Primary FRCA Regional Teaching Day - SBAs Vivek Sinha ST4 Anaesthetics HRI 11/05/2013 Physiology 1) A patient on the intensive care unit is being ventilated in a volume-controlled mode with an FiO2 of 0.6. Arterial blood gas analysis reveals a PaO2 of 7.5kPa and a PaCO2 of 4.7kPa. Which ONE of the following is the best intervention aimed at increasing the PaO2? a) Increase the FiO2 b) Increase the tidal volume c) Increase the frequency d) Increase the inspiratory time e) Increase the expiratory time Physiology 2) A hormone is produced in the cytoplasm of an endocrine cell and is then stored in granules within the cytoplasm. On release from the cell it is carried in the blood-stream to a target cell, where it crosses the cell membrane and binds directly to the nucleus, increasing cell gene transcription. Which hormone is best described in these terms? a) Adrenaline b) Thyroxine c) Aldosterone d) Thyroid-stimulating hormone e) Growth hormone Explanation 3 main Classes of Hormone Peptides (eg. Growth Hormone) Synthesised in cell nucleus and then stored in granules and released by exocytosis Surface receptor Act via second messengers Amines Synthesised in the cytoplasm and then stored in granules Two sub-types: Catecholamines (eg. adrenaline) – act at cell membranes and use second messengers Thyroid hormones (eg. Thyroxine) – binds directly to nucleus receptors, stimulating transcription Steroid (eg. Aldosterone) Synthesised from cholesterol Immediately released (not stored) Lipid-soluble Enter cytoplasm and typically bind with receptors there and then enter nucleus to stimulate transcription Explanation Adrenaline & TSH – Gs protein-coupled receptors T3 & T4 stored in follicle stems between thyroid cells as the protein thyroglobulin 33% Thyroxine (T4) converted to T3 in target tissues and 45% to Reverse T3 T3 acts on nuclear receptors to alter cellular function via messenger RNA T4 has much less affinity to nuclear receptor Explanation Thyroid Follicular Cells Physiology 3) A patient with chronic obstructive pulmonary disease presents for assessment for long-term oxygen therapy (LTOT) and is found to have a compensated respiratory acidosis. Which of the following sets of arterial blood gases best demonstrates compensated respiratory acidosis? a) pH=7.30, PCO2=7.2kPa, PO2=9.5kPa, HCO3-=25mmol/L b) pH=7.36, PCO2=8.5kPa, PO2=7.5kPa, HCO3-=43mmol/L c) pH=7.24, PCO2=10.1kPa, PO2=7.0kPa, HCO3=27mmol/L d) pH=7.24, PCO2=3.5kPa, PO2=8.5kPa, HCO3-=18mmol/L e) pH=7.20, PCO2=6.2kPa, PO2=9.0kPa, HCO3-=15mmol/L Physiology 4) Which of the following statements regarding humoral mechanisms involved in controlling haemorrhage is INCORRECT? a) Circulating catecholamines increase b) Atrial natriuretic peptide (ANP) levels increase c) Vasopressin release is mediated via the GauerHenry reflex d) Stimulation of the adrenal cortex promotes release of aldosterone e) Circulating levels of enkephalins increase Explanation Aldosterone Secreted by zona glomerulosa of adrenal cortex Major regulators Renin-angiotensin system Plasma concentration of potassium ACTH Miscellaneous regulators Sympathetic nerves Baroreceptors Plasma concentration of sodium Aldosterone feedback Explanation Enkephalins and endorphins Endogenous opioids that bind to and activate opioid receptors throughout the CNS Levels of enkephalins increased when adrenal medulla is stimulated Gauer-Henry reflex Atrial stretch sensors sense decrease in volume and transmit signals to increase ADH secretion Gravitational change from 1g to microgravity may cause cephalad fluid shift, resulting in suppression of ADH secretion and diuresis Explanation ANP Plays important role in blood volume and electrolyte homeostasis in normovolemia and in hypervolemic states Secreted primarily from atria Hypervolemia and elevation of left atrial pressure or volume are the major known factors stimulating its release (local wall stretch) Plays important role in blood volume homeostasis by inducing rapid natriuresis and water excretion Lowers BP and antagonises renin-angiotensin-aldosterone axis Mild bleeding induces a rapid decrease in ANP secretion Some studies show increased plasma ANP after prolonged severe haemorrhage (possible biphasic effect of haemorrhage) Physiology 5) A farmer slips and falls in a remote field during a hot summer. He has nothing to eat and his only drink is whisky from a