),45%
Describetheprinciplesofcerebralprotectioninapatientwithanisolatedclosedheadinjury–(Oct2009Q15)Q9-Nitrousoxidediscussion,68%
Nitrousoxideshouldnotbeusedroutinelyasacomponentofgeneralanaesthesia.Discuss.N2O–usedwithotheragentsinGAoraloneasanalgesia.
Pros
• Cheap,available
• Rapidonset/offset
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• Concentration/2ndgaseffect
• Innert,andeliminationviaventilationnotaffectedbyimpairedorganicmetabolism
• MAC-sparepropertyandadvantages:haemodynamics,uterinetoneetc.
• NMDA-antagonismanalgesicproperty
Cons
• Supportscombustion
• Riskofhypoxicmixturewhenhighconcused;cannotbeusedasoleanaesthetic
• Causesexpansionofairspace(ETTcuff,PTX,GItract,venousairembolism)
• DiffusionhypoxiaifnotsupplementedwithO2.
• WorsenspulmHTN.HighICP.
• Bonemarrowsuppression-oxidisescobaltioninvitB12,inhibitsmethionine/THF
(tetrahydrofluoride)synthesis,impairedDNAsynthesis,megaloblasticchangesin
bonemarrow,agranulocytosis,centralneurodegenerativeeffect.
• Environmentalgreenhouseeffect.
Onbalance,N2OhasroleinGA,butmostofproscanbeachievedbyothermeansof
balancedanaesthesia–eg.useofopioidstoMAC-spare,useofketamineforanalgesiavia
NMDA-antagonism;useofsevo/O2aloneforgasinduction;thereforeN2Oisnt’used
routinelyinmostmodernanaesthesia,andisonlyreservedinselectedsituations–
obstetricsorpaedsgasinduction.
Q10-RSIinchild,46%
Discussindetailthetechniqueofrapidsequenceinductionwithcricoidpressureinachild.Includethereasonsforyourchoiceofrelaxant.RSI=Detaileddiscussionoftechniquewithcricoidinchild
o Assessment:PatientassessmentforindicationofRSI+airway–isthisforlife-
threateningsurgeryorurgentsurgerybutwithoptionofwakeupiffailed
intubation?o Difficultairwayfeatures?o Anycontraindicationtomusclerelaxantchoice?Anaphylaxis,suxapnoea,
electrolytedisturbance,MH,significantburn>48hr,paraplegia,myopathies,
hyperkalaemia.o Ifnocontraindicationforsuxamethonium,andifoptimalintubation
conditionrequired,eg.appendicectomy,bowelobstruction;thenwilluse
sux.o Teamcommunication:Clearcommunicationwithtechnician,nursingstaffforplanof
RSIo Including
§ Airwayequipment:laryngoscopebladesize,ETTsize/type.§ backupplaniffailedintubation
• eg.maintainoxygenationandwakepatientup• maintainoxygenationwithBMVor2
ndgenSGA+size
§ cricoidplano Pre-induction–DAMSIP:ensuremachinecheckedandready,reliableIVline,drug
choice(prop2-3mg/kg+sux2mg/kgIV+dosepredetermined);patientwell
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positioned(sniffingposition/ramped),optimalpreoxyaimforEtO2>80%;suction
closeby;monitorattached+vitalsignsstableàmaybedifficultinyoungchildren
andpracticallimitationapplies.o Resusdrugsready:ephedrine+metaraminolprefilledsyringes.Atropine
20mcg/kgIV.o WouldnotinvolveparentsinRSIduetoneedforcompletefocuswithpatient
fromverybeginning.o Induction:
o Cricoidrequirededicated,experiencedassistanttoapplycorrectly.30N
pressurevertically90degtopatienthorizontalaxis;oncricoid.Maintained
untilETTplacementconfirmedandcuffinflated.§ Issuesinchildren–cricoidlieshigherC3-4;andcandistort
laryngoscopyview;inwhichcasecricoidshouldberemovedto
improveview.Alsoconcernwoesophagealruptureifpatientvomits
(pressureshouldberemoved).Relaxantchoice
§ Sux:
o (givennocontraindication)
o givesfastest/optimalintubationcondition.
o Clearend-point(fasciculationstops).
o Howevercancausebradycardia,requiringatropine.
§ Roc:
o Ifsuxcontraindicated
o 1.2mg/kgIV.Notasscwithbradycardia,butlongdurationcanbeaproblem.
Q11–periopbetablokeruse(repeat),47%Critically evaluate the use of Beta blockers in the perioperative period to prevent
myocardial infarction. = repeat
Q12-Ketaminediscussion,56%Discuss the role of ketamine in current anaesthesia practice.
Ketamine • non-competitive NMDA-R antagonist • Use = induction agent for GA, part of TIVA, sedation, analgesia.
Induction: IV or IM (1-10mg/kg). Quick onset due to high lipid solubility and offset due to redistribution.
• Therefore needs infusion to maintain anaesthesia. • Useful if haemodynamic unstable because of increased SNS tone with ketamine hence
tends to maintain haemodynamics on induction (although in extremely high risk cases, due to myocardial depressant effect, can still cause CVS collapse).
• Also good bronchodilator for use in asthmatic. Maintenance of GA?
• Good agent for TIVA, esp in field anaesthesia due to relative maintenance of SV/CVS. • Offset t1/2 beta is by hepatic metabolism; and CSHT increases with duration of infusion
(although this is comparable to propofol) o Vd2L/kg, Cl 20ml/kg/min, t1/2-2hours.
Sedation: multiple formulations available (PO,IV) with relative maintenance of CVS/Resp functions hence can be used as premed.
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Analgesia – opioid spare, preemptive + preventive analgesia property. Treatment of neuropathic / chronic pain. Cons:
• Howewver, increase airway secretion, does not obtund airway reflex hence need coinduction with muscle relaxant or propofol.
• CBF/ICP, relative contraindication in high ICP; • Dissociative anaesthesia making BIS/EEG monitor unreliable. • Psychomimetic effect with vivid dreams, hallucination; not ideal for use in confused,
psychiatric patient or patient with cognitive dysfunction. • Abuse potential.
Q13–CVLrisk,70%List the risks associated with the placement of a central venous catheter? Discuss the
ways in which these risks may be modified.
Risks + Risk minimisation • Arterial puncture/dilatation
o USS guidance, see needle tip at all times, and to verify guideline position IV not IA.
o Pressure transduce cannula to ensure IV placement before dilatation. • Pneumothorax
o Site selection: SC highest risk > IJ > femoral. o Vigilant of needle position and avoid deep needle puncture beneath neck.
• Nerve damage – vagal, phrenic, brachial plexus o USS to visualize structure and avoid needle coming in contact
• Airway/oesophageal trauma o USS to avoid contact
• Pericardial tamponade/arrhythmia o Avoid deep insertion of guidewire + dilator. o Verify CVL tip position post-insertion with CXR, ensure tip not in cardiac shadow
(ideally just outside it or <2cm below carina) and ensure CVL tip lie parallel to vessel wall, not digging into it.
o Secure catheter carefully at 2 points to avoid migration. • Thyroid gland trauma
o USS to avoid contact with structure • Venous air embolism
o Prime line with saline before use. Close all lumen. o Trendelenburg to increase venous P when using IJ route. IPPV/PEEP if patient
intubated. • Bleeding
o Do not cut skin excessively. Check coagulation, avoid insertion when coagulopathy presents.
o Insert at site where compression possible (Tricky with SC) • Infection/CLAB.
o Site selection: IJ better than femoral. o Strict aseptic technique. Clear dressing and daily site check to allow early
detection. o Aseptic technique when using CVL.
• Venous thrombosis: o Remove line asap when not required. o Hep saline lock.
• Anaphylaxis to chlorhex
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Q14-F7adiscussion,36%Critically evaluate the role of recombinant factor VIIa in blood loss requiring massive
transfusion in the trauma patient.
Pros
§ Theoretical basis § Success in case reports § No risk of infection transmission § Accepted by some Jehovah’s witness § Long shelf life in powder formulation § Avoids problems assc with transfusion: hypothermia, electrolyte, volume overload
Cons
• No good evidence; likely publication bias
• ?side effects ?thrombtic risk
• only considered for use after MTP packages have been tried and abnormal physiology corrected, but still persistent coagulopathy
• off-label use; consent problem esp in Paeds patient. • Cost / availability
• No agreed protocol On balance (report wants it)
• F7a is unlikely to be effective if acute physiological derangement isn’t corrected first. My priorities will be on correction of these + surgical haemostasis. After all these have been done and patient is still bleedy, I’d consider using F7a 90mg/kg.
Q15-ASAdiscussion,45%Discuss the usefulness of the ASA grading as a measure of perioperative risk.
ASA = grading of patient’s physical status.
1 - A normal healthy patient 2 - A patient with mild systemic disease without functional limitation (under control) 3 - A patient with severe systemic disease with functional limitation 4 - A patient with severe systemic disease that is a constant threat to life 5 - A moribund patient who is not expected to survive without the operation 6 - A declared brain-dead patient whose organs are being removed for donor purposes E – Emergency Surgery Evaluation of ASA use in perioperative risk assessment
Use o Standardized grading of patient’s overall physical health, allows for synthesis of patient’s
overall clinical status and aids in team prelist briefing, communication. o Although not designed for direct periop risk assessment; ASA grade is correlated with
periop risk. o On management level, ASA information is commonly collected by hospital, DHB for audit
purpose and possibly risk prediction of public health, and for health economics analysis and funding allocation.
Limitation o Does not include class between ASA 2 + 3, which may be ‘moderate’ in nature. o Does not indicate number of medical problems or allow for correct classification with ‘frail’
patient – in whom significant functional limitation isn’t easily attributed to a ‘systemic disease’.
o Does not consider significance of ‘age’ o Is subjective to author’s interpretation of ASA definitions. Eg. some would classify
pregnancy as ASA2, some would classify as ASA1. § Making inter-hospital comparison of study results difficult based on ASA
classification. o Problems with ‘E’ – some author include current acute condiidion when scoring ASA, eg.
young fit healthy patient with multi-trauma would get ASA 4E, but some would use
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premorbid condition, hence grade such patient as ASA 1E.
May-2006,62%
Q1–Aspirationprophylaxis,87%
Listthepredisposingfactorsforaspirationofgastriccontentsinapatientundergoinggeneralanaesthesia.Discussthemeasuresyouwouldtaketopreventthiscomplication.
Riskfactors&Increasedacidity/volume–GORD,hiatushernia,obesity,pregnancy
• Delayedgastricemptying–Intraabdopathology(bowelobstruction,GIsepsis),drugs
(opioid,ETOH),pain(traumaafterfood,labour)
• Increasedriskofaspirationifregurgitationhappens
o Notprotectingairway-LowGCS,LAtolarynx,unabletocough
o Uncoordinatedswallow–CVA/TIA,LNpalsy
minimizationstrategies• Preop
o Identifyingriskfactors–previousaspiration?GORD?
o Ensurepreopfasting(asperANZCAfastingguideline)–2hoursofclearfluid,
6hoursforsolids
o Antacids:Nacitrate0.3M30ml<30mins.Ranitidine150mgBD,omeprazole
20mgfor2days.
o AspirationofNGTifin-situ.
• Intraop
o RSI/cricoid–
o EnsureETTcuffadequatelyinflated
o Optimiseextubationcondition:reversalofNMBD,mouth/NGsuction,fully
awakeandconsiderpositionL/lateralheaddown.
• Postop
o Recoveryposition+ongoingmonitor.
Q2–IVdrugerrorprevention,39%
Describethefactorsthatcontributetointravenousdrugerrorsinanaesthesiapractice.Discussthemethodsavailabletoreducetheincidentsofsucherrors.
IVdrugerrorcouldmeanwrongdrug/doseorgiventowrongpatientetc.Humanerror
knowntobepredominantfactor.
