Sunteți pe pagina 1din 1064

HUGE RESOURCE OF ANAESTHESIA TESTS AND EXAMINATION QUESTIONS

From the Internet (www.manbit.com, www.anaesthesiauk.com)

2005 Pcs, Hungary


For every person who wants to pass..

Contents:

TESTS 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, ANATOMY ANAESTHESIA MONITORING CARDIORESPIRATORY PHYSIOLOGY CLINICAL INVESTIGATION GENERAL ANAESTHESIA OPIATES AND OTHERS MEDICINE ECHOCARDIOGRAPHY OBSTETRIC ANAESTHESIA PEDIATRIC ANAESTHESIA PERFUSION PHARMACOLOGY OTHER PHYSIOLOGY REGIONAL AND SPECIALTY RELAXANT AND LOCAL ANAESTHETICS RENAL AND NEUROPHYSIOLOGY STATISTICS SURGERY TRAUMA TRIVIAL PURSUITS X-RAY ECG GENERAL PRIMARY MCQS MCQS A-K MCQ PAPERS PHYSIOLOGY MCQS PHARMACOLOGY MCQS pgs :3-66 pgs: 66-129 pgs: 130-160 pgs: 160-173 pgs: 174-260 pgs. 260-309 pgs: 309-395 pgs: 396-401 pgs: 402-426 pgs: 426-450 pgs: 450-471 pgs: 471-492 pgs: 492-499 pgs: 499-564 pgs: 564-595 pgs: 595-607 pgs: 607-617 pgs: 617-642 pgs: 642-660 pgs: 661-677 pgs: 677-689 pgs: 690-706 pgs: 707-776 pgs: 776-859 pgs: 859-900 pgs: 901-922 pgs: 922-937

ORAL QUESTIONS 28, 29, OSCE AND VIVA QUESTIONS FINAL FRCA QUESTIONS pgs: 937-1020 pgs: 1020-1064

ANATOMY TESTS Number: 84 In adults, the angle at which the right main bronchus leaves the carina is: A. 15 degrees. B. 20 degrees. C. 25 degrees. D. 30 degrees. E. 35 degrees. Select the single best answer ABCDE Correct Answer: C In adults, the angle between the left and right main bronchi and the midline are 45 and 25 degrees respectively. In infants, these are 47 and 30 degrees. LATTO, I.P & ROSEN, M. (EDS); Difficulties in Tracheal Intubation, Balliere Tindall, pp 910. Number: 134 Which of the following are true of a cervical rib? A. It occurs commonly. B. It is apparent on palpation in the supraclavicular region. C. It originates from the 7th cervical vertebra. D. It commonly causes compression of the subclavian artery and brachial plexus. E. All of the above. Select the single best answer ABCDE Correct Answer: C In 0.5-1% of individuals, the costal elements of the 7th cervical vertebra form projections called cervical ribs. Commonly they have a head, neck, and tubercle, with varying amounts of body. They extend into the posterior triangle of the neck where they may be free anteriorly, or be attached to the first rib and/or sternum. Usually these ribs cause no symptoms, and are diagnosed after incidental finding on CXR. In some cases, the subclavian artery and the lower trunk of the brachial plexus are kinked where they pass over the cervical rib. Compression of these structures between this extra rib and the anterior scalene muscle may produce symptoms of nerve and arterial compression, producing the "neurovascular compression syndrome".

Often the tingling, numbness, and impaired circulation to the upper limb do not appear until the age of puberty when the neck elongates and the shoulders tend to droop slightly. MOORE, K.L.; Clinically Oriented Anatomy, Williams and Wilkins, 1980, pp 701. Number: 135 With respect to the intercostal nerves: 1. They represent the dorsal rami of the thoracic spinal nerves. 2. The twelfth intercostal nerve is also known as the subcostal nerve. 3. Anteriorly they run in the costal groove on the upper margin of the rib. 4. Each is connected to a ganglion of the sympathetic trunk. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: C The intercostal nerves represent the ventral rami of the first 11 thoracic spinal nerves. The twelfth, being below the 12th rib is subcostal, hence is called the subcostal nerve. Each intercostal nerve is connected to a ganglion of the sympathetic trunk by rami communicantes to and from which it carries preganglionic and postganglionic fibres which innervate blood vessels, sweat glands, and muscles. The 3rd to 6th intercostal nerves behave typically. A typical nerve enters the intercostal space between the parietal pleura and internal intercostal membrane and muscle. At first it runs along the middle of the intercostal space, then at the angle of the rib, it passes between the internal and innermost intercostal muscles (which begins here). Here it enters the costal groove on the inferior margin of the rib, where it runs with the intercostal vessels. It continues forward giving off several branches and terminates about 1 cm from the sternum as an anterior cutaneous branch. The branches comprise: (1) A collateral branch which arises near the angle of the rib and runs along the upper margin of the rib below to supply the intercostal muscles. (2) A lateral cutaneous branch which arises beyond the angle of the rib and pierces the internal and external intercostal muscles about halfway around the thorax. The cutaneous branches divide into anterior and posterior branches which supply the skin of the thoracic and abdominal walls. (3) Muscular branches supply the subcostal, transversus thoracis, levator costae, and serratus posterior muscles. Note that the intercostal nerves do not supply the muscles connecting the pectoral muscles, trapezius, lattisimus dorsi, rhomboids, or levator scapulae. These muscles are supplied by the accessory nerve and the cervical and brachial plexuses.

The other intercostal nerves have some individual characteristics. (1)The first intercostal nerve usually has no lateral cutaneous branch. It divides into a large upper and small lower part. The upper part joins the brachial plexus; the lower part becomes the 1st intercostal nerve. (2) The second intercostal nerve may also contribute a small branch to the brachial plexus. Its lateral cutaneous branch is called the intercostobrachial nerve which supplies sensory innervation to the floor of the axilla and communicates with the medial cutaneous nerve of the arm to supply the medial aspect of the arm as far as the elbow. (3) The 7th to 11th intercostal nerves supply the abdominal as well as the thoracic wall. References MOORE, K.L.; Clinically Oriented Anatomy, Williams and Wilkins, 1980, pp 29-30. Number: 136 The musculocutaneous nerve: A. Is a branch of the lateral cord of the brachial plexus. B. Leaves the plexus at the point at which it crosses the first rib. C. Receives fibres from the 8th cervical spinal root. D. Only contains sensory fibres. E. None of the above. Select the single best answer ABCDE Correct Answer: A The musculocutaneous nerve is the major terminal branch of the lateral cord of the brachial plexus. The lateral cord contains fibres from the superior and middle trunks which represent the spinal roots of the 5th to 7th cervical vertebrae. It leaves the plexus as the cords give off their branches to the major nerves of the arm. The cords correspond to the point at which the plexus emerges from behind the clavicle. It courses the axilla in the coracobrachialis muscle, and then descends obliquely and laterally between the biceps and brachialis muscles, sending motor fibres to all of these. It terminates in the forearm as the lateral antebrachial cutaneous nerve supplying sensation to the lateral aspect of the forearm. WINNIE, A.P.; Plexus Anesthesia, vol 1, Churchill Livingstone, 1984, p 224 & pp 16-28. Number: 137 Which of the following are branches of the brachial plexus? 1. Lateral pectoral nerve. 2. Medial pectoral nerve. 3. Medial brachial cutaneous nerve. 4. The intercostobrachial nerve.

A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: A The intercostobrachial nerve represents the lateral cutaneous branch of the second intercostal nerve. It forms a loop and runs with the medial brachial cutaneous nerve, together supplying sensory innervation of the medial aspect of the arm as far as the elbow. All the others represent infraclavicular branches of the brachial plexus. WINNIE, A.P.; Plexus Anesthesia, vol 1, Churchill Livingstone, 1984, pp 19-42.

Which of the following structures accompany the median nerve in the carpal tunnel? A. Flexor carpi ulnaris. B. Flexor digitorum profundis. C. The ulnar artery. D. All of the above. E. None of the above. Select the single best answer ABCDE Correct Answer: B The carpal tunnel is an osseofibrous tunnel formed by the flexor retinaculum in the wrist. The median nerve and tendons of the long flexor muscles of the digits pass through it. MOORE, K.L.; Clinically Oriented Anatomy, Williams and Wilkins, 1980, p 767. Number: 139 Transection of the facial nerve as it passes through the facial canal will be evidenced by: 1. Inability to wink the eye. 2. Inability to whistle. 3. Dribbling. 4. Inability to raise the eyebrows.

A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: A All the muscles of facial expression are supplied by the facial nerve. The frontalis is part of the a scalp muscle called the occipito-frontalis. It elevates the eyebrows. This muscle receives part of its innervation from the contralateral motor cortex and preservation of this manoeuvre in the presence of ipsilateral facial weakness is suggestive of an upper motor neuron lesion occurring in the motor cortex or internal capsule, before the contralateral fibres join the ipsilateral fibres and become the facial nerve. The facial nerve also innervates the buccinator, hence difficulty chewing, whistling, and withholding dribble may occur. MOORE, K.L.; Clinically Oriented Anatomy, Williams and Wilkins, 1980, pp 878-82. Number: 139 Transection of the facial nerve as it passes through the facial canal will be evidenced by: 1. Inability to wink the eye. 2. Inability to whistle. 3. Dribbling. 4. Inability to raise the eyebrows. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: A All the muscles of facial expression are supplied by the facial nerve. The frontalis is part of the a scalp muscle called the occipito-frontalis. It elevates the eyebrows. This muscle receives part of its innervation from the contralateral motor cortex and preservation of this manoeuvre in the presence of ipsilateral facial weakness is suggestive of an upper motor neuron lesion occurring in the motor cortex or internal capsule, before the contralateral fibres join the ipsilateral fibres and become the facial nerve. The facial nerve also innervates the buccinator, hence difficulty chewing, whistling, and withholding dribble may occur.

MOORE, K.L.; Clinically Oriented Anatomy, Williams and Wilkins, 1980, pp 878-82. Number: 141 Which of the following structures pass through the foramen magnum? 1. The vertebral arteries. 2. The glossopharyngeal nerves. 3. Spinal arteries supplying the upper portion of the spinal cord. 4. The vagi. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: B The structures passing through the foramen magnum are: (1)The spinal cord- the junction of the spinal cord and medulla of the brainstem. (2)The spinal roots of the accessory nerves (cranial nerves IX) (3)The meningeal branches of the upper cervical nerves (C1to C3) (4)The meninges (5)The vertebral arteries ascending to supply parts of the brain (6)The anterior and posterior spinal arteries descending to supply the upper part of the spinal cord. Four other foramina exist in the posterior cranial fossa. These are the jugular foramen, the hypoglossal canal, the condylar canal, and the internal acoustic meatus. The contents of the jugular foramen are: (1)The superior bulb of the internal jugular vein. The sigmoid sinus enters into this. The jugular glomus is a small ovoid body consisting of chemoreceptor tissue which is enclosed in the adventitia of the jugular bulb. (2)The glossopharyngeal nerve (3)The vagus (4)The accessory nerve (5)The inferior petrosal sinus on its way to the upper end of the internal jugular vein. References MOORE, K.L.; Clinically Oriented Anatomy, Williams and Wilkins, 1980, pp 911-13.

Number: 141 Which of the following structures pass through the foramen magnum? 1. The vertebral arteries. 2. The glossopharyngeal nerves. 3. Spinal arteries supplying the upper portion of the spinal cord. 4. The vagi. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: B The structures passing through the foramen magnum are: (1)The spinal cord- the junction of the spinal cord and medulla of the brainstem. (2)The spinal roots of the accessory nerves (cranial nerves IX) (3)The meningeal branches of the upper cervical nerves (C1to C3) (4)The meninges (5)The vertebral arteries ascending to supply parts of the brain (6)The anterior and posterior spinal arteries descending to supply the upper part of the spinal cord. Four other foramina exist in the posterior cranial fossa. These are the jugular foramen, the hypoglossal canal, the condylar canal, and the internal acoustic meatus. The contents of the jugular foramen are: (1)The superior bulb of the internal jugular vein. The sigmoid sinus enters into this. The jugular glomus is a small ovoid body consisting of chemoreceptor tissue which is enclosed in the adventitia of the jugular bulb. (2)The glossopharyngeal nerve (3)The vagus (4)The accessory nerve (5)The inferior petrosal sinus on its way to the upper end of the internal jugular vein. References MOORE, K.L.; Clinically Oriented Anatomy, Williams and Wilkins, 1980, pp 911-13.

