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Documente Profesional
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© 1997
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Geoffrey Rushman
Page vii
Contents
Preface v
2. General anaesthesia
What factors show that intubation of the larynx will be difficult enough to indicate 6
fibroptic intubation?
What are the factors that prolong the action of nondepolarising relaxants? 7
What are the advantages and limitations of the laryngeal mask airway? 9
Under what circumstances should general anaesthesia for elective cases be postponed 11
and why?
How would you determine the causes of arterial hypotension (80/60 mmHg.) during a 12
prostatectomy, and how would you manage it?
Page viii
What causes bradycardia during general anaesthesia and what is the management of 13
this condition?
List the causes and briefly note the management of tachycardia (>100 bpm) during 14
general anaesthesia in an adult
What signs would lead you to suspect that a patient under general anaesthesia was 16
developing malignant hyperpyrexia? Describe your immediate management
You are asked to construct a question sheet for day-case patients to answer on 18
admission to hospital. What questions would you ask?
What protocol would you construct to guide surgeons on selecting adult patients for 19
day-case anaesthesia?
List the causes of "suxamethonium apnoea". How would you diagnose and manage it 23
once it had occurred?
What are the safety devices involved in delivery of oxygen from a cylinder on an 24
anaesthetic machine to an anaesthetised patient through a Bain system?
Compare two types of anaesthetic breathing system used for a healthy spontaneously 24
breathing child weighing 20kg
Describe the circle system for anaesthesia. What are its advantages and limitations? 26
What are the features of an anaesthetic machine which are designed to minimise the 27
risk of delivering hypoxic gas mixtures?
List the physical properties of desflurane, and describe the characteristics of a suitable 29
vaporiser
3. Paediatric anaesthesia
How does the physiology of children aged 1 year differ from that of adults? 34
What psychological factors influence your anaesthesia for children aged 2-3 years? 35
What facilities are required for transfer of a 2-month old baby to a paediatric unit? 35
A 6-week old child has projectile vomiting and is presented for laparotomy. Describe 36
the general anaesthetic problems of this case
What are the aims of premedication in children? Describe the pharmacology of two 37
such premedicant drugs
4. Neuroanaesthesia
What monitoring do you consider necessary for a posterior fossa craniotomy? What 40
are the possible sources of error associated with two of the monitors you mention?
Describe the physiological effects of high arterial carbon dioxide tension (10 kpa, 70 41
mmHg.)
What factors affect cerebral blood flow? State briefly their importance in relation to 41
anaesthesia within 12 hours of head injury
5. Obstetric anaesthesia
How do obstetric factors affect the management of anaesthesia for the removal of a 44
retained placenta?
You are asked to help with a case of severe pre-eclamptic toxaemia of pregnancy. 46
What is your management?
Page x
6. Cardiothoracic anaesthesia
Describe the adverse effects of blood transfusion. How may they be reduced? 55
What are the contents of a unit of transfusion blood? Describe briefly the alternatives 56
which can be used in an emergency haemorrhage situation until transfusion blood
becomes available
Describe the features of the Boyle's anaesthetic machine and Bain system which 57
protect the patient from pulmonary barotrauma
What is the physiological response to the rapid loss of 1 litre of blood in the adult? 58
Detail the immediate rescusitation (in the first hour) of an unconscious patient 60
admitted to the A & E department after falling off a ladder
8. Acute and nonacute pain management
Discuss the methods available for the relief of pain following abdominal 63
hysterectomy
Describe the adverse reactions which may follow the use of non-steroidal anti- 65
inflammatory drugs
9. Intensive therapy
A patient is admitted to the intensive care unit with a relapse of myasthenia gravis. 68
How do you cope with the medical problems of this situation?
A patient is admitted to the intensive care unit with Guillain Barre Syndrome. How do 68
you cope with the medical problems of this situation?
Why do some patients develop ARDS following colectomy? What are the 69
pathophysiological processses?
What is the venturi principle? Describe the clinical uses of high frequency jet 70
ventilation
What are the possible complications of internal jugular vein cannulation, and how do 71
you avoid them?
What are the possible complications of subclavian vein cannulation, and how do you 71
avoid them?
List the properties of an ideal inotrope. Compare the properties of dopamine with this 72
ideal
List the factors which determine the supply of oxygen to the tissues of the body. How 72
may these factors be altered by septic shock?
Discuss the occurrence of metabolic acidosis in patients in the intensive care unit 74
Give a brief account of the pulmonary problems that occur during intermittent positive 74
pressure ventilation of the lungs in ARDS
What arrangements are required for an adult head-injured patient, during transfer to a 80
neurosurgical unit?
What are the advantages and disadvantages of the local anaesthetic and epidural 84
anaesthetic techniques for the repair of an inguinal hernia?
What factors influence the choice of anaesthetic for insertion of arteriovenous shunt 87
for haemodialysis?
What are the advantages and disadvantages of the supraclavicular and axillary 89
approaches to the brachial plexus block
What is the place of local analgesic nerve blocks in the anaesthetic technique for 90
cholecystectomy (excluding ''spinal" and extradural techniques)? State briefly how
they are performed. What are their shortcomings? What are their risks?
Give a brief description of the sensory nerve supply of the thoracic cage and 91
abdominal wall
Describe the anatomy of the epidural space at the level of the fourth lumbar vertebra 93
Page xiii
What precautions should you take when anaesthetising a patient known to have 96
suffered from viral hepatitis?
How would you manage atrial fibrillation which occurs during anaesthesia? What 97
could be done to prevent it?
What problems does hiatus hernia pose for the anaesthetised patient and how would 99
you cope with them?
How does the presence of aortic stenosis affect the management of an anaesthetic? 100
What would happen if a full dose of thiopentone was given to a patient with acute 101
intermittent porphyria and why?
In what ways does Down's Syndrome affect the management of an anaesthetic? 102
What precautions should be taken when anaesthetising a patient with dystrophia 102
myotonica?
How do the intraoperative surgical complications of excision of thyroid goitre affect 103
the management of the anaesthetic?
What are the anaesthetic problems posed by surgical removal of a parathyroid 104
adenoma, and how do you cope with them?
What are the complications of mitral valve disease during anaesthesia and how do you 104
prevent them?
A patient with congestive cardiac failure presents for hip replacement. Describe your 106
management for the anaesthetic
A patient presenting for prostatectomy has a pulse rate of 39 beats per minute. 106
Describe the common causes and management of this
How does the common cold influence fitness for anaesthesia? 107
How do you judge the significance and plan the management of preoperative 108
anaemia?
What are the functions of the thyroid gland and how are they controlled? What are the 111
effects of thyroid dysfunction on anaesthesia?
In what circumstances may fluid overload occur during operation? How is it 111
diagnosed and managed?
Name and define the different types of hypoxia. Where are they seen clinically? 112
What is the mode of action of the following, in lowering arterial pressure? 112
Describe all the clinical actions of one anaesthetic agent and two other drugs you 113
might use to lower arterial pressure during anaesthesia
What complications of operations on the bony structures of the lower half of the face 116
may affect the anaesthetic management, and how do you deal with them?
A patient requires an anaesthetic for removal of an infected molar tooth which is 116
causing severe trismus. Describe the problems and outline the anaesthetic methods
Describe the anaesthetic management for a patient with a perforating eye injury who 117
had a large meal in the last hour
Describe the anaesthetic management for a 5-year-old patient who requires 117
reoperation for haemorrhage an hour after tonsillectomy
Chapter 1
Advice on Answering Short Answer Questions
Page 2
1. The questions in examinations in Anaesthesia are carefully designed to assess whether you are a safe anaesthetist and whether you
have a good sense of judgement in practising this specialty.
There are many areas in the life of an anaesthetist where there is no single right or wrong answer to a problem, but various
possibilities, depending on the circumstances of the case. The examination is therefore designed to test two aspects of your
professional skill. First, it tests knowledge, which is the "tools" of the professional. Secondly, it tests your judgement, which is
whether you know how to use these "tools". The less knowledge you have, the less equipment you have at your disposal for the
problems of everyday anaesthesia. Knowledge can be gained from books, lectures, and seminars. The more you read and listen, the
better.
A shortage of judgement means that you may be unable to handle problems which are more complex, or "out of the ordinary run of
things". Judgement is gained on the floor of the operating theatre, the intensive care unit and the clinic, in the company of
experienced colleagues who are inclined to teach you. The more experience you have in these areas the better.
2. In your preparation for this test, read all the exam question books in your subject, including this one!
3. Try to read all the review articles in your subject, published in the last year.
4. Do many practice exam essays beforehand, especially ones from previous papers if you can get them, and ask a sympathetic senior
colleague to mark them for you.
At the Exam
5. Make sure that you have spare pens and possibly coloured pencils in your pocket as well.
You must answer the requisite number of questions. Make sure you know how many this is.
6. Divide the time of the whole examination paper by the number of questions and do not overrun on any one answer by more than a
minute or so. It will probably help to put your watch or clock on the desk in front of you
Use a blank sheet of paper on which to make rough notes for all the questions. You can add to these later as you go along, if you
think of further points.
7. There is very little time for each answer - about 15 minutes. For many candidates this time allows writing only one or two sides of
paper (in the books provided) for each answer.
8. There will probably not be time to write the question out at the start of each answer. This means that you should read the carefully-
worded question at least twice to be sure of what it is asking.
If it is in an area with which you are very familiar, then you will find the answer easy. If it is in an area which you may not personally
have encountered (such as anaesthesia for kyphoscoliosis operations), then you may need to adopt the strategy of paragraph 9
(below).
Page 3
9a. Make notes briefly on what you think is the main answer to the question. (For example, the management of the anaesthetic for
kyphoscoliosis. This would involve general anaesthesia, prone position and all that entails.)
9b. Then think "laterally" about what else might be involved, e.g., why are scoliosis operations performed? (interference with
respiratory function as well as skeletal deformity) Are there preoperative problems? (e.g., some are congenital and may have other
congenital problems, the patients are often teenagers and will be anxious, needing premedication). What operative problems are
likely? (prolonged surgery, patients get cold). What postoperative problems are likely? (pain, respiratory problems).
9c. Then think about the "worst scenario" or "worst case" situation. This may prevent you from missing something big! Remember
that you will gain marks for every correct, relevant fact or opinion.
For example, in kyphoscoliosis, what is the worst thing that could happen preoperatively? (respiratory failure with possible cardiac
problems - this may require preoperative testing).
What is the worst thing that could happen during the operation? (haemorrhage may be profuse - so how much blood needs to be
crossmatched, and what monitoring would be needed; pneumothorax; damage to the spinal cord - the "wake-up test" during the
operation tests for this).
Postoperatively, the pain may be severe - would regional blocks be useful, or should they not be used? (interferes with testing for
damage to the spinal cord). Another "worst scenario" situation in the postoperative period is the occurrence of spinal cord damage.
Don't forget to mention testing for it!
Another question which should cross your mind is, "Do any of these cases need to go to the ITU or HDU?"
10. If the question is about "anaesthetic management", do include preoperative and postoperative care, unless the wording of the
question is specific to one or other area, in which case concentrate on what the question specifically asks.
11. If the question is about clinical anaesthesia, always think about local/regional analgesia as well as general anaesthesia. It might or
might not be appropriate, but you will probably gain marks by saying so.
12. Try to think "clinically" - what actually happens about these types of cases in the hospital where you work? How are the
problems in question coped with in practice? If you can prioritise the points in your answer and put the important points first, so
much the better.