hip flask. He is not found for 3 days. On admission to hospital he is peripherally cold, with a heart rate of 110 beats/min and a blood pressure of 85/40mmHg. Which of the following is the most potent stimulus for antidiuretic hormone release? a) Stimulation of central osmoreceptors b) Stimulation of aortic arch baroreceptors c) Ingestion of alcohol d) Pain e) Stress Explanation Alcohol inhibits ADH Pain and stress stimulate ADH Osmoreceptors are very sensitive They respond to a change as small as a 1 to 2% increase in tonicity Baroreceptors are less sensitive (but more potent) than the osmoreceptors Hypovolaemia is a more potent stimulus for ADH release than is hyperosmolality. A hypovolaemic stimulus to ADH secretion will override a hypotonic inhibition and volume will be conserved at the expense of tonicity Physiology 6) Prior to induction of anaesthesia you preoxygenate the patient with a Bain circuit and a close fitting mask for 5 min. The reason for this is: a) To increase dissolved oxygen in the blood b) To flush out nitrogen c) To increase FRC d) To increase oxygen Hg capacity e) To increase the amount of oxygen in the alveoli with 3l Explanation Dissolved oxygen plays a tiny part in oxygen content and transport compared to haemoglobin. 100ml of arterial blood contains approximately 20ml of oxygen, 19.7ml of which is combined with haemoglobin, whereas only 0.3ml is dissolved in plasma. In venous blood these figures are 14.9 and 0.1 respectively. The oxygen content equation is as follows: Oxygen content = (1.34 x Hb x sats)/100 + 0.023pO2, where the Hb is measured in g/dl and the pO2 is measured in kPa and the solubility coefficient of O2 is 0.023 ml/dl/kPa. Explanation In normal person breathing room air with Hb 15g/dl, pO2 13.3kPa and sats 97% Even if the pO2 is increased to 80kPa Total arterial oxygen content would come to 19.80ml (bound to Hb = 19.497ml and dissolved in plasma = 0.3059ml). Total oxygen content would rise to only 21.337ml (bound to Hb = 19.497ml and dissolved in plasma = 1.84ml). This is just a 1.08% rise in total oxygen content Hyperbaric oxygen chamber Explanation 3L lung volume doesn't correlate with any physiological lung measure and alveoli is a very general term when you discuss preoxygenation Physiology 7) A 78 year old patient has been admitted to the intensive care unit for intubation and ventilation due to a low GCS. The family give a history of progressive weakness over several weeks with abdominal pain, decreased appetite, confusion and weight loss. The patient is known to have ischaemic heart disease, peripheral vascular disease, glaucoma, prostatic carcinoma and COPD. Blood results have come back showing Hb 9, Platelets 90, WCC 13, Na 149, K 5.6, Ur 14, Cr 220, Ca 3.6. ECG shows a prolonged PR and prolonged QT. What is the most likely cause of the ECG findings? a) Congenital b) Hypercalcaemia c) Hyperkalaemia d) Hypernatraemia e) Myocardial Ischaemia Explanation Very rare for a electrolyte abnormality to produce prolonged PR and QT as well - as it needs both conduction and repolarisation to be affected Hypercalcaemia Range Normal serum corrected calcium = 2.1 – 2.6 mmol/L Mild hypercalcaemia = 2.7 – 2.9 mmol/L Moderate hypercalcaemia = 3.0 – 3.4 mmol/L Severe hypercalcaemia = > 3.4 mmol/L ECG Main ECG abnormality seen with hypercalcaemia is shortening of the QT interval ST segment duration shortened In severe hypercalcaemia, Osborn waves (J waves) may be seen Ventricular irritability and VF arrest has been reported with extreme hypercalcaemia Explanation Typical progressive changes of hyperkalaemia: Tall, pointed, narrow T waves. Decreased P wave amplitude, decreased R wave height, widening of QRS complexes, ST segment changes (elevation/depression), hemiblock (esp. left anterior) and 1st degree heart block. Advanced intraventricular block (very wide QRS with RBBB, LBBB, bi- or tri-fascicular blocks) and ventricular ectopics. Absent P waves, very broad, bizarre QRS complexes, AV block, VT, VF or ventricular asystole No significant changes on the ECG occur with hypo/hypernatraemia Pharmacology 8) You are asked to provide anaesthesia for a pregnant woman undergoing emergency appendicectomy. Of the following drugs administered to the woman, which is the least likely to accumulate in the fetus? a) Bupivacaine b) Pethidine c) Thiopental d) Diamorphine e) Diazepam Explanation