Number: 142 Which of the following are true statements concerning the blood supply of the spinal cord via the anterior spinal artery? A. A single pair of arteries supply the anterior region for the entire length of the cord. B. No collateral blood supply exists. C. Thrombosis results in paraplegia and paraesthesia. D. All of the above. E. None of the above. Select the single best answer ABCDE Correct Answer: E The anterior spinal artery is a single vessel lying in the pia mater in front of the anterior median fissure. It arises from the junction of two small arteries which are branches of each vertebral arteries at the level of the foramen magnum. It descends along the entire length of the spinal cord, receiving small communications from the intercostal and lumbar arteries. To provide the extra blood supply needed in the thoracic and lumbar enlargements, the communicating branches at the level of T1 and T2 are larger than the others (the arteries of Adamkiewicz). Thrombosis of the anterior spinal artery results in the syndrome in which there is paraplegia without involvement of the modalities subserved by the posterior columns: joint position, touch, and vibration sense. The posterior spinal arteries are two or three in number on each side and originate in the posterior inferior cerebellar arteries at the base of the brain. They supply the posterior columns of the cord. There are no anastomoses between the anterior and posterior arteries: in fact, the vascularization of the cord comprises three distinct territories- one anterior, and two posterior. LEE, J.A. ET AL; Sir Robert Macintosh's Lumbar Puncture and Spinal Analgesia, 5th Ed., Churchill Livingstone, 1985, p 53. Number: 143 A palsy of the third cranial nerve will result in which apparent gaze of the eyeball? A. Inferolaterally. B. Inferomedially. C. Superolaterally. D. Superomedially. E. Laterally. Select the single best answer

10

ABCDE Correct Answer: A The cranial nerves, CN III (oculomotor), IV (trochlear), and VI (abducens) supply the muscles of the orbit. They enter the orbit through the superior orbital fissure. CN IV supplies the superior oblique which rotates the eyeball in an inferolateral direction; CN VI supplies the lateral rectus which abducts the eye; and CN III supplies the levator palpebrae superioris which elevate the eyelid, and the medial , superior, and inferior rectus muscles, which rotate the eyeball in the same direction. A palsy of CN III will result in the unopposed action of CN IV and VI. The eye will appear to gaze "down and out". MOORE, K.L.; Clinically Oriented Anatomy, Williams and Wilkins, 1980, p 970. Number: 144 Which of the following structures would be encountered if a needle were passed directly back at a site two fingerbreadths medial and inferior to the anterior superior iliac spine? 1. The aponeurosis of the external oblique muscle. 2. The transversalis fascia. 3. Scarpa's fascia. 4. Camper's fascia. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: E The fascia of the anterior abdominal wall is divided into superficial and deep. The superficial fascia consists of a fatty superficial layer (Camper's fascia) and membranous deeper layer (Scarpa's fascia). The deep fascia forms a layer over the external oblique muscle. The transversalis fascia lines the entire abdominal wall. It covers the deep surface of the transversalis muscle and its aponeurosis. MOORE, K.L.; Clinically Oriented Anatomy, Williams and Wilkins, 1980, pp 127-9.

11

Number: 145 A needle inserted directly backwards into the sacral hiatus: 1. Will penetrate the sacro-coccygeal ligament. 2. Will encounter the 3rd sacral vertebral segment. 3. Is likely to remain extradurally. 4. Is at the level of the posterior superior iliac spines. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: B The sacral hiatus is formed by the failure of fusion of the 5th and often the 4th vertebral laminae. It is covered by the sacro-coccygeal ligament. The sacral canal ends at the sacral hiatus. It follows the curve of the sacrum and in cross section is triangular. In the average adult, the dural sac extends to the lower border of the 2nd sacral vertebra which is at the level of the posterior superior iliac spines. This discrepancy between the dural sac and the sacral canal is exploited in caudal anaesthesia. The filum terminale extends from the cord, through the dura to the coccygeal periosteum. The canal contains in addition to the dural sac, the sacral nerves, loose fat, veins, and the filum terminale. LEE, J.A. ET AL; Sir Robert Macintosh's, Lumbar Puncture and Spinal Analgesia, 5th Ed., Churchill Livingstone, 1985, p 66. Number: 146 Which of the following arteries form part of the "circle of Willis"? 1. Anterior communicating artery. 2. Posterior communicating arteries. 3. Internal carotid artery. 4. Basilar arteries. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE

12

Correct Answer: E The " circle of Willis " is formed at the base of the brain and represents the fusion of the four major arterial systems supplying the brain: the internal carotid arteries, and the vertebral arteries. It is formed by the anterior communicating artery, the anterior cerebral, a short segment of each internal carotid, the posterior communicating, the posterior cerebral and the basilar arteries. The middle cerebral artery is a continuation of the internal carotid artery and is not part of the circle. MOORE, K.L.; Clinically Oriented Anatomy, Williams and Wilkins, 1980, pp 949-50. Number: 147 Which of the following are contained within the carotid sheath? 1. The common carotid artery. 2. The external carotid artery. 3. The internal carotid artery. 4. The sympathetic trunk. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: B The carotid sheath is a tubular, fascial condensation that extends from the base of the skull to the root of the neck. It is formed by the fascial extensions of the cervical fascia, and its fibres fuse with the prevertebral fascia. It contains several structures: 1. The common and internal carotid arteries. 2. The internal jugular vein. 3. The vagus nerve. 4. The superior root of the ansa cervicalis is sometimes embedded within the carotid sheath. 5. Deep cervical lymph nodes. The cervical part of the sympathetic trunk runs posterior to the sheath. MOORE, K.L.; Clinically Oriented Anatomy, Williams and Wilkins, 1980, p 1128.

13

Number: 148 Which of the following statements are true? A. The most prominent spinous process palpable represents T1. B. The tip of the spine of T9 is opposite the inferior angle of the scapula. C. The dimples overlying the posterior superior iliac spines are on a line crossing the termination of the dural sac in the spinal canal at S2. D. The lower end of the spinal cord is opposite the lower border of the body of L2 and sometimes extends a little below this. E. All of the above. Select the single best answer ABCDE Correct Answer: C The spinous process of C7 (vertebra prominens) is generally easily palpated and represents the most prominent spinous process. The tip of the spine of T7 is opposite the inferior angle of the scapula when the arms are held by the side. The lower end of the spinal cord is opposite the lower border of the body of L1 and sometimes extends a little below this. LEE, J.A. ET AL; Sir Robert Macintosh's, Lumbar Puncture and Spinal Analgesia, 5th Ed., Churchill Livingstone, 1985, p 38. Number: 149 With respect to the extradural space: 1. The spinal dura mater is loosely attached to the foramen magnum and permits some spread of local anaesthetic agent cephalad during a "high" extradural block. 2. It terminates with the filum terminale at the lower border of the second sacral vertebra. 3. It is of uniform width from the anterior to posterior compartments. 4. The extradural veins mainly occupy the antero-lateral compartment. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: D

14

The dura mater, although continuous, can be described in two parts, cranial and spinal. The cranial dura mater consists of two layers, endosteal and meningeal (opponents of this view state that the endosteal layer is actually the inner periosteal lining), closely united except where they enclose the great venous sinuses which drain the blood from the brain. At the foramen magnum, the endosteal layer is reflected back to become continuous with the periosteum on the outer surface of the bone. In the vertebral canal, it is represented by the periosteal lining of the vertebrae. The meningeal layer invests the brain and folds inwards to form the tentorium cerebelli and falx cerebri. In the vertebral canal, the spinal dura mater represents the downward continuation of the meningeal layer of the cranial dura mater. It is firmly attached around the circumference of the foramen magnum. The spread of methylene blue injected into the extradural space has been observed. The upward spread is limited by the attachment of the spinal dura mater to the foramen magnum. The spinal dura mater invests the spinal cord forming a "dural sac" between itself and the arachnoid mater. The dura mater and its sac terminate at the lower border of the second sacral spinal vertebra. The potential space which is the extradural space extends with the filum terminale caudad to this; the lowermost point of the extradural space occurs at the sacral hiatus and the filum terminale inserts into the periosteum at the back of the coccyx. This discrepancy is exploited in caudal anaesthesia. The width of the extradural space largely depends upon the amount of fat contained at any site. This is greatest in the median plane posteriorly where the summit of the vertebral arch is commonly separated from the rounded posterior aspect of the dura by 5-6 mm, and anterolaterally where it is continuous with the pads of fat surrounding the spinal nerves in the intervertebral foramina. Between the posterior-lateral walls of the lumbar vertebral canal and the dura, the space is narrower, and the fat is less evident. Anteriorly, in a thin subject, the space is only potential, since here the dura lies close to the posterior longitudinal ligament on the posterior aspects of the vertebral bodies The extradural veins form a plexus which is most dense in the antero-lateral compartment. LEE, J.A. ET AL; Sir Robert Macintosh's, Lumbar Puncture and Spinal Analgesia, 5th Ed., Churchill Livingstone, 1985, pp 53-60. Number: 150 The depth of the subarachnoid space in the thoracic region is: A. 1 mm. B. 3 mm. C. 5 mm. D. 9 mm. E. 12 mm. Select the single best answer ABCDE Correct Answer: B

15

In the cervical and thoracic regions of the spinal cord. the subarachnoid space is annular and has a depth of only 3 mm between the arachnoid mater and the pia mater which is adherent to the spinal cord. The spinal cord terminates at the lower border of L1 (or upper border of L2 in some texts). At this point, the subarachnoid space becomes circular and has a diameter of approximately 15 mm. LEE, J.A. ET AL; Sir Robert Macintosh's, Lumbar Puncture and Spinal Analgesia, 5th Ed., Churchill Livingstone, 1985, p 60 Number: 151 In a neonate, the spinal cord terminates at the lower border of: A. T12. B. L1. C. L2. D. L3. E. L4. Select the single best answer ABCDE Correct Answer: D In early foetal life, the spinal cord is as long as the vertebral canal. During development, however, increase in the length of the cord does not keep pace with the growth of the vertebrae. At birth the tip of the spinal cord has risen from the level of the second coccygeal vertebra to the lower border of the third lumbar vertebra. LEE, J.A ET AL; Sir Robert Macintosh's, Lumbar Puncture and Spinal Analgesia, 5th Ed., Churchill Livingstone, 1985, p 64. Number: 152 Which of the following statements concerning the innervation of the abdomen by the autonomic nervous system are true? 1. Afferents accompanying sympathetic fibres enter the spinal cord between T5 and L1. 2. All splanchnic sympathetic nerves pierce the crura of the diaphragm. 3. The coeliac plexus receives sympathetic and parasympathetic fibres. 4. Afferent impulses accompanying parasympathetic fibres cannot be abolished by a block to T5. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct

16

E: All Correct ABCDE Correct Answer: E The visceral motor nerve supply to the abdominal and pelvic organs are derived from both sympathetic and parasympathetic components of the autonomic nervous system. Sympathetic preganglionic fibres leave the spinal cord between the levels of T5 and L1 or L2. After leaving the paravertebral ganglia they fuse to form three splanchnic nerves on each side. These enter the abdomen by piercing the crura of the diaphragm and end in the coeliac plexus and the other pre-aortic plexuses from which they reach the viscera with the arterial supply. Visceral afferent impulses from the abdomen travel along fibres which accompany the efferent sympathetic fibres, pass through the paravertebral sympathetic ganglia and proceed up the splanchnic nerves to enter the spinal nerves. They enter the spinal cord via the dorsal root ganglia between T5 and L2. The visceral parasympathetic nerves leave the central nervous system in two distinct parts; cranial and sacral. That section of the cranial parasympathetic outflow which supplies the viscera consists of fibres in the vagus nerves which run their course outside the vertebral canal to enter the abdomen, passing through a hole in the diaphragm with the oesophagus at the level of the 10th thoracic vertebra. Here they innervate the stomach, and communicate freely with the coeliac plexus through which they are distributed to the rest of the alimentary canal up to the distal part of the transverse colon. Afferent impulses accompany the vagi as evidenced the inability to abolish "visceral" type sensation with a block of spinal segments to T5. LEE, J.A .ET AL; Sir Robert Macintosh's, Lumbar Puncture and Spinal Analgesia, 5th Ed., Churchill Livingstone, 1985, p 78-9. Number: 153 Which cranial nerves contribute to the sensory innervation of the tongue? 1. V. 2. VII. 3. IX. 4. XII. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: A