Factors
• Humanfactor
o Slips=anunplannedactionwasperformedieskillbasedattentionfailure
§ Eg.writingdownwrongunitssuchasmginsteadofmcg
§ Failuretocheckampoulelabel,expirydate
o Lapses=missedactionieforgottentoperformactionieskillbasedmemory
failure
§ Eg.forgottentogiveantibiotic
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§ ForgottentoenterallnecessarydatawhileprogrammingIVinfusion
pump
o Mistake=wrongplanascarriedoutleadingtoerrorierulebasedfailure
§ Eg.wronglabelonsyringe
§ Wrongconcentrationofdrug
§ Inadequateknowledgeondrugeffect
• OthercontributingfactorstoHumanfactor:
o Distractioneg.teaching,multitastking(performingTOEandGAatsame
time),previouspatientinrecovery.
o Stressegcriticallyillpatient,crisis
o Fatigueegworkingovertime
o Boredom
o Interpersonalfactoreglackofcommunicationbetweenanaesthetistsduring
handover
• Systemicfactors:errorinsystem
o Similarappearanceofdifferentdrugampoules
o Changesinappearanceofdrugampouletoadifferentformwithout
informingClinicians
o Poorrosteringàfatigue
o Poordrugorganizationintrolley
o Poorlabellingsystemwithsimilarcolourfordifferentclassesofdrugs
o Unfamiliarenvironmentsinunderstaffedwardswithoutadequate
orientation
Riskminimization
• General
o Goodrostertoavoidfatigue
o Avoiddistractionduringcase
• Drug
o Wellorganizedtrolley
o Tidyworkspace
o Avoidsimilarpackagingswithintrolley
o Prefilledsyringesforhighriskmedicationseg.ketamine,sux,insulin
o Clearcommunicationwithinteamofdrugdrawnupandlabelallsyringes
o Establishruleofcheckinglabelonampoule,onsyringebeforeuse
o Colourcodedlabelfordifferentclasses
o Barcodereaderwithaudiovisualalarmsandruleofscanbeforeadminister
o Ruleof2personscheckforcomplexdrugdosecalculations
• Qualityassurance
o Reportoferrorandrootcauseanalysistoallowqualityimprovementtaking
place.
o InvolvePharmacyinensuringconsistentvialstockusedthroughouthospital
o Standardisedrugconcentrationsusedandlabelsystemthroughouthospital
Q3-DMmanagement,75%
Asixty-fiveyearoldwomanpresentsforatotalabdominalhysterectomy.Shehasnon-insulindependentdiabetesmellitusthatisnormallycontrolledwithanoralhypoglycaemicagent.Describeyourperioperativemanagementofherbloodsugar.
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Q4-NSAIDuse,77%
Discusstheroleofnonsteroidalanti-inflammatorydrugsforpostoperativeanalgesiainadultdaysurgerypatients.NSAID=non-selective(COX-1+2);orselective(COX-2).AnalgesiaachievedthroughinhibitionofCOX-2;SEprofielsarefrominhibitionofCOX-1andhomeostaticprostaglandin
production.
Useindaycase
- Aim=goodanalgesia,minimalSE:PONV,sedation,bleed,CVS/Respeffect.§ NSAIDworkswelltoachievethesegoals.
- Proso Multipleformulations,cheap–IV,PO,rectal.o Effectiveanalgesiaespusedinmultimodalanalgesia.o Opioidspare–lessPONV,sedation,urineretention,respdepression.o Hasformulationtoachieveprolongedeffecteg.etoricoxibODorIVparecoxib
OD-BD.- Cons
o Stillrequirestrongopioidformanaginghighlevelpaino Multiplecontraindications(relativeorabsolute)
§ Asthma,CHF/IHD,Renal,GI,bleedingrisk,severalstagesduring
pregnancy(catC);allergies(implicatedinsomesulphurallergy)o PotentialSEs:
§ Bleed,gastritis,ulcer,potentialimpairedbonehealing(although
controversial);§ InteractionwithhighPPBdrugs–causingdisplacementandincreased
effect.
Q5-MyastheniaGravis(repeat),73%
Afiftyyearoldmantakingcorticosteroidandpyridostigmineformyastheniagravisistohaveanelectiverighthemicolectomyundergeneralanaesthesia.Discussyourmanagementofhismyastheniapreandpostoperatively.
NB.
Useofneomaycausecholinergiccrisis;hencespontaneousrecoveryfromNMDR
recommendedifpractical
Q6–smokeinhalationmanagement,57%Describe your immediate assessment + management of airway in patient with smoke
inhalation injury
Smoke inhalation = inhales heat and chemical smoke, can cause • Thermal injury – airway swelling, tissue sloughing, scarring, stricture • Chemical injury – inflammation, oedema, hypoxaemia due to CO toxicity or
methaemoglobinaemia à leading to airway obstruction
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Assessment • Hx-
o duration of smoke inhalation and time course since inhalation; o facial burn? o Mechanism? Blast injury may involve multisystemic injury o Plastic burn? May cause cyanide poisoning, hypoxaemia, methaemoglobinaemia o Other important routine AMPLE history.
• Exam o Is patient in severe resp distress / desaturation / agitated, decreased LOC
requiring urgent intervention? o Extent of facial burn, especialy close to airway (nose/oral cavity, singeing of
eyebrows). o Oral cavity exam – any swelling, sloughing, presence of soot/carbon deposit?
Carbonaceous sputum? Change of voice o Nasoendoscopy assess laryngeal swelling o Presence of pulm oedema from inhalational injury/chemical pneumonitis? o Other important routine airway assessment – Malampati, mouth opening, TMD,
neck movement etc. Management
• Consider if urgent intervention required. Even if non-critical, would still consider timely intubation as indicated by potential worsening of airway swelling.
• If severe swelling suspected, consider surgical airway or AFOI. • Otherwise, plan for RSI +/- C-spine immobilization; Note the contraindication for sux for
burn >2 day old. • (still required by report) Subsequently, watch for:
o Hypoxaemia from CO toxicity/methaemoglobinaemia à oxygen supplement therapy; sats may be misleading with CO toxicity.
o Bronchospasm à bronchodilators o Ventilatory difficulty with eschar à escharotomy o LRTI/VAP à high vigilance, ICU care and timely antibiotic o ARDS à lung protected ventilation strategy o Significant burn requiring care in burn center?
Q7–restlessinTURP,89%
Aseventyfiveyearoldmanhavingatransurethralresectionoftheprostateunderspinalanaesthesiawhichhasbeenuneventful,becomesrestless70minutesintotheprocedure.Hehad2milligramsofmidazolamatthestartofthecaseandnofurthersedation.Describeyourassessmentandmanagementofthisproblem.
AssessmentofrestlessnessduringTURP
• Considerdifferentials:
o A:OSA,airwayobstruction
o B:hypoxaemia,hypercarbia,pulmoedema,PE,
o C:MI,hypotension,anaemiafromexcessivebloodloss,
o D:CVA,pain,inadequateblock,discomfort,drugerror,hypoglycaemia
o E:hypothermia,TURPsyndrome,
• Management
o (simul)Managepatientatthesametimeconsiderdifferentials
§ Scanmonitor,arethevitalsignsstable?ECGchanges?
§ Scansurgicalfield:Istherelargevolumeofirrigationfluidusedwith
deficitinfluidoutputtosuggestTURPsyndrome?Signofpulm
oedema?
§ Invx:bloodgasforelectrolyte,osmolality,UECr,FBC.
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o MxABCDE
§ IspatientinseveredistressrequiringGA,airway+ventilateto
facilitatecare?
o Frequencygambling,wouldmxTURP
§ Dependsondifferential,howeverinthiscontextTURPsyndrome
mostprobablediagnosis=absorptionofexcessiveglycinebased
hypotonicfluidàhypoosmolarhyponatraemia.
o Notifystaff/Surgeon,callforhelpforjobdelegation
o 1stinstance:stopoperationifsafe,stopIVfluids.
o A:maintainairway,intubateifpatientbecomesunconsciousofrequireGAto
facilitatemanagement
o B:maintainoxygenationtitrateFiO2.Likelyrequire100%initially.Maintain
normocarbia.
§ Considerfrusemideifsignsofpulmoedemawithcoarsecrackles,
desatandrespdistress.Balanceriskwithhypovolaemia.
o C:maintainMAP.NotethatifexcessivefluidabsorbedpatientmayhaveHTN
withreflexbradycardia.
o D:ifseizureàgiveIVmidazolamandconsiderGA.
o E:checkelectrolytelevelswithbloodgas.
§ IfconfirmsacutehyponatraemiaNa<120withseizure,needtotreat
withhypertonicsaline:3%NaCl1-2.5ml/kg/hràuntilsymptom
improvementofNa>125.
§ HourlyNalevelcheck.LimitacuteNariseto<10mmol/day.
o Montior:routineANZCAguideline+arterialline+CVLtoguide
electrolyte/fluidtherapy.
Q8–pacemakermanagement(repeat),86%The first patient on your orthopaedic list tomorrow is scheduled for left total hip
replacement. He has an implanted (permanent) cardiac pacemaker. Discuss the
relevant factors in your pre-anaesthetic assessment of this patient.
PPM used usu. for symptomatic bradyarrhythmia Preop assessment: Hx
o indication o concurrent medical problem, cause for bradyarrhythmia
o CAD, CHF, HTN, DM o Hx/exam of decompensated CHF or unstable angina? Needing Cardiology referral?
Invx: o PM interrogation from recent electrophysiology service?
o Dependence, mode, underlying rhythm, battery life, magnet response? o ?AICD function
o Referral for check as per local policy, eg. >6/12 in my own institution. Planning:
o Patient: usu no reprogramming required given surgery >15cm away from PPM. However, if at risk of EM inteferrence, will need to consider disabling rate responsiveness, asynchronous pacing.
o Ensure o Surgical factor: discuss diathermy precaution, bipolar w lowest feasible energy, burst
duration, pad away from site as far as possible. o Anaesthetic: resus equipment ready: drug, ext pacing pad / defib applied.
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o Monitor o Postop care plan: need to have EP service available if re-interrogation required.
Q9-Bupivacainetoxicity,56%Describe the clinical features and management of bupivacaine toxicity.
LAST Feature
• Systemic – CNS: circumoral tingling, metallic taste, paresthesia, seizure, coma, death. • CVS – hypotension, heart block, VF (refractory), death • Anaphylaxis – very rare – CVS/resp/cutaneous features.
Mx
• STOP LA, call for help, if systemic toxicity seen, this is medical EMERGENCY! • ABC approach + early defib as per ANZCA endorsed LAST guideline + ACLS protocol.
o With caveat of very careful use of adrenaline – as 1mg bolus assc with 100% mortality. If using adrenaline, consider small boluses of <1mcg/kg.
• Key = hyperventilate to low normal CO2, to reduce unionized portion of LA which acts on effect site. Balance risk with seizure induced by hypocapnoea.
o Avoid hypoxaemia and acidosis that would worsen LAST. • Timely administration of 20% intralipid.
o 1.5ml/kg bolus followed by 15ml/kg/hour infusion. Repeat bolus Q5 mins. Maxium dose given = up to 12ml/kg.
• Seizure control. • ICU/HDU care.
Q10-peribublareyeblockanatomy,33%Describe the anatomy of the orbit relevant to a peribulbar eye block.
Peribulbar=instilLAintowithinorbitoutsidefibrotendinousringofextraocularrectimuscles.
AnatomyforPeribulbarblockOrbit:
• Orbit=pyramidalshape,40-50mmdeep.
• Extraocularmuscles,forfibrotendinousringencasingthecone-shapedorbit,
attachessclerea.
o 4recti
o SO+IO
• Bloodvesslesarerichinsuperonsasalquadrant(opthamlicartery/opticN);hence
approach=2injectionsclassically.(inferotemporal,midlinesuperior).
Neuroanatomy
o SensaEontotheEye
§ CorneaandSupero-nasalconjunctivaànasociliaryN(V1)
§ TheRestàLacrimal,Frontal,Infra-orbital
o Motorsupply
§ SC,levatorpalpebral–III(upper)
§ MR,IR,IO–III(lower)
§ LR–VI(abducens)
§ SO–IV(trochlear)
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Optimalblock=sensoryblockandakinesisoftheglobe(motorblock)isrequired.
• NB.ieinsidemusclecone=2,3,5,6.
• Outside=4
NB. Globe(superficialàdeep)
• Conjunctivaàtenon’scapsuleàsubtenonspace(potential
space)àscleraàchoroid/ciliarybody/irisàretina Q11-Carotidendarterectomymanagement,77%Discuss the principles underlying the management of a general anaesthetic for carotid
endarterectomy.
Issues/Aims (from Auckland 2016)
- BC: These patients often have comorbidities: IHD/CHF/CVA/DM/renal failure o Myocardial protection from ischaemic injury o Ablation of surgical + stress responses
- D: Cerebral circulation may be compromised by preexisting disease + also clamping intraop o Cerebral protection from ischaemic injury + bleed from CVS instability o Control of HR and BP o Awake patient at end for neurological monitoring
Management
Pre
- Thorough preassessment, look for comorbidities outlined above. Routine AMPLE hx + airway + cardioresp exam; document existing neuro deficit.