13. If you have time, underline key points. Leave a line between each paragraph of your answer - it makes it clearer, and will also
give a little space for you to insert an extra sentence if you think of another point later on.
14. Where questions on scientific and technical subjects are concerned, there is no substitute for knowledge!
15. Where questions on anatomical subjects are concerned, do read the question carefully a second time, to be absolutely sure of
everything the examiners are asking. E.g., if the question asks for the arterial supply of the forearm and hand. To answer this by
simply writing about the arteries in the wrist and the hand will lose you marks.
Page 4
You may be rather rusty on the anatomical details for which the question asks. However, all is not lost! Put down what you know,
and make an educated guess to fill in the gaps. Diagrams are generally helpful as a part of your answer.
Chapter 2
General Anaesthesia
Page 6
What factors show that intubation of the larynx will be difficult enough to indicate fibroptic intubation?
1. Examination of patient
a) history of rheumatoid arthritis; known history of difficult intubation - Cormack & Lehane scores from previous laryngoscopies;
f) neck stiffness or injury (need to mention neck X-rays), atlanto-occipital distance, atlanto-odontoid distance (> 3mm);
2. Trismus.
4. Known or suspected laryngeal obstruction (need to mention soft tissue X-ray of neck).
This answer needs a note on whether any of these factors are absolute indications, and how many of the predictive factors need to be
present to indicate fibreoptic intubation.
<><><><><><><><><><><><>
Page 7
How do you manage the physiological consequences of surgical manoeuvres during abdominal laparoscopy?
3. Gas in blood vessels causes air embolism (requiring "air embolism drill").
5. Haemorrhage (you need to state that this can be massive, requiring urgent group-specific transfusion).
6. Gas in pleural cavity causes tension pneumothorax (this requires a comment on how to make the correct diagnosis and the
insertion of a needle in correct side of chest).
<><><><><><><><><><><><>
What are the factors that prolong the action of nondepolarising relaxants?
1. Structure of relaxant - basic scientific knowledge (bonus marks if you state what difference the structure makes).
2. Physiology of patient - hypokalaemia, hypocalcaemia, hypothermia, acidosis, poisons (e.g., botulinus toxin).
3. Volatile anaesthetics.
4. Myasthenia and other rare diseases (bonus marks if you can name any).
5. Other drugs, especially local anaesthetics and aminoglycoside and lincomycin antibiotics in high dosage.
Comment: This is common everyday anaesthetic practice and would be marked severely.
<><><><><><><><><><><><>
Page 8
1. Definition of morbid obesity in terms of body mass index is required (greater than 30 kg/M2).
Problems:
Respiratory system — increased work of breathing, diaphragmatic splinting, difficult intubation, underventilation, reduced lung
volumes, pulmonary "shunting", hypercapnia, hypoxia (operative and postoperative), slow equilibration with inhaled anaesthetics.
Cardiovascular system — blood volume increased, increased cardiac work, hypertension and coronary disease, risk of DVT, less
water per unit of body weight;
Technical — difficult to move, lift and nurse — spontaneous respiration restricted, difficult to intubate, especially when front dental
crowns are present, difficult venepuncture, estimation of drug dosage is difficult, inaccuracy of noninvasive arterial pressure
monitoring, regional and local blocks are technically difficult, surgery is often more prolonged.
Comment: This is a large answer to complete in 10-15 minutes, unless you have thought it out beforehand.
<><><><><><><><><><><><>
1. History from patient (previous unplanned awareness; physiological resistance to anaesthesia; alcoholism, etc.).
2. Preoperative checks of machine, vaporisers (or syringe drivers if using total intravenous anaesthesia). Vaporisers are refilled
before they become empty.
3. Monitoring of breathing system — including agent, especially when using the closed circle system. 1 MAC of volatile anaesthetic
is normally sufficient.
6. Monitoring of patient (this needs a very brief discussion of the value of "clinical" signs, and a few details about the available
awareness monitors).
<><><><><><><><><><><><>
Page 9
1. Monitoring of breathing system — (including anaesthetic agent), and/or syringe driver system.
2. Monitoring of patient
a) Clinical;
d) Bisectral Index;
<><><><><><><><><><><><>
What are the advantages and limitations of the laryngeal mask airway?
Advantages: general ease of use, does not require neck movement for insertion; good in difficult airway situations, bearded patients;
allows remoteness from mouth for head and neck operations. (Some comment on sizes is helpful.)
Limitations: can cause laryngospasm; can turn, kink and obstruct in other ways; no airway protection from gastric reflux, logistic
difficulties of sterilisation, pharyngeal damage on insertion, especially if the cuff is too tightly evacuated, dental damage, occlusion
by biting, if anaesthesia is too light or the patient wakes up with the laryngeal mask in situ.
Comment: The laryngeal mask does not guarantee anything, but it is wonderfully useful.
<><><><><><><><><><><><>
Page 10
1. Reliable IV cannula.
2. Reliable syringe pump — with battery backup, alarms for blockage, disconnection, and empty syringe.
3. Reliable full monitoring of airway, breathing (anaesthetic bag movements, SpO2, EtCO2), Circulation (ECG, arterial pressure,
SpO2) and depth of anaesthesia (details not needed).
4. Use of reliable drugs (e.g., propofol) and typical infusion rates (e.g., 10-6 mg/kg/hr for propofol).
<><><><><><><><><><><><>
Pharmacy:
Pharmacodynamics:
Dose, 4-8 mg
Onset, minutes
Duration, 8 hrs.
Pharmacokinetics:
Metabolism, liver
<><><><><><><><><><><><>
Page 11
1. Sedative drugs used, benzodiazepines, ketamine, opioids, phenothiazines, the doses required and undesirable side-effects.
3. Monitoring — you need to state that this is complete as for full general anaesthetic, because the patients selected for this type of
anaesthesia are sometimes very ill.
4. A brief discussion of a strategy for coping with failed local analgesia, e.g., appropriate analgesics.
<><><><><><><><><><><><>
Under what circumstances should general anaesthesia for elective cases be postponed and why?
Uncontrolled hypertension, recent myocardial infarction, colds, URTI, chest infection, head injury, acute pancreatitis, acute LVF,
uncontrolled arrythmia, inadequate preparation or investigations; serious electrolyte abnormality, e.g., hypokalaemia; serious acute
anaemia; uncontrolled shock.
Comment: This is a safety question, and needs only a brief reason for each area noted here.
<><><><><><><><><><><><>
Page 12
How would you determine the causes of arterial hypotension (80/60 mmHg.) during a prostatectomy, and how would you
manage it?
1. Bloodloss — inspection and analysis of bladder washouts — requires a discussi on of difficulty of assessment.
2. TURP syndrome — clinical signs, use of ethanol marker and breathalyser monitoring.
3. Anaesthetic — too deep, severe hypocapnia, severe bradycardia, spinal block too extensive, or made more severe by presence of
significant cardiac disease.
4. Other medical conditions — myocardial infarction, co-existing aortic stenosis, cardiac failure — need comment about usefulness
of monitoring.
<><><><><><><><><><><><>
What are the causes and management of hypoventilation immediately following anaesthesia?
Causes:
1. Obstructed airway.
4. Pain.
5. Shock.
7. Obesity and medical problems of the patient, e.g., myasthenia, pulmonary disease, raised intracranial pressure.
Management:
<><><><><><><><><><><><>
Page 13
What causes bradycardia during general anaesthesia and what is the management of this condition?
First of all, this needs a comment about what pulse rates constitute bradycardia.
Causes: deep anaesthesia, hypoventilation (e.g., disconnected ventilator), hypoxia, hypotension (which may also be caused by
bradycardia), oculocardiac and other vagal reflexes, drugs (opioids, neostigmine, B-blockers), cardiac ischaemia/failure/
bradyarrythmias, cerebral compression, high spinal blockade.
Management: assess reasons for it and state what limits should provoke action.
<><><><><><><><><><><><>
Page 14
List the causes and briefly note the management of tachycardia (> 100 bpm) during general anaesthesia in an adult
Causes: light anaesthesia, hypercarbia, hypovolaemia, hypotension, tachy-arrythmia, drugs (atropine, adrenaline), endocrine
problems (thyroid crisis, phaeochromocytoma), malignant hyperpyrexia, toxaemia.
General Management:
a) assess significance: (e.g., associated with hyper- or hypotension — pulse rates well above 100 bpm may adversely affect
circulation), state need for experienced help;
Specific Managements:
Sinus tachycardia — carotid sinus massage; Beta-blockers (and contraindications to these drugs).
Supra Ventricular Tachycardia —carotid sinus massage, adenosine, amiodarone, verapamil is controversial.
Ventricular tachycardia — amiodarone (lignocaine, flecaine and verapamil are used much less).
<><><><><><><><><><><><>
Page 15
Why do some patients suffer circulatory collapse at the induction of general anaesthesia and how would you manage it?
Causes:
1. Nature of patient's disease e.g., untreated hypertension, sudden arrythmia, cardiac failure (for example in emergency CABG),
severe aortic stenosis, pacemaker failure, phaeochromocytoma, and other rare syndromes
b) O2/ventilation.
c) Adrenaline 50-100µg.
e) Antihistamines.
f) Steroids.
g) Blood samples.
h) Prevent awareness.
i) Inform patient).
General Management:
Firstly, diagnosis of the cause, based on knowledge of the patients preoperative medical condition, and full monitoring.
In general, anticipation of the problem, with full monitoring; elevation of the legs and careful use of catecholamines. ACLS plus
control of the cause if the collapse progresses to cardiac arrest.
<><><><><><><><><><><><>
Page 16
What signs would lead you to suspect that a patient under general anaesthesia was developing malignant hyperpyrexia?
Describe Your immediate management
Signs:
• high tachycardia; hypercapnia; cyanosis/hypoxia; hypothermia; muscle rigidity; metabolic and respiratory acidosis; initial
hypertension; followed by cardiovascular failure; mottled rash.
Management:
• hyperventilate with oxygen; stop trigger agents; repeatedly measure blood gases; electrolytes and temperature;
• inject dantrolene, 1mg/kg, i.v., repeated (to inhibit sarcoplasmic Ca++ release);
• active cooling;
• ITU admission.
<><><><><><><><><><><><>
Page 17
What is the pathophysiology of malignant hyperpyrexia? How would you investigate it?
1. Abnormal Ca++ flux with uncontrolled release of Ca++ from sarcoplasmic reticulum on exposure to triggers gives rise in Ca++
pump activity; binding of troponin C causes massive muscle contraction and uncoupling of oxidation from phosphorylation.
Investigation:
• After the crisis: muscle biopsy (MHSusceptible, MHEquivocal, MHNonsusceptible). MHEcould be exposed to ryanodine.
<><><><><><><><><><><><>
Page 18
You are asked to construct a question sheet for day-case patients to answer on admission to hospital. What questions would
you ask?
• Have you ever had an anaesthetic? If so, did you have any problem with it?
• Are you taking any sort of medicine, pill or tablet? If so, which ones?
• How many stairs can you climb quickly before you get short of breath?
• Have you got someone to take you home and stay with you for the night after the operation?
<><><><><><><><><><><><>
Page 19
What protocol would you construct to guide surgeons on selecting adultpatients for day-case anaesthesia?
Operations to Avoid:
• those which are lengthy (more than 30 min), painful, haemorrhagic, enter thorax or abdomen.