17

Sensation to the anterior two thirds of the tongue is supplied by the lingual branch of the mandibular nerve, the third division of the trigeminal nerve (CN V). This nerve also carries the taste fibres of the chorda tympani branch of the facial nerve (CN VII). Common sensation and taste to the posterior one third of the tongue is supplied by the glossopharyngeal nerve (CN IX). A few fibres of the superior laryngeal branch of the vagus (CN X) also supply sensation to this area. The hypoglossal nerve (CN XII) provides motor innervation to all the muscles of the tongue except palatoglossus which is innervated by CN XI via the pharyngeal plexus. MORRIS, I.R; " Functional Anatomy of the Airway ", Emergency Medicine Clinics of North America, vol 6, no 4, Nov. 1988, p 650. Number: 154 The cricoid cartilage in an infant is located at the level of which cervical vertebra? A. C1. B. C2. C. C3. D. C4. E. C5. Select the single best answer ABCDE Correct Answer: D In infants, the glottis is located two to three segments higher than in adults. The cricoid cartilage in infants is at the level of C4 as opposed to C6 in adults. ROGERS, M.C. ET AL (EDS); Principles and Practice of Anesthesiology, Mosby, 1993, p 442. Number: 155 Which of the following structures are contained within the posterior mediastinum? 1. The thoracic duct. 2. Oesophagus. 3. Azygos vein. 4. The thymus gland. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct

18

ABCDE Correct Answer: A The posterior mediastinum is the part of the mediastinum located posterior to the fibrous pericardium, below the fourth thoracic vertebra. Its lower part lies at a lower level than the anterior part of the diaphragm, but at the level of the diaphragm posteriorly. It contains the thoracic aorta, oesophagus, thoracic duct, azygos and hemiazygos veins, posterior intercostal arteries and some intercostal veins. The thymus gland is contained in the superior mediastinum. References MOORE, K.L.; Clinically Oriented Anatomy, Williams and Wilkins, 1980, p 99. Number: 156 The oesophagus: A. Extends for 1.5 cm below the diaphragm. B. Pierces the diaphragm to the left of the midline. C. Forms a groove in the left lobe of the liver. D. All of the above. E. None of the above. Select the single best answer ABCDE Correct Answer: D The oesophagus pierces the diaphragm just to the left of the midline and extends for 1.5 cm intraabdominally before joining the stomach. It forms a groove on the surface of the left lobe of the liver before joining the stomach. References MOORE, K.L.; Clinically Oriented Anatomy, Williams and Wilkins, 1980, pp 158-9. Number: 185 The internal jugular vein: 1. Is lateral to the carotid artery at the level of the cricoid cartilage. 2. Is postero-lateral to the carotid artery at the base of the skull. 3. Is anterior to the carotid artery at the base of the neck. 4. Lies outside the carotid sheath.

19

A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: A Emerging from the base of the skull through the jugular foramen, the internal jugular vein enters the carotid sheath dorsally to the internal carotid artery (CA). Initially, it runs posterolateral to the internal, then the common carotid artery, beneath the sternocleidomastoid muscle. As it approaches the base of the neck, its relationship with the CA becomes lateral, and then anterior. References ROHEN, J.W. & YOKOCHI; Color Atlas of Anatomy, Igaku-Shoin, 1988 . Number: 209 In this Left Anterior Oblique view of the heart, the artery indicated by the figure "2" is: A. Left Anterior Descending. B. 1st Diagonal C. Obtuse Marginal D. Circumflex E. Septal Select the single best answer

ABCDE

20

Correct Answer: B 1. Left Anterior Descending. 2. 1st Diagonal 3. Obtuse Marginal 4. Circumflex

Number: 214 A patient who has suffered a penetrating wound above the clavicle and who has evidence of degeneration in the axillary, musculocutaneous and long thoracic nerves will may have severed which ventral ramus? A. C4 B. C6 C. C8 D. T1 E. None of the above. Select the single best answer ABCDE Correct Answer: B Number: 215 Which nerve usually accompanies the external jugular vein as it crosses the surface of the sternocleidomastoid muscle. A. Spinal accessory. B. Great auricular. C. Lesser occipital. D. Greater occipital. D. All of the above. Select the single best answer ABCDE Correct Answer: B The great auricular nerve winds around the posterior border of the sternomastoid (where it is occasionally palpable as a small nodules) and ascends obliquely across that muscle onto the parotid gland, where it divides to supply the skin over the gland and over the mastoid process, together with both surfaces of the auricle.

21

Number: 216 Which nerve constitutes the afferent (sensory) supply to the piriform fossa? A. Glossopharyngeal (IX) B. External laryngeal C. Internal laryngeal D. Hypoglossal (XII) E. Recurrent Laryngeal Select the single best answer ABCDE Correct Answer: C The internal laryngeal nerve, is afferent from the mucous membrane of the larynx. The area of mucosa supplied extends from the epiglottis and the back of the tongue down to the vocal folds. Simulation of the internal laryngeal nerve results in sensations of touch and pain. The nerve pierces the thyrohyoid membrane above the superior laryngeal artery and divides into terminal branches. A twig is given to the transverse arytenoid muscle, but whether these fibers are motor or proprioceptive is disputed). The internal laryngeal nerve ends by joining branches of the recurrent laryngeal nerve. The anastomosis may take place behind or in the substance of the posterior crico-arytenoid and the connection may pierce the inferior constrictor of the pharynx. Number: 216 Which nerve constitutes the afferent (sensory) supply to the piriform fossa? A. Glossopharyngeal (IX) B. External laryngeal C. Internal laryngeal D. Hypoglossal (XII) E. Recurrent Laryngeal Select the single best answer ABCDE Correct Answer: C The internal laryngeal nerve, is afferent from the mucous membrane of the larynx. The area of mucosa supplied extends from the epiglottis and the back of the tongue down to the vocal folds. Simulation of the internal laryngeal nerve results in sensations of touch and pain. The nerve pierces the thyrohyoid membrane above the superior laryngeal artery and divides into terminal branches. A twig is given to the transverse arytenoid muscle, but whether these fibers are motor or proprioceptive is disputed). The internal laryngeal nerve ends by joining branches of the recurrent laryngeal nerve. The anastomosis may take place behind or in the substance of the posterior crico-arytenoid and the connection may pierce the inferior constrictor of the pharynx.

22

Number: 218 The dorsal scapular nerve innervates: A. trapezius B. levator scapulae C. latissimus dorsi D. splenius cervicis E. None of the above Select the single best answer ABCDE Correct Answer: B The dorsal scapular nerve (Nerve to the rhomboids) arises mainly from C5, pierces scalenus medius, runs deep to levator scapulae (which it usually supplies) and finally enters the deep surface of the rhomboids. Levatot scapulae may also be supplied directly from C3 and C4 by superficial branches. Number: 219 The nerve which is most closely associated with the radial artery in the forearm is the : A. Median nerve. B. Superficial radial nerve. C. Deep radial nerve. D. Anterior interosseous nerve. E. None of the above. Select the single best answer ABCDE Correct Answer: B

23

Number: 220 Which nerve accompanies the deep palmar arch? A. Deep branch of the radial nerve B. Superficial branch of the radial nerve C. Deep branch of the ulnar nerve D. Superficial branch of the ulnar nerve E. None of the above. Select the single best answer ABCDE Correct Answer: C Number: 225 Hilton's law, applied to the knee joint, would predict innervation of the joint by: 1. The femoral nerve 2. The tibial nerve 3. The obturator nerve 4. The Common Peroneal nerve A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: A Hilton's law states that the innervation of a joint is by all nerves which supply muscles which act across the same joint. Number: 234 Which nerve root, if compressed by a herniated disc, would result in a diminished knee jerk? A. L1 B. L2 C. L3 D. L4 E. L5 Select the single best answer

24

ABCDE Correct Answer: D L4 nerve root compression results a diminished knee jerk. Number: 273 The thyroid gland: 1. Has C cells that are derived from the ultimobranchial body 2. Is at the level of the fifth to seventh cervical and first thoracic vertebrae 3. May have accessory nodules in the tongue 4. Develops from the endoderm between the second and third pharyngeal pouches A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: A It develops from the endoderm between the first and second pharyngeal pouches. Number: 275 Which of the following statements about the anatomy of the coronary arteries are correct: 1. Tthe anterior two thirds of the interventricular septum are supllied by the anterior descending artery 2. The atrioventricular node is typically supplied by the right coronary artery 3. The circumflex artery runs in the left atrioventricular groove 4. The left coronary artery arises from the anterior aortic sinus A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: A

25

The right coronary artery arises from the anterior aortic sinus. Number: 299 The corticospinal tract: 1. Runs on the anterior aspect of the medulla. 2. Originates predominantly from the cortical cells of the precentral gyrus. 3. Runs in the pyramid. 4. Decussates in the midbrain. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: A The decussation is in the hindbrain. Number: 335 All the following muscles have an insertion on the radius, EXCEPT: A. Supinator B. Pronator quadratus C. Pronator teres D. Biceps brachii E. Brachialis Select the single best answer ABCDE Correct Answer: E Brachialis arises from the front of the lower two-thirds of the humerus and the medial intermuscular septum. Its upper fibres clasp the deltoid insertion; some fibres arise from the lower part of the spiral groove. The broad muscle flattens to cover the anterior part of the elbow joint and is inserted by mixed tendon and muscle fibres into the coronoid process and tuberosity of the ulna.

26

Number: 336 Which artery and region that it primarily supplies are incorrectly paired: A. Right gastroepiploic : greater curvature B. Left gastric cardiac part of stomach C. Right colic ascending colon D. Right gastric : pyloris of stomach E. Middle colic: descending colon Select the single best answer ABCDE Correct Answer: E The middle colic supplies the transverse colon.

Number: 336 Which artery and region that it primarily supplies are incorrectly paired: A. Right gastroepiploic : greater curvature B. Left gastric cardiac part of stomach C. Right colic ascending colon D. Right gastric : pyloris of stomach E. Middle colic: descending colon Select the single best answer ABCDE Correct Answer: E The middle colic supplies the transverse colon. Number: 337 The recurrent (or inferior) laryngeal nerve innervates all the intrinsic laryngeal muscles, EXCEPT: A. Lateral cricoarytenoid B. Posterior cricoarytenoid C. Cricothyroid D. Vocalis E. Aryepiglottis Select the single best answer

27

ABCDE Correct Answer: C Cricothyroid Cricothyroid arises from the arch of the cricoid backwards to fan out towards its attachment to the inferior horn and lower border of the thyroid lamina. Its contraction causes the arch of the cricoid and the Adam's apple to approach each other. The effect of contraction is to lengthen the vocal fold. Number: 338 With regard to Pectoralis Major: 1. It is supplied by the pectoral nerves. 2. It can abduct and laterally rotate the humerus. 3. Its contraction is used in testing the mobility of a breast lump. 4. Its lower border forms the posterior axillary fold. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: B Pectoralis Major is a medial rotator of the arm. In combination with latissimus dorsi it is also a powerful adductor of the arm. Number: 339 The ulnar nerve: 1. Supplies flexor carpi ulnaris muscle. 2. Supplies abductor pollicis brevis. 3. Arises from medial cord of the brachial plexus 4. Supplies the 2nd lumbrical muscle. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct

28

ABCDE Correct Answer: B In 95% of cases flexor carpi ulnaris is supplied by the ulnar nerve. The muscles of the thenar eminence (abductor pollicis brevis, flexor pollicis brevis and opponens pollicis) are supplied by the median nerve. The ulnar nerve is the largest branch of the medial cord of the brachial plexus. The 1st and 2nd lumbricals are supplied by the median nerve. Number: 356 In this plan of the right lumbar plexus, The nerve marked 'A' is: A. Ilio-Hypogastric. B. Lateral cutaneous nerve of the thigh. C. Femoral. D. Obturator. E. Genitofemoral Select the single best answer