- Carotid dopploer result. Intra
- A: secure intubation, as access may be difficult intraop. o LMA could potentially reduce carotid BF. o Obtund airway reflex with prop/remi/roc, avoid hypotension with
ephedrine/phenyl. - B+C: maintain optimal oxygen delivery with oxygenation>90% (and Hb>70-80g/L),
normocarbia + MAP within 20% of patient’s baseline. o Care w hypocarbia as à reduced CBF! o Avoid venous congestion: no excessive PEEP, avoid venous compression from
tube tie. - Monitor: ANZCA routine + art line, 5 lead ECG + cerebral BF monitor:
o TCD, EEG, stump pressure monitor, NIRS, SSEP - X-clamp: keep MAP high normal for patient.
o May need shunt distal to clamp if cerebral perfusion dysfunction evident. Post
- Cough-free extubation with remi extubation or LMA exchange; o minimize risk of haematoma, wound dehiscence.
- Multimodal analgesia, consider superficial cervical plexus block to opioid spare + avoid cough à facilitates neuro assessment + wound dehiscence.
- HDU/ICU close monitor of potential complications: - A. Neck haematoma - C. MI, Hyper/hypotension - D. Stroke, Neurological deficit; Hyperperfusion syndrome
NB. -airway oedema; cervial haematoma occurs ~5-10% of cases. Q12–AFcausesandmanagementinPACU,71%List the causes of acute atrial fibrillation in the perioperative period. Describe your
management of acute atrial fibrillation which occurs in the PACU (Post- anaesthesia
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Care Unit) in a patient who has had a total hip replacement.
List: o Preexisting
o PAF, cardiac disease (LVF, valvular, dilated LA), Pulm dx o Stress induced: pain, inflammatory response, bleed, anaemia
o Acute cardiac event: o Hypoxaemia, hypovolaemia,
o hypoK, Mg. o Hypothermia o VTE – PE o NB: AF in PACU setting often a short lived complication that resolved once acute peri-
operative physiological changes were reversed Mx:
o Decide if life threatening with haemodynamic compromise or not, fast vs. rate controlled? o If compromise à emergency, help, manage ABC, urgent DC cardioversion indicated. o If not compromised, then consider causes and support concurrently:
o Causes? History of previous AF? Medical condition? Chest pain, dyspnea, palpitation? Pain, fever.
§ r/v anaesthetic chart – drugs, blood loss, fluid balance. § Exam to rule out heart failure. Vital signs. Hypovolaemia?
• Monitor: ECG/pulse ox, NIBP; Art line if necessary § Invx: electrolyte, lactate, acid/base, Hb. ECG. CXR +/- ECHO.
o Mx: § Treat hypoxaemia with O2 supplement § Support BP with fluid +/- vasopressor § Rate control vs. rhythm control
• In context of acute AF, I’d rate control. Agent choice: • BB, eg. esmolol if no CI and esp patient already on BB. 10-20mcg
bolus. If tolerable without haemodynaic compromise, consider IV metoprolol
• Digoxin if concern with haemodynamic lability esp hx of heart failure.
• Amiodarone for rate control which is relatively haemodynamic stable 300mg loading over 1 hour, followed by 900mg over 23 hours.
§ Notify Surgical Team +/- Cardiology referral § Consider HDU level care.
Q13–preoxygenation(repeat),25%What is the physiological basis of preoxygenation? Describe method of
preoxygenation and how to assess its adequacy (Chang’s airway)
(report) • Few candidates addressed alterations in FRC, such as posture, pregnancy, anaesthesia, age
or disease processes; • Closing volume and oxygen consumption were seldom mentioned; • Method of pre-oxygenation was often incomplete in detail; • End tidal oxygen was often given as the sole determinant of adequacy of pre-oxygenation.
Q14-Desfluraneuse,73%Discuss the role of desflurane in current anaesthesia practice.
Desflurane: methyl ethyl ether, halogenated. • Low blood:gas partition coefficient, hence rapid onset • Low fat:blood partition coefficient, hence very low accumulation in adipose tissue and quick
offset despite long duration of use. o Elimination via ventilation. Minimally metabolized (0.02%).
Use = GA, prolonged case, obesity, neurosurgery.
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Other properties:
• Ischaemic preconditioning • Relative maintenance of metabolic autoregulation of CBF – esp with 1<MAC; hence use in
Neurosurgery is acceptable. However limitations:
• Pungent, bronchospasm in smokers • Need special vaporizer due to high SVP (dual circuit gas vapour blender) • Produces carbon monoxide when react with sodalime/baralyme, esp with low flow. • Expensive, • High greenhouse effect and global warming potential.
Q15-epiduralanalgesiaconsent,62%Discuss the elements you consider important when obtaining consent for epidural
analgesia in labour.
Sep-2005,62%
Q1-croup,paedsmanagement,76%
Whataretheindicationsfortrachealintubationina3yearoldwhopresentswith“croup”?Describeyourtechniqueforintubation.Indications
o Respiratoryfailure
o IncreasedWOBwithsignsoffatigue
o Cyanosis
o ReducedLOC
o Croupscorecanbecalculatedbasedonrespdistress/cyanosis/WOB.
o Tofacilitatetransport
Intubationtechnique=CAREWITHAIRWAYOBSTRUCTIONSUBGLOTTICALLYo Obtainingviewisnotnecessarilydifficult,howeverpassageofETTlikelydifficult.
• Transfertotheatre
• TemporizefortransfertoOTwithMedicalTreatment:
• Medicalmanagementtotemporizewhileoptimizingintubationcondition…
o Minimisepatientdistress.DonotforceIVaccessifpatientfights.
o HumidifiedO2-astolerated
o Adrenalineneb1:1000-5ml(0.5ml/kgif<10kg;)Q30-60minutes
o Dexamethasone0.6mg/kgIVorIM
o Heliox
• ObtainimportantAMPLEhistory.
• Anaestheticmanagement(Auckland2016).
o InformTech,ENTsurgeon,OTnursingstaff+2ndPaedsAnaesthetist.
o Gasinduction-100%oxygen,sevoflurane,maintainCPAP
o Cantakelong
o LAtoairway
o IVaccessonceasleep
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o SmallerthannormalETTtube(crouptubes–ielongtubetofitpast
obstructionintrachea)–nasaltubeallowsforsuperiorfixationinchildren
andfacilitatesinPICU(report)–useage/4+3.5uncuffed+/-onesize
down.ie3.5-4ETT.
o NeedsENTbackupwithrigidbronchoscopy+/-surgicalairway
o TransfertoPICU
NB.
Croupusu.viral,duetoparainfluenza,influenzaA/B,RSV,rhinovirus.
VeryriskyifhavetointubatepaedsinED,ifnecessary…
o informMDTtooptimizeintubationsituationinED–tech,ENTsurgeon,EDstaff.
Ensureavailabilityofequipment–airway,drug,oxygen,suction,difficultairway
equipmentincludingsurgicalairwayequipment.
Q2-Statistics,biasreduction,72%
Discusswaysinwhichyoucandecreasebiasinaclinicaltrialforanewantihypertensiveagent.
Bias=systematicerrorinatrial.Increasingsamplesizedoesn’tremovebias.
Potentialsourceofbiasinclude• Selectionbias:
o sampleunrepresentativeofpopulation
o controlsnotcomparablewithstudygroup
§ defineinclusionandexclusioncriteriathatallowsforgood
generalizabilityofsampletothepopulationitrepresents.
§ Considermulticentertrialstoimprovesamplerepresentativenessand
bettergeneralizability.
• Interventionbias:
o patientsreceivingmoreattentionbecauseoftheirtreatmentgroup
o espifunblindedcomparison.
§ Blinding,ensureadequaterandomization.
§ Ensuresimilarbackgroundcharacteristicsbetweeninterventionand
controlarms.
§ Ensureprotocolisedtreatmentforbotharmstoachieve
standardisation
• Follow-upbias:
o whenpatientsarelosttothestudyitmaybeduetoconfoundingeffecteg.
lesscapabletocontinuewithstudyduetoillness
§ minimizeeffectbyusingintention-to-treatanalysis
§ minimizelsottofollowuporwithdrawifpractical.
§ Minimizecrossoverofpatients.
• Recallbias:
o patientmistakenrecollectioneg.abilitytodescribepainwhenveryunwell
post-laparotomy
§ questionnaire/interviewconductedintimelymanner,whenpatient
clinicallysstable.Useobjectiveassessmentincombinationto
subjective.
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• Measurementorinformationbias:
o exaggerationofeffect:egitiswellknownthatpatientsincludedintrials
oftendobetterthanthosenotincluded,thepatientsincludedinthetrialwill
havebetteranalgesiathanthosenotincluded(ieHawthorneeffect)
• minimizebycarefulstudydesigntoensureappropriate
definitionofinclusion+exclusionstudycriteria.Referto
alreadypublishedhighqualitystudyduringstudydesign.
o Confusionofoutcomemeasureanddatacollection
• Cleardefinitionofoutcometoavoidconfusion
• Donotchangeoutcomemeasurefromstudyprotocol
o inaccurateoruncalibratedinstruments
• minimizebyensureworking,calibratedequipmentbefore
studytakeplace.
• Usestandardizedmachinetoallowobjectivemeasurement,
ratherthanbymanualsphygmomanometer.
• Analysisbias
o withdrawalsordesignviolations
• minimizebysample-sizecalculationwithQualifiedStatistician
Consultanddedicatedresearchteamtofollowuppatient.
• Gooddatahandlingwithappropriatestatisticalanalysis
method
• Statisticianconsult
• Conclusion:
• Noexaggerationandnooversimplification.
• Mustaccuratelyreflectstudyresultgenerated.
• Publication
• avoidpublicationbias;publishifitiswelldesignedevenifthe
resultisnegative.
Q3-ANSneuropathymanagementinDM,36%
Whatarethesymptoms,signsandanaestheticimplicationsofanautonomicneuropathyassociatedwithdiabetesmellitus?manifestationCVS,GI/GU,sweat
Signs:
• lossofHRvariability–Valsalva,respiration,posturalchange;BP
Issues:• CVS,silentMI,thermoregulation,poorglycaemiccontrol
• Aspirationprophylaxis
Q4-CrVanatomyforLA/dental,44%
Describetheanatomyofthetrigeminalnerverelevanttolocalanaesthesiafordentalextraction
Dentalextractionsrelevantnerve:(report)
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o MaxillaryNV2
o Uppermolar:postsupalveolarN.(PSAN)
o Upperpremolar:midsupalvnerve(MSAN)
o Uppercanine/incisor:antsupalvN(ASAN)
o MandibularNV3:Lowerteeth:infalvN(IAN)
Multipledentalextractionswillrequirenerveblock:
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Hardplate:
o Greater/nasopalatinenerveblocked(=branchesofpterygopalatineganglion(aka
sphenopalatineganglion).
Upperextractions:1-2ofSAN.
o PSANinpterygopalatinefossa
o MSAN/ASAN=continuationofinfraorbitalN.
§ CandopterygopalatineganglionblockformostN.above,butriskof
haematoma+injurytomaxillaryartery,venousplexus.
Lowerextractions:
o IANblock(alsoblockslingual,mental,incisiveN);runmedialaspectofmandibular
ramus.
1-2teethextractioncanbewithLAinfiltration.
Q5–LMAuseinlaparotomy,94%What’s role of LMA in failed intubation for laparotomy
LMA in failed intubation –
• Supraglottic device allowing for airway maintenance + ventilation. • may be a necessary life-saving rescue technique to provide oxygenation when intubation
has failed. If LMA succeeded in oxygenation, subsueqnet management depends use in laparotomy depends on
• risk assessment of aspiration • urgency of case – is wake up a practical option?
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Emergency case:
• LMA allows ventilation. If emergency surgery where time is critical, may have to proceed; balancing urgency of surgery with an unprotected airway + aspiration risk.
• Consider cricoid pressure to minimize risk of aspiration; however may compromise airway or injure oesophgus and benefit may be limited.
• Alternatively, consider fibreoptic guided intubation through LMA to protect airway – smaller ETT eg. 6.5 should be used, with size 5 FOB, which would fit through size 5 LMA, lubricate ETT.
If non-critical surgery eg. elective with low risk of aspiration • Then may wake patient up and consider AFOI. • Alternatively, can also attempt FOI through LMA.