Patients to Avoid:
• myocardial infarction in last year, or multiple or severe previous infarctions with restriction of activity; Angina;
• electrolyte abnormalities;
• those with no-one to take them home and look after them;
<><><><><><><><><><><><>
Page 20
Describe the anaesthetic arrangements involved in a gynaecological day-case list of 15 patients for dilatation and curettage of
the uterus
1. There is a need for a selection protocol for surgeons choosing the patients (e.g., patients may be obese).
4. Organisation of the day of operation: preoperative visits, confirmation of the correct order of the list/no waiting for patients/coffee
break for staff! Routine checks of patient identity and expected operation.
5. Anaesthetic techniques for rapid awakening (e.g., sevoflurane, desflurane, or TIVA) and no nausea (routine use of antiemetics).
9. Postoperative visit.
<><><><><><><><><><><><>
Page 21
Pharmacy:
Pharmacodynamics:
Onset, 60 secs.
Pharmacokinetics:
Metabolism, liver
Plus other features: rapid onset due to low receptor occupancy, with high biophase concentrations.
<><><><><><><><><><><><>
Page 22
Pharmacy:
Type of chemical (phenol), storage (glass ampoules), preparation (emulsion), concentration (10 mg/ml.).
Pharmacodynamics:
Brain (reduction CMRO2 and anaesthesia), heart, bloodvessels (vasodilator), respiratory depression.
Pharmacokinetics:
Doses (1-2 mg/kg.), blood levels (3.5-4.5 µg/ml.), onset (one circulation time), lipid solubility (high), distribution (initially to
extracellular fluid, brain, then other sites, especially fat), short half life; 99% metabolised.
Side effects: extrapyramidal movements, mild relaxation of muscles; depression of pharyngeal reflexes.
Contraindications:
<><><><><><><><><><><><>
An ethane (halothane) compared with a more highly fluorinated ether (desflurane); physical properties, MAC values, rates of onset
and offset, pharmacodynamics, metabolism, side effects, vaporiser design.
<><><><><><><><><><><><>
Page 23
What are the pharmacological problems presented by a patient taking monoamine-oxidase inhibitors (MAOI) who requires
emergency anaesthesia for a bleeding duodenal ulcer? discuss the pharmacological problems presented.
Problem of cardiovascular support and need for inotropes (with their interactions), place of dopamine in renal support; need mention
of careful volume replacement before and during anaesthesia. This answer needs a mention of strategies for analgesia and the
problem of interaction with pethidine causing hypotension and coma.
<><><><><><><><><><><><>
List the causes of "suxamethonium apnoea". How would you diagnose and manage it once it had occurred?
Causes:
2. Acquired — pregnancy, malnutrition, plasmapheresis, myxoedema, the newborn, lupus, and drug-induced.
Diagnosis:
c) Neuromuscular monitoring;
d) Later — investigation of patient and relatives. Dibucaine no.; fluoride no.; serum cholinesterase levels.
Management:
Oxygenation; IPPV and sedation for about 1-2 hr. until muscle power returns.
<><><><><><><><><><><><>
Bain system — modified Mapleson D, coaxial, outlet valve by machine, small deadspace, always some rebreathing except at very
high flows, breaks of central tube gives high deadspace — safety check before use, not antistatic, sterilising procedures. the outlet
valve usually has an airway pressure limiting device, set at 50-60 mm Hg., which prevents barotrauma, but not pressure effects on
pulmonary circulation.
<><><><><><><><><><><><>
Page 24
What are the safety devices involved in delivery of oxygen from a cylinder on an anaesthetic machine to an anaesthetised
patient through a Bain system?
Pin-index on cylinders, tap on cylinders, pressure reducing valve, filter, flow restrictor, needle valve, rotameter (on the left in UK),
vaporiser with adequate gas seals, machine pressure relief valve, standardised 22mm outlet, bag, coaxial pipes, mask, Heidbrink exit
valve with airway pressure limiting device (50-60 mm Hg).
<><><><><><><><><><><><>
Compare two types of anaesthetic breathing system used for a healthy spontaneously breathing child weighing 20kg
Issues for discussion (any descriptions of the systems should be very brief).
• Simplicity of use.
• Safety for patient (valves (or lack of them); ease of disconnections; antistatic protection; risks of hypoxia, prevention of pulmonary
barotrauma).
• Economy.
• Fresh Gas Flows — requires figures for the systems you describe.
Comment: The size of the patient in question here has been chosen to allow you the maximum choice of breathing systems.
<><><><><><><><><><><><>
Page 25
Pharmacy:
Pharmacodynamics:
Dose, MAC = 6%
Duration, N/A
Pharmacokinetics:
Plus other features (low solubility, blood/gas partition coefficient 0.4, oil/gas 18.7; high SVP (88 @ 20° C; MAC50 6%; Boiling point
22.8° C; vaporiser designed to run above boiling point).
<><><><><><><><><><><><>
Page 26
Describe the circle system for anaesthesia. What are its advantages and limitations?
Corrugated tubes, soda lime, low-resistance, NON-stick valves, gas entry port on inspiratory limb.
Advantages
Soda lime — 90% Ca(OH)2, 5% NaOH, 1% KOH, silicates and water. Used to absorb CO2 (up to 20% of its own weight). Granule
size, air spaces important, Colour indicator change on exhaustion.
Limitations
1. Risk of
• hypoxia
• hypercapnia
• O2
• CO2
• anaesthetic agents
<><><><><><><><><><><><>
Page 27
What are the features of an anaesthetic machine which are designed to minimise the risk of delivering hypoxic gas mixtures?
The features which should be mentioned are: colour coding of cylinders, pin-index, pressure gauge, Schrader valves and colour-
coded pipe for pipelines, flow control by rotameters, O2/N2O interlock, O2 failure warning device, O2 monitor, safety checklist card.
Issues for discussion — effectiveness, proof against operator failure, areas of failure of reliability, need for audible alerts for
operator, operator involvement in safety checks, effect of electrical failure.
<><><><><><><><><><><><>
Pharmacy:
Type of chemical, storage (powder, with mannitol), i.v. preparation is very highly alkaline
Pharmacodynamics:
Mode of action, muscle fibre relaxant, acting at excitation-contraction coupling zone, preventing Ca++ release from sarcoplasmic
reticulum
Onset, rapid
Pharmacokinetics:
Metabolism, liver
<><><><><><><><><><><><>
Page 28
Pharmacy:
Type of chemical (a cyclohexanone), storage (aqueous solution in glass ampoules) preparation, concentration (10, 50, and 100
mg/ml.)
Pharmacodynamics:
Pharmacokinetics:
Metabolism, liver
Side effects, dreams and hallucinations, vasoconstrictor — hypertension, mild rises of ICP and IOP, salivation, PONY, increased
muscle tone and movements.
Interactions, dreams and hallucinations prevented by low dose benzodiazepines. Prolonged hypnosis with barbiturates.
Plus other features: low-dose use in sedoanalgesia. Has been used in patients with full stomachs without regurgitation.
<><><><><><><><><><><><>
Page 29
List the physical properties of desflurane, and describe the characteristics of a suitable vaporiser
5. MAC: 6%.
Vaporiser characteristics:
Splitting of gas inflow, temperature controlled @ 39° C, calibration independent of flow, electronic vapour injection with differential
pressure transducer system, electronic monitoring of liquid content with alarm, keyed filling ports and bottles, spill-proof device,
easily mounted and demounted from machine, interlocks to allow only one in use, at any one time.
<><><><><><><><><><><><>
1. Clinical condition of patient e.g., capillary refill, warm periphery, quality and volume of pulses in various parts of body.
2. Monitoring CVP; arterial pressure — invasive and noninvasive (with comment on pressures needed for production of urine) (MAP
70 mm Hg.).
3. Visual assessment of swabs, drapes and sucker bottle, allowing for volume of saline washouts.
<><><><><><><><><><><><>
Page 30
Definition: a measure of the potency of volatile anaesthetics. MAC50 is the minimum alveolar concentration required to prevent
physical reaction to skin incision in 50% of subjects.
Isoflurane 1.15%; enflurane 1.7%; desflurane 6%; sevoflurane 2%; halothane 0.75%.
It varies with age, greatest at one month; lowest in premature babies and old age.
MAC95 is the minimum alveolar concentration required to prevent reaction to skin incision in 95% of subjects.
Other features: in mixtures of anaesthetic gases, the various MAC's are additive.
<><><><><><><><><><><><>
Pharmacy:
Type of chemical (phenol) storage (emulsion in soybean oil, in glass ampoules) concentration (10mg/ml.)
Pharmacodynamics:
Dose, 1-2 mg/kg; infusion 10-6 mg/kg/hr. effective blood level is 3.5-4.5 µg/ml.
Pharmacokinetics:
Metabolism, liver
<><><><><><><><><><><><>
Page 31
Pharmacy:
Type of chemical (benzylisoquinoline), storage, (aqueous, in glass ampoules) preparation, concentration 10mg/ml
Pharmacodynamics:
Onset, 3 mins.
Duration, 10 mins.
Pharmacokinetics:
<><><><><><><><><><><><>
Pharmacy:
Type of chemical, storage, preparation (aqueous, tablet or syrup), concentration (400 µg/ml.)
Pharmacodynamics:
Dose, 7 µg/kg.
Duration, 3hrs
Pharmacokinetics:
Metabolism, liver
<><><><><><><><><><><><>
Page 32
Pharmacy:
Type of chemical, storage (aqueous solution in glass ampoules,) preparation, concentration 200 µg/ml.
Pharmacodynamics:
Dose, 7 µg/kg.
Pharmacokinetics:
Metabolism, liver
<><><><><><><><><><><><>
Page 33
Chapter 3
Paediatric Anaesthesia
Page 34
How does the physiology of children aged 1 year differ from that of adults?
Infants have:
1. More increased heart and respiratory rates in response to demands than adults. The ribs are more horizontal, and the respiration is
more diaphragmatic.
5. Greater sensitivity to opioids, partly due to nervous system immaturity, partly to hepatic clearance.
Comment: the question sounds complex, but the answer is quite simple!
<><><><><><><><><><><><>
Pharmacy:
Type of chemical (eutectic mixture of local anaesthetics), storage (cream in a tube), preparation, concentration (2.5% lignocaine;
2.5% prilocaine)
Pharmacodynamics:
Dose, 5 ml.
Onset, 1 hr.
Pharmacokinetics:
Metabolism, liver
<><><><><><><><><><><><>
Page 35
What psychological factors influence your anaesthesia for children aged 2-3 years?
1. Very easily frightened — need to be seen with parents and spoken to kindly; need discussion of place of premedication, including
day cases.
a) need EMLA or similar cream for venepuncture and discussion of management of gaseous induction
b) need careful analgesia (but sensitive to opioids and not able to control own PCA) — need discussion of pro's and con's of the main
techniques for pain relief.
Comment: The question sounds complex, but the answer is quite simple!
<><><><><><><><><><><><>
What facilities are required for transfer of a 2-month old baby to a paediatric unit?
A trolley which is easily mobile and physically secure, warm, with O2 supply, humidification, IPPV available (secure tracheal tube if
appropriate), good IVI. Monitoring which is portable, shakeproof, battery powered (need SpO2, EtCO2, ECG, pulse meter,
thermometer; laryngoscopes, spare tracheal tubes and i.v. cannulas.)
Drugs and other facilities for CPR. Easy access to the patient.