Physiochemical properties Increased placental transfer High lipid solubility (eg. Diazepam, most sedatives, pethidine) MW (<600 dalton for lipid-soluble, <100 dalton for polar) Bases (LAs & most opioids are weak bases) Non-ionised (eg phenobarbital) Low protein-binding Decreased placental transfer Acids Charged (eg. heparin) Size (heparin, IgM) Altered or bound by enzymes within placenta (eg. amines, insulin) Firmly and highly bound to maternal RBC (eg. CO) Plasma proteins (eg dicloxacillin, propranolol) Explanation Basic drugs Fetal pH lower (0.1-0.15) than maternal pH Relatively more ionized than in maternal blood and "ion trapping" may occur, leading to fetal drug accumulation LAs, Pethidine However, significant ion-trapping of bupivacaine only occurs in significant acidosis Pethidine Pethidine and Norpethidine (active metabolite of pethidine) accumulates in both the mother and fetus with a half-life of 4 and 20 hours respectively in mother and 13 and 62 hours in neonate Explanation All used inhalational agents cross the placenta Thiopental, propofol, benzodiazepines and ketamine all cross placenta but only benzodiazepines known to produce significant fetal effects Diamorphine Very little fetal depression if <1MAC & delivery occurs within 10min of induction Rapidly eliminated by the placenta Diamorphine, diazepam & pethidine broken down to lipid-soluble products Pharmacology 9) A new drug is being tested. Its onset of action depends on the rate of diffusion across the cell membrane. The following factors increase the rate of diffusion of a substance across a biological membrane, EXCEPT which one? a) Decreased molecular weight b) Increased concentration gradient c) Decreased solubility of a gas d) Increased lipid solubility e) For a weakly acidic substance, a low environmental pH Explanation Factors Influencing Rate of Diffusion Graham’s Law Fick’s Law Rate of transfer proportional to concentration gradient across membrane Ionization Rate of passive diffusion is inversely proportional to square root of molecular size For acidic substance more unionized in lower pH Lipid-solubility Protein-binding Rate of simple diffusion = permeability constant x membrane area x concentration gradient Pharmacology 10) An adult patient distressed by shivering in the postoperative period would be most effectively treated with which ONE of the following? a) Pethidine 25mg b) Doxapram 100mg c) Clonidine 150 µg d) Ketanserin 10mg e) Alfentanil 250 µg Pharmacology 11) After intravenous administration of anaesthesia you notice the area around the injection site has become very swollen, erythematous and inflamed. Which of the following is most likely to cause most damage? a) Rocuronium b) Morphine c) Ondansetron d) Dexamethasone e) Thiopental Explanation Drugs used in anaesthesia/intensive care unit with potential to cause tissue damage Acids/alkalis Hyperosmolar agents Calcium chloride Calcium gluconate Glucose >10% Magnesium sulphate 20% Mannitol 10% and 20% Parenteral nutrition Potassium chloride Sodium bicarbonate Sodium chloride >0.9% X-ray contrast media Aminophylline Amiodarone Amphotericin Co-trimoxazole Diazepam Erythromycin Phenytoin Thiopental Vancomycin Vascular regulators Epinephrine Dobutamine Dopamine Metaraminol Norepinephrine Prostaglandin Vasopressin Contin Educ Anaesth Crit Care Pain (2010) 10 (4): 109-113. Pharmacology 12) You are to carry out an experiment to assess the speed of gastric emptying. A standard dose of a marker drug is to be given to healthy volunteers. You will then measure plasma drug concentration at standard time intervals. Which of the following drugs will be suitable for this: a) Aspirin b) Gentamicin c) Paracetamol d) Propranolol e) Vancomycin Explanation pH = pKa + log [BASE]/[ACID] PKa of the drug (Dissociation or ionization constant): pH of the medium: Too much absorbed in stomach to be useful as marker Still absorbed in small intestine despite low unionised fraction, due to large intestinal surface area Propranolol (weak base), pka= 9.4 Affects ionization of drugs. Weak acids best absorbed in stomach. Weak bases best absorbed in intestine. Aspirin (weak acid), pka=3.0 pH at which half of the substance is ionized & half is unionized. Absorbed mainly in small intestine Extensive first-pass metabolism Paracetamol (weak base), pKa=9.5 Absorbed mainly in small intestine Paracetamol