Once intubated, LMA can be left in-situ, which allows for interval extubation postop. Care with airway oedema and monitor LMA cuff pressure. If removing LMA, need to be vigilant not to dislodge ETT. Note, if oxygenation fails with LMA and BMV, ie CICO situation = emergency and requires cricothyroidotomy immediately.
Q6-Anaesthesiaandthermoregulation,59%How does anaesthesia alter temperature homeostasis?
Thermoregulation is normally interated by hypothalamus, where threshold is set for behavioural changes (clothe change, body posture) or autonomic response eg. shiver, sweat, vasomotor activity; these work to maintain body temp within the interthreshold range. Interthreshold range (body temp) = range of body temp where no ANS response occur; usu +/- 0.2C at 37C. However, under GA
• interthreshold range is widened in dose-response fashion, and lower threshold (2 deg) more than upper threshold (1 deg).
• Patient is unable to perform behavioural change; which further impair thermoregulation. § Net effect is the tendency for patient to become cold.
• GA also induces 3 phases of temperature change via: § Redistribution (1st hour) where core body temp lower and equalizes
peripheral body temp due to vasodilation § Ongoing heat loss by rad 40/convec 30/evap 15/conduct 5+ resp heat
loss 10+ reduced metabolic rate § Plateau phase where thermogenesis eqpuilibrates with heat loss.
• Shiver may also be inhibited by muscle relaxant + neuraxial may abolish vasomotor response, which all further compounds effect of patient becoming cold.
NB. • Interthreshold range (body temp) = range of body temp where no ANS response occur;
usu +/- 0.2C at 37C. • Thermoneutral zone (environmental temp) = range of environment temp in which heat
production is minimal; thermoregulate largely by vasomotor activity. § Range 22-28C adult; 32-34C neonate.
Q7–Latexallergy,46%
Howwouldyoudiagnoseaclinicallysignificantlatexallergyoccurringintraop?Latexallergy=mainly2types(asdescribedinANZCAWelfareresourceonlatexallergy)
• Type1:anaphylacticreaction=usuallyimmediate,potentiallylife-threatening
• Type4:delayedhypersensitivityreaction
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Diagnosisintraop:
• Hx
o Symptomonset?Cleartemporal-relationshiptoexposureoflatex?
o Otherpotentialconcurrentexposuresexcluded?Eg.antibiotic,chlorhexidine,
musclerelaxant.
o OthercausesforCVScollapse,severebronchospasm?PE,MI,hypotensive
agents
o Riskfactors:
§ Knownallergytolatex?Asscwithsomefoodallergieseg.kiwifruit,
banana.
§ Occupationalexposure?Eg.healthprofessional
§ Comorbidities?Spinabifida,atopy.
• Exam
o Cutaneoussign?Localized,systemicurticaria
o Angioedema?Swellinginlips/tongue/pharynx?
o Resp:bronchospasm,wheeze
o CVS:hypotension,CVScollapse?
• Invx(asperreport)
o Tryptasetakenat1,4,24hoursasperANZAAGguidelinetoobserverise+fall
ofleveltodiagnoseanaphylaxis.Althoughtriggerstillneedtobeconfirmed.
o Skinpricktest:
§ Canconfirmlatexallergyorexcludeotherdifferentials;performed
>6weekspostincidentforhistaminetoreplenish.
o Intradermaltest
o RAST(radioallergosorbenttest):testforlatexantibodyinserum.
o NB:potentialfulminantreactioncouldhappen,thereforetestingshouldbe
doneatSpecialistAllergyTestingcenterwhereresuscitationfacilityis
available.
• Onbalance,diagnosisintraopisdifficultandfurtherinvestigationisrequired.
Q8–Pneumothoraxmanagement,61%
A35yearoldfemaleisfoundtohaveasmallpneumothoraxfollowingremovalofabreastlumpunderlocalanaesthesiainadaysurgeryfacility.Howwouldyoumanagethis?
Immediatemanagemetn=simultaneouslyassessseverity+manage
o A:ispatientmaintainingairway?Istheresurgicalemphysemawithairwayswelling
o B:provideFiOw100%andmaintainspontaneousventilation.Howeverifsevereresp
distresswillneedurgentneedlepleurocentesis+chestdrainplacement.
o CallforhelpfromSurgicalTeamandneedanaeesthesiaassistance.
o C:ispatientshockedfromtensionpneumothoraxindicatingurgentdecompression?
MaintainMAPwithfluid+vasopressor.
Ongoingmonitoring:
o InrecoverywithO2supplement.Monitorfullvitalsigns+extentofsurgical
emphysema.
o NeedrepeatCXReg6hourslater.
Subsequentcare:
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o Ifunstable,needadmissiontohospitalHDUformonitor
o Ifstablewithoutevidenceworseningofpneumothorax,mayconsideroutpatient
management,providing:
o Physicalproximitytohospital/medicalassessment
o SensibleSupportperson
o Transportvehicle,phoneavailable.
o Clearinstructiononwarningsignstoreturntohospitalimmediately:eg.
worsenedSOB,presyncope,chestpain,worsenedsurgicalemphysema.
o Patientshouldreturntohospitaldailyovernextfewdaystoconfirm
resolutionofpneumothorax.
PreventworseningofPTX:
o Don’tgiveN2O
o Explaintopatientonflightrestriction,divingrestrictionuntilresolutionof
pneumothorax.
Q9-Postopvisitpurpose,63%
Discussthepurposeofapostoperativevisit.
POvisitshouldbeinPACUbutalsoonthewardthefollowingdayormoreasrequired.
Purposeistoassesso Patient’sgeneralwell-being
o Providegeneralinfo–reassurance,answerquestions
o Assessairway,pulm,CVSfunctionstoensureanyissuesareaddressed
• Eg.sorethroat?Anyrespdistress?AnyCVSinstability
• Periopmedicationrationalization
o Neurofunction?–recoveryfromregionalblock?Anysignofneuroinjury?
o Pain?PONV?–provideappropriatemultimodaltreatment.
o GI/GU–pointake+returnofbowelfunction?Urinaryfunction?–consider
laxativeifconstipationdevelopingespwithopioiduse.
o Anyotherconcerns?Eg.PP,itch,coagulopathy,ongoingbleeding?
o Followupanyanaestheticcomplicationso Informpatientofanyanaestheticcomplication
§ Eg.difficultairway->needsdocumentationandexplanationoffuture
plan
§ Otherseg.dentaldamage,anaphylaxis,MHetc.
§ Furtherinvestigationorfollowupplanningexplainedeg.allergy
testingafteranaphylaxis;patientinformationsheetprovided+
medicalalertsystemsinplace.
o Askforpatient’sfeedbackandoverallsatisfactionofcare
Q10–Cardioversioninintraoparrhythmias,38%Critically evaluate the role of cardioversion in the management of intraoperative
arrythmias.
Intraop arrhythmias are common o From Surgical stress and anaesthetics on haemodynamics o Usu. self-limiting
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o Causes include: o Preexisting
o PAF, cardiac disease (LVF, valvular, dilated LA), Pulm dx o Stress induced: pain, inflammatory response, bleed, anaemia
o Acute cardiac event: o Hypoxaemia, hypovolaemia,
o hypoK, Mg. o Hypothermia o VTE – PE
Cardioversion = treatment aim at restoring sinus rhythm.
o mainly indicated if there’s tachyarrhythmia causing haemodynamic compromise o Can be electric or chemical
Benefit, can be life saving in event of tachyarrhythmia induced shock. Especially in context of VF/VT/Torsades de Pointes cardiac arrest. Defibrillation is immeidatley required.
o Mortality increase by 10% with every minute of persistent VF/VT arrest without cardioversion.
o Externally pacing may also be performed Risks:
o dislodging thrombi à CVA o not always successful if cause not treated o other treatment may be more effective and more accessible eg. adenosine for SVT o complications from DC cardioversion: skin burn, myocardial stun/scarring, fire risk, staff
injury o chemical cardioversion eg. amiodarone: thyroiditis, pulmonary fibrosis, arrhythmia (eg. VF
in torsades de pointe), corneal deposits, peripheral neuropathy. Q11–HFassessment,66%How would you assess the severity of cardiac failure in a 75 year old man presenting
for joint replacement surgery? Include any relevant investigations.
Cardiac failure: dysfunctional myocardium causing hypoperfusion to organs Causes include:
o IHD o Valvular disease eg. ASàhypertrophyàischaemiaàHF o Restrictive cardiomyopathy o Dilated cardiomyopathy: ETOH, post-partum
Severity (not aetiology) Assessed by: History
o NYHA classification – functional capacity – SOB at rest, on minimal exertion or strenuous exercise?
o Symptoms of: orthopnoea, PND, oedema, Chest pain, palpitation. o Treatment of heart failure
o CRTàindicate severe heart failure o Medical: if high dose of multiple diuretics, HF likely be severe
o Look for other systemic complications o Liver cirrhosis, portal HTN (LFT, abdo USS) o Renal impairment (Cr/UE)
o Cardiology clinical letter; Exam
o Pulm oedema, S3, gallop, elevated JVP, peripheral oedema, poor peripheral circulation, resp distress, heave.
o Haemodynamic instability - HR, BP, RR, sats. Investigations (severity grading + diagnostic)
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o Echo - LV/RV function, EF
§ Ventricular dimensions - Other problems such as valvular disease
o CXR o BNP o FBC
Q12–upperlimbnerveinjury,59%Describe the symptoms and signs of commonly seen perioperative nerve injuries in
the upper limb. List the causes and possible strategies for prevention. Do not include
injuries due to neural blockade or direct surgical trauma.
Common periop upper limb nerve injuries s/s
o Sensory changes in affected nerve distribution; paresthesia, numbness or neuropathic pain development: allodynia, hyperalgesia.
o Motor changes: with weakness over upper limb over muscle group innervated by damaged nerve.
o If sensory changes only, tends to have better recovery than if mixed sensory/motor. o Brachial plexus injury – deficit/weakness can extend over large area over upper limb,
outside of single N distribution
o Radial nerve – posterior aspect of arm and forearm; wrist drop; unable to extend thumb
o Ulnar nerve – medial aspect of palm (little finger + ½ of ring finger); weakness in lumbrical muscles; unable to ab/ad fingers.
Cause list – STOP: surgery, tourniquet, obstetrics, position
o Position of shoulder, neck, head turned away from abducted shoulder, arms fallen off from table unnoticed under drape à brachial plexus injury
o excess pressure point over elbow, inappropriate elbow hyperflexion à unlar N. palsy
o median/radial nerve injury from excess compression or stretch. o Limb tourniquet ischaemic injury o CVL insertion injury brachial plexus o Other pathophysiology:
o Hypoxia, hypotension, hypothermia, hypoglycaemia. Increasedriskineg.diabetes,PVD,smoker
Strategies for prevention
o Preop: optimize risk factor control: DM, PVD o Intraop: optimal physiology control to avoid hypoxia, hypotension, hypothermia,
hypoglycaemia o Meticulous care on position:
§ Neutral head/neck position § Shoulder abducted <90 deg and ext rotated <90. § Elbow not hyperflexed, ideally <90 deg. § Avoid excessive wrist extension or compression. § Pressure point protection with gel pad
o Limit tourniquet time to <2 hours or have tourniequet break for 15 mins after 2 hours. Soft cotton bandage underneath tourniquet.
o USS guidance for CVL placement. Q13-Ethicsre:discontinuetreatmentsupply,49%
ThehospitalpharmacistnotifiesyouasDirectorofAnaesthesiathatThiopentoneistobewithdrawnfromthehospitalformularyduetominimalusage.Outlineandjustifyyourresponse.
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Datacollection• Useindepartment:Reviewrecordeduse,pharmacyrecord,explorerationalefor
withdrawal• Anaesthetist’sopinion:Collectdataondepartmentalusage,collectanaestheticstaff
opinionswiththisproposal.Discussionneedtoinclude:o Indicationso Literaturereviewo Drawbacko Currentuseacrossdepartment+
§ Considerimpactonpotentialhighusageareaieobstetricanaesthesia,
paediatricoremergencyresponseteamformanagementofstatus
epilepticus.o DecisionmakingasDepartment.