<><><><><><><><><><><><>
Page 36
A 6-week old child has projectile vomiting and is presented for laparotomy. Describe the general anaesthetic problems of this
case.
4. Hypokalaemia.
5. Full stomach (regurgitation risk — need for preoperative nasogastric tube with clear washouts and rapid sequence induction of
anaesthesia).
6. Small size of patient, with special paediatric problems — risk of hypothermia, risk of overventilation, risk of fluid overload,
sensitivity to opioids, narrow cricoid ring, short trachea, more difficult intubation. If the patient is a premature baby, extra risk of
intracranial haemorrhage.
<><><><><><><><><><><><>
Rapport with parents. Minimum interference with child prior to careful transfer to theatre with humidified O2, ENT surgeon standing
by, careful O2/halothane or sevoflurane induction, difficult intubation (with possible use of steroid cream), throat swab; then — need
for IV infusion, blood tests for bacteria and RSV, antibiotics (usually cephalosporin for Haemophilus A), IPPV, sedation,
humidification, transfer to ITU, fluid management, protocol for eventual extubation.
<><><><><><><><><><><><>
Page 37
Describe the management of acute laryngotracheitis in a child of three years of age, presenting with cyanosis
Humidified O2 therapy; cyanosis makes this case severe enough to require intubation; induction of anaesthesia (gas or iv), potentially
difficult intubation, throat swab; need for rehydration by i.v. infusion, blood cultures for bacteriology and virology, antibiotics (broad
spectrum in the first instance), ITU, IPPV, sedation, humidification, paediatric fluid management, protocol for eventual extubation.
<><><><><><><><><><><><>
What are the aims of premedication in children? Describe the pharmacology of two such premedicant drugs
1. Needs a comment on sedation, analgesia, drying secretions, routes of administration; and about which patients need greater and
which need lower dosage.
2. Needs comment on selection criteria for premedication in children and influence on dosages of premedicants in children with
relevant concomitant diseases, e.g., effect of Downs syndrome on dosages of sedatives.
3. Details about two drugs, e.g., benzodiazepines, atropine, hyoscine, trimeprazine; using the format described for answers on ''write
short notes on" questions.
Comment: An easy answer for those who premedicate children. In answer to the first part of the question, it would also be acceptable
to argue the case against premedicating children!
<><><><><><><><><><><><>
Page 39
Chapter 4
Neuroanaesthesia
Page 40
How does concomitant head injury influence your anaesthetic management of operation for a fracture of the hand?
Monitoring of head injury required as it may be getting worse — monitoring of GCS. The intracranial critical volume/pressure
compliance point may be reached suddenly.
If the head injury is unstable, cerebral oedema would be worsened by coughing, straining, vomiting, and jugular venous obstruction.
Hypoxia, and hypercapnia may critically compress brain, and hypotension would carry risk of cerebral hypoxia. Operation may need
to be postponed.
If head injury is stable and improving, brachial plexus and wrist blocks and local infiltration are OK, Biers block OK, but care is
needed with dosages of local anaesthetics because of side effects.
<><><><><><><><><><><><>
What monitoring do you consider necessary for a posterior fossa craniotomy? What are the possible sources of error
associated with two of the monitors you mention?
Invasive arterial pressure (damping, clotting in cannula, zero errors, height of transducer).
Pulse oximetry (mechanical and electrical interference; digit too large or too small for transducer; abnormal haemoglobins; venous
pulsation; delay in alerting hypoxia).
Capnography (sampling site too far from lungs, blocked sample tube, interference by N2O, leak in sample tube, monitor wrongly
calibrated).
FiO2 (blocked sample tube, leak in sample tube, monitor wrongly calibrated, fuel cell dead).
Pulse (if counting from ECG, a high T wave can apparently double the rate, if counting from a digit, electrical and mechanical
interference).
CVP (catheter tip peripheral — reading is too high, catheter tip in right ventricle — reading is too high; damping, clotting in cannula,
zero errors, height of transducer).
Page 41
Describe the physiological effects of high arterial carbon dioxide tension (10 kpa, 70 mmHg.)
On general circulation — increased arterial pressure; raised arteriolar tone, dilation of skin blood vessels.
On cerebral circulation — vasodilation, increase in flow and volume of vessels. Raising of ICP.
On pH — reduction
<><><><><><><><><><><><>
What factors affect cerebral blood flow? State briefly their importance in relation to anaesthesia within 12 hours of head
injury
Control Factors
Pathological Factors
• raised intracranial pressure, due to vomiting coughing and straining reduces it;
Drugs
General anaesthesia — disruption of controlling factors by the anaesthetic; e.g., cardiovascular instability, raised jugular venous
pressure (coughing, vomiting, fluid loading, hypoxia, intubation, IPPV, cardiac failure) hypercapnia, hypocapnia, hypothermia;
hyperventilation with low CO2 tension causes cerebral vasoconstriction;
Comment: This answer also needs a little discussion of the significance to the anaesthetist of raised intracranial pressure.
<><><><><><><><><><><><>
Page 43
Chapter 5
Obstetric Anaesthesia
Page 44
How do obstetric factors affect the management of anaesthesia for the removal of a retained placenta?
1. A retained placenta can cause severe blood loss, therefore good IV access essential, and that potential hypovolaemia is as
dangerous in regional block as in general anaesthesia.
2. Acid gastric juice — with risks of severe pneumonitis from regurgitation and aspiration.
3. Pre-partum narcotic drugs may have been given, which will accentuate responses to anaesthesia.
4. The possible presence of an existing epidural for obstetric analgesia, which can be used for the anaesthetic.
<><><><><><><><><><><><>
Pharmacy:
Pharmacodynamics:
Onset, 1 hr.
Duration, 4 hrs.
Pharmacokinetics:
Metabolism, liver
Excretion
Side effects, cardiovascular disturbances, bradycardia, AV block, asystole; CNS disturbances — mental confusion, headache
dizziness; anaphylaxis, nosocomial pneumonia
Describe the anaesthetic management of massive intrapartum haemorrhage requiring emergency operation
1. Give oxygen.
2. Stop haemorrhage — need for oxytocics; immediate delivery and even emergency hysterectomy. Need for large, fast infusion to
replace bloodloss.
3. Anaesthetic for severely shocked patient (hypovolaemia, acute anaemia, oxygen carriage problems), who may have a full stomach
with acid gastric juice.
<><><><><><><><><><><><>
Pre-eclamptic toxaemia arises from changes in the placenta which lead to:
• hypertension;
• albminuria;
• intrauterine haemorrhage;
• sodium retention;
You are asked to help with a case of severe pre-eclamptic toxaemia of pregnancy. What is your management?
1. Assessment: hypertension, proteinuria, weight gain. How serious and how acute is it?
4. Monitoring: arterial pressure, blood gases, platelet levels, coagulation screen, CVP, urinalysis.
5. Treatment: there should be a continuous attempt to make all abnormal parameters normal. Arterial pressure control is a high
priority (IV colloid, epidural, hydrallazine, alphamethyldopa), magnesium sulphate to prevent convulsions.
FFP for coagulopathy, attempt at early delivery. If general anaesthetic is required, upper airway oedema may make intubation
difficult.
Chapter 6
Cardiothoracic Anaesthesia
Page 48
Origin (cricoid, C6); termination (carina, T4); tubular midline structure of horseshoe-shaped cartilages (keep airway open), fascia and
muscle; lined by ciliated epithelium, which moves mucus. Innervated by recurrent laryngeal nerves and vagi; blood supply from
thyroid arteries, draining to inferior thyroid plexus.
Relations:
Neck – pretracheal fascia, strap muscles, thyroid, platysma; laterally – carotid sheath, recurrent nerves and vagi, posteriorly –
oesophagus.
Chest – anteriorly innominate artery, vein, aorta; laterally subclavian arteries, recurrent nerves and pleura on right side; posteriorly
oesophagus. Carina is related to pulmonary artery bifurcation.
Comment: In an anatomy question, extra marks can often be gained by noting the function of the structure in question. In this case it
is simply the airway!
<><><><><><><><><><><><>
A sheet of muscle, arising from the lower 6 costal cartilages, the xiphisternum, arcuate ligaments and crura; inserted into central
tendon. There are three main openings – for oesophagus, aorta, and inferior vena cava. (Also perforated by thoracic duct and
hemiazygos vein).
Function:
Rhythmic respiration and abdominal straining. Innervated by phrenic nerve (C345); blood supply from surrounding vessels, e.g.,
internal mammary artery.
Relations:
Above – pleura, pericardium, lungs, heart, ribs, spine, oesophagus (passing through hiatus) aorta, inferior vena cava; below –
stomach, spleen, liver, kidneys, arcuate ligament.
Page 49
1. R coronary (dominant in 50%) from right coronary sinus, between aorta and right auricle, goes down right atrioventricular groove
(marginal branch down right ventricle), to posterior atrioventricular groove, to anastomose with left coronary, with posterior
interventricular and posterolateral branches. Supplies SA node, AV node, Bundle of His, pulmonary conus.
2. L coronary (dominant in 20%) from left (posterior) sinus between left auricle and pulmonary trunk, gives left anterior descending
(anterior interventricular) branch which supplies anterior left ventricle, septum and bundle branches. It continues as circumflex in
atrioventricular groove, with obtuse, marginal and left lateral branches.
<><><><><><><><><><><><>
1. Thebesian veins (venae cordis minimae) drain into the cavities of the heart. Anterior cardiac veins open into right atrium.
2. The coronary sinus drains 90% of left ventricular blood supply from five tributaries (great, middle and small cardiac veins;
posterior vein of left ventricle, and oblique vein of left atrium).
3. It lies in the atrioventricular groove, and drains into the right atrium to the left of the opening of the inferior vena cava.
Page 50
This system is specialised myocardial tissue and has pacemaker activity and conduction functions.
SA node on right side of SVC root, near the top of the crista terminalis and the right auricle. There are 3 internodal pathways
(anterior, middle, posterior).
Function:
Other (pathophysiological) pathways: Bundle of Kent bypasses AV node, James fibres go to Bundle of His.
AV node on right side of central fibrous body (has labyrinthine structure which delays conduction and limits number of impulses
coming through), has atrionodal, nodal and nodal-His regions. Bundle of His is inferoposterior to membranous portion of septum. left
bundle (below posterior cusp of aortic valve) has 2 branches which ramify in the muscle of left ventricle and interventricular septum.
right bundle goes under base of anterior papillary muscle of tricuspid valve (as the moderator band) and ramifies in the muscle of the
right ventricle.
<><><><><><><><><><><><>
• Atrial fibrillation;
• Heart block;
• Re-entry arrythmias, and their significance (usually ischaemic). Mention of oesophageal and intracardiac leads;
Comment: Each one needs a small description of what the abnormality looks like.
Page 51
2. It is a branching tubular structure, stiffened by small rings and plates of cartilage. Lined by pseudostratified columnar ciliated
epithelial cells with goblet and serous cells. Bronchial artery supply from aorta (and third right posterior intercostal artery), to
pulmonary and azygos veins.
3. Nerve supply from the pulmonary plexus — vagus is constrictor, adrenergic is dilator; nonadrenergic, noncholinergic (NANC)
system is bronchodilator and mucus secreting.
4. R main 15mm x 2cm from carina to intermediate bronchus. Branches — upper — APA, middle — LM, lower — AMALP. (Each
letter represents the name of a branch)
5. L main 13mm x 5cm, Branches: left upper APA (lingular SI), lower-APAL.
<><><><><><><><><><><><>
Superior laryngeal nerves — external — motor to cricothyroid; internal — sensory from mucosa above cords.