29

ABCDE Correct Answer: D The lumbar plexus is derived from the anterior primary rami of the 1st, 2nd, 3rd and part of the 4th lumbar nerve roots. About 50 percent of subjects receive an additional contribution from TI2. In much the same way as the brachial plexus, the lumbar plexus may be prefixed, with its lowest contribution from L3, or postfixed, when it extends to L5. The plexus assembles in front of the transverse processes of the lumbar vertebrae within the substance of the psoas major. LI, joined in 50 per cent of cases by a branch from TI2, divides into an upper and lower division. The upper division gives rise to the iliohypogastric and ilioinguinal nerves; the lower joins a branch from L2 to form the genito-femoral nerve. The rest of L2, together with L3 and the contribution to the plexus from L4, divide into dorsal and ventral divisions. Dorsal divisions L2 and 3 form the lateral cutaneous nerve of the thigh and L2, 3 and 4 form the femoral nerve. The ventral branches join into the obturator nerve (L2, 3, 4) and, when present, the accessory abturator nerve (L3, 4). 30

Number: 357 In this plan of the right lumbar plexus, The nerve marked 'B' is: A. Ilio-Hypogastric. B. Lateral cutaneous nerve of the thigh. C. Femoral. D. Obturator. E. Genitofemoral Select the single best answer

ABCDE Correct Answer: C The lumbar plexus is derived from the anterior primary rami of the 1st, 2nd, 3rd and part of the 4th lumbar nerve roots. About 50 percent of subjects receive an additional contribution from TI2. In much the same way as the brachial plexus, the lumbar plexus may be prefixed, with its lowest contribution from L3, or postfixed, when it extends to L5. The plexus assembles in front of the transverse processes of the lumbar vertebrae within the substance of the psoas major. LI, joined in 50 per cent of cases by a branch from TI2, divides into an upper and lower division. The upper division gives rise to the iliohypogastric and ilioinguinal nerves; the lower joins a branch from L2 to form the genito-femoral nerve. The rest of L2, together with L3 and the contribution to the plexus from L4, divide into dorsal and ventral divisions. Dorsal divisions L2 and 3 form the lateral cutaneous nerve of the thigh and L2, 3 and 4 form the femoral nerve. The ventral branches join into the obturator nerve (L2, 3, 4) and, when present, the accessory abturator nerve (L3, 4). Number: 358 In this plan of the right lumbar plexus, The nerve marked 'C' is: A. Ilio-Hypogastric. B. Lateral cutaneous nerve of the thigh. C. Femoral. D. Obturator. E. Genitofemoral Select the single best answer

31

ABCDE Correct Answer: B The lumbar plexus is derived from the anterior primary rami of the 1st, 2nd, 3rd and part of the 4th lumbar nerve roots. About 50 percent of subjects receive an additional contribution from TI2. In much the same way as the brachial plexus, the lumbar plexus may be prefixed, with its lowest contribution from L3, or postfixed, when it extends to L5. The plexus assembles in front of the transverse processes of the lumbar vertebrae within the substance of the psoas major. LI, joined in 50 per cent of cases by a branch from TI2, divides into an upper and lower division. The upper division gives rise to the iliohypogastric and ilioinguinal nerves; the lower joins a branch from L2 to form the genito-femoral nerve. The rest of L2, together with L3 and the contribution to the plexus from L4, divide into dorsal and ventral divisions. Dorsal divisions L2 and 3 form the lateral cutaneous nerve of the thigh and L2, 3 and 4 form the femoral nerve. The ventral branches join into the obturator nerve (L2, 3, 4) and, when present, the accessory abturator nerve (L3, 4).

Number: 359 In this view of the dorsal surface of the left first rib, the structure crossing the rib at point 'A' is: A. The Subclavian vein. B. The Subclavian artery. C. The Brachial plexus. D. The Thoracic duct. E. The Scalenus Anterior. Select the single best answer

32

ABCDE Correct Answer: A The upper surface of the shaft of the 1st rib slopes down at about 45 degrees, and is at the root of the neck. It is grooved obliquely at its greatest lateral convexity. The groove between 'B' and 'C' is called the subclavian groove. It lodges the lower trunk of the brachial plexus. The fibres in contact with the rib are all from T1, and the C8 fibres lie above them, not yet intermingled. The subclavian artery has its upward convexity Iying more transversely. The artery does not lie in the groove, and it touches only the outer border of the rib. Between the groove and the tubercle the large quadrangular area of the upper surface gives attachment to scalenus anterior. Number: 360 In this view of the dorsal surface of the left first rib, the muscle inserted at point 'B' is: A. Scalenus Medius. B. Scalenus Posterior. C. Posterior belly of Omo-hyoid. D. Scalenus Anterior. E. None of the above. Select the single best answer 33

ABCDE Correct Answer: D The upper surface of the shaft of the 1st rib slopes down at about 45 degrees, and is at the root of the neck. It is grooved obliquely at its greatest lateral convexity. The groove between 'B' and 'C' is called the subclavian groove. It lodges the lower trunk of the brachial plexus. The fibres in contact with the rib are all from T1, and the C8 fibres lie above them, not yet intermingled. The subclavian artery has its upward convexity Iying more transversely. The artery does not lie in the groove, and it touches only the outer border of the rib. Between the groove and the tubercle the large quadrangular area of the upper surface gives attachment to scalenus anterior.

Number: 363 In this view of the dorsal surface of the left first rib, the muscle inserted at point 'C' is: A. Scalenus Medius. B. Scalenus Posterior. C. Posterior belly of Omo-hyoid. D. Scalenus Anterior. E. None of the above. Select the single best answer

ABCDE Correct Answer: A The scalenus medius: The scalenus medius arises from the posterior tubercles and costo-transverse lamellae of all the cervical vertebrae and is inserted into the quadrangular area between the neck and subclavian groove of the first rib . Number: 365 With regard to the brachial plexus the nerve labelled 'A' is: A. Lateral Pectoral. B. Musculocutaneous. C. Suprascapular. D. Median E. Nerve to subclavius

34

Select the single best answer

ABCDE Correct Answer: B The musculocutaneous nerve: The musculocutaneous nerve (C5, 6, 7) is the continuation of the lateral cord after this has given off the lateral head of the median nerve at the lower border of pectoralis minor. Because of its derivation from the lateral cord, the nerve naturally lies lateral to the axillary artery. It first supplies and then pierces coracobrachialis, then descends downwards and laterally between biceps and brachialis, supplying both these muscles. The nerve emerges between biceps tendon and brachioradialis, pierces the deep fascia of the antecubital fossa and continues downwards as the lateral cutaneous nerve of the forearm.

35

Number: 366 With regard to the brachial plexus the nerve labelled 'B' is: A. Lateral Pectoral. B. Musculocutaneous. C. Suprascapular. D. Median E. Nerve to subclavius Select the single best answer ABCDE Correct Answer: D The median nerve: The median nerve (C5, 6, 7, 8, TI) carries fibres from all the roots of the brachial plexus; C5, 6 and 7 from the lateral head, which is derived from the lateral cord of the plexus, and C8 and TI from the medial head, derived from the medial cord. The two origins of the nerve unite in front of the third part of the axillary artery. The nerve descends through the arm first on the lateral side of the brachial artery, then on its medial side, crossing the artery at the mid-point of the upper arm at the insertion of coracobrachialis. Usually the nerve passes across the front of the artery, but occasionally crosses behind it. Number: 367 With regard to the brachial plexus the nerve labelled 'E' is: A. Phrenic B. Nerve to Serratus Anterior C. Suprascapular. D. Nerve to rhomboids E. Nerve to subclavius Select the single best answer ABCDE Correct Answer: B Nerve to Serratus Anterior: The long thoracic nerve (nerve to serratus anterior) arises from the roots of the brachial plexus (C5, 6, 7). The branches from C5 and 6 join in the scalenus medius muscle and emerge from its lateral border as a single trunk which enters the axilla by passing over the first digitation of serratus anterior. The contribution from C7 also passes over the first digitation of serratus

36

anterior and joins the former nerve on the medial wall of the axilla (i.e., on the surface of serratus anterior) to form the nerve to serratus anterior. The nerve lies behind the midaxillary line (i.e., behind the lateral branches of the intercostal arteries) on the surface of the muscle, deep to the fascia, and is thus protected in operations on the axilla. The muscle is supplied segmentally; C5 into the upper two digitations, C6 into the next two, and C7 into the lower four digitations. Number: 381 The structure marked 'A' on this lateral view of the pharynx is: A. Superior Constrictor. B. Middle Constrictor. C. Inferior Constrictor. D. Hyoglossus. E. Buccinator. Select the single best answer

ABCDE

37

Correct Answer: C Inferior Constrictor: The inferior constrictor, which is the thickest of the pharyngeal constrictors, arises from the side of the cricoid, from the tendinous arch over the cricothyroid muscle and from the oblique line on the lamina of the thyroid cartilage. The muscle consists functionally of two parts: the lower portion, arising from the cricoid (the cricopharyageus), which acts as a sphincter and the upper portion, with obliquely placed fibres which arise from the thyroid cartilage, which has a propulsive action. Number: 383 The structure marked 'C' on this lateral view of the pharynx is: A. Superior Constrictor. B. Middle Constrictor. C. Inferior Constrictor. D. Hyoglossus. E. Buccinator. Select the single best answer ABCDE Correct Answer: D Hyoglossus: The hyoglossus muscle arises from the length of the greater horn of the hyoid bone and from the body of that bone lateral to genio-hyoid. It extends as a quadrilateral sheet on the side of the tongue; its upper border, interdigitating at right angles with the fibres of stylo-glossus, is attached to the side of the tongue. Number: 387 The structure marked 'B' on this lateral view of the pharynx is: A. Superior Constrictor. B. Middle Constrictor. C. Inferior Constrictor. D. Hyoglossus. E. Buccinator. Select the single best answer ABCDE Correct Answer: A

38

The Superior Constrictor arises from the medial pterygoid plate and is inserted into the pharyngeal ligament. Number: 395 The phrenic nerve: 1. Arises predominantly from the third cervical nerve 2. Runs in front of the root of the lung 3. Is a purely motor nerve 4. Iinnervates the diaphragm from below A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: C The phrenic nerve (C3, 4, 5) is, the most important branch of the cervical plexus. It provides the motor innervation of the diaphragm (apart from a clinically insignificant contribution to the crura from T11 and T12) and transmits proprioceptive sensory fibres from the central part of the diaphragm. In addition filaments are supplied to the pleura and pericardium. Number: 419 Which artery is NOT a branch of the internal carotid artery? A. Middle cerebral B. Anterior cerebral. C. Posterior cerebral. D. Choroidal. E. Retinal. Select the single best answer ABCDE Correct Answer: C The posterior cerebral arteries are terminal branches of the basilar artery.

39

Number: 420 Afferent fibres from the carotid sinus travel via the: A. Glossopharyngeal nerve. B. Vagus nerve. C. Cervical sympathetics. D. Recurrent laryngeal nerve. E. Accessory nerve. Select the single best answer ABCDE Correct Answer: A The sinu-carotid nerve (a branch of the glosspharyngeal nerve) supplies the carotid sinus and carotid body. The fibres pass centrally to the vasomotor centre. Number: 421 The radial artery : 1. Lies between flexor carpi radialis and brachioradialis at the wrist. 2. Passes beneath the flexor retinaculum. 3. Accompanies superficial branches of the radial nerve at the wrist. 4. Has no branches in the forearm. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: B The radial artery has a recurrent branch at the elbow which anastomoses with branches from the ulnar and interosseous arteries. It also supplies muscular branches to all the muscles which it passes. The flexor retinaculum contains the median nerve and flexor tendons of the thumb and fingers.