Ethics:• Beneficencevsnon-malevolencevs.justice/utility• Basedonethicalprincipleofnon-malevolence,thioremovalneedstobecarefully
consideredtoensurenopotentialharmiscausedbylackingsupplyofit.• Basedonprincipleofutility–ifresourcefundingcanbejustifiedtoreallocateto
anotheruse,thispotentiallymakesuseofresourcemoreefficientlyandreduce
wastage.Responsedependson…
• DependingonDepartmentaluserecord+Anaesthetist’soverallconsensus,will
decidewhethertoputforwardastructuredargumenttothehospitalPharmacy
againstthisproposal.o BasedonpersonalexperienceinmyDepartment,thiopentoneisstilllargely
usedinobstetricanaesthesia.• Prosofthio:
o Thio:rapidonset,offset,lesshaemodynamicimpactaspropofol;potent
anticulsant;idealforuseinObstetricsGAespifthere’srefractoryseizurein
eclampsia.§ However,thesecanbeeffectivelyachievedbypropofoltoo+/-
vasopressoruse.• Consofthio:
o Thioalsorequiresreconstitutionwithwater,hasproblemoftissuenecrosisif
extravasates,andcausesintra-artthrombosis,damageifgivenintra-
arterially.o NotsuitableforuseasinfusionduetolongCSHT.Metabolismbecomeszero-
orderkineticafterhepaticmetabolismissaturated.o InducesCYP450system;potentiallylesseningeffectofothermedicationso Riskofinducingacuteporphyria.o Muchlessairwaysuppressioncfpropofol;difficultwithLMAinsetion.
Q14-Ethicsre:alternativemedicineuse,52%You see a patient in the APC who asks you do administer an alternative medicine as
part of their anaesthetic for total hip replacement. How would you respond to this?
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Alternative medicine = practice not integrated into mainstream of evidence based health care system. Issue here = tension between clinician’s obligation to provide evidence based health care service vs. respecting patient’s autonomy. It is important not to disregard patient’s belief system. I’d respond as follows:
o FIFE: Discuss with patient their view, belief, reason of requesting use of this alternative medicine.
o Establish patienet’s expectation of outcome. o Establish source of patient’s belief – from internet? From friend’s experience? Personal
experience? o Explain my view: I’d then explain my appreciation of patient’s view, but outline:
§ Alternative medicine use outside my scope of practice § No endorsement of alternative medicine use by governing body ie ANZCA § My personal lack of knowledge of its: pharmacology + potential
interaction with my anaesthetics o Ethics: Therefore as per ethical principal of ‘non-malevolence’, I am unable to
administer this alternative medicine. Provide an apology for this act. o Review thoughts/2nd opinion: Explore patietn’s view/feeling about this and offer
second opinion if requested by patient. o If patient insist on alternative medicine, I would politely refuse to provide anaesthesia and
document our discussion. I’d offer to seek further advice from Pharmacy regarding Safe Medication Administration policy.
Q15-ECT,70%List the physiological effects of ECT and how they may be modified?
Aim of ECT = induce gen seizure w characteristic EEG changes to treat refractory psychosis, depression. Phys effect + modification
CVS due to activation of ANS o Initially PSNS, first ~15 sec à brady, hypotension, likely asystole! o Followed by SNS, longer lasting à tachy, hypertension; likely arrhythmia.
o à increased myocardial O2 consumption + increased metabolic demand from seizure à likely ischaemia esp with tachycardia reducing O2 supply.
• Modified by
• Obtuned haemodynamic changes
• PSNS: consider atropine/glycol – but balance potential tachycardia esp when SNS tone occurs
• SNS: propofol, remifentanil/alfentanil, sux
o If high risk patient of cardiac decompensation, consider betablocker esmolol (0.5mg/kg)
o GTN for HTN control if at high risk
CNS due to seizure – increased CMRO2, ICP, CBF, seizure. o Risk of cerebral ischaemia for susceptible patients unable to maintain CBF due to carotid
stenosis. o Long term effect assc with memory impairment, cognitive impairment.
• Modified by • Control of haemodynamics, ensure maintenance of CPP +
oxygenation. • All induction agent has anti-convulsant activity, therefore balanced
induction with remi/alfen to MAC spare or MAC-Bar spare. • Use methohexital 0.5-1.5mg/kg; • Use sux 0.5mg/kg or miva 0.1-0.2mg/kg • Remi 0.5-1mcg/kg bolus
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Others: o Fracture and dislocation -> use of muscle relaxant plus continuous watch by staff to ensure
safety. o Trauma to tongue/lips -> bite block o Headache/myalgia -> simple analgesia o Drowsiness, weakness, nausea -> antiemetic
NB. Contraindication for ECT:
o CVS: HF, phaeo o CNS: cerebral aneurysm o Eye-glaucoma, retinal detach o MSK-unstable #, severe osteoporosis o Coag-DVT o Other-cochlear implant.
May-2005,44%
Q1-Nimodipineinaneurysm,37%
Discusstheperioperativeuseofnimodpineforapatientundergoingclippingofacerebralaneurysm.Cerebralaneurysmissues
o Pronetobleed(SAH)andsubsequentvasospasmàdelayedcerebralischaemiaand
neurodeficit(3-15days)(haemolysedblood,oxyHbspasmogenic)
o Nimodipineshowntobeeffectiveinpreventingvasospasm,shouldbecommenced
assoonaspracticalandcontinuedfor3weeks
Nimodipine=o DihydropyridineCCB,witheffectivepenetrationofBBBandworkpreferentiallyon
cerebralvessels
o preventsCainfluxtocellsviaLtypeCachannels
o Usedasprophylaxisofvasospasm
o UsedastreatmentofvasospasminconjunctionwithHHHtherapy
o Dose=PO/NG60mgQ4horIV1-2mg/hr;butbalanceagainstriskofhypotension
o Closemonitoringrequired.
o ShowntobeeffectiveinpreventingreductioninCBF,secondaryischaemiaand
cerebraloedema
Q2–DVTprophylaxis(repeat),76%
DiscusswaysinwhichriskofDVTcanbeminimizedinadultpatientshavingintra-abdosurgeryQ3-RIJanatomy,62%
Outlinetheanatomyoftherightinternaljugularveinasitisrelevanttoyourpreferredmethodofpercutaneouscannulation.Intro
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IJsarecommonsitesforCVLinanaesthesiaduetoeaseofaccessingpatient’sneckduring
anaesthesia+easeforsettingupmedicationinfusions+asscwithlessCLABratethan
femoralsite.
ReasonsforpreferenceR/IJiscommonsiteforCVLas
o ShorterdistancetoSVCcf.L/IJ
o StraighterangletoSVCcf.L/IJ
o EasierforPACcatheterfloating
R/IJcourses:incarotidsheathinneck,joinsR/SCveinàjoinsinnominateveinfromL/IJà
SVCàRA.
Superficialtodeep:Surfaceanatomy:skin-(EJV)-SCM-carotidsheath-IJV.
Vulnerablestructurestoavoid–visualizeclearlywithUSSandensureneedletipisseentoavoidgoingclosetothesestructures
o Artery–carotidA;usu.medialtoIJV,buttendstolieposttoIJVasittravelsdistally.
o Nerve–vagusnerveinsheath;phrenicnerveposttosheath+anttoantscalene
o Brachialplexuslieintheinterscalenegroove
o Lung–liebelowclavicles
o Thyroidgland/esophagus/trachea–anteromedially
Q4-PCAdiscussion,21%
Discusstherequirementsforandlimitationoftheuseofpatient-controlledanalgesia(PCA)asatechnique.Requirements
- Patient
§ UnderstandprincipleofPCA;age/intellectualcapacity
§ PhysicallyabletousePCA(mayhavedifficultwithsevereRAin
hands)
§ Lowriskofdrug-abuseandnofamily/visitoratriskofdrug-abuse
- System/Technical
§ PCAmanagement,monitorprotocol
§ WorkingIV+carryingfluidtokeepveinopen+non-returnvalveto
ensure1wayflow.
§ Pump–reliable,robust,portable,locktopreventtampering;ableto
setbolusdose,lockoutandhourlylimit+/-backgroundinfusion;
recordingofdose+alarmforocclusion.
- Monitor
§ Patientneedsregularmonitor,sedation,RR,painlevels;
§ DailyreviewbyAPMs.
Limitation• Needalloftherequirementabovetobemet.• InadverdentdoubledosingofopioidsiePOgiveninadditiontoPCA.• Faultysettingonpump• TissuesIVline.
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• NeedsadequateinitialanalgesialoadingpriortostartingPCAtobeeffective,asPCA
deliverssmalldosebolusonlywhichwouldtakelongtimetoreachadequate
analgesia.• ShortdurationofactionwithinfrequentPCAuse;espduringsleepaspatient
discontinuesPCAusewithsleepthenwakesupwithpain.• SEwithopioids–respdepression,sedation,NV,pruritus.(althoughtheoreticallyless
likelywithprincipleofPCA–asifpatientissedatedtheycannotcontinuetousePCA
tocauseexcessivesedation).§ Stillneedmultimodalanalgesia.
Q5-fluidoptioncomparison,48%
Comparetherelativemeritsofgelatin-basedintravenoussolutionsanddextranintravenoussolutions.Q6-PACvsTOEcomparison,85%
Comparetheuseofapulmonaryarterycatheterandtransoesophagealechoinevaluatingcardiacfunctionintraoperatively.PAC=viaIJVàcatheterfloatedtoPA(maythenbewedgedtoassessPCWP)
- Proso Assessmentof:-pressure,sats,CO
§ CVP(fluidstatus,RVfunction)§ PCWP(LVfunction)§ SvO2monitor(globaloxygenation=surrogatemeasureofCO)§ COmonitorusingthermodilutiontechnique(continuous)§ PAP;PVR§ Tracemonitoralsoallowsdiagnosisofsomevalvularpathology
- Conso RiskofinsertionasanyCVLaccess(infection/bleed/arterialpuncture,nerve
damage,PTX),arrhythmia,pericardialeffusion,tamponade+pulmArupture.
o Accuracydependantonmanyvariableseg.LV/RVfunctions,valvularfxn,
pulmdisease,timingofinjection(forCOmonitorwthermodilution)
o Needsskillstoplaceandinterpretdata.
TOE- Pros
o Assessmentof:
§ Cardiacfunctionquantification,EFcalculation
§ CO
§ Volumestatus-LVEDV
§ Valvulardiseaseandseverityassessment
§ Structuralabnormality
§ Intracardiacthrombus
§ Pericardialeffusion
§ Aorticpathology–aneurysm,dissection.
o continuous,timelyassessmentpossible.
o Relativelynon-invasive
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o MoredirectassessmentofcardiacfunctionevaluationthanbasedonPAC
- Cons
o Needsskillstoperformandinterpretdata
o Expensive
o COoutputmonitornotcontinous
o Riskinoesophagealrupture,dentaldamage;CIinoesophageal
stricture/tumour/varices.
Q7–failuretoemergefromGA(repeat),78%
Listthepossiblecausesoffailuretoemergefromgeneralanaesthesiaanddescribehowyouwoulddifferentiatethem–see2015AQ9Cerebralpathology
Systemicpathology
Drugeffect
Q8-Circlebreathingsystem,49%
Drawacirclebreathingsystemandgivereasonsforthelocationofthecomponents.
Components(EAR-Aii,6)–positionedstrategicallytominimizerebreathing+CO2absorberworkloadorventingofFGF
• Expunidirectionalvalveßcircuitfrompatient’smaskYconnector
o Preventsbackflowofexpiredgas;avoidrebreathingwhenIPPVoccurs
o MaximalefficiencyifplacedclosetoY-connector,butduetoitsbulkysizeis
usu.placedatthemachineside.
• APLvalve
o BeforeCO2absorbertoreduceabsorberworkload+
o AfterexpvalvetopreventFGFventing
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• Reservoirbag
o AfterexpvalvetopreventCO2rebreath
o BeforeCO2absorbertodecreaseresistancetoexpiration
• CO2absorber
o AfterAPLtoreduceabsorberworkload+
o BeforefreshgasinlettopreventmixingofCO2withFGF/CO2rebreath
• FreshgasinlettoprovideFGF
o BeforeinspvalvetominimizemixingofCO2withFGF
o Afterexpvalve+APLtominimizeventingofFGF
• Inspiratoryunidirectionalvalveàcircuittopatient’smaskYconnectedtocircuitout
o Preventsbackflowandensureexpirationintoexp.Limbàensures
unidirectionalflowofgas
NB.
Mostefficientcirclesystemarrangementwiththehighestconservationoffreshgases
• Unidirectionalvalvesnearthepatient
• APLlocatedjustdownstreamfromtheexpiratoryvalve.
o Minimizesdeadspacegasandpreferentiallyeliminatesexhaledalveolar
gases.