Recurrent laryngeal nerves — sensory below cords and motor to the other small muscles. They arise in the chest, curve round the
aorta and subclavian artery, and return to the neck alongside trachea and oesophagus. They enter the larynx behind the cricothyroid
joints, beneath the lower part of the pyriform recess.
First rib has upper and lower surfaces (lower surface featureless), curves downwards and forwards, sickle shaped, head articulates
with body of T1, and tubercle with transverse process, muscle insertions: scalenus anterior inserted into scalene tubercle (vein in
front, artery behind), lev. costae and serratus anterior inserted into lateral border. Function: formation of rib cage and respiration.
Relations:
• neck of rib — root of T1, vagus, phrenic nerves and sympathetic chain;
• inferiorly — first intercostal space, with intercostal muscles vessels and nerves;
• superiorly — clavicle, subclavius, the brachial plexus crosses from superomedial to inferolateral, the subclavian artery and vein
cross the medial end of the first rib and join the brachial plexus.
Page 53
Chapter 7
Trauma and Emergency Anaesthesia
Page 54
4. Drug overdose effects in general; often overdosed with other drugs and alcohol, loss of airway control, regurgitation risk, skin
necrosis, hypothermia, retention of urine.
<><><><><><><><><><><><>
A child of 12 years has been admitted following a road accident. At emergency laparotomy the surgeon announces that the
liver is ruptured. Describe your management of the case up to the end of the operation
This is severe road trauma and needs a comment about search for, and possible presence of, other injuries, especially head injury.
• circulatory support (drugs and colloids and crystalloids in severe haemorrhage), citrate problems;
• organisation of ITU;
<><><><><><><><><><><><>
Page 55
Pharmacy:
type of chemical (intravenous electrolyte solution) storage (glass or plastic) preparation, concentration (isotonic) Na+ 131; K+ 5; Cl-
111; Ca++ 2; Lactate 29; mmol/l.
Pharmacodynamics:
onset, immediate
duration, N/A
Pharmacokinetics:
excretion, kidney
<><><><><><><><><><><><>
Describe the adverse affects of blood transfusion. How may they be reduced?
1. Acute and delayed haemolytic reaction, circulatory overload, hypothermia, embolism, hyperkalaemia, citrate intoxication,
crossinfection, ARDS, immunosuppression, hypomagnesaemia, hypocalcaemia, coagulopathy.
a) Set up a good transfusion service! (the administrative side, including correct labelling is as important as the technical side);
c) Ca++ and fresh frozen plasma are given to correct coagulopathy. Platelet transfusion may be needed;
<><><><><><><><><><><><>
Page 56
4. Haemoglobin infusion with 2,3 DPG analogue (nephrotoxicity of red cell stroma).
<><><><><><><><><><><><>
What are the contents of a unit of transfusion blood? Describe briefly the alternatives which can be used in an emergency
haemorrhage situation until transfusion blood becomes available
Contents:
350 ml. blood, 150 ml. CPD adenine or SAGM. (Most is plasma-reduced and therefore low in albumin and globulins). It becomes
progressively more hyperkalaemic and acidotic during storage, with lower clotting factors and low platelets.
Alternatives:
<><><><><><><><><><><><>
Page 57
Pharmacy:
Type of chemical (high molecular weight colloids 30-70 K.Daltons) storage (glass or plastic), preparation, concentration (frequently
slightly hypertonic)
Pharmacodynamics:
Onset, immediate
Duration, hours
Pharmacokinetics:
Comment: This answer will also need details of the various types of product.
<><><><><><><><><><><><>
Describe the features of the Boyle's anaesthetic machine and Bain system which protect the patient from pulmonary
barotrauma
1. Reducing valve and flow restrictor for cylinders, needle valves on flowmeters to restrict flow, thin-walled bag, which limits
pressure rises, heidbrink valve (the pressure relief valve protects the machine, not the patient).
<><><><><><><><><><><><>
Page 58
1. Blood volume falls causing reduced venous return; reduced RA pressure, CO.
3. Baroreceptors firing reduced, leads to tachycardia, vasoconstriction, adrenaline secretion, Cortisone secretion, redistribution of CO
from skin, muscle and viscera to heart and brain. BP maintained till loss of 20% volume.
4. Atrial receptors cause ADH secretion (resulting in oliguria and water retention). Aldosterone secretion (causes Na+ retention),
thirst, endorphin secretion, water transfer from ECF to circulation, resulting in dilutional anaemia.
<><><><><><><><><><><><>
What is the physiological response to the rapid loss of 1 litre of blood in the adult?
1. General description of the clinical picture in the hypovolaemic patient with fall of cardiac output, vasoconstriction and
hypotension. Some indication of signs—reduced capillary refill, tachycardia, oliguria, distress, loss of muscle tone.
2. Compensation:
a) baroreceptors—arteriolar resistance, venoconstriction, cardiac effects (tachycardia, raised diastolic) respiratory effects
(hyperventilation);
Comment: This is similar to the previous question, and demonstrates that any subject may be asked in several different ways.
<><><><><><><><><><><><>
Page 59
3. Diastolic coronary blood flow and PaO2, supplying the substrates for muscle action.
4. Inotropic hormones, PaCO2 levels, and heart rate (especially in children)—Bowditch effect.
<><><><><><><><><><><><>
Causes:
convection: evaporation of skin prep or water vapour from exposed serous cavities during operation, especially when there is
vasodilation, loss of hypothalamic control, absent shivering response (due to anaesthesia or alcohol intoxication); dry, cold inspired
gases;
conduction of heat to cold surroundings, as when a limb is packed in snow, or a donor organ transported in melting ice;
cooling of the blood: cold IV infusions, deliberate hypothermia during cardiopulmonary bypass.
Effects:
Dysrythmias at < 31° C. Prolonged action of general anaesthetics and relaxants, slow metabolism of drugs and citrate, increased Hb
oxygen affinity, fall in CBF, reduced O2 consumption, peripheral vasoconstriction, acidosis, coagulation problems, shivering and
hypoxia on recovery.
<><><><><><><><><><><><>
Page 60
Describe the immediate rescusitation (in the first hour) of an unconscious patient admitted to the A & E department after
falling off a ladder
Primary survey—the main elements of ATLS. Airway, Breathing, Circulation—pulse, BP, capillary refill (hypotension is likely to be
due to extracranial bleeding or spinal injury); Disability of cerebrum (level of consciousness, pupils, GCS monitoring is
commenced); Exposure (other injuries).
Resuscitation.
IV access is established.
O2 is given.
Items A and B; O2, intubation (with care of cervical spine); cricoid pressure (because of the vomiting risk); note of the appropriate
anaesthetic drugs; and IPPV.
C: volume replacement as necessary with monitoring of arterial pressure, capillary refill, urine output and CVP.
Investigations: FBC, Cross-match, ABG's. Blood sample for drug levels if history indicates this.
<><><><><><><><><><><><>
Page 61
Chapter 8
Acute and Nonacute Pain Management
Page 62
1. Analgesia
2. Addiction
3. Respiratory depression
5. Bradycardia
6. Miosis
7. Sedation
8. Hallucinations
9. Bronchospasm
13. Itching
<><><><><><><><><><><><>
Pharmacy:
Type of chemical, (phenylpiperidine) storage (aqueous in glass ampoules), preparation (synthetic) concentration
Pharmacodynamics:
Clinical effects, analgesia, respiratory depression, nausea and vomiting, sedation, addiction, relaxation of smooth muscle
Dose, 1 mg/kg.
Onset, minutes
Pharmacokinetics:
Metabolism, liver
Side effects, respiratory depression, nausea and vomiting, addiction, histamine release,
Interactions, MAOI's—collapse and coma
Discuss the methods available for the relief of pain following abdominal hysterectomy
Advantages:
• Other oral analgesics: very safe but most are not so powerful.
• PCA (powerful, swift reaction to pain, patients can customise dosage to their own needs).
This answer needs a note about customising treatment for the individual patient and discussing patient preferences!
Complications:
• PCA (needs common sense, reasonably strong fingers and may cause vomiting and hallucinations. Serious overdose has occurred.).
• Epidural catheters (weak, numb legs and risk of unrecognised apnoea from opiates; and hypotension).
<><><><><><><><><><><><>
Page 64
Pharmacy:
Type of chemical (nonsteroidal anti-inflammatory drug), storage (powder or tablet), preparation, concentration
Pharmacodynamics:
Onset, minutes
Pharmacokinetics:
Metabolism, liver
<><><><><><><><><><><><>
Describe the principles involved in prevention and treatment of postherpertic neuralgia in the upper limb
Place of preventive analgesia of herpes zoster, acyclovir cream. This is neuropathic pain and is self-limiting; may be helped by
tricyclic drugs and other coanalgesics, local analgesics, capsaicin cream, IV guanethidine block.
<><><><><><><><><><><><>
Both Controlled Drugs, analgesics and constipators; but codeine doesn't sedate and has less respiratory depression by IM route. The
examiner also needs to see the usual pharmacological details e.g., using the answer format for questions which start ''Write short
notes on. . .".
<><><><><><><><><><><><>
Page 65
Describe the adverse reactions which may follow the use of non-steroidal anti-inflammatory drugs
PGE1 synthase inhibition causing (reversible) gastric irritation, renal failure, exacerbation of asthma, angioedema, rashes, water
retention, aseptic meningitis in patients with SLE, hepatic damage. Thromboxane A inhibition causes irreversible loss of the
adhesiveness of existing platelets.
<><><><><><><><><><><><>
Pharmacy:
Pharmacodynamics:
Onset, minutes
Pharmacokinetics:
Metabolism, liver
<><><><><><><><><><><><>
Page 66
Pharmacy:
Pharmacodynamics:
Onset, minutes
Pharmacokinetics:
Metabolism, liver
Side effects, respiratory depression and acute heart failure; overdose convulsions
<><><><><><><><><><><><>
Page 67
Chapter 9
Intensive Therapy
Page 68
A patient is admitted to the intensive care unit with a relapse of myasthenia gravis. How do you cope with the medical
problems of this situation?
2. Problems of inability to swallow and excessive secretion of saliva due to anticholinesterases; nasogastric tube and enteral nutrition
will be required.
3. Respiratory failure (and how it is diagnosed) would indicate intubation and IPPV, with risk of chest infections. Antibiotics may be
needed for this.
Comment: The mention of ITU indicates that this relapse is severe, and the answer should address this.
<><><><><><><><><><><><>
A patient is admitted to the intensive care unit with Guillain Barre Syndrome. How do you cope with the medical problems of
this situation?
3. Intubation and IPPV for respiratory failure, with risk of infections. Antibiotics may be needed.
<><><><><><><><><><><><>
Page 69
Why do some patients develop ARDS following colectomy? What are the pathophysiological processses?
gut wall ischaemia — endotoxinaemia — eicosanoid secretion — endothelial damage — capillary closure — tissue hypoxia and
oedema — destruction of type I cell — proliferation of type II cells — hyaline membrane formation — shunting, hypoxia —
deadspace, hypercapnia—barotrauma (due to IPPV)—lung destruction.