40

Number: 432 The inferior vena cava: 1. Is formed at the 5th lumbar vertebral level. 2. Passes through the tendinous part of the diaphragm. 3. Passes behind the horizontal part of the duodenum. 4. Has a valve at its opening in the right atrium. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: E The inferior vena cave is a large, valveless, venous trunk that receives the blood from the lower limbs, and much of the blood from the back and from the walls and contents of the abdomen and pelvis It is formed by the junction of the two common iliac veins, slightly below and to the right of the bifurcation of the aorta. It ascends at the right of the aorta, through the central tendon of the diaphragm, and empties into the right atrium. From below upward it lies behind peritoneum (crossed by the root of the mesentery and right gonadal vessels), duodenum and pancreas, portal vein, epiploic foramen, and the liver, The right renal artery crosses behind it. The tributaries of the inferior vena cava are the common iliac, gonadal, renal, suprarenal, inferior phrenic, lumbar, and hepatic veins. Number: 433 With regard to the foetal circulation: 1. Most of the blood bypasses the liver in the ductus venosus. 2. The ductus arteriosus connects the root of the right pulmonary trunk to the descending aorta. 3. The valve of the inferior vena cava helps to direct the blood through the foramen ovale. 4. The umblical arteries arises from the external iliac artery. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct

41

ABCDE Correct Answer: B The economy of the foetal circulation is improved by three short-circuiting arrangements, all of which cease to function at the time of birth. The three short-circuiting structures are the ductus venosus, the forarnen ovale and the ductus arteriosus. The Ductus Venosus. Oxygenated blood returns from the placenta by the (left) umbilical vein, which joins the left branch of the portal vein in the porta hepatis. This oxygenated blood short-circuits the sinusoids of the liver; it is conveyed directly to the inferior vena cava by a channel called the ductus venosus. The ductus venosus lies along the inferior surface of the liver, between the attached layers of the lesser omentum. After birth, when blood no longer flows along the thrombosed umbilical vein, the blood in the ductus venosus clots and the ductus venosus becomes converted into a fibrous cord, the ligamentum venosum, lying deep in the cleft bounding the caudate lobe of the liver. The intra-abdominal part of the umbilical vein persists as a fibrous cord, the ligamentum teres. The two are continuous. The Foramen Ovale. The interatrial septum of the foetal heart is patent, being perforated by the foramen ovale. Blood brought to the right atrium by the inferior vena cava is directed by its 'valve' through the aperture in the inter-atrial septum and so enters the left atrium. The oxygenated placental blood is thus made to by-pass the right ventricle and the airless lungs, and is directed into the left ventricle and aorta and so to the carotid arteries. After birth this aperture, the foremen ovale, is closed by approximation and overlap of flanges of cardiac muscle which act from below and above like shutters. The two flanges are the septum primum and the septum secundum. The two flanges overlap and adhere together, so closing the interatrial septum. The site of union is marked by a shallow depression, the fossa ovalis, in the right side of the interatrial septum. After closure of the foramen ovale all the blood in the right atrium perforce passes into the right ventricle and so to the lungs. The Ductus Arteriosus. It has already been noted that oxygenated blood in the umbilical vein passes via the ductus venosus, inferior vena cava and right atrium through the foremen ovale to the left side of the heart locally, of a raised oxygen tension. and so to the head. Venous blood from the head is returned by way of the brachio-cephalic veins to the superior vena cava. In the right atrium this venous blood stream crosses the stream of oxygenated blood brought there via the inferior vena cava. The two streams of blood scarcely mix with each other. The de-oxygenated blood from the superior vena cave passes through the right atrium into the right ventricle and so into the pulmonary trunk. It now short-circuits the airless lungs by the ductus arteriosus. This is a thick artery joining the left branch of the pulmonary trunk to the aorta, distal to the origin of the three branches of the aortic arch. The de-oxygenated blood thus passes distally along the aorta and via the umbilical arteries to the placenta to be re-oxygenated. After birth the ductus arteriosus is occluded by contraction of its muscular walls. It persists as a fibrous band, the ligamentum arteriosum, which connects the commencement of the left pulmonary artery to the concavity of the arch of the aorta. After the closure of the ductus arteriosus blood from the right ventricle perforce circulates through the lungs.

42

Number: 436 In this diagram of the cervical plexus, the nerve labelled 'A' is: A. Phrenic. B. Supraclavicular. C. Descendens cervicalis. D. Descendens hypoglossi. E. Anterior cutaneous nerve of the neck. Select the single best answer ABCDE Correct Answer: A Phrenic. The phrenic nerve (C3, 4, 5) is the most important branch of the cervical plexus. It provides the motor innervation of the diaphragm (apart from a clinicallyinsignificant contribution to the crura from T11 and T12) and transmits proprioceptive sensory fibres from the central part of the diaphragm. In addition filaments are supplied to the pleura and pericardium. The principal component of the nerve is derived from the anterior primary ramus of C4 but contributions are also provided from C3 and C5. The three roots of the nerve join at the lateral border of scalenus anterior and then the fully constituted nerve runs downwards and medially across the anterior face of the muscle, covered by, and showing through, the prevertebral fascia. On scalenus anterior the phrenic nerve is overlapped by the internal jugular vein and sternomastoid, and is crossed by the inferior belly of the omohyoid and by the transverse cervical and transverse scapular vessels. On the left side, in addition, the nerve is crossed by the thoracic duct. Number: 437 In this diagram of the cervical plexus, the nerve labelled 'B' is: A. Phrenic. B. Supraclavicular. C. Descendens cervicalis. D. Descendens hypoglossi. E. Anterior cutaneous nerve of the neck. Select the single best answer

43

ABCDE Correct Answer: C Descendens Cervicalis. The ansa cervicalis lies on the front of the internal jugular vein and gives branches to the infrahyoid muscles. It is formed by union of superior and inferior rami. The superior ramus (descendens hypoglossi) is a branch of the hypoglossal nerve given off where the nerve loops just below the posterior belly of the digastric muscle, on the occipital, external carotid and lingual arteries. It runs down on the front of the internal jugular vein. It contains only C1 fibres, which have hitch-hiked along the hypoglossal nerve. The inferior ramus (descendens cervicalis) is formed by union of a branch each from C2 and C3 in the cervical plexus. The single nerve so formed spirals from behind around the internal jugular vein and runs down to join the superior ramus at a variable level. Sometimes a wide loop is formed over the lower part of the vein and the branches arise from the loop. Sometimes the two nerves join, Y-shaped, high up and the branches are given off from the stem of the Y. In either case they are distributed to the infrahyoid muscles (sterno-hyoid, stereo-thyroid and omo-hycid) segmentally, Cl, C2 and C3 from above down. Number: 438 In this diagram of the cervical plexus, the nerve labelled 'C' is: A. Phrenic. B. Supraclavicular. C. Descendens cervicalis. D. Descendens hypoglossi. E. Anterior cutaneous nerve of the neck. Select the single best answer ABCDE Correct Answer: D Descendens hypoglossi. The ansa cervicalis lies on the front of the internal jugular vein and gives branches to the infrahyoid muscles. It is formed by union of superior and inferior rami. The superior ramus (descenders hypoglossi) is a branch of the hypoglossal nerve given off where the nerve loops just below the posterior belly of the digastric muscle, on the occipital, external carotid and lingual arteries. It runs down on the front of the internal jugular vein. It contains only C1 fibres, which have hitch-hiked along the hypoglossal nerve. The inferior ramus (descendens cervicalis) is formed by union of a branch each from C2 and C3 in the cervical plexus. The single nerve so formed spirals from behind around the internal

44

jugular vein and runs down to join the superior ramus at a variable level. Sometimes a wide loop is formed over the lower part of the vein and the branches arise from the loop. Sometimes the two nerves join, Y-shaped, high up and the branches are given off from the stem of the Y. In either case they are distributed to the infrahyoid muscles (sterno-hyoid, stereo-thyroid and omo-hycid) segmentally, Cl, C2 and C3 from above down. Number: 439 At birth, the spinal cord is most likely to terminate at: A. L1. B. L2. C. L3. D. L4. E. L5. Select the single best answer ABCDE Correct Answer: C L3. By adulthood it has migrated upwards to the L1-2 region. Number: 440 Which of the following nerves contribute to the supply of the external auditory meatus: 1. Auriculo-temporal. 2. Great auricular. 3. Auricular branch of the vagus. 4. Lesser occipital. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: B The nerve supply of the external auditory meatus is from the auriculo-temporal nerve overlapped by the facial nerve and the auricular branch of the vagus.

45

The skin of the auricle is supplied by the great auricular and the auriculo-termporal nerves. The great auricular nerve supplies the whole of the cranial surface and the lateral surface below the meatus with fibres from C2. The auriculo-temporal nerve supplies the outer surface of the tympanic membrane, the external acoustic meatus and the skin of the auricle above this level. The auricular branch of the vagus supplies the posteroinferior quadrant of the tympanic membrane and skin of the adjoining meatus and a small area of skin of the cranial surface near the mastoid. The facial nerve by branches from the tympanic plexus also supplies the cutaneous surface of the tympanic membrane and external meatus, and these areas show vesicles in cases of facial herpes. The lesser occipital nerve (C2) overlaps the great auricular nerve at the upper margin of the cranial surface. The lesser occipital nerve (C2) is a slender branch that hooks around the accessory nerve and runs up along the posterior border of stereo-mastoid to supply the posterior part of the neck below the superior nuchal line (i.e., over the upper part of stereo-mastoid). It may overlap to the tip of the auricle. Number: 471 The greater splanchnic nerves usually synapse in the: A. Superior mesenteric ganglion B. Coeliac ganglion C. Hypogastric plexus D. Inferior mesenteric ganglion E. Ganglia of the lower thoracic sympathetic trunk Select the single best answer ABCDE Correct Answer: B The greater splachnic nerves arises from T5-T9 and pass forwards and downwards on the sides of the vertebral bodies. They pierce the crus of the diaphragm and then join the coeliac ganglion. Number: 474 The sixth cranial nerve: 1. Supplies the superior oblique muscle 2. Passes through the superior orbital fissure 3. Innervates the lacrimal gland 4. May be involved in an injury to the petrous part of the temporal bone

46

A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: C The abducent nerve, like the trochlear nerve, supplies only one eye muscle, the lateral rectus.Its nucleus is part of the somatic efferent column and lies immediately deep to the floor of the 4th ventricle in the upper part of the pons. From this nucleus, fibres pass through the pontine tegmentum to emerge on the base of the brain at the junction of the pons and medulla. The nerve then passes forwards to enter the cavernous sinus. Here it lies lateral to the internal carotid artery and medial to the IIIrd, IVth and Vth cranial nerves. Passing through the tendinous ring just below the IIIrd nerve, it enters the orbit to pierce the deep surface of the lateral rectus. Because of its long and oblique intracranial course, the Vith nerve is frequently involved in basal skull injuries. If damaged, diplopia and a covergent squint are the result. Number: 514 Concerning a typical intercostal nerve: 1. It arises from the posterior primary ramus of a thoracic spinal nerve. 2. It lies superior to the artery in the costal groove. 3. It lies between the internal and external intercostal muscles. 4. It is both motor and sensory. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: D The intercostal nerves are the primary anterior rami of the thoracic spinal nerves. They are mixed, motor (to the intercostal muscle) and sensory (serving skin). From above downwards in the costal groove lie the intercostal vein, artery and nerve. The vein, artery and nerve lie between the internal intercostal and the transverse thoracis muscles.

47

Number: 534 In this posterior view of the right popliteal fossa, the structure labelled 'A' is: A. Biceps Femoris. B. Semimembranosus. C. Semitendinosus. D. Gracilis. E. Sartorius. Select the single best answer ABCDE Correct Answer: A Biceps Femoris. - The long head originates from a common tendon with semitendinosus from the superior medial quadrant of the posterior portion of the ischial tuberosity; and the short head from the lateral lip of the linea aspera, lateral supracondylar ridge of femur, and lateral intermuscular septum of the thigh. It is inserted into the fibular head; also the lateral collateral ligament and lateral tibial condyle. Its action is to flex the knee, and also rotate the tibia laterally; the long head also extends the hip joint. The long head is innervated by tibial nerve; and the short head by common peroneal nerve. Its arterial supply is from perforating branches of the profunda femoris artery, the inferior gluteal artery, and superior muscular branches of the popliteal artery.