absorption depends on gastric emptying Low first-pass metabolism (approx 25%) Pharmacology 13) NIDDM patient had a 30 minute knee arthroscopy. Pre-op BM 7. Given Ondansetron and Dexamethasone for PONV. Post-op BM 13. What is the most likely cause for raised BM post-op? a) Dexamethasone b) Ondansetron c) Surgical stress d) Missed morning dose of anti-diabetic medication e) Metabolism of Hartmann's fluid Pharmacology 14) An asthmatic patient developed bronchospasm from diclofenac. Which one of the following could this be due to? a) Thromboxane A2 b) Arachidonic acid c) Leukotriene d) Prostacyclin e) Prostaglandin Explanation Pharmacology 15) A 25 year old male has just been transferred to the operating table for a repair of an umbilical hernia. After pre-oxygenation and induction of general anaesthesia with thiopentone, fentanyl, mivacurium, an i-gel was inserted and the patient was ventilated with IPPV. A bag of gelofusine was being transfused and remifentanil and sevoflurane used for maintenance of anaesthesia. A dose of teicoplanin was given for surgical prophylaxis. 5 minutes into the surgery the patient develops hypotension, bronchospasm, flushing. Anaphylaxis was diagnosed and appropriate treatment was started. What is the most likely cause of the anaphylaxis. a) thiopentone b) fentanyl c) mivacurium d) gelofusine e) teicoplanin Explanation Since 1980 more than 4,500 cases of perianaesthetic anaphylaxis have been reported by French and English authors. The drugs most frequently responsible for anaphylactic reactions in the French epidemiological survey were NMBAs (54%) Latex (22.3%) Antibiotics (14.7%) Opioid agents (2.4%) Hypnotic agents (0.8%) Colloids (2.8%) Others (3%) World Allergy Organization (WAO) Explanation Among the cases of anaphylaxis attributed to NMBAs in the literature, the following substances have been incriminated, in decreasing order of importance: suxamethonium, vecuronium, atracurium, pancuronium, rocuronium, mivacurium and cisatracurium. If one expresses the number of reactions observed in terms of the number of subjects exposed to NMBAs, the drugs can be divided into 3 groups: those associated with a high frequency of allergic reactions, including suxamethonium and rocuronium; those associated with an intermediate frequency of allergy, including vecuronium and pancuronium; those associated with a low frequency of allergy, including atracurium, mivacurium and cisatracurium. World Allergy Organization (WAO) Expanation Causes of life-threatening allergic reactions during anaesthesia Neuromuscular blocking agents (70%) Steroid-based compounds (vecuronium and pancuronium) cause anaphylactic reactions, whereas benzylisoquinoliniums (mivacurium and atracurium) tend to cause anaphylactoid reactions. Of drug reactions caused by neuromuscular blocking agents, 43% are caused by succinylcholine, 37% vecuronium and 7% atracurium. Latex (12.6%) Colloids (4.7%) The risk is greatest with gelatin solutions. All hyperosmolar solutions can release histamine directly. Contin Educ Anaesth Crit Care Pain (2004) 4 (4): 111-113. Expanation Causes of life-threatening allergic reactions during anaesthesia Induction agents (3.6%) Antibiotics (2.6%) Penicillins most frequently implicated Benzodiazepines (2%) Opioids (1.7%) Incidence of severe reactions to thiopental been reported approx 1 in 14000 Reactions to propofol less common Least common to etomidate Opioids usually cause anaphylactic reactions; morphine implicated most commonly. Reactions to synthetic opioids rare Morphine, codeine and meperidine can cause a dose-dependent, nonimmunological cutaneous histamine release Other agents (2.5%) Contin Educ Anaesth Crit Care Pain (2004) 4 (4): 111-113. Explanation Incidence of anaphylaxis according to the NMBA in France over 6 years ( 1997-2002 ) Rocuronium 1 : 5,100 patients exposed Succinylcholine 1 : 5,500 patients exposed Vecuronium 1 : 13,000 patients exposed Pancuronium 1 : 14,700 patients exposed Mivacurium 1 : 38,200 patients exposed Atracurium 1: 52,800 patients exposed Cisatracurium 1 : 148,7000 patients exposed Explanation Fentanyl Teicoplanin “To date, there have been seven reported cases of fentanylinduced anaphylaxis” (Br. J. Anaesth. (2011) 106 (2): 283-284) “Anaphylactic Reactions: Uncommon - More than 1 in 1000 people who have Teicoplanin” (NHS Choices website) “Anaphylactic Shock: The frequency