<><><><><><><><><><><><>
Short Term:
• bronchospasm;
• herniation of cuff;
• laryngospasm on extubation;
• sore throat;
Longer Term:
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Page 70
What is the venturi principle? Describe the clinical uses of high frequency jet ventilation
Principle:
High speed gas jet causes suction on surrounding areas with entrainment of surrounding gas.
Rates: 1-1.5 Hz. 1.5-5 Hz. 5-10 Hz. (high frequency oscillation).
Uses:
<><><><><><><><><><><><>
The subclavian is the continuation of the axillary vein, from lower border of first rib. Arches up across rib, then medial, downwards
and forwards, across scalenus anterior insertion to enter thorax, and join internal jugular vein behind sternoclavicular joint. Anterior
is clavicle, postero-laterally lies subclavian artery and pleura, posteriorly is vagus and phrenic nerves.
<><><><><><><><><><><><>
Jugular—large thin-walled vein, traverses the neck from jugular bulb to subclavian vein; in carotid sheath with artery and vagus.
From above lies posterior, then lateral, then anterior to artery. The lower part is behind sternomastoid. It lies in front of prevertebral
fascia, vertebral muscles, transverse processes, and lower down, subclavian artery, phrenic, vagus, and cupola of pleura.
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Page 71
What are the possible complications of internal jugular vein cannulation, and how do you avoid them?
Complications:
Air embolism, pneumothorax, carotid or vertebral artery puncture with cerebral damage, haematoma, sepsis, sympathetic trunk
damage, surgical emphysema.
Avoidance:
e) avoidance of unwanted damage to other structures in neck by good knowledge of anatomy and inserting needle in upper half of
neck to avoid pleura;
<><><><><><><><><><><><>
What are the possible complications of subclavian vein cannulation, and how do you avoid them?
Complications:
Air embolism, pneumothorax, artery puncture, haematoma, sepsis, thoracic duct injury on left, surgical emphysema.
Avoidance of Complications:
d) use of seldinger system and careful direction of insertion towards suprasternal notch;
e) avoidance of unwanted damage to other structures e.g., pleura by not allowing needle to go between ribs;
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Page 72
An example would be: prostacyclin (inhibits platelet aggregation, half life 3 min., infusion 2-5 µg/kg/min, side effects — pulmonary
and systemic vasodilation, bradycardia, flushing, headaches hypotension, pallor, sweating, severe anticoagulation with heparin);
thrombocytopenia.
<><><><><><><><><><><><>
List the properties of an ideal inotrope. Compare the properties of dopamine with this ideal
Effective in normal and abnormal hearts, doesn't raise myocardial VO2; raises renal and splanchnic perfusion, preventing
endotoxinaemia; no side effects, no alpha effects, no arrythmias. Dopamine comes out quite well!
<><><><><><><><><><><><>
List the factors which determine the supply of oxygen to the tissues of the body. How may these factors be altered by septic
shock?
Factors:
• O2 supply to lungs;
• capillary function;
• body temperature.
• tissue oedema;
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Page 73
Need a description of how pHi is derived and measured (catheter with a balloon, completely filled with saline. CO2 from gastric
mucosa diffuses into this, and a sample is withdrawn and measured. At the same time, serum bicarbonate is measured, and pHi
derived from the Henderson-Hasselbalch equation) and in which situations it is deranged (pHi is reduced in shock, sepsis and
hypotension).
<><><><><><><><><><><><>
• method of inserting the flotation catheter, e.g., via internal jugular line;
• pressures during insertion, in the superior vena cava, right atrium, right ventricle, and pulmonary artery;
• interpretation of readings;
<><><><><><><><><><><><>
Pharmacy:
Pharmacodynamics:
Clinical effects, at pH < 4 polymerises and adheres to ulcer craters, preventing peptic ulceration
Onset, immediate
Duration, hours
Pharmacokinetics:
Plus other features: the name means sucrose (aluminium) sulphate — it increases gastric production of mucus, and does not cause
nosocomial pneumonia.
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Page 74
Pharmacy:
Type of chemical (catecholamine), storage (aqueous solution in coloured glass ampoules), preparation, concentration
Pharmacodynamics:
Onset, immediate
Pharmacokinetics:
Metabolism, liver
<><><><><><><><><><><><>
Discuss the occurrence of metabolic acidosis in patients in the intensive care unit
1. Causes — tissue hypoxia, renal failure, insulin antagonism (with the various acids involved).
2. Prevention — The methods of preventing the above, and their considerable limitations.
<><><><><><><><><><><><>
Give a brief account of the pulmonary problems that occur during intermittent positive pressure ventilation of the lungs in
ARDS
misplacement of tracheal tube, crusting, deadspace problem due to capillary blockage, shunting problem due to hyaline membrane,
diffusion problem due to oedema, barotrauma due to hyperventilating normal lung in juxtaposition to areas of stiff diseased lung.
Secondary nosocomial infection.
<><><><><><><><><><><><>
Page 75
Pharmacy:
Pharmacodynamics:
Onset, immediate
Pharmacokinetics:
Metabolism, liver
Side effects, pulmonary and systemic vasodilation, bradycardia, flushing, headaches hypotension, pallor, sweating
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Page 77
Chapter 10
Clinical Measurement
Page 78
Hb and HbO have different absorption spectra. Light absorbed depends on their concentrations and the thickness of the medium.
(Beer-Lambert Law; there is some doubt about the relevance of this.) Comparison of absorption at different wavelengths (not
necessarily the isobestic point) gives relative concentrations of HbO and Hb, the SpO2. Infrared light from diode emitter passes
through or is reflected from skin to a photodetector. The steady (DC) component is rejected. The pulsing (AC) component is
amplified and displayed digitally or graphically. Calibration of each model (at the top end of the SpO2 scale) is done using volunteers.
<><><><><><><><><><><><>
Principle of the infrared device: two different atoms in a molecule cause infrared absorption; infrared beam splits and passes through
a reference and sample gas chambers. CO2 absorbs the infrared and emergent beams are compared by photoelectric cells. Analyser
sites may be direct (instream) or indirect via withdrawn sample.
Calibration: electronic/physical; zero = air; span — using accurately known CO2 sample from machine, cylinder or reference cell
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Page 79
• adequacy of ventilation;
• disconnection of anaesthetic system (sudden fall of CO2 to zero), emphysema, airtrapping (sloping plateau);
<><><><><><><><><><><><>
1. Sources of error: interference; mechanical (fingers too large for probe, movement artefacts), electrical, light, nail polish and dirt.
3. Methylene blue, methaemoglobin and bilirubin counted as Hb, so SpO2 falsely low. Inaccurate in presence of venous congestion
(venous pulsation) or low SpO2 (not calibrated in this range).
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Page 80
What arrangements are required for an adult head-injured patient, during transfer to a neurosurgical unit?
2. Clear notes of injuries, with investigations (e.g., X-rays), and ongoing Glasgow Coma Score chart.
5. Intubation and ventilation of patients who are comatose, depressed conscious level, or who have fitted; with added oxygen.
<><><><><><><><><><><><>
a) Normal range: (with variations erect/supine/head down; spont./IPPV; and effect of tachycardia and bradycardia);
d) Monitoring cardiac performance, esp. right side of heart, and acute left ventricular failure; note also assessment of venous waves a,
c, v.
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Page 81
Chapter 11
Regional and Local Analgesia
Page 82
Immediate: inappropriate dosage causing total spinal; hypotension, respiratory depression, apnoea; bradycardia; intravascular
injection of local anaesthetic; headache, itching, incontinence, retention of urine, paralysis of legs preventing ambulation.
Later complications: arachnoiditiis, meningitis, backache, epidural haematoma and abscess; neurological damage from inadvertent
injection of toxins; spinal artery syndrome; foreign body left in dural space.
Comment: There is still a widespread misconception that spinals are always safe!
<><><><><><><><><><><><>
Pharmacy:
Type of chemical (catecholamine), storage (aqueous solution in glass ampoules), concentration (30mg/ml.).
Pharmacodynamics:
Onset, seconds
Pharmacokinetics:
Metabolism, liver
<><><><><><><><><><><><>
Page 83
• Inadvertent spinal or total spinal. Subdural injection, with effects similar to total spinal.
a) cardiovascular; low arterial pressure; low cardiac output; low systemic vascular resistance; bradycardia
• Backache.
• Abducens palsy.
• Neurological damage, spinal artery syndrome, arachnoiditis, radiculitis, sepsis (meningitis or abscess).
Comment: It is difficult to know where to stop with this list! These are only the main complications.
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Page 84
What are the advantages and disadvantages of the local anaesthetic and epidural anaesthetic techniques for the repair of an
inguinal hernia?
Ilioinguinal
Advantages:
• simple;
• no hypotension;
• conscious;
• no IPPV;
Disadvantages:
Epidural
Advantages:
Disadvantages:
• hypotension;
• hypovolaemia;
• backache;
• infection;
• drug toxicity;
• total spinal;
• haematoma;
Pharmacy:
Pharmacodynamics:
Onset, minutes
Pharmacokinetics:
Excretion, kidney
<><><><><><><><><><><><>
Page 86
What factors would influence your decision to choose a regional technique in preference to a general anaesthetic for
transurethral resection of the prostate?
Patient preference in favour of RA, COAD, good postoperative analgesia; reduction of haemorrhage due to parasympathetic
blockade.
Contraindications of RA:
Patient preference against RA, uncooperative patient, untreated hypertension, ischaemic heart disease, fixed cardiac output, physical
abnormalities (spinal deformity), local sepsis, disorders of haemostasis, e.g., anticoagulants.
• Avoidance of respiratory depression in the obese and in respiratory failure; easier recognition of TURP syndrome, less bleeding,
easier recovery as patient is fully awake.
• Immediate: inappropriate dosage causing total spinal; hypotension, respiratory depression, apnoea, bradycardia, intravascular
injection of local anaesthetic, headache itching, incontinence, retention of urine, paralysis of legs preventing ambulation.
• Later complications: arachnoiditis, meningitis, backache, epidural haematoma and abscess; neurological damage from inadvertent
injection of toxins; spinal artery syndrome; foreign body left in dural space.
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Page 87
Pharmacy:
Pharmacodynamics:
Onset, minutes
Pharmacokinetics:
Metabolism, liver
Excretion, kidney
Side effects, overdose causes unconsciousness, with loss of airway control, and hypoxia
<><><><><><><><><><><><>
What factors influence the choice of anaesthetic for insertion of arteriovenous shunt for haemodialysis?
The effect of general anaesthetics on renal function (risks of hypoxia and hypotension; the effect of NSAIDS on renal function).
• anaemia;
• hyperkalaemia (suxamethonium, cardiac arrythmias — not a problem if patient has been dialysed very recently);
Thus regional blocks are ideal, for example plexus block may dilate blood vessels and make the operation easier; and they avoid the
problems of general anaesthetics, but some patients may prefer general anaesthesia in addition. Furthermore, brachial plexus block
would be contraindicated if the patient were anticoagulated.
Comment: There is no right or wrong technique here, there are merely advantages and disadvantages.
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Page 88
Pharmacy:
Type of chemical, (oxymorphone derivative), storage (aqueous solution in glass ampoules), preparation, concentration
Pharmacodynamics:
Mode of action, opiate antagonist with receptor affinity but no receptor stimulation
Clinical effects, reversal of respiratory depression caused by natural and synthetic opioids
Dose, 7 µg/kg.