48

Number: 535 In this posterior view of the right popliteal fossa, the structure labelled 'B' is: A. Tibial N. B. Lateral Cutaneous N. of the calf. C. Sural Communicating N. D. Posterior Tibial N. E. Sural N. Select the single best answer ABCDE Correct Answer: A Tibial N. Number: 536 In this posterior view of the right popliteal fossa, the structure labelled 'C' is: A. Tibial N. B. Lateral Cutaneous N. of the calf. C. Sural Communicating N. D. Posterior Tibial N. E. Sural N. Select the single best answer 49

ABCDE Correct Answer: C Sural Communicating N. Number: 537 In this posterior view of the right popliteal fossa, the structure labelled 'D' is: A. Biceps Femoris. B. Semimembranosus. C. Semitendinosus. D. Gracilis. E. Sartorius. Select the single best answer ABCDE Correct Answer: C Semitendinosus originates from a common tendon with long head of biceps femoris on the superior medial quadrant of the posterior portion of the ischial tuberosity. It is inserted into the superior aspect of the medial portion of tibial shaft. Its action is to extend the thigh, flex the knee, and rotate the tibia medially - especially when the knee is flexed. It is innervated by the tibial nerve and draws its blood supply from perforating branches of profunda femoris, the inferior gluteal artery, and superior muscular branches of the popliteal artery. Number: 538 In this posterior view of the right popliteal fossa, the structure labelled 'E' is: A. Biceps Femoris. B. Semimembranosus. C. Semitendinosus. D. Gracilis. E. Sartorius. Select the single best answer ABCDE Correct Answer: B Semimembranosus takes origin from the superior lateral quadrant of the ischial tuberosity and is inserted onto the posterior surface of the medial tibial condyle. It acts to extend the thigh, flex the knee, and rotate the tibia medially, especially when the knee is flexed.

50

It is innervated by the tibial nerve and derives its arterial supply from perforating branches of the profunda femoris artery, inferior gluteal artery, and the superior muscular branches of the popliteal artery. Number: 577 Which of the following vertebrae has the most prominent spinous process? A. T1. B. T2. C. C7. D. T11. E. T12. Select the single best answer ABCDE Correct Answer: C C7 - 'Vertebra Prominens'. Number: 586 The femoral sheath: 1. Contains the femoral nerve, artery and vein 2. Has the inguinal ligament as its anterior border 3. Has the lacunar ligament as its lateral border 4. Has the pectineal ligament as its posterior border A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: C The femoral nerve lies outside the femoral sheath which contains the artery, vein and lymphatics. The lacunar ligament is on the medial border of the femoral sheath.

51

Number: 712 In the case of a patient sitting upright with his arms by his side, a line drawn between the tips of the scapulae will correspond to the vertebral body of: A. T6. B. T7. C. T8. D. T9. E. T10. Select the single best answer ABCDE Correct Answer: B Vertebra Prominens is C7. A line drawn between the tips of the scapulae corresponds to the vertebral body of T7. A line drawn between the superior margin of the iliac crests is level with the vertebral body of L4. Number: 748 A patient presents with a history of low back pain and sciatica. The pain radiates to the little toe, the ankle reflex is absent and the patient has difficulty in everting the foot. Which nerve root is likely to be trapped? A. L3 B. L4 C. L5 D. S1 E. S2 Select the single best answer ABCDE Correct Answer: D The root supply to the peroneal muscles (which control eversion of the foot and which also participate in the the reflex arc of the ankle jerk reflex) is S1 via the tibial and superficial peroneal nerves. The sensory dermatome of the S1 root gives innervation to the postero-lateral aspect of the leg and foot down to and including the little toe and sole of foot.

52

Number: 777 Which of the following are branches of the MEDIAL CORD of the brachial plexus? 1. Ulnar Nerve. 2. Axillary Nerve. 3. Medial Pectoral Nerve. 4. Radial Nerve. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: B The axillary nerve is a branch of the posterior cord. The radial nerve is a branch of the posterior cord. Number: 778 Which of the following are branches of the POSTERIOR CORD of the brachial plexus? 1. Dorsal scapular nerve. 2. Nerve to serratus anterior. 3. Nerve to subclavius. 4. Upper subscapular nerve. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: D The dorsal scapular nerve, nerve to serratus anterior and the nerve to subclavius all arise from the roots of the brachial plexus.

53

Number: 779 Which of the following is a branch of the LATERAL CORD of the brachial plexus? A. Suprascapular nerve. B. Lower subscapular nerve. C. Medial pectoral nerve. D. Musculo-cutaneous nerve. E. Upper subscapular nerve. Select the single best answer ABCDE Correct Answer: D The suprascapular nerve arises from the upper trunk of the plexus. The upper and lower subscapular nerves arise from the posterior cord of the plexus. The medial pectoral nerve arise from the medial cord of the plexus. Number: 779 Which of the following is a branch of the LATERAL CORD of the brachial plexus? A. Suprascapular nerve. B. Lower subscapular nerve. C. Medial pectoral nerve. D. Musculo-cutaneous nerve. E. Upper subscapular nerve. Select the single best answer ABCDE Correct Answer: D The suprascapular nerve arises from the upper trunk of the plexus. The upper and lower subscapular nerves arise from the posterior cord of the plexus. The medial pectoral nerve arise from the medial cord of the plexus.

54

Number: 831 The right middle lobe bronchus: 1. Divides into superior and inferior segmental bronchi. 2. Is medial to the right middle lobe artery. 3. Arises from the posterior aspect of the right main bronchus. 4. Is about 1.5cms in length. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: C The right middle lobe bronchus divides into medial and lateral segmental bronch. It is about 1.5cms in length and arises from the anterior aspect of the right main bronchus. The right middle lobe artery runs on its lateral side and the right middle lobe vein on its medial side. See: Anesthesia for Thoracic Surgery.2nd ed.Jonathan L. Benumof. ISBN: 0721644678. Publisher: WB Saunders. Number: 832 In the left lung, the number of bronchopulmonary segments is: A. 7. B. 8. C. 9. D. 10. E. 11. Select the single best answer ABCDE Correct Answer: B This is a 'trick' question. In one sense, there are 10 bronchopulmonary segments in the left lung, but the apical and posterior segments of the upper lobe and the anterior and medial basal segments of the lower lobe both combine into single segments. Hence the correct answer is 8. These are: Upper lobe: Apico-posterior

55

Anterior Lingula: Superior Inferior Lower Lobe: Superior ('Apical') Anterior-medial basal Lateral basal Postero-basal See: Anesthesia for Thoracic Surgery.2nd ed.Jonathan L. Benumof. ISBN: 0721644678. Publisher: WB Saunders. Number: 833 In the right lung, the number of bronchopulmonary segments is: A. 7. B. 8. C. 9. D. 10. E. 11. Select the single best answer ABCDE Correct Answer: D There are 10 bronchopulmonary segments in the right lung. These are: Upper lobe: Apical Posterior Anterior Middle Lobe: Medial Lateral Lower Lobe: Superior ('Apical') Anterior basal Posterior basal Medial basal

56

Lateral basal See: Anesthesia for Thoracic Surgery.2nd ed.Jonathan L. Benumof. ISBN: 0721644678. Publisher: WB Saunders. Number: 854 The incidence of probe-patent foramen ovale (PFO) in the general population is approximately: A. 5%. B. 10%. C. 15%. D. 20%. E. 25%. Select the single best answer ABCDE Correct Answer: E The incidence of PFO in the normal population is approximately 25%, as determined by postmortem examination. See: Hagen PT, Scholz DG, Edwards WD. Incidence and size of patent foramen ovale during the first 10 decades of life: an autopsy study of 965 normal hearts. Mayo Clin Proc 1984; 59: 17 20. Sweeney LJ, Rosenquist GC. The normal anatomy of the atrial septum in the human heart. Am Heart J 1979; 98: 1949. Number: 857 Abduction of the vocal cords is achieved by contraction of the: A. Posterior cricoarytenoids. B. Lateral cricoarytenoids. C. Interarytenoids. D. Cricothyroids. E. Thyroarytenoids. Select the single best answer ABCDE Correct Answer: A

57

The posterior cricoarytenoids are the (only) cord abductors. They are innervated by the recurrent laryngeal nerve. Number: 858 Adduction of the vocal cords is achieved by contraction of the: A. Posterior cricoarytenoids. B. Lateral cricoarytenoids. C. Aryepiglottics. D. Cricothyroid. E. Thyroarytenoid. Select the single best answer ABCDE Correct Answer: B The lateral cricoarytenoids (and the interarytenoids) are the cord adductors. The lateral cricoarytenoids are innervated by the recurrent laryngeal nerve, while the interarytenoids are innervated by both the recurrent and superior laryngeal nerves. Number: 860 In this posterior view of the intrinsic muscles of the larynx, the muscle labelled 'A' is: A. Interarytenoid. B. Posterior cricoarytenoid. C. Aryepiglottic. D. Thyroarytenoid. E. Thyroepiglottic. Select the single best answer

58

ABCDE Correct Answer: C Muscle 'A' is the Aryepiglottic. It is innervated by the recurrent laryngeal nerve.

Number: 861 In this posterior view of the intrinsic muscles of the larynx, the muscle labelled 'B' is: A. Interarytenoid. B. Posterior cricoarytenoid. C. Aryepiglottic. D. Thyroarytenoid. E. Thyroepiglottic. Select the single best answer ABCDE Correct Answer: A Muscle 'B' is the transverse component of the Interarytenoid. It is innervated by the recurrent laryngeal nerve and probably by branches from the superior laryngeal nerve.

59

Number: 861 In this posterior view of the intrinsic muscles of the larynx, the muscle labelled 'B' is: A. Interarytenoid. B. Posterior cricoarytenoid. C. Aryepiglottic. D. Thyroarytenoid. E. Thyroepiglottic. Select the single best answer ABCDE Correct Answer: A Muscle 'B' is the transverse component of the Interarytenoid. It is innervated by the recurrent laryngeal nerve and probably by branches from the superior laryngeal nerve. Number: 862 In this posterior view of the intrinsic muscles of the larynx, the muscle labelled 'C' is: A. Interarytenoid. B. Posterior cricoarytenoid. C. Aryepiglottic. D. Thyroarytenoid. E. Thyroepiglottic. Select the single best answer ABCDE Correct Answer: B Muscle 'C' is the posterior cricoarytenoid. It is innervated by the recurrent laryngeal nerve.

Number: 879 Klumpke's paralysis may be associated with: 1. Wasting of the small muscles of the hand. 2. Horner's syndrome. 3. Sensory loss on the medial side of the arm. 4. An inability to extend the metacarpophalangeal joints.

60

A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: A Klumpke's paralysis is caused by upward traction on the arm (as may occur in forcible breech delivery or, during anaesthesia, by wide abduction of the limb when an arm board is used) which results in damage to the lowest root of the brachial plexus (T1). This provides the segmental supply of the intrinsic muscles of the hand. The hand assumes a clawed appearance because of the unopposed actions of the long flexors and extensors of the fingers. (The extensors, which are inserted into the bases of the proximal phalanges, extend the metacarpophalangeal joints; flexor profundus and sublimis, inserted respectively into the distal and middle phalanges, flex the interphalangeal joints.) An area of sensory loss may be present on the inner aspect of the arm and upper forearm. Traction may also tear the white ramus communicans from T1 to the stellate ganglion, so that there may be an associated Horner's syndrome. Number: 934 With respect to the veins of the upper limb found at the cubital fossa: 1. The basilic vein lies occupies a lateral position. 2. The cephalic vein accompanies the brachial artery above the cubital fossa. 3. Generally, the most prominent vein in the cubital fossa is the cephalic. 4. The aponeurosis of the biceps muscle is the non-vascular structure most commonly encountered at venepuncture. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: D At the cubital fossa, the veins of the upper limb are divided into deep and superficial. The deep brachial veins are arranged in pairs which accompany the brachial artery. They begin at

61

the elbow by the union of the venae comitantes (companions) of the ulnar and radial arteries and end in the axillary vein. The brachial veins contain valves and are connected at intervals by short transverse branches. The superficial veins are the cephalic (medial) and basilic (lateral) veins. They are linked by the median cubital vein anterior to the bicipital aponeurosis. The latter vein is most commonly used for venepuncture, however, considerable anatomic variation exists. MOORE, K.L; Clinically Oriented Anatomy, Williams and Wilkins, 1982, pp 740-1. Number: 949 The pudendal nerve: 1. Crosses the greater sciatic foramen. 2. Crosses the lesser sciatic foramen. 3. Gives off the inferior rectal (inferior haemorrhoidal) nerve. 4. Gives off the posterior cutaneous nerve of the thigh. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: A See: "Anatomy for Anaesthetists" Ellis and Feldman ISBN 0865427216 According to these authors: "The pudendal nerve (S2, 3, 4) provides the principal innervation of the perineum; its course is complex, passing from the pelvis, briefly through the gluteal region, along the side-wall of the ischiorectal fossa and through the deep perineal pouch to end by supplying the skin of the external genitalia. Arising as the lower main division of the sacral plexus (although dwarfed by the giant sciatic nerve), the pudendal nerve leaves the pelvis through the greater sciatic foramen below piriformis. It appears briefly in the buttock region, accompanied laterally by the internal pudendal vessels, merely to cross the dorsurn of the ischial spine and straightway disappear through the lesser sciatic foramen into the perineum, The nerve now traverses the lateral wall of the ischiorectal fossa, accompanied by the internal pudendal vessels, and lies within a distinct fascial. compartment on the medial aspect of obturator internus termed the pudendal canal (Alcock's canal). Within the canal, it first gives off the inferior rectal nerve which crosses the fossa to innervate the external anal sphincter and the perianal skin, then divides into the perineal nerve and the dorsal nerve of the penis.