Miller’s3Rulestomakecirclesystemwork
• I&Eunidiriectionalvalvebetweenpatientandreservoirbag–avoidsCO2rebreath
• FGFcannotenterthecircuitbetweenexpiratoryvalveandthepatient–rebreathing
ofCO2andpreferentialventingoffreshgas
• APLcannotbelocatedbetweenpatientandinspiratoryvalve–Lossofgaswithlow
CO2level,becomesveryinefficient
o Ifaboverulesarefollowed,thenanyarrangementofothercomponentswill
preventrebreathingofcarbondioxide.
Q9-Antiemetic,61%
Whatsignificantside-effectsareassociatedwiththeuseofanti-emeticagents?- DroperidolcausesadosedependantincreaseinQTintervalandisassociatedwith
torsadedepointes.ThishasbeenassociatedwiththeFDAissuinga“blackbox
warning”
o CVS:hypotension(droperidol-alpha-antagnosimeffect),tachycardia
(anticholinergic)…etc.
o Sedation,EPS,NMS,increasedprolactinlevel.
- Dexamethasone:
o BGLespinDM;perinealpain.Immunosuppression(althoughcontroversial)
o Chronicusechangesisunlikelytobeseenwithsingledose:Cushing’s
response,adrenalsuppression,osteoporosis,PUD.
- Ondansetron:headache,constipation,QTprolong(althoughclinicallyinsignificant
withthelowdoseusedinantiemetic)
- Cyclizine,promethazine
o Anticholinergiceffects.
o Antihistamineeffect.
- Scopolamine:sedation,drymouith,burredvision,urineretention,constipation,mild
tachycardia.
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- Aprepitant:fatigue,GIupset,hairloss,allergy
Q10-Proneposition(repeat),47%
WhataretheproblemswiththepronepositionforsurgeryEnvironment
• Transfer:Duringtransfer,atriskoflosingairway,IVaccess,monitoring,IDC,chest
drain.• Safety:Potentialinjuryduringtransfer:
o patientduetopoorbodysupporto staffduetoheavylifting
§ ensureenoughnumberofhelperstoturn/supportpatiento Access:Limitedaccesstopatientduringsurgery;airway,circuit,IV
§ Ensureairwaysecuredwithbothtapeandtie.
o Circuitdisconnectionduringpositionchangeàensuresecurejoints
o Lossofmonitoringduringpositionchangeàsecuremonitortobodywithtape;
vigilanceduringpositioning.
Patient• Airwaydislodgement(EndobronchialorETTfallenout)whileproneanddifficulty
withmanagement:§ Preventdislodgebyextrasecure,withtie+tape.
• B:pulmcompliancedecreasedduetochestwall/abdocompression;although
increasedFRCmaybalanceeffectfromdecreasedcompliance.§ Minimizecompressionfromensuringpropersupportoverchestwall+
abdomenwithWilsonFrame.• C:
o Mayhavesignificanthaemodynamicchangeduringtransfer;venouspooling
àhypotension;espwithmonitortemporarilystopped:§ Optimizehaemodynacmisbeforeturn:fluid,vasopressor§ Resumemonitorandvasopressorinfusionwithoutdelayafterturn
o Ineventofcardiacarrest,performingCPRisverydifficultinprone:§ Havelowthresholdtoturnpatientsupinewheneverpossiblewith
protectiontosurgicalfield.§ ProneCPRshouldstillbeperformedastemporizingmeasure
• Positionrelatedinjury:o C-spine:ensureneckneutralpositionandheadwellsupportedbyfoam.o Eyeprotection:vigilanceofavoidingcompressionandregularcheck
throughoutcaseo Nervedamage:brachialplexus,ulnarnerve;ensureabduction/extrotation
<90andelbownothyperflexedie<90.o Pressuresore:iliaccrests,knees,feet–paddingmandatory
AnaesthesiaQ11-epiduralabscessmanagement,47%
Discussthemanagementoptionsforanepiduralabscess.
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Surgery
o Earlydecompression/washoutandprolongedantibiotic(6-12weeks)coursearethe
mainstaytreatment.
o Commonlyinvolvepostlaminectomy,althoughantapproachsometimesisrequire;
whichaimtoremovepus,debrideinfectivetissueanddrainaffectedareaofanyfurther
collection.
o CT-guidedpercutaneousdrainagemaybeanoptioninselectedpatients.–eg.well
delineatedabscessesonimaging
Conservative
o Assoletreatment,maybeconsideredinsmallproportionofpatients.§ Eg.no/minorneurosignsandpatientisalreadyonantibiotics,or
patientrefusaltosurgery,orseverecomorbiditiesrendering
excessivelyhighriskforsugery/GA.o ConsultInfectiousDiseasePhysiciansforadviceon1
stlineantibiotic
treatmentbasedonlocalguidelineforempiricaltreatmentordefinite
treatmentbasedonculture+sensitivity.§ TypicalmicroorganismsincludeS.aureus,E.coli.
o Antibioticchoiceshouldbesensitivebasedonculture,abletopenetrate
boneeffectivelyandhaslowtoxicityprofileforprolongedcourse.§ Eg.staphàflucloxacillinor2
ndgencephalosporin
§ IfMRSAàclindamycinorvancomycinOsteomyelitismaycomplicateepiduralabscessandwillrequirelikelyevenlongercourseof
IVantibiotic/surgicaldebridement,washouts.o monitorofsymptomespredflagsymptoms:weakness,paresthesia,
urinary/bowelincontinenceshouldbeongoing.o MonitorCRP,radiologytoguideprogressoftreatment.
NB.(apartfromB-lactam,allarepoorinCSF;mostaregoodfortissue;gentgoodforfluids
butpoorinCSF/eye/biliarytree/adipose.
o -Betalactamdistributewidelytotissues/fluids;CSF-IVlimitedunless
inflamedmeninges
o -Aminoglycoside:eggent;hydrophilic,widelydistributedinbodyfluids,butverypoorintoCSF,eye,biliarytree,prostate,tracheobronchialsecretions,
adipose;veryeffectiveinUTIas90%ofdrugeliminatedunchangedviakidney
o -Macrolide:egerythro;greattissue/intracellularpenetration,(sonotmuchin
serum),butpoorinbrain/CSF.Crossesplacenta/breastmilk.
o -Fluoroquinolones:eg.Cipro;goodtissuedistribution,poorCSF.(greatforabdo/UTI,butusu.2ndlineashighriskforC.diff)
o -Tetracycline:egdoxycycline.goodtissue,poorCSF.(goodforskin/bone/joint)
Q12-CasereportsinEBM,39%
Discussthevalueofcasereportstoanaesthetistsintheeraofevidencebasedmedicine.EBM=conscientioususeofresultderivedfromhighqualityresearchtomakedecisions
abouttheclinicalmanagementofpatients.
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Typeofresearchconsideredtoprovidedifferentlevelsofsignificancetoclinicalpractise
• highest=systemicreview,metanalysis• RCT• Non-randonmisedtrialseg.casecontrol,cohort• Caseseries• Lowest=Expertopinions
Prosofcasereportso 1
stlineofevidenceespfornewtreatmentsorrareconditions
o Stimulationfor
o Hypothesisgenerationforfurtherstudies
o Newdiseases,newsideeffectsofdrugs
o Complementotherlevelstypesofresearch
o Eg.certainraresideeffectsofmedicationsgeneratedfromcasereportscan
significantlyaffectpracticeguidedbyRCTs.
Conso Unabletoconfirmcause-effectrelationship.
o Unabletocontrolforconfounderswhichcouldleadtogenerationofmultiplefalse
hypothesis–howeverthisiswhereotherstudytypescomplementtheshortfallof
casereports–byprovingorrejectinghypothesis
o thelimitationsofcasereportsintermsofbiasandperhapsundueinfluenceon
practice
Q13-assessingthyroidfunctionclinically,70%
Howwouldyouassessapatient’sthyroidfunctionpreoperativelyatthebedside?Q14-impairedcolleague,(repeat)63%
ArecoverychargenurseapproachesyouasSupervisorofTrainingbecausesheisconcernedattheamountofopiatesoneofyourtraineeshasbeensignedoutforpatients.Whatwillbeyourprioritiesinaddressingthenursesconcern?
o Signingoutincreasedamountofopioid=amajorsignindicatingopioidmisuse.
o Concernfromchargenurseshouldbetakenseriously+confidentiallytoavoid
reputationalharm.
o Confidentilainvestigationshouldtakeplace.
o InvolveWelfareOfficer,HOD.
Q15-Intraopbloodsalvage(repeat),54%
Discusstheadvantagesanddisadvantagesofintra-operativebloodsalvage.
Sep-2004
Q2–visuallos
Outlinethepossiblecausesofpostoperativelossofvision
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Q3-Whataretheproblemsofusingthebeachchairpositionforshouldersurgery?
(repeat)
Q7-Diabetesinsipidus
Describethepathophysiologyanddiagnosisofdiabetesinsipidusfollowingheadinjury.Diabetesinsipidus,has2types
o Central:decreasedADHrelease
o Peripheral:renaltubuleunresponsivetoADH
o Characterizedbyfreewaterloss,hypovolaemia,hypernatraemia.
Pathophysiology(similartodiabetesmellitus)
o Normally:IncrasedserumosmolarityàADHreleasefrompostpituitaryàV2
receptoronrenaltubuleàwaterreabsorption
o Inheadinjury(espdamagetoposteriorpituitary),ADHreleasemechanismis
disrupted,waterconservationmechanismdisruptedàdiabetesinsipidus.
Diagnosis
o Hx
o Headinjury,polydipsia/polyuria?
o Exam
o Signofhypovolaemia?(althoughthismaybecompensatedbyincreased
waterintake)Tachycardia,hypotension.
o NeurologicalexamandGCS
o LargeUO?Upto30L/day
o Invx
o SerumADHlevel
o Electrolytedisturbance?hyperNa,hyperosmol
o Urineelectrolyte:hypotonic,lowNa<20mmol/L
o CT/MRIheadscan
o Fluidrestrictchallenge:UOwilstillbehigh;
o DDAVPresponse:willreduceUO.
§ CautiouswithDDAVPtest,shouldbedone/monitoredcloselyinICU.
dosenomorethan1-2mcgonly
• 0.4mcgPRNIVor100-200mcgintranasal
§ monitorNacloselyeguptoQ2h
NB.
knowhowtodistinguishwithSIADH,serumsaltwastingsyndrome:lowNaduetoexcessNa
excretion,dehydration.
- Bleedpreventiondose=0.3mcg/kgover30mins.
Q8-regionalankleblock
Describetheanatomyrelevanttoprovidinganankleblockforsurgeryonthebigtoe.Block:
- Deepperoneal–lateraltoDPartery,betweenanttib+exthalx
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- Superficialperoneal–sameneedleentrypointasabove,thendirecttowardslat
malleolus;liesbetweenexthalx+latmalleolus
- Posttibial–posttomedmalleolus,palpateAtheninjectposttoA.
NB.Ankleblockinfulldetail:
Needtoblockabovethreenerves:
Supine:
- -DeepperonealN.-lielateraltoDPartery,betweenAntTib+ExtHalxtendon:
contactbone,withdrawslightly,instil2-4mlsLA.
- -superficialperonealN-directneedlefromabovetowardsanteriorsurfaceoflateral
malleolus.Itliesbetweenextensorhalxandlateralmalleolus.5mlsLA
- -saphenousN:betweentibanttendonandmedialmalleolus.5mlsLA
- -posteriortibialisN-palpateposttibartery(liesbehindmedialmalleolus),insert
needleposteriorlytoartery.3-5mls
- -sural:betweenachillestendon,latmalleolus,SCinfiltrationalongcourse5ml.
Q9-Bier’sblockdicussion
Givereasonsforyourchoiceoflocalanaestheticagenttoprovideintravenousregional
anaesthesiaforareductionofaColle'sfractureinan80yearoldwomanweighing95kg.
NYSORA:Lignocaine2%plain
Dose-<3mg/kg;dependingonweightofpatient;usu.~10-15mlsisenough
inthispatient,coulduseupto285mgie14mls.
wouldchoose10mlsforapotentiallyfrail/elderlypatient.
Reasons:- widelyusedformulationinliterature,cheap,avaialable.
- wellstudiedtoprovidesafe,effectiveIVRA.
- avoidsriskofmethaemoglobinaemiawithprilocaineorpotentialcardiotoxicitywith
bupivacaine.
- fastacting,
- -Sincethedurationofanesthesiadependsonthelengthoftimethetourniquetis
inflated,thereisnoneedtouselong-actingormoretoxicagents.itisusedtypically
forprocedureslasting30to45minutes.