Onset, rapid
Pharmacokinetics:
Metabolism, liver
<><><><><><><><><><><><>
Effects:
Treatment:
Oxygen, IPPV, ACLS for cardiac arrest; diazepam, anticonvulsants. Careful volume loading, needs mention of dangers of inotropes
in worsening of arrythmias, and dangers of some anticonvulsants, e.g., thiopentone in worsening of cardiac failure.
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Page 89
What are the advantages and disadvantages of the supraclavicular and axillary approaches to the brachial plexus block
Supraclavicular:
Advantages:
Disadvantages:
pneumothorax risk, vessel damage (inc. thoracic duct); risk of intravascular injection; location of plexus may be difficult.
Axillary:
Advantages:
Disadvantages:
inadequate block above elbow unless large volumes of analgesic are used; vessel damage; axillary skin may be infected; risk of
intravascular injection.
Comment: An easy question for those who have performed these blocks!
<><><><><><><><><><><><>
Pharmacy:
Pharmacodynamics:
Clinical effects, rise of pulse rate and atrerial pressure, redistribution of circulation, dilate bronchus and pupil raise central excitatory
state, quieten gut
Dose, 0.1 mg for anaphylaxis; 1mg for CPR; 1/200,000 vasoconstrictor for local anaesthetics
Onset, rapid
Duration, 10 mins
Pharmacokinetics:
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Page 90
What is the place of local analgesic nerve blocks in the anaesthetic technique for cholecystectomy (excluding ''spinal" and
extradural techniques)? State briefly how they are performed. What are their shortcomings? What are their risks?
Place: very helpful for supplementary and postoperative analgesia, using long-acting agents.
Shortcomings: Note that these blocks by themselves are inadequate for surgery, because the gall bladder is often innervated by vagus
and/or phrenic nerves.
Performance: Clean skin first, have i.v. access and available resuscitation equipment.
Subcostal block: infiltrate subcostal area of abdominal wall in both subcutaneous and muscle layers, with local analgesic.
Intrapleural block: insert i.v. or special cannula into pleural space at angle of rib, taking care to avoid pneumothorax and intercostal
artery puncture.
Risk: pneumothorax, and volumes of local analgesic required are close to toxic doses.
Intercostal block: short bevel needle inserted just below rib, posterior to angle, into subcostal groove.
Risk: haematoma and pneumothorax. The problem of overlap of innervation from adjacent intercostal nerves is solved by blocking
multiple spaces.
Comment: There is a great risk of over-running your allotted time. Keep this answer in note form.
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Page 91
Give a brief description of the sensory nerve supply of the thoracic cage and abdominal wall
The thoracic intercostal nerves T1-T12; each one has sensory input to dorsal horn; these nerves cross intra- and extradural spaces,
and traverse intervertebral foramina, T1 goes via brachial plexus, other anterior divisions travel in subcostal grooves. Cutaneous
branch given off in midaxillary line; intramuscular branch continues, both cross the costal cartilages, and enter abdominal wall (in
subcutaneous and intramuscular layers respectively), and proceed to midline, where intramuscular branch surfaces. T4 to sternum,
T10 to umbilicus. Lumbar nerve of L1 supplies inguinal region, scrotum and labia.
<><><><><><><><><><><><>
Pharmacy:
Type of chemical (amide), storage (aqueous solution in glass ampoules), concentration (0.5-1%).
Pharmacodynamics:
Dose, 0.5-1%
Onset, 20 mins.
Pharmacokinetics:
Metabolism, liver
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Page 92
Relations:
Transverse processes of C5-T1; scalenus anterior and medius, whose fascia helps to form its sheath.
In the posterior triangle of the neck, it lies on the upper surface of the first rib. Under the clavicle and subclavius it joins the
subclavian vessels, and lies on the second rib and first intercostal space, which separate it from the pleura. The shoulder joint and
humerus lie laterally as it traverses the axilla.
Comment: It is a great help to have thought this answer out before meeting it in an examination!
<><><><><><><><><><><><>
What are the complications of the supraclavicular and axillary brachial plexus blocks and how do you recognise them?
1. Nerve damage (pain on injection, involuntary movement of arm, failure to recover function after block wears off).
2. Vessel damage (intravascular injection, with immediate toxic effects; later, haematoma and ensuing thrombosis).
3. Pleural damage with pneumothorax (cough, collapse, cyanosis, hypoxia, seen on chest X-ray).
Comment: Extra marks for identifying major and minor complications and their frequency.
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Page 93
Extends from the lower border of L5 to sacral hiatus, S4-5; bounded posteriorly by fused laminae, anteriorly by fused vertebral
bodies, laterally by pedicles and sacral intervertebral foraminae. It is lined with periosteum. Contents—fat, cauda equina with pia
mater, filum terminale, veins, lymphatics and minor arteries, dura (to lower border of S1 or upper border of S2 (S3 in small children).
<><><><><><><><><><><><>
Describe the anatomy of the epidural space at the level of the fourth lumbar vertebra
A canal formed anteriorly by body of vertebra and discs; posteriorly by neural arch (laminae), laterally by pedicles with neural
foraminae. Lined by periosteum with posterior longitudinal ligament anteriorly, ligamentum flavum posteriorly.
Traversed by dural sac—dura and arachnoid maters, subarachnoid space and CSF. This is traversed by cauda equina with pia mater
(cord ends at L2), and filum terminale.
<><><><><><><><><><><><>
Page 95
Chapter 12
Medicine and Surgery Related to Anaesthesia
Page 96
What precautions should you take when anaesthetising a patient known to have suffered from viral hepatitis?
1. Protect staff and other patients—assessment of infectivity of patient (HBAge, Hepatitis A, Hepatitis C and other infective
diseases), information to all staff, use of disposable equipment and safe disposal. Use of gloves etc., practice of correct "sharps drill".
Check Hepatitis B immunisation status of all staff.
2. Protect patient—liver function tests to assess hepatic reserve, and appropriate care with dosages of drugs.
Comment: It would be difficult to know how much detail to give in this answer. This would have to be dictated by the time available.
<><><><><><><><><><><><>
Pharmacy:
Pharmacodynamics:
Mode of action, Ca++ channel blocker, mainly slow channel cardiac effects
Clinical effects, class 4 antiarrythmic; increases refractory period, reduces excitability and dilates arterioles
Onset, minutes
Duration, hours
Pharmacokinetics:
<><><><><><><><><><><><>
Page 97
How would you manage atrial fibrillation which occurs during anaesthesia? What could be done to prevent it?
1. Management:
b) Use of DC shock (bonus marks for management of this during regional analgesia);
f) need for notes about the care of resulting cardiac failure and embolism problems.
2. Prevention:
a) recognition of the at-risk patients (thyrotoxicosis/myocardial ischaemia/ mitral stenosis/previous atrial fibrillation/Sick sinus
syndrome/elderly with hypokalaemia). Preoperative ECG is essential for this;
<><><><><><><><><><><><>
1. Diagnosis:
The answer needs comments about when this is likely to confront the anaesthetist, and the difficulty of locating the side.
a) symptoms: pain, dyspnoea, cyanosis, cardiovascular collapse, especially in tension pneumothorax or bilateral pneumothorax;
2. Treatment:
This may be a major life-threatening emergency. IPPV may make the condition worse! Need for (i.v.) cannula in third ribspace
anteriorly, and chest drain techniques, after which IPPV will be safer.
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Page 98
Pharmacy:
Type of chemical, storage (aqueous solution in glass ampoules and plastic bags), preparation, concentration (2 mg or 20 mg/ml.)
Pharmacodynamics:
Onset, minutes
Duration, 1 hour
Pharmacokinetics:
Metabolism, liver
<><><><><><><><><><><><>
Pharmacy:
Pharmacodynamics:
Onset, rapid
Pharmacokinetics:
<><><><><><><><><><><><>
Page 99
What problems does hiatus hernia pose for the anaesthetised patient and how do you cope with them?
1. Regurgitation and aspiration of highly acidic juice causes pulmonary airways burn; if this occurs, it is managed by tracheal
washout, IPPV, possibly steroids and antibiotics.
4. Managed by premedication with H2 antagonist and metoclopramide. Cricoid pressure is needed during induction, with tracheal
intubation to protect lungs.
<><><><><><><><><><><><>
What is the relevance to anaesthetic management of ankylosing spondylitis? What strategies would you employ to overcome
them?
Problems:
Stiff neck and jaw—intubation difficulty; reduced pulmonary function needs assessment, esp. if kyphotic.
Strategies:
1. Use of regional blocks; spinal blocks are desirable but difficult!—spinal X -ray is needed.
2. Elective fibreoptic intubation or tracheostomy may be needed if general anaesthesia is unavoidable, especially if there is:
a) known history of difficult intubation—Cormack & Lehane scores from previous laryngoscopies;
f) neck stiffness (you would need to mention neck X-rays here). This is perhaps the most critical of these features.
<><><><><><><><><><><><>
Page 100
Pharmacy:
Pharmacodynamics:
Dose, 10 mg.
Onset, minutes
Pharmacokinetics:
<><><><><><><><><><><><>
How does the presence of aortic stenosis affect the management of an anaesthetic?
Fixed cardiac output, with risk of severe hypotension on induction; vasodilation is to be avoided. Coronary flow reduced, risk of
endocarditis (need for antibiotic cover) and subendocardial ischaemia if inotropes are given in large dosage. (Bonus marks for stating
that HOCM is worsened by inotropes).
Comment: It is particularly important to mention that coronary flow is dependent on diastolic pressure, and that tachycardia is to be
avoided as it shortens diastolic interval.
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Page 101
What would happen if a full dose of thiopentone was given to a patient with acute intermittent porphyria and why?
Thiopentone stimulates hepatic delta ALA synthase, giving excess porphyrins, causing:
d) red urine.
Neuropathy may last for weeks, needing IPPV, and intensive care.
<><><><><><><><><><><><>
<><><><><><><><><><><><>
Page 102
1. Resistance to sedatives.
4. Associated ASD and VSD, with risk of intracardiac shunting and endocarditis (need for antibiotics).
6. Communication problems resulting in fear and failure to comply with instructions (rapport with parents essential).
<><><><><><><><><><><><>
What precautions should be taken when anaesthetising a patient with dystrophia myotonica?
3. Prevention of cardiovascular depression and dysrhythmias by being sparing with volatile agents.
10. Preparedness for these patients to be very heavy for their age.
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Page 103
How do the intraoperative surgical complications of excision of thyroid goitre affect the management of the anaesthetic?
1. Stimulation of carotid baroreceptors by surgical manipulations may destabilise arterial pressure. Surgery may cause haemorrhage,
pneumothorax; splitting of sternum would require IPPV; recurrent laryngeal palsy and external laryngeal palsy may cause
postoperative airway obstruction; concomitant parathyroidectomy may cause early postoperative tetany.
2. Damage to the trachea (including tracheomalacia) may occur with postoperative airway obstruction.
<><><><><><><><><><><><>
1. Preoperative unstable arterial pressure requiring alpha and (later) beta blockade with restoration of circulating blood volume.
<><><><><><><><><><><><>
Page 104
What are the anaesthetic problems posed by surgical removal of a parathyroid adenoma and how do you cope with them?
1. Excessively high Ca++ would pose a risk of serious arrythmias (may need emergency lowering of Ca++, antiarrythmic drugs and K+
infusion).
3. Air embolus (prevention by avoiding too steep head-up tilt, treatment by turning patient on side and evacuation by central line).