62

The perineal nerve is the larger of the two. It bifurcates almost at once; its deeper branch enters the deep pouch and there supplies sphincter urethrae and the other muscles of the anterior perineum the ischio-cavernosus, bulbospongiosus and the superficial and deep transverse perinei. Its more superficial branch innervates the skin of the posterior aspect of the scrotum. The dorsal nerve of the penis (or clitoris) traverses the deep perineal pouch, pierces the perineal membrane near its apex, then penetrates the suspensory ligament of the penis to supply the dorsal aspect of this structure." The posterior cutaneous nerve of the thigh arises directly from the S1-3 roots of the sacral plexus. Number: 950 The sphenoplatine ganglion: 1. Receives parasympathetic inflow from the greater superficial petrosal nerve. 2. Provides secretomotor fibres to the lacrimal gland. 3. Receives sympathetic inflow via the deep petrosal nerve. 4. Provides parasympathetic supply to the pupillary sphincter. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: A See: "Anatomy for Anaesthetists" Ellis and Feldman ISBN 0865427216 According to these authors: "The sphenopalatine ganglion (which is associated closely with the maxillary nerve) is deeply placed in the upper part of the pterygopalatine fossa. It receives para-sympathetic, sympathetic and sensory nerve fibres. The parasympathetic component is derived from the greater superficial petrosal nerve which originates from the geniculate ganglion of the facial nerve (VII). This nerve traverses the petrous temporal bone then runs in a groove on the anterior surface of the bone deep to the trigeminal ganglion to enter the foramen lacerum. Here it is joined by the deep petrosal nerve to form the nerve of the pterygoid canal (the vidian nerve) which passes through the pterygoid canal to reach the sphenopalatine ganglion. These parasympathetic fibres, having arrived at the ganglion, have not completed their complicated journey. They are transmitted via the zygomaticotemporal branch of the

63

maxillary nerve to the lacrimal branch of the ophthalmic nerve by which they arrive at their final destination as secretomotor fibres to the lacrimal gland. Sympathetic fibres, derived from the internal carotid plexus, form the deep petrosal nerve which, as described above, reaches the ganglion via the nerve of the pterygoid canal. The sensory component is derived from the two sphenopalatine branches of the maxillary nerve. The sensory and sympathetic (vasoconstrictor) branches of the ganglion are distributed to the nose, nasopharynx, palate and orbit via the following branches: (i) The long sphenopalatine nerve passes medially through the sphenopalatine foramen, crosses the roof of the nasal cavity, then passes downwards and forwards along the nasal septum, grooving the vomer as it does so, to reach the incisive foramen and thence the mucous membrane of the roof of the mouth. It supplies filaments to the posterior part of the nasal roof, to the nasal septum, and to those parts of the gums and anterior part of the hard palate which are in relation to the incisor teeth. (ii) The short sphenopalatine branches also pass medially through the sphenopalatine foramen; they supply sensory fibres to the superior and middle conchae and to the posterior part of the nasal septum. (iii) The greater palatine nerve descends through the greater palatine canal, then emerges on to the hard palate from the greater palatine foramen just posterior to the palatomaxillary suture. It innervates the mucosa of the gums and hard palate as far forward as the level of the canine teeth. Other fibres pass backwards to serve both aspects of the soft palate and nasal branches pierce openings in the perpendicular plate of the palatine bone to supply the region of the inferior nasal concha. (iv) The lesser palatine nerves, two or occasionally three in number, pass through the greater palatine canal in company with the greater palatine nerve but emerge through separate lesser palatine foramina, which perforate the inferior and medial aspects of the tubercle of the palatine bone. They supply the soft palate, uvula and tonsil. (v) The pharyngeal nerve passes backwards through the pharyngeal canal in the posterior wall of the pterygopalatine fossa to supply an area of nasopharyngeal mucosa immediately behind the orifice of the Eustachian tube. (vi) The orbital branches are small; they constitute two or three fine twigs which pass through the superior orbital fissure to supply the adjacent periosteum and perhaps also to carry some secretomotor fibres from the sphenopalatine ganglion to the lacrimal gland." The parasympathetic supply to the pupillary sphincter arises from the ciliary ganglion. Interest in this neurological backwater has recently been rekindled by pain doctors! See: Klein RN, Burk DT, Chase PF. Anatomically and physiologically based guidelines for use of the sphenopalatine ganglion block versus the stellate ganglion block to reduce atypical facial pain.

64

Cranio. 2001 Jan;19(1):48-55. Cohen S, Trnovski S, Zada Y. A new interest in an old remedy for headache and backache for our obstetric patients: a sphenopalatine ganglion block. Anaesthesia. 2001 Jun;56(6):6067. Number: 983 The sphenoplatine ganglion: 1. Is situated in the pterygopalatine fossa. 2. Provides sensory innervation to the soft palate. 3. Receives sympathetic inflow via the deep petrosal nerve. 4. Provides sympathetic innervation of the nasopharynx. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: E See: "Anatomy for Anaesthetists" Ellis and Feldman ISBN 0865427216 According to these authors: "The sphenopalatine ganglion (which is associated closely with the maxillary nerve) is deeply placed in the upper part of the pterygopalatine fossa. It receives para-sympathetic, sympathetic and sensory nerve fibres. The parasympathetic component is derived from the greater superficial petrosal nerve which originates from the geniculate ganglion of the facial nerve (VII). This nerve traverses the petrous temporal bone then runs in a groove on the anterior surface of the bone deep to the trigeminal ganglion to enter the foramen lacerum. Here it is joined by the deep petrosal nerve to form the nerve of the pterygoid canal (the vidian nerve) which passes through the pterygoid canal to reach the sphenopalatine ganglion. These parasympathetic fibres, having arrived at the ganglion, have not completed their complicated journey. They are transmitted via the zygomaticotemporal branch of the maxillary nerve to the lacrimal branch of the ophthalmic nerve by which they arrive at their final destination as secretomotor fibres to the lacrimal gland. Sympathetic fibres, derived from the internal carotid plexus, form the deep petrosal nerve which, as described above, reaches the ganglion via the nerve of the pterygoid canal.

65

The sensory component is derived from the two sphenopalatine branches of the maxillary nerve. The sensory and sympathetic (vasoconstrictor) branches of the ganglion are distributed to the nose, nasopharynx, palate and orbit via the following branches: (i) The long sphenopalatine nerve passes medially through the sphenopalatine foramen, crosses the roof of the nasal cavity, then passes downwards and forwards along the nasal septum, grooving the vomer as it does so, to reach the incisive foramen and thence the mucous membrane of the roof of the mouth. It supplies filaments to the posterior part of the nasal roof, to the nasal septum, and to those parts of the gums and anterior part of the hard palate which are in relation to the incisor teeth. (ii) The short sphenopalatine branches also pass medially through the sphenopalatine foramen; they supply sensory fibres to the superior and middle conchae and to the posterior part of the nasal septum. (iii) The greater palatine nerve descends through the greater palatine canal, then emerges on to the hard palate from the greater palatine foramen just posterior to the palatomaxillary suture. It innervates the mucosa of the gums and hard palate as far forward as the level of the canine teeth. Other fibres pass backwards to serve both aspects of the soft palate and nasal branches pierce openings in the perpendicular plate of the palatine bone to supply the region of the inferior nasal concha. (iv) The lesser palatine nerves, two or occasionally three in number, pass through the greater palatine canal in company with the greater palatine nerve but emerge through separate lesser palatine foramina, which perforate the inferior and medial aspects of the tubercle of the palatine bone. They supply the soft palate, uvula and tonsil. (v) The pharyngeal nerve passes backwards through the pharyngeal canal in the posterior wall of the pterygopalatine fossa to supply an area of nasopharyngeal mucosa immediately behind the orifice of the Eustachian tube. (vi) The orbital branches are small; they constitute two or three fine twigs which pass through the superior orbital fissure to supply the adjacent periosteum and perhaps also to carry some secretomotor fibres from the sphenopalatine ganglion to the lacrimal gland." Interest in this neurological backwater has recently been rekindled by pain doctors! See: Klein RN, Burk DT, Chase PF. Anatomically and physiologically based guidelines for use of the sphenopalatine ganglion block versus the stellate ganglion block to reduce atypical facial pain. Cranio. 2001 Jan;19(1):48-55. Cohen S, Trnovski S, Zada Y. A new interest in an old remedy for headache and backache for our obstetric patients: a sphenopalatine ganglion block. Anaesthesia. 2001 Jun;56(6):6067.

66

Number: 999 All of the following nerves arise from cords of the brachial plexus, EXCEPT: A. Dorsal scapular (Nerve to rhomboids). B. Lateral pectoral. C. Thoracodorsal. D. Median. E. Ulnar. Select the single best answer ABCDE Correct Answer: A The Dorsal Scapular Nerve (nerve to the rhomboids). From the brachial plexus a posterior branch from the C5 root passes through scalenus medius, runs down deep to levator scapulae (which it supplies) and lies on the serratus posterior superior muscle to the medial side of the descending branch of the transverse cervical artery. It supplies each rhomboid on the deep surface. ANAESTHESIA MONITORING TESTS Number: 3 The train-of-four (TOF) ratio measured at the adductor pollicis (AP) which is commonly accepted as correlating with adequate reversal of neuromuscular blockade (NMB) is: A. 0.5. B. 0.6. C. 0.7. D. 0.8. E. 0.9. Select the single best answer ABCDE Correct Answer: C Torda has recently published a superb review entitled "Monitoring Neuromuscular Transmission". According to this author "In fact, what constitutes adequate recovery is in some dispute. The commonly accepted figure of 0.7 for the TOF ratio of the AP as 'adequate reversal' appears to have been introduced about 25 years ago. More recent work has called this 'standard' into serious doubt. The criteria for choosing 0.7 as the critical ratio were that patients were able to produce peak inspiratory pressure of -25 cm H20 and that their ventilation was normal. Swallowing and coughing, however, requires better neuromuscular recovery, equivalent to an inspiratory pressure of ~45 cm H20. The group from the University of Copenhagen, which is often quoted in this review, suggested 0.8 as the minimum adequate level of recovery. Bevan

67

has suggested that upper airway obstruction was possible following small doses of NMB drugs and may cause morbidity. Eriksson et al have shown that at TOF ratio of the AP of 0.7 there is significant weakness of the muscles of swallowing and contrast media entered the laryngeal vestibule in 25% of subjects under the study conditions. They concluded that patients with TOF ratio < 0.9 are at increased risk of pulmonary aspiration. Another possible source of adverse effects is the demonstrated 25% reduction in hypoxic respiratory response following partial NMB with the TOF ratio at 0.7. The significance of partial paralysis as a risk factor in postoperative pulmonary complications has been prospectively documented." Thus, although I have cited 0.7 as the 'correct' answer, 0.9 is probably more appropriate. See: Torda TA. Monitoring Neuromuscular Transmission. Anaesth. Int. Care. 2002, April (30): 123-133. Number: 9 The pattern of neural stimulation which is most useful for monitoring profound neuromuscular blockade (NMB) is: A. Train-Of-Four (TOF). B. Double Burst Stimulation (DBS). C. 50 hz tetanic burst (T50). D. 100 hz tetanic burst (T100). E. Post-tetanic Count (PTC). Select the single best answer ABCDE Correct Answer: E Torda has recently published an excellent review entitled "Monitoring Neuromuscular Transmission". The order of utility (least appropriate to most appropriate) appears to be: TOF, DBS, T50, T100, PTC - that is in the order A,B,C,D,E above. According to Torda, "Intense NMB cannot be quantified by twitch or TOF stimulation. Even before there is a return of a response to TOF, some quantitation of the NMB can be made by exploiting the Post-Tetanic Facilitation (PTF) phenomenon. The post-tetanic count (PTC) is elicited by administering a 5 s, 50 Hz tetanic train, followed after a 3 s pause by twitches at 1 Hz. A count of 10 or 11 twitches coincides usually with the reappearance of the first response to TOF stimulation. This can be used to maintain intense NMB but of course, it is not useful in predicting reversability of the NMB or the absence of residual blockade." A post-tetanic burst technique has also been described which is as good as the PTC for the monitoring of prfound NMB. See: Torda TA. Monitoring Neuromuscular Transmission. Anaesth. Int. Care. 2002, April (30): 123-133. Number: 40