Q11–cardiacscanutilityWhat is the role for radionucleotide imaging in the assessment of ischaemic heart
disease prior to general anaesthesia for non-cardiac surgery?
Radionucleotide imaging is a form of non-invasive cardiac function investigation.
o coronary vasodilator (dipyridamole) and radio isotope (thallium) which is up taken into perfused myocardium
o impaired perfusion shows up as reversible perfusion defects caused by dipyridamole causing a steal phenonmena
o dobutamine induced tachycardia to assess response to stress.
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o non-perfused areas show up as permanent perfusion defects o key findings one is looking for = reversible perfusion defects, permanent perfusion defects
and cavity dilation (report said: Details of techniques of Radionucleotide Imaging were not required) Role in CAD assessment: General Indication: As of any cardiac functional investigation, indication include:
o History of poor exercise tolerance with functional capacity less than 4, especially undergoing moderate to high risk surgery.
o Also: unstable angina, severe arrhythmia. Specific indication:
o Difficulty in functional assessment due to OA or claudicaion. o Abnormal ECG making other forms of assessment difficult.
Detection of IHD: o High sensitivity ~90% o Limited specificity 75% o High negative PV
Assessment of severity, risk stratification o LV function, EF and performance with chemically induced tachycardia
Limitation: o False positive o Radiation exposure (~1x of CT chest or abdo) o MI risk o Arrhythmia risk
Q12-chronicimpairedcolleagueWhat are your obligations if you suspect a colleague to be chronically impaired?
- See PD doc summary
May-2004
Q1–MImanagement(repeat)A 50yo patient with a past history of well controlled ischaemic heart disease is
anaesthetised for an emergency laparotomy. Thirty minutes into the surgery, you
notice new ST segment depression on the ECG. Describe your management
(repeat)
Q6-AcuteherpeszosterA 71 year old man presents with acute herpes zoster involving the ophthalmic division
of his left trigeminal nerve. He complains of severe unrelenting facial and eye pain
which started 3 days ago. Discuss the pharmacological treatment options. Include
information about the relevant efficacy of the treatments you prescribe.
HZ
= reactivation of varicella-zoster virus ie shingles – burning, throbbing, shooting, lancinating, dysaesthesia, allodynia.
- Self limiting, but may lead to PHN. Treatment options:
Goals:
- Treat the infection Acyclovir 800mg tds for 7days, within 72hrs of rash reduces acute pain. Conflicting evidence about PHN effect.
§ however not applicable in this patient as already >3 days; does not prevent PHN.
- Ophthalmic involvement = Eye spec within 48-72 hours.
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- Pain – treat aggressively and early Strategies: (NNT all ~2-4).
1. Lignocaine 5% patch NNT 2 2. TCAs NNT 2.8 (Nortriptyline less cardiac toxicity than Amitriptyline in elderly) 3. Gabapentin (Pregabalin similar) NNT 2.4 4. Capsaicin (0.025-0.075%) NNT 3.2 (Capsaicin 8% patch not available in NZ) 5. Opioids NNT 2.6 (including Tramadol) 6. TENS level 3 7. Corticosteroids reduces acute pain (?PHN effect)
• Oral prednisone start 30mg BD taper to nil over 3 weeks • Epidural steroid NNT 10, no evidence alters PHN
8. RA; Series of PVB every 2nd day for 7/7 (2009 A/A) 9. Neurosurgery procedures controversial (DRG rhizotomies) 10. Sympathetic blocks conflicting evidence (from Auckland)
- VZVvaccineprevention=NNT40in>60yo;topreventPHN;
- NNT11topreventshingles
- Acyclovir<72hourofacuteattackeg.800mgtdsfor7days
§ Ifeyeinvolvement,seeSpecialist<72hrs.
- Aggressivetreatmentofacutepain,lowthresholdforinpatientcare.
§ Lignocaine5%patchNNT2
§ TCANNT2.8
• Losedoseamitriptylinefor90days
§ GabapentinNNT2.4
§ Capsaicin(0.025-0.075%)NNT3.2
§ Opioids/tramadolNNT2.6
§ Steroid/prednisone30mgbdtaperover3weeks(foracutepain,not
forPHN)
§ PVBRAseriesover7/7.
§ Psychosocialinput.NB. Cf. trigeminal neuralgia:
- =neuropathicpainintrigeminaldermatomes;episodic,paroxysmal,severe.
- Oftenhascompressionoftrigeminalnervenearconnectiontopons;vascularor
neoplastic
§ MRItoruleout
- Mx:carbamazepineNNT2,otherseg.topiramate
§ Otherantineuropathicanalgesiaeg.gabapentin,TCA,ketamine.
§ Surgicaldecompression,destruction.
§ Psychosocialinput Q7-Pros/consofsubtenonsblock(repeat)Discuss the advantages and disadvantages of sub-tenon's eye block compared with
other eye block techniques.
Q11-renalprotectioninAAADiscuss the strategies you would consider in order to protect renal function during a
laparotomy for an abdominal aneurysm repair.
Overcapping issue: AAA repair = major surgery with large volume fluid shift, bleed likely
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putting stress on mult-systemi including kidney. - Aortic clamping in particular imposes compromise on renal blood flow and renal
dysfunction is common. - Myoglobin release from ischaemia with clamping also could cause ATN. - If at high risk, consider EVAR which is associated with reduced early periop morbidities.
Pre - ABC: Optimize oxygen delivery
o Avoid hypoxaemia, anaemia o Avoid hypotension, hypovolaemia o Avoid hypervolaemia as RPP = MAP – renal venous pressure; high CVP may
potentially reduce RPP - Renal: Optimize renal function; treat any concurrent infection
o Stop or minimize nephrotoxins (unless indicated for life-saving reasons): ACEi, NSAID, gentamicin, IV contrast, large volume of normal saline.
Intra • Minimize cross-clamp time = strongest factor • Infrarenal clamp if possible • Consider aorto-renal shunt • Maintain optimal perfusion, oxygen delivery: volume, BP, sats, Hb. • Avoid large volume resus with normal saline (as hyperchloraemic acidosis assc with worse
renal dysfunction); use balanced fluid eg. Hartmanns/P148. • May consider mannitol to enhance renal blood flow and for oxygen free radical scavenging
effect (although balance with risk of hypovolaemia) Post
• Continue with maintaining oxygen delivery: volume, BP, oxygen, Hb. • Monitor urine output closely • Avoid nephrotoxins
Q12-NLS(repeat)
Workinginasmallobstetricunityouareaskedtoattendatthebirthofachildwherethereismeconiumstainedliquor.Howwillyoumanagetheinfant'sresuscitation?
Q13-neonatalventilatorcharacteresticsDescribe the characteristics of a ventilator suitable for neonates.
Why ventilator characteristics should be different.
Neonatal has very different respiratory physiology and anatomy. Key differences include:
• smaller TV, airway caliber, tubing and airway devices; higher RR. • Apparatus deadspace contributes to greater proportion to total deadspace (+ physiological
deadspace) Therefore in order to measure spirometry (volume, airway pressure, pCO2/pO2/AA) accurately, different ventilator characteristics is desirable. Ventilator features suitable for neonates.
• General – non-bulky and portable, low resistance, low compliance • Ventilator modes – should have at least: volume/pressure control, pressure support, SIMV
modes + manual ventilation mode with APL adjustment. • Adjustability – can deliver small TV + high RR required to maintain neonatal physiology; IE
ratio adjustable, PEEP setting to prevent atelectasis (esp with closing capacity above FRC in neonates).
• Measurement – for accurate measurement of TV/MV/FiO2/CO2/AA – low resistance/compliance circuit is essential to allow for accurate measurement.
• alarm system – good visual display and auditory feedbacks.
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§ Alarm for Maximal pressure limitation to prevent barotrauma. § Low FiO2 alarm. § Apnoea alarm. § Low/high TV/MV alarm.
(report)
• Some excellent answers detailing why Neonatal ventilators need to be different. • Volumes to be measured are extremely small, and compliance of the equipment can alter
the results. • Adult ventilators can be used with appropriate monitoring. (But to accurately measure tidal
volume is difficult). • High frequency oscillatory ventilation is done in the Neonatal Intensive Care (8-12 cps).
Sep-2003
Q15-DLTpositioncheck(Thoracic)
Evaluatethemethodsavailabletoconfirmcorrectplacementofadoublelumenendobronchialtube.
Clinical• Auscultation+inspectionofbilaterallungfieldsandensureisolationpossiblewith
alternativeisolation/ventilation.IeforL/DLT
§ Firstly,trachealcuffuponly;ensureventilationofbothlungspossible
§ Thenbothcuffsup;
• Isolatetracheallumentoisolaterightlung,ensureventilation
L/lungpossible;
• Thenisolatebronchiallumentoisolateleftlung,ensure
ventilationofR/lungpossible;ifcannot,probablybronchial
cuffherniation;àassessdepthandattempttoplacedeeper
thenreassess.
• Pros-quick,ventilationnotinterrupted,noneedforbronchoscope• Cons-potentiallylessaccuratethanbronchoscope,difficulttoassessif
endobronchial/trachealmass;R/DLTmaybedifficulttoplacecorrectly;difficultto
assessinraopaspatient’slateral+accesstosurgicallungislimitedmaking
auscultationdifficult.
Bronchoscope• Confirmwithdirectvisualizationofposition.
§ Entertrachea,seeprimarycarina,thencheckpositionof
endobronchialcuff;shouldjustseecuffandnoherniation.
• ForL/DLT,thenenterrightmainbronchusintoRULtosee
trifurcation.
• Thenenterbronchiallumen,ensureLULlumenisn’toccluded.
§ ForR/DLT,confirmcorrectpositionofendobronchialcuff,ensureit’s
notoccludingRULorice;thenenterRULtoensurecorrectplacement.
• Pros-goldstandard,mostaccurate,abletoassessdisease,abletosuction,easierto
verifyR/DLTcorrectposition;canstillperformclinicalassessment;abletoreassess
easilyduringsurgerywithoutinterruptiontosurgery.
• Cons-cost,skill,ifbleed/highsecretion,visualizationispoor.
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Sep-2002
Q4-Bowelprepdiscussion
Healthy34yomanrequirescolonoscopyunderIVsedationbecauseofstrongFHxofbowel
Ca.Describethecompositionandeffectsofbowelprepsolutionscommonlyusedbefore
colonoscopy
Bowelprep=usedforpurgingfecestoensureoptimalviewduringcolonoscopy;surgical
access;reducecontaminationrisk
2maintypes• Polyethyleneglycol(PEG)solution
o CHDbased,inbalancedelectrolytesolutionàholdswaterinGItract
o Needtodrink2-4Lofsolution;hencelikelylesscompliance
• Sodiumphosphatesolution(fleet’sphosphor-soda)
o Osmoticlaxative,henceadequateH2Ointakeessential
o Avoidedinrenalimpairmentduetopotentialseriouselectrolytedisturbanec
o Smallervolume(45mlBD)ortabletformwith200mlsofwaterTDS;hence
likelybettercompliance
• Others
o Magnesiumsulphate-incrasewatercontentandstimulateperstalsis
o Diphenylmethnes(bisacodyl,sodiumpicosulfate)-stimulatesperstalsis
Adverseeffects
• Abdocramping,nausea,vomit,bloating,diarrhea,sleepdisturbance
• Electrolytedisturbances:
o hyperNa,hypoK,hypoMg,hyperPhandhypoCa
• Dehydration
NB.(Auckland)
•Mechanicalbowelpreparation(MBP)hasgoneoutoffashion,butrecentmeta-analysis
suggestbowelprepplusoralsAB’smaydecreaseinfectionrate.
•MBPeffectsdependonwhichtype
•OsmoticcatharticieNaphosphate
•Non-absorbedosmoticegPEG
•Stimulantlaxativeeg.bisacodyl
•Combinationsofaboveeg.Napicosulfate/Mgcitrate
•Osmoticcathartichavemorecomplicationsbutarebettertolerated
MBP Complications
Commonside
effects
ElectrolytedisturbanceesppotassiumDehydration Paradoxical
waterintoxicationfromtoomuchfreewater Postural
hypotension ECGchanges/arrythmias Constitutional
Sx Confusion/convulsions/vomiting
Osmoticcathartic
(duetoelectrolyte
composition)
Hyperphosphataemia+/-AKIHypernatraemiaHypocalcaemia
Hypermagnesemia
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Q14–MIinvestigationsdiscussionDiscuss the methods available for investigating a clinical suspicion of acute
postoperative MI
ECG o Serial as time-sensitive o TWI, ST seg changes, Q wave, LBBB. o Pro: Cheap, easy to obtain, allows continuous monitor, and likely site of CAD. o Con: non-specific, old changes may be hard to differentiate from new changes. Need old
ECG to compare. Troponin
o Elevation very likely to suggest MI. detectable 6 hours post MI, peak 12-24 hrs. remain detectable for 10 days.
o Pros: Sensitive. Peak assc w degree of MI. o Cons: However may see false positive eg. in old MI w renal failure. Serial sample required.