of these side-effects is unknown” (NHS Choices website) Gelofusine “Anaphylactoid reaction to Gelofusine, that contains succinylated gelatin and other plasma expanders carries an estimated incidence of 0.07–0.15%.” (Ioannis Polyzois et al. Anaphylaxis due to gelofusine in a patient undergoing intramedullary nailing of the femur: a case report. Cases Journal 2009, 2:12) Physics & Measurement 16) A 25-year-old woman who is 16 weeks pregnant is admitted to hospital with sudden onset of breathlessness and collapse. A transthoracic echocardiogram suggests a massive pulmonary embolus. An ECG is studied and shows sinus tachycardia with right axis deviation. The cardiac axis is likely to lie at which of these angles? a) -60 degrees b) +60 degrees c) +90 degrees d) +120 degrees e) -90 degrees Explanation both I and aVF +ve = normal axis both I and aVF -ve = axis in the Northwest Territory lead I -ve and aVF +ve = right axis deviation lead I +ve and aVF -ve lead II +ve = normal axis lead II -ve = left axis deviation Physics & Measurement 17) Whilst checking the anaesthetic machine in theatre you notice that a piece of monitoring equipment has the symbol of a man enclosed in a box. Which ONE of the following is not true regarding the electrical safety of this equipment? a) It is a floating circuit b) It cannot be used in direct connection with the heart c) It has a maximal leakage current of 10 μA d) It contains an isolating transformer e) It has a maximal leakage current of 500 μA Explanation This is the symbol for type BF equipment. Therefore has a maximal leakage current of 500 μA and Cannot be used in direct connection with the heart Equipment classified into 3 groups Class I equipment - any accessible conductible part must be connected to earth Class II equipment has double or reinforced insulation of any conductible parts For this system to work correctly, fuses must be present in the live and neutral wires. Does not have an earth wire. Class III equipment uses batteries at a voltage unlikely to cause electrocution But may result in microshock. Davis PD, Kenny GNC. Basic Physics and Measurement in Anaesthesia, 5th edn. Oxford: Butterworth Heinemann, 2003; pp. 181-5. Explanation Further classified by the maximum leakage current it allows (type B, BF and CF). Type B or BF equipment is used in medical monitoring equipment. Type B has a maximum leakage current of 100–500 μA under single fault conditions and should not be directly connected to the heart. It can be class I, II or III. Type BF is type B but also uses a floating circuit. Type CF has a floating circuit and a maximal leakage current of 10–50 μA. It is used in equipment which may contact the heart directly. Davis PD, Kenny GNC. Basic Physics and Measurement in Anaesthesia, 5th edn. Oxford: Butterworth Heinemann, 2003; pp. 181-5. Explanation Circuit breakers exist that are current-operated Consist of coils of the live wire around a transformer An equal number of coils of the neutral wire are also wound around the transformer A third wire connects to a relay that operates the circuit breaker With equal currents in the live and neutral wire, the magnetic fluxes are equal and opposite and therefore there is no magnetic field. With a small leakage current, the magnetic fluxes are different, and a magnetic field that induces a current in the third winding results in the relay breaking the circuit. Davis PD, Kenny GNC. Basic Physics and Measurement in Anaesthesia, 5th edn. Oxford: Butterworth Heinemann, 2003; pp. 181-5. Physics & Measurement 18) Consider a hypothetical situation in which the following gases or vapours are stored separately in cylinders in a hot operating theatre (the thermometer reads 35 degrees Celsius). Which one of the following would NOT contain gas alone, irrespective of the pressure within the cylinder? a) Oxygen b) Nitrogen c) Nitrous oxide d) Carbon dioxide e) Air Explanation Nitrous Oxide Storage French blue cylinders In a liquid phase with its vapour on top At a gauge pressure of 4400 kPa at room temperature. As the liquid is less compressible than a gas, the cylinder should be only partially filled. The filling ratio is weight of the fluid in the cylinder divided by weight of water required to fill cylinder In the UK, the filling ratio for N2O is 0.75 But in hotter climates the filling ratio needs to be 0.67, to avoid cylinder