6. Postoperative tetany requiring Calcium injection (needs details of preparations and doses).
<><><><><><><><><><><><>
What are the complications of mitral valve disease during anaesthesia and how do you prevent them?
1. Fixed cardiac output, with risk of serious vascular instability (avoidance of cardiac depression, vasodilation and tachycardia).
2. Acute left ventricular failure, with pulmonary oedema, requiring diuresis with frusemide.
4. Atrial fibrillation (requiring control of rate and treatment of left ventricular failure). This may cause:
<><><><><><><><><><><><>
Page 105
A patient's arterial pressure on admission for moderately urgent appendicectomy is 170/115 mmHg. Describe your
anaesthetic management
The anaesthetist checks it for himself! (It can be due to pain, a full bladder, and the answer requires a brief discussion of hypertension
due to fear.)
a) generalised vascular disease, possible renal and other rare causes of hypertension (e.g., phaeochromocytoma);
b) is the patient's abdominal pain due to another, medical, cause? Could it be angina due to hypertensive crisis?
Management:
Prevention of risks;
• myocardial infarction;
• cerebral haemorrhage;
• ECG required;
• this diastolic pressure is too high for safety. The operation is postponed for emergency medical treatment, involving relevant
specialists.
Relevant Drugs:
• nifedipine;
• beta blockers;
• ACE inhibitors;
• Ca channel blockers;
Antibiotics are required to cope with a short period of postponement of operation. Spinal anaesthesia not advisable because of
cardiovascular instability.
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Page 106
A patient with congestive cardiac failure presents for hip replacement. Describe your management for the anaesthetic
Problems:
1. The implication is that the patient has serious cardiac and possibly other organ disease, and requires full investigation, e.g., by
ECG, echocardiography and relevant blood tests.
3. uncontrolled vasodilation from cement are the notable risk points, with the emphasis on prevention.
4. Haemorrhage may be considerable with need for accurate volume replacement with monitoring.
<><><><><><><><><><><><>
A patient presenting for prostatectomy has a pulse rate of 39 beats per minute. Describe the common causes and
management of this
This answer needs a comment on what pulse rates are acceptable and what the target pulse rate would be.
Causes:
2. Treatment with beta blockers (reduce the dose and/or use other drugs; premedicate with anticholinergics).
3. Sick sinus syndrome (common in this patient population with risk of atrial fibrillation, supraventricular tachycardia, ventricular
tachycardia and ventricular fibrillation).
ECG and full drug history is essential (esp. beta blockade). Specialist medical advice is helpful. Operation will need to be postponed
until the pulse rate is normal.
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Page 107
1. A genuine cold presents a risk of postoperative chest infection, which depends on severity of cold and need for intubation.
This answer requires a brief discussion about difficulty in diagnosis because of fast onset of colds in children, and differentiation
from teething, and blocked nose due to adenoid hypertrophy—the presence of pyrexia is a useful sign.
Tonsillectomy during a cold may cause marked haemorrhage and local infection.
<><><><><><><><><><><><>
Causes: ischaemia, rheumatic heart disease, thyrotoxicosis; triggers: hypotension and hypokalaemia.
Diagnosis: irregularly irregular pulse (including deficit), and cannon waves. The ECG makes the diagnosis. The answer needs a
comment on the significance of uncontrolled rate.
Complications: poor cardiac output, left ventricular failure, emboli (requiring anticoagulation).
Treatment: need to mention adenosine, DC shock, amiodarone, digoxin, and the indications for anticoagulation.
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Page 108
How do you judge the significance and plan the management of preoperative anaemia?
Significance: What has caused it? How severe is it? (When the Hb is below 10g/dl. it will cause reduced oxygen carriage). Is it acute
or chronic (with compensation by raised 2.3 DPG)?
Does the patient have chronic renal failure (high blood urea and creatinine)/ carcinomatosis (skeletal X-ray survey)/leukaemia (blood
film)/malnutrition (red cell volume)/coagulopathy (coagulation profile, drug history)/chronic bloodloss from gut, bladder or uterus
(microcytosis)/aspirin or NSAID usage? There will be reduced O2 flux and possibly high output cardiac failure if severe.
Investigations: The medical history will have indicated which lines should be further investigated.
a) how severe;
b) how acute the anaemia is and whether it is ''renal" (accept Hb of 7-8g/dl); and how urgent surgery is (emergency indicates
transfusion, and possibly urgent need to stop cause of bleeding if possible).
The non-urgent situation calls for discussion of Fe++ therapy, erythropoeitin, and correction of haemostasis factor levels.
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Page 109
A patient with non-insulin-dependent diabetes is to undergo amputation of an infected gangrenous leg. What is the correct
peri-operative management of the diabetes?
b) Involvement of diabetologist.
c) Assessment of current biochemical status plus awareness of possible loss of control due to gangrene—danger of hyper- and
hypoglycaemia—requiring assessment of blood glucose, electrolytes, hydration status (Hartmann's solution is avoided because of
lactate load).
d) Preoperative management—antibiotics, rehydration urine output, hourly blood glucose and electrolyte monitoring, insulin
prescription (sliding scale/Alberti regime: K+, insulin, glucose infusion).
e) Operative management—maintain diabetic regime, monitor blood sugar (intervals of 1 hour on average).
f) Postoperative management—Awareness of rapid improvement in diabetes, use of sliding scale, timing of return to preoperative
regime.
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Causes:
Is there infective hepatitis?—need to test for HBAge, Hepatitis A, Hepatitis C, and enquire about malaria, glandular fever. Would
there be a crossinfection risk for staff?
Is it due to; drugs (paracetamol, halothane), with risk of fulminating hepatic failure (what is the drug history?); gallstones; Gilbert's
syndrome; haemolysis; cirrhosis; Ca pancreas; pancreatitis (Serum amylase and blood glucose levels are required)?
Effects:
Has it affected blood coagulation, and therefore jeopardise haemostasis? Is there hepatic failure (function tests needed)? Is there
concomitant renal failure (electrolyte tests)?
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1. They reduce raised arterial pressure (this needs a little discussion of the limits, and target pressures at different ages).
2. They commonly vasodilate the patient, which requires care in the use of vasodilating anaesthetics.
3. They commonly increase circulating volume, which is a safety factor, and the indication for continuing medication through the
perioperative period.
4. Beta blockers may limit changes of cardiac rate and output and cause severe bradycardia.
5. Some cause renal failure in certain situations, with problems of anaemia, hyperkalaemia, acidosis and prolongation of relaxants.
7. Thiazides lower the serum K+, prolonging and potentiating nondepolarising relaxants.
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What are the functions of the thyroid gland and how are they controlled? What are the effects of thyroid dysfunction on
anaesthesia?
Functions: production of thyroxine and T3 to control metabolic rate, growth, cerebral activity. They interact with other hormones.
Effect of Dysfunction:
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In what circumstances may fluid overload occur during operation? How is it diagnosed and managed?
4. Where the patient has inappropriate ADH secretion, renal failure, acute left ventricular failure.
Diagnosis: onset of hypoxia, rise of ventilation pressures, auscultation of crepitations in the lungs, froth in tracheal tube.
Management: diuretics, treatment of acute heart failure, oxygenation, fluid restriction, triple strength albumin if appropriate.
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Name and define the different types of hypoxia. Where are they seen clinically?
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• Isoflurane — vasodilation
• Propofol — vasodilation
• Desflurane — vasodilation
• GTN — vasodilation
• Septic shock syndrome — negative inotropy, pulmonary vasoconstriction, opening of A-V anastomoses
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Describe all the clinical actions of one anaesthetic agent and two other drugs you might use to lower arterial pressure during
anaesthesia
Many drugs can do this, e.g., halothane, enflurane, isoflurane, desflurane, alpha and beta blockers, ganglion blockers, direct
vasodilators (SNP and nitrates), hydrallazine clonidine.
Comment: Space forbids a full treatment of all the possibilities for this answer. The pharmacodynamics and side-effects should all be
mentioned as in the answers to the "Write short notes on. . ." questions).
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Pharmacy
Pharmacodynamics:
Mode of action, a K+ channel blocker which uncouples beta receptors from the regulatory unit of the adenylate cyclase complex
Onset, rapid
Duration, months
Pharmacokinetics:
Side effects, mild negative inotrope; microdeposits of drug in cornea; pulmonary interstitial infilatration.
Plus other features: affects thyroid function; avoid in porphyria, contains iodine.
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Pharmacy:
Pharmacodynamics:
Clinical effects, negative chronotropy on sinus node, negative dromotropy on atrioventricular node; termination of supraventricular
tachycardias
Dose, 3 mg.
Duration, 1 minute
Pharmacokinetics:
Plus other features: avoid in sick sinus syndrome, heart block, and asthma
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Chapter 13
Faciomaxillary, Ophthalmic and ENT
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What complications of operations on the bony structures of the lower half of the face may affect the anaesthetic management,
and how do you deal with them?
2. Interference with tracheal tube, the nasal route may be preferable, and armoured tube may be required.
3. Massive haemorrhage, requiring massive crossmatch and massive transfusion, with CVP monitoring.
5. Postoperative vomiting problems when the jaws have been wired together, requiring antiemetics, awake extubation and strategy
for emergency unwiring.
Comment: This is another example of demonstrating your skills in an important clinical scenario.
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A patient requires an anaesthetic for removal of an infected molar tooth which is causing severe trismus. Describe the
problems and outline the anaesthetic methods
1. Problems — woody swelling in pharynx, unable to open mouth, severe local infection and toxaemia, pus in pharynx. Local
anaesthesia is unhelpful. Relaxants will not usually relax trismus, because the spasm arises in the muscles of mastication themselves.
2. The airway should be secured, and needs a brief discussion of four methods: General anaesthesia; awake fibreoptic intubation;
blind nasal (not easy because of swollen tissues); tracheostomy (difficult if the neck is also swollen); induction of general
anaesthesia: the safest is inhalation induction, using high O2, spontaneous breathing, e.g., with halothane or sevoflurane; not IV
induction.
3. Trismus relaxes under general anaesthesia and cords may be visualised in the usual way. There is still the problem that pus may be
in the pharynx.
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Describe the anaesthetic management for a patient with a perforating eye injury who had a large meal in the last hour
3. The use of intubation is controversial as it also raises intraocular pressure. Opiates are important here.
4. If intubation is essential, cricoid pressure is required, and a very careful laryngeal spray with lignocaine.
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Describe the anaesthetic management for a 5-year-old patient who requires reoperation for haemorrhage an hour after
tonsillectomy
1. Assessment and resuscitation: intravenous infusion of colloids and blood until the patient is clinically not shocked (details needed).
Oxygen is required.
2. Premedication: not usually required for tonsillar haemorrhage in the first six hours after operation.
3. Induction of anaesthesia: rapid sequence induction with cricoid pressure and intubation.
4. Maintenance of anaesthesia: light anaesthetic, a nasogastric tube is passed and the stomach emptied.
5. Postoperative care: further assessment of shock, anaemia, and analgesia. Oxygen is required.
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2. Operative: availability of resuscitation equipment, i.v. access, clean skin. Full monitoring is applied.
3. Short-bevel needle is inserted below mid point of zygoma, above mandible, and advanced towards contralateral eyeball until it
meets pterygoid plate. It is then angled upwards and forwards and advanced 1 cm. to enter the pterygomaxillary fissure, close to the
maxillary nerve. Aspiration is performed:
c) air is aspirated — withdraw needle 0.5-1cm — the tip is in the nasal cavity!
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NOTES