Slower detection than CK-MB. CK-MB
o Rise may suggest MI. o Pro: earlier detection than trop (2-3 hrs), sensitive, more specific than CK. o Cons: serial samples required, false positive likely (eg. from damaged non-cardiac muscle),
less specific than trop. Echo-
o Wall motion abnormality indicative of MI. o Pros: allows assessment of LV fxn, EF, o Cons: Need baseline to compare to be reliable.
Should be interpreted with history, exam finding. Crushing chest pain radiating down to left arm with ECG change is strongly indicative of MI.
May-2002
Q14-ECTanaestheticrisks(repeat)
Outlinetheanaestheticrisksspecifictothepatientsundergoingelectro-convulsivetherapy
Sep-2001
Q12-TBI,fixeddilatedpupilmx
OntransfertotheCTscannerhisleftpupildilates.Describeyourmanagement.
NB.
LITFLonintracerebralbleed:(CtargetsimilartoSAH)
-C:bloodpressurecontrol–aimforSBP<140(e.g.labetalol,esmolol,nicardipine,SNP–
aggressiveBPcontrolreduceshaematomaexpansionandnorealprenumbrainICH)
Specifictherapy-reversalofanypreexistingcoagulopathy(aimforanINR<1.4):
->stopwarfarinandotheranticoagulants
->FFP15mL/kg
->prothrombinX25-50IU/kg(factorsII,IX,X)(increasinggivenasthesoleagentforwarfarin
reversal)
->vitaminK5mgIV(onset6to24hours)->importantforsustainedreversal
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Strokeingeneral:
-ConsiderBPcontrolwithanischaemicstrokeifBPelevated>220/120mmHg,thoughno
agentsignificantlyaffectedoutcomefromthe43suitabletrialsreviewed.
-Becautiouswithnomorethana10-20%changemaximum(i.e.notlowerthan180/100
mmHginitially).
InTBI:-avoidintracranialhypertension;sustainedICP>20mmHgcausesischaemia
maintainCPPof60mmHg
—higherproducesmoreARDS
—lowerproducesafallinbraintissuePO2
controlPaCO2to35
—mannitol0.25-1g/kgQ3hrly
—hypertonicsaline(3%)3mL/kgover10minor10-20mL20%saline
May-2001Stem: A 63 yo man who lives independently, presents with a perforated ulcer
requiring laparotomy. He has been treated for cardiac failure for 5 years
Q1–ClinicalassessmentofCHF(repeat)How would you assess the severity of his cardaic failure at the bedside?
(repeat) Q2–VTEprophylaxis(repeat)Justify your choice of deep venous thrombosis prophylaxis
= repeat General: Anaesthetic: Mechanical should be used:
o Thromboembolic deterrent (TED) stockings Chemical considered Q3–intraoppulmoedemamanagementHow would you manage him if he developed pulmonary oedema during his surgery?
If emergency: call for help Mx aim: optimize oxygen supply to myocardium + reduce demand. Intraop (assuming GA with ETT in-situ having IPPV)
o ABC
o Give Oxygen, consider PEEP +/- bipap o Optimize preload, maintain contractility, afterload. Consider transfusion if Hb
<80. Avoid tachycardia/arrhythmias. § Decrease SNS drive with analgesia. Control temperature. Maintain
normocarbia. § Use A-line, CVP to guide further management. § If overload, and haemodynamic stable, consider frusemide (eg. 20mg IV)
carefully. § Reduce afterload with GTN to improve CO. § Support contractility with inotrope : ephedrine, adrenaline, milrinone
(inodilator) o Cause control
o IHD o Arrhythmia
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o Valvular disease o Sepsis/SIRS from bowel perforation o Iatrogenic (too much crystalloid)
o Invx with FBC, UECr, ABG, ECG, Echo. Postop
o Consider HDU/ICU o Cardiology consult o Mx goal set – prolonged IPPV may not be appropriate in severely compromised heart
failure, where ??palliation should be considered.
Aug-2000
Q1-lungisolationmethoddiscussionStem: A 57 yo man with a primary lung tumour is scheduled to have a thoracotomy for a
left pneumonectomy. Justify your choice of airway device for this surgery and describe
how it is placed.
Left pneumonectomy, prefer use right side DLT for lung isolation.
• Isolation is required to prevent soiling, improve surgical access. • R/DLT used as it avoids getting in the way of surgical field
o L/DLT may be contraindicated if tumour invades into proximal L/bronchus. R/DLT evaluation
• Pros
o Easier than bronchial blocker to place; o can be placed without bronchoscope o can alternate lung isolation easily o can suction with bronchoscope on either side o more rapid deflation of isolated lung o Can apply PEEP to non-ventilated lung
• Cons
o Maybe difficult to place esp if features of difficult airway; § Trouble shoot: stylet, bougie, fibreoptic assisted,
• Need long scope; otherwise, use following techniques: • place DLT until in trachea; insert scope, locate carina and cannulate
bronchus & slide tube over • Use aintree mounted over scope / ETT
o Easy to obstruct RUL bronchus; check with bronchoscope is preferred; otherwise accurate position of DLT may be difficult based on clinical assessment alone.
o Sizing of tube is big and potentially more traumatic to airway o Requires tube exchange postop if continuous IPPV required o R/DLT may dislodge easily esp during position change; need frequent check
• CI for DLT:
o Very distorted tracheobronchial anatomy contraindicates DLT. o Intraluminal tumour à as may cause bleed from trauma
How it is placed:
• Choose correct size • Prepare for laryngoscopy with routine precaution; then pass DLT through vocal cords, then
tild tip to side to be inserted, turn patient head slightly to contralateral side may assist with better alignment for DLT to pass endobronchially, advance tube to estimated depth.
o ~29cm for height of 170cm; with 1cm adjust for each 10cm of height. • Assess position (see other SAQ answer)
o Clinically § Inflate tracheal cuff § Inflate both cuff
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§ Clamp bronchial side then tracheal side o Bronchoscope – 4.2mm size.
NB. • (OHA) use largest DLT that can pass easily; usu. 41/39Ch male; 37Ch female. • Mallickrodt; (other brands include Sheridan, Rusch)
InChildren:(Aucklandcourse)• Neonate bronchoscope = 2.2mm; paed = 3.2mm. • < 6 yrs - elective bronchial intubation or bronchial blocker • 6-8 yrs - bronchial blocker, bronchial intubation, uninvent • 8 yrs - bronchial blocker, bronchial intubation, univent, DLT
Extra:Comparelungisolationmethods
Bronchialblockerwitharndtendobronchialblocker• 2types:uninventvs.cookwire-guidedblocker(inoroutsideofETT;outside
preferredifETTsmall<4.5)
• Pros:o easiertoinsertthanDLT.
o Allowsisolationoflobarbronchus,eg.lungabscess,bronchPfistula.
o Avoidsreintubationifpostopventrequired.
• Cons:o Slowerdeflationofisolatedlung(improvewithFiO2100%+inflatecuffby
endofexpiration+suction+surgicalfacilitated)
o Easilydislodged;needrecheckafterpositioningpt;cannotsuction.
Elective bronchial intubation
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• Pros: easy, esp in emergency – PTX, haemorrhage…etc; FO to confirm position. • Cons: poor seal with uncuffed ETT, poor collapse of operative lung; contamination of non-
op lung, unable to suction op lung; RUL obstruction with RMB intubation can à hypoxaemia
Q2-DLTpositioncheck(repeat)Discuss the advantages and disadvantages of using a bronchoscope to check the
position of the device.
(see SAQ)
• also; allows for bronchial blocker placement • allows assessment of disease within lumen
o Cons: potential trauma to airway; leak in ventilation during use. Q3-hypoxaemiaunderOLVOutline your management of an oxygen saturation of 82% during one lung ventilation.
Notify Surgeon, Anaesthetic Tech, OT Team Simultaneously manage + assess differentials
• Ensure ventilationg possible + FiO2 100% • If EtCO2 is present, then problem is most likely related to ventilation:
o Optimise ventilation: § Ensure adequate ventilation with TV (5-6ml/kg) + RR; consider muscle
relaxation; § If cause is V/Q mismatch related to OLV
• Give FiOw 100% to non-ventilated lung (apnoea oxygenation, moves ~50-100ml of air)
• CPAP to non-ventilated lung 5-10cmH2O; communicate with Surgeon. Distends lung slightly ~100ml, but shouldn’t interefere with surgery
• Recruite ventilated lung + balanced use of PEEP (to prevent atelectasis but avoid diverting blood to non-ventilated lung)
• May need intermittent ventilation of operative lung – avoid overdistension.
• PA occlusion of non-ventilated lung; if RV can cope with increased PVR.
• CPB/ECMO. • If EtCO2 absent; consider other differentials
o Machine/circuit intact + working. o Airway – not obstructed, not in wrong place. o Ensure adequate CO/Hb o Monitor error?
NB. oxygen flux = chemical O2 delivery + dissolved O2 delivery = [CO x [Hb] x SaO2 x k] + [CO x PaO2 x 0.003] CO in unit of dL/min; Hb g.dL
• EMACDifferentials:
o O2supply
o Machine/Circuit________________________(machine)
o Airway–obstructorwrongplace?
o Vent/Lungs
o Hypoventilation,lowerrespdrive,MSKimpair
o Deadspace,shunt,V/Qmismatch
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o Circulation
o Tissueuptake–hypermetabolism:sepsis,thyroid,MH
Apr98Stem: A 59 yo patient presents for the first time with a subacute bowel obstruction requiring laparotomy in the next two or three days. You are asked by the surgeon to review the patient because on admission his blood pressure is 210/120. Hypertension has not been previously diagnosed in this man and he is on no medications. Q1) Describe your assessment of his hypertension by history and examination.
Q2) How would you proceed with investigation of his hypertension if no cause was
apparent from the assessment described above?
Q3) How would you manage his blood pressure in the peri-operative period if no
cause had been found for this hypertension?
HTN assessment by hx + exam
o HTN diagnosis need repeat measurement (at least 3 separate occasion) and exclude external causes like drug, pain etc.
o Assess: If HTN confirmed, need to assess: o Severity / CVS risk status o End organ damage? o Cause: Differentials for HTN
o Hx + exam
o CVS: Angina, MI, PCI? SOB, decreased exercise, heart failure, PVD? o CNS: CVA, TIA? o Renal: AKI? Weight gain, swelling? Malaise, anorexia, itch, tendency to bruise
(uremia)? o Causes:
o Drugs
o C- Coarctation? Essential HTN? o B- OSA? - STOPBANG o Renal dx – bilat RA stenosis; RA bruit? o Endo- Phaeo – abdo masses, weight loss, sweat?
§ Conn’s syndrome § Thyrotoxicosis – weight loss, heat intolerance, palpitation § Hyperparathyroidism/hypercalcaemia
Invx of HTN
o Aim: assess end-organ dx? CVS risks? Differentials? o Bloods: FBC, UECr, glucose, TFT, PTH level, cortisol level o Urine: microalbuminuria, urine metanephrine/normetanephrin for phaeo, aldosterone serum
level. o ECG: LVH, ischaemia o Imaging: CXR, CT/MRI/Doppler for renovascular abnormality
o CT for coarctation o ECHO for function, LVH.
o PSG for OSA if high risks by screen Management of HTN in periop period
Preop o Normally in elective setting, would postpone until investigation and better control.
o Risk benefit ratio may tilt towards delay/cancel in elective if SBP >180. But controversial
o But this semi-ugent case, will try optimize within limited time available. o Aim = ctronol BP, minimize CVS risk, + optimize end-organ damage
o Control BP
o Labetalol o Hydralazine
o GTN
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o BB - o CCB - o ACEi o Alpha blocker
§ Key = avoid large drop in BP suddenly; a realistic aim = SBP160 in this acute setting.
Intraop: o Minimise CVS risk
o Monitor – routine ANZCA + art line + 5 lead ECG. o Optimize O2 supply and minimize O2 demand.
Postop: o Ongoing care + monitor in HDU. Cardiology for input.