explosion. Hospitals store N2O in large cylinders (e.g. size J) in two groups of cylinder manifolds. Physics & Measurement 19) Capnography is part of the AAGBI minimal monitoring requirements for general anaesthesia. Regarding capnography, which of following is the LEAST correct? a) Capnography is based on the principle that gases with two or more different atoms in the molecule will absorb infrared radiation b) The particular frequency of infrared radiation is selected by first passing it through a crystal window c) A reference cell increases accuracy of the system d) The use of infrared radiation with a wavelength of 4.28 µm for the analysis of carbon dioxide should reduce interference from the presence of nitrous oxide e) In the sidestream capnograph, a sample is drawn at about 150mL/min Explanation Basic analyser system consists of an infrared source, sample chamber and detector Basic principle of capnograph is based on Beer Lambert Law Beer Law Amount of infrared rays absorbed is proportional to the concentration of the infrared absorbing substance ie. The more CO2 present, the more infrared rays absorbed The chamber is made of special material that freely allows infrared waves to pass through (e.g. sapphire). Explanation Explanation CO2 maximally absorbs infrared waves with wavelengths of about 4.28 micrometers Nitrous oxide maximally absorbs infrared waves with wavelengths of about 4.5 micrometers Collision Broadening Absorption pattern of CO2 broadens when N2O or O2 added Can lead to a potential source of error in measurement Modern analysers measure the amount of N2O and O2 present to correct for errors due to collision broadening. Physics & Measurement 20) A group of doctors from your hospital have recently returned from a charity trip climbing Mount Everest. They are relieved to be home as they said they couldn’t have a good cup of tea on the mountain. Which of these responses would best explain why? a) The boiling point of water is 373.15 kelvin b) The boiling point is the temperature of a substance at which its saturated vapour pressure equals external atmospheric pressure c) A gas is a substance at a temperature above its critical temperature d) Boiling point increases with increasing pressure e) The saturated vapour pressure of a substance increases with increasing temperature Physics & Measurement 21) Arterial line pressure curve can measure ventricular contraction by a) Dicrotic notch b) Area under the curve c) Wave upstroke d) Height of curve e) Length of curve Explanation Information in Arterial Waveform Arterial blood pressure The slope of the upstroke of the wave reflects myocardial contractility (dP/dt). The stroke volume The position of the dicrotic notch on the down stroke. Calculated by measuring the area from the beginning of the upstroke to the dicrotic notch. If this is multiplied by the HR, then CO can be estimated. A low dicrotic notch is seen in hypovolaemic patients. The slope of the diastolic decay indicates resistance to outflow (SVR). A slow fall is seen in vasoconstriction. Physics & Measurement 22) The potential difference across the capacitor decreases, if the frequency of AC current increases. What is the reason for this? a) Capacitance inversely proportional to AC frequency b) Impedence inversely proportional to AC frequency c) Inductor inversely proportional to AC frequency d) Resistance inversely proportional to AC frequency e) Conductance inversely proportional to AC frequency Explanation Conductance = A measure of a material's ability to conduct electric charge; the reciprocal of the resistance Resistance (R) = Opposition to current. (The part which is constant regardless of frequency). Reactance (X) = measure of the opposition of capacitance and inductance to current. Reactance varies with the frequency of the electrical signal Impedance (Z) = measure of overall opposition of a circuit to current. Takes into account both resistance and reactance. Explanation Explanation C=Q/V Energy (E) needed to move an electric charge (Q) through a p.d. (V): E= QV As p.d. between plates increases more energy needed to add extra charge In DC circuit, current will flow initially and then die away as capacitor becomes fully charged In AC circuit, current will flow as capacitor being constantly charged and discharged AC frequency directly proportional to current size R=V/I AC frequency therefore inversely proportional to impedence Physics & Measurement 23) Long plastics operation approx 4 hours long. Temp measured 34.5. No body warmer or fluid warmer. What is the main reason for the drop in temp: a) iv fluids b) convection c) conduction d) radiation e) evaporation Explanation “Royal” “College” “Exam” “Room” Conduction Radiation (~40%) Convection (~30%) Evaporation (8-15%) Respiration (8-10%) Conduction (~5%) Clinical Scenario 24) You are working as a ship’s doctor in the tropics. The ship rescues a 40-year-old, 72 kg man from an island who was shipwrecked 2 days previously. He has had nothing to eat or drink for 2 days and the average daytime temperature has been 34 degrees Celsius. He looks severely dehydrated but is conscious and cooperative. Which ONE of the following would be your fluid resuscitation of choice over the next 24 hours? a) Let him drink water freely b) Cautiously allow to drink water and administer 2000mL of 5% dextrose solution intravenously over the next 24 hours c) Cautiously allow to drink water and administer 3000mL of Hartmann’s solution intravenously over the next 24 hours d) Prohibit oral fluids and administer 4000mL of 0.9% saline solution intravenously over the next 24 hours e) Prohibit oral fluids and administer 5000mL of dextrose saline solution intravenously over the next 24 hours Explanation Patient conscious and cooperative so can be given mixture of oral + IV rehydration Just oral water will not replace lost elecrolytes (neither will just 5% dextrose) Clinical Scenario 25) You are required to take over an emergency laparotomy in a 54year-old, 80 kg male patient with a history of well-controlled hypertension who is otherwise previously fit and well. You insert an oesophageal Doppler probe and note the following haemodynamic observations: heart rate103 beats/min, blood pressure 74/49 mmHG, cardiac output 4.1 L/min, flow time corrected (FTc) 290 milliseconds. Your initial management should be ONE of the following: a) Give a 200mL intravenous colloid bolus over 5 minutes b) Give a 200mL intravenous colloid bolus over 5 minutes and start an intravenous infusion of dobutamine c) Give a 200mL intravenous colloid bolus over 5 minutes and start an intravenous infusion of metaraminol d) Give a 200mL intravenous colloid bolus over 5 minutes and start an intravenous infusion of noradrenaline e) Start an intravenous infusion of gliceryl trinitrate Explanation Explanation Reference ranges in adult with no comorbidities CO 5-8L/min SV 60-100ml PV 20yrs: 90-120cm/s 50yrs: 70-100cm/s 70yrs: 50-80cm/s FTc 330-360ms Explanation Flow time Systolic ejection time Will clearly vary according to heart rate, so to allow comparison, corrected to HR of 60bpm (FTc) FTc inversely related to SVR, therefore narrow waveform base (<330ms) is indicator of vasoconstriction, of which hypovolaemia is commonest cause PV directly related to left ventricular contractility (agedependent) An increase of SV or stroke distance of >10% would be seen as positive response and challenge should be repeated Concurrent shifts in FTc and PV indicates changes in afterload Increase in afterload gives simultaneous reduction in FTc and PV (narrow waveform with decreased amplitude) Explanation Examples Narrow waveform base, decreased FTc characteristic of hypovolaemia Explanation Examples Same patient after fluid resuscitation Explanation Examples Explanation Examples Clinical Scenario 26) Regarding the management of acute myocardial infarction presenting with ischaemic symptoms and persistent ST elevation, which ONE of the following would be an absolute contraindication to fibrinolytic therapy? a) Previous fibrinolysis 5 months ago b) Resuscitated cardiac arrest within the last hour c) Diabetic retinopathy d) Ischaemic stroke 2 months ago e) Pregnant at 36 weeks gestation Explanation Absolute Contraindications Any prior ICH Known structural cerebral vascular lesion (eg. AVM) Known malignant intracranial neoplasm (primary or metastatic) Ischaemic stroke within 3 months EXCEPT acute ischaemic stroke within 3 hours Suspected aortic dissection Active bleeding or bleeding diathesis (excluding menses) Significant closed-head or facial trauma within 3 months 2004 ACC/AHA Practice Guidelines Explanation Relative Contraindications History of chronic, severe, poorly-controlled HTN Severe uncontrolled HTN on presentation (SBP >180mmHG or DBP >100mmHg) History of prior ischaemic stroke greater than 3 months, dementia, or other known intracranial pathology Traumatic or prolonged (>10min) CPR or major surgery (<3 weeks) Recent internal bleeding (<2-4 weeks) Noncompressible vascular punctures Pregnancy Active peptic ulcer Current use of anticoagulants: the higher the INR, the higher the risk of bleeding For streptokinase: prior exposure (>5 days) Prior allergic reaction to these agents 2004 ACC/AHA Practice Guidelines Clinical Scenario 27) You are fast bleeped to an elderly medicine ward to find a 84 year old morbidly obese patient with weak respiratory effort on 15L nonrebreathe and a weak pulse with an unrecordable blood pressure. Just as you try and assess the patient the patient stops breathing and you call the cardiac arrest team and initiate CPR at 30 compressions to two breaths. After one cycle the AED demonstrates VF and one shock is administered. An i-Gel is inserted and the second cycle of CPR commences. Peripheral IV access has proven difficult with multiple attempts. What is your next action during this cycle of CPR? a) Remove the i-Gel and perform tracheal intubation with an ETT tube and give 1 mg Adrenaline down the Ett Tube b) Give 1mg adrenaline IM c) Attempt to gain central venous access and give 1 mg adrenaline d) Give an intracardiac injection of adrenaline e) Gain intraosseous access and give 1mg Adrenaline Explanation Resuscitation Council (UK) Guidelines 2010 Delivery of drugs via a tracheal tube is no longer recommended – if intravenous (IV) access cannot be achieved give drugs by the intraosseous (IO) route. When treating VF/VT cardiac arrest, adrenaline 1 mg is given once chest compressions have restarted after the third shock and then every 3-5 min (during alternate cycles of CPR). In the 2005 Guidelines, adrenaline was given just before the third shock. This subtle change in the timing of adrenaline administration is to separate the timing of drug delivery from attempted defibrillation. It is hoped that this will result in more efficient shock delivery and less interruption in chest compressions. Amiodarone 300 mg is also given after the third shock. Atropine is no longer recommended for routine use in asystole or pulseless electrical activity (PEA). Clinical Scenario 28) You have anaesthetised a patient for a routine cystoscopy and dilatation of urethral stricture. The patient is normally fit and well, is a smoker and previous similar operations have been uneventful. You have inserted a laryngeal mask airway and allowed the patient to spontaneously breathe on a mixture of oxygen/air/desflurane. Induction and transfer to theatre have been uneventful but10 minutes into the procedure you notice the oxygen saturations reading 84%. Attempted bag ventilation is impossible and you notice seesawing of the abdomen. You diagnose laryngospasm tell the surgeon to stop. what would be your next course of action. a) Give 100% oxygen and increase your concentration of desflurane and apply CPAP b) Give a dose of alfentanil 1mg c) Give 100% oxygen and give a bolus of propofol and apply CPAP d) Give 100% oxygen and give a bolus of suxamethonium e) Give 100% oxygen and apply CPAP Clinical Scenario 29) You have just induced your last patient on an elective orthopaedic list. He is a 60 year old man for a bunionectomy of left forefoot. You have used 200mg Propofol, 100 micrograms of fentanyl and inserted an LMA and he is breathing spontaneously on a mixture of oxygen/air/sevoflurane. His next blood pressure is 76/30 with a heart rate of 56 bpm. hat would you do next? a) Give 600 micrograms atropine b) Give 200 micrograms glycopyrrolate c) Give metaraminol 0.5 mg d) Give ephedrine 6 mg e) Give a fluid challenge of 250 mls Hartmanns Clinical Scenario 30) A 42 year old female is undergoing a laparoscopic incisional hernia repair for a large abdominal hernia developed after a laparotomy for small bowel obstruction 12 months earlier. During the surgery the patient develops high ventilation pressures, desaturation, distended neck veins , hypotension, reduced air entry and movement on the left side of the chest. What should be the next step for this patient? a) Endotracheal suction b) Increasing PEEP c) Increasing minute ventilation d) Give muscle relaxant e) Needle decompression and insertion of an intercostal chest drain