68

This tracing was recorded from the distal lumen of a Swan-Ganz catheter inserted to a distance of 32 cms via the left subclavian vein with balloon inflated. The waveform shown below most probably represents: A. An unwedged pulmonary artery pressure trace. B. A wedged pulmonary artery pressure trace from a patient with mitral incompetence. C. A right ventricular pressure trace. D. 'Cannon' waves in a right atrial pressure trace. E. A coronary sinus pressure trace. Select the single best answer

ABCDE Correct Answer: C This is a typical right ventricular pressure trace. Note the low diastolic pressure (similar to the central venous pressure) which tends to rise through the diastolic interval as the ventricle becomes filled. Note also that the systolic wave is timed to the 'T' wave of the ECG. - If this were a wedged trace from the pulmonary artery of a patient with mitral incompetence, the systolic wave would be timed after the 'T' wave. If this were an unwedged pulmonary artery pressure trace, the diastolic pressure would be higher and tend to fall during the diastolic interval. Cannon waves cannot occur in the presence of regular sinus rhythm (such as is the case here).

69

Number: 42 Which of the following units are BASIC SI units of measurement? 1. Kilometre. 2. Candela. 3. Watt. 4. Kilogram. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: C There are seven basic units of measurement in the SI system. These are: Unit of length: meter: The meter is the length of the path travelled by light in vacuum during a time interval of 1/299 792 458 of a second. Unit of mass: kilogram: The kilogram is the unit of mass; it is equal to the mass of the international prototype of the kilogram. Unit of time: second: The second is the duration of 9 192 631 770 periods of the radiation corresponding to the transition between the two hyperfine levels of the ground state of the cesium 133 atom. Unit of electric current: ampere: The ampere is that constant current which, if maintained in two straight parallel conductors of infinite length, of negligible circular cross-section, and placed 1 meter apart in vacuum, would produce between these conductors a force equal to 2 x 10-7 newton per meter of length. Unit of thermodynamic temperature: kelvin: The kelvin, unit of thermodynamic temperature, is the fraction 1/273.16 of the thermodynamic temperature of the triple point of water. Unit of amount of substance: mole: 1. The mole is the amount of substance of a system which contains as many elementary entities as there are atoms in 0.012 kilogram of carbon 12; its symbol is "mol." 2. When the mole is used, the elementary entities must be specified and may be atoms, molecules, ions, electrons, other particles, or specified groups of such particles. Unit of luminous intensity: candela: The candela is the luminous intensity, in a given direction, of a source that emits monochromatic radiation of frequency 540 x 1012 hertz and that has a radiant intensity in that direction of 1/683 watt per steradian.

70

A permanent transvenous pacemaker set 'DDDR': 1. 2. 3. 4. Can change the pacing rate during exercise. Will inhibit Atrial Pacing in the presence of atrial systole. Can be made to go faster by tapping over the box. Can be inhibited by surgical diathermy.

A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: E The 4 letters refer to the chamber being paced, the chamber sensed, the pacing mode and whether or not the device is rate adaptive. The devices can be reset either with a programmer, or if immediate conversion to VOO is required, with a simple magnet. If the unit is rate adaptive, tapping over the box (which is interpreted as muscle activity by the pacemaker) will temporarily increase the rate. An increase in heart rate is a major determinant of increased cardiac output during exercise and various sensing techniques have been used to trigger rate adaption during exercise: - If P waves are present SA node activity can be used. - If P waves are absent: 1. Muscle activity can be detected piezo-electrically. 2. Minute ventilation changes can be detected by measuring the cyclical change in impedance between the electrode tip and the pulse generator. 3. QT shortening (which occurs during exercise as a result of neurohumoral mechanisms), can be measured. A fifth category is used by some pacemakers and refers to the antiarrhythmic functions of the device. Thus the performance criteria of all pacemakers can be defined according to the following table: Chamber Paced Chamber Sensed Response to sensing Antiarrhythmic Function O = None O = None A = Atrial P = Pacing V = Ventricle S = Shock O = None A = Atrial V = Ventricle O = None T = Triggered I = Inhibited Programmability O = None P = Simple M = Multi

71

D = Dual (A+V) D = Dual (P+S)

D = Dual (A+V)

D = Dual (T+I)

R = Rate modulated

The antiarrhythmic functions include overdrive pacing for VT and SVT and the capacity to deliver a 25 J shock for VF. Prys-Roberts, C; Current Opinion in Anesthesiology, 4, 1991, pp 130-133. Zaiden, J.R. Pacemakers. Anesthesiology, 60, 1984, pp 319 et seq. Baig, MW and Perins, EJ. The Haemodynamics of Cardiac Pacing. Progress in cardiovascular disease. (1991). 33: pp283 et seq. Number: 80 What is the largest size endotracheal tube that will pass readily through the lumen of a size 3 laryngeal mask airway (LMA)? A. B. C. D. E. 6.00 mm (Internal Diameter (ID). 6.50 mm ID. 7.00 mm ID. 7.5 mm ID. 8.0 mm ID. Select the single best answer

ABCDE Correct Answer: A A size 3 or 4 LMA will allow up to a size 6.00 mm ID endotracheal tube to be passed without an introducer. Reference: ATKINSON, R.S. ET AL (EDS); Lee's Synopsis of Anaesthesia, 11th Ed., Butterworth, 1993, p227. Dr Douglas Fahlbusch has supplied the information that: 1. An adult size 5 LMA takes a 7.0 ID Endotracheal tube (ETT). In paediatric practice: 1. A size 2.5 LMA will allow the passage of a 5.0 mm ID ETT or a 4.0mm outside diameter flexible bronchoscope with an ETT loaded on it. 2.A size 1 LMA will allow the passage of a 3.5 mm ID ETT which will protrude 8 cm from grille using ETT adaptor

72

Number: 81 With respect to electronic defibrillators, which of the following are associated with increased transthoracic impedance? 1. Triggering during inspiration. 2. Repeated shocks. 3. Inadequate use of coupling gel. 4. Small paddle size. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: B Defibrillation is accomplished by passage of sufficient electrical current through the heart. Current flow (amperes) is determined by the energy chosen (joules) and the transthoracic impedance or resistance to current flow (ohms). The average transthoracic impedance in adults is 70-80 ohms. Recommended energy requirements for cardioversion and defibrillation are calculated on this assumption. If transthoracic impedance is unexpectedly high, insufficient current may be generated from shocks using standard energy levels. Transthoracic impedance is increased with inspiration, large paddle size, inadequate use of coupling gel, excessive gel outside of the paddles which allows the current to dissipate, and inadequate force applied by the operator. Transthoracic impedance decreases with successive shocks. Theoretically, the energy required on successive shocks should not need to be increased, however, the recommendations are that they be increased. (ie 200, 300, 360 J). References 1992 National Conference on Cardiopulmonary Resuscitation (CPR) and Emergency Cardiac Care (ECC), JAMA - Symposium issue, vol 268, no 16, October 28th, 1992, p 2212. Number: 82 With reference to perioperative myocardial ischaemia as detected by the ECG, which of the following are correct? 1. QRS complexes with a taller R wave exhibit greater ST depression in response to ischaemia. 2. Minor degrees of ST depression often result by going from a .05 Hz cutoff to a O.5 Hz cutoff. 3. It may mimic changes produced by subarachnoid haemorrhage. 4. The "monitor" mode is preferable to the "diagnostic" mode.

73

A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: A The taller the R wave, the greater the amount of ST depression that will occur during an ischaemic episode. This phenomena is known as the "R wave gain factor", and is a well known cause of greater amounts of ST depression in response to ischaemia. Treadmill studies have been made more sensitive and specific by normalizing for the interpatient variability in R wave amplitude. It is well known that subarachnoid haemorrhage can produce a variety of ECG changes, including T inversion or flattening, ST depression or elevation, and QT prolongation. Monitor and diagnostic modes on ECG monitors alter the frequencies filtered out to produce the final displayed signal. Monitor mode usually filters out frequencies below 4 Hz (0.5 Hz in some machines), whereas diagnostic mode filters frequencies below 0.05 -0.1 Hz. Although a higher filtration cutoff renders the baseline more stable, an isoelectric ST segment may become elevated or depressed, mimicking ischaemia. Therefore, going from a 0.05 to 0.5 Hz cutoff may produce ST depression. Diagnostic mode is preferred for this reason. MILLER, R.D (ED); Anesthesiolgy, Churchill Livingstone, 2nd Ed., 1986. ASA Annual Refresher Course Lectures, 1991. HOLLENBERG, M.ET AL;" Influence of R wave amplitude on exercise induced ST depression: need for a gain factor correction when interpreting stress electrocardiograms ", Am J Cardiol, 56, 1985, pp 13-17. SLOGOFF, S & KEATS, A.S; " Does perioperative myocardial ischaemia lead to postoperative myocardial infarction? ", Anesthesiology, 62, 1985, pp 107-114. Number: 83 When using a pulmonary artery flotation catheter: 1. Complete heart block can be precipitated in patients with left bundle branch block (LBBB). 2. Measurement of cardiac output is equally as accurate with room temperature and ice cold injectates. 3. Obesity increases the gradient between PCWP and left atrial pressure. 4. Mixed venous blood samples can be drawn from the port distal to the wedged balloon. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct

74

D: 4 Correct E: All Correct ABCDE Correct Answer: A Complete heart block is a well documented complication of these devices in patients with preexisting LBBB, possibly due to mechanical trauma to the vulnerable subendocardial portion of the right bundle. Although the signal to noise ratio is improved by using ice cold injectate, room temperature injectates are equally as accurate for measurement of cardiac output by thermodilution. Moreover, ice cold solutions may precipitate arrhythmias (atrial fibrillation and bradyarrhythmias). The assumption made when interpreting PCWP measurements as an index of left atrial pressure (LAP), is a continuous column of blood between the wedged balloon and the left atrium, with the pressure equilibrated throughout. This correlation becomes tenuous in the presence of high airway pressures and pulmonary vascular disease. The PCWP-LAP gradient will be increased by PEEP, CPAP, airway obstruction, obesity and hypovolemia. A wedged catheter can only conceivably draw blood from an area distal to itself, and therefore may contain some pulmonary capillary blood, which would artificially elevate the mixed venous oxygen tension. BLITT, C.D.; Monitoring in Anesthesia and Critical Care Medicine, Churchill Livingstone, New York, 1985. Number: 157 Which of the following are methods of measuring the content of oxygen in a gas mixture? 1. Paramagnetic analysis 2. Mass spectrometry. 3. Fuel cell analysis 4. Katharometry. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: A

75

The measurement of gases by katharometry is dependent upon the property of the gas to be thermally conducted. If resistance elements are incorporated into an electric circuit, and the gas to be measured introduced across the circuit, them the change in temperature will cause a change in electrical resistance, resulting in a potential difference. This potential difference is related to the content of the gas. CO2 and helium, but not oxygen are measured in this way. References SYKES, M.K. VICKERS, M.D. & HULL, C,J; Principles of Measurement and Monitoring in Anaesthesia and Intensive Care, 3rd Ed., Blackwell, 1991, p 228. Number: 158 With regard to a pneumotachograph: 1. It is a fixed orifice, variable pressure device. 2. It measures laminar flow. 3. The pressure drop across the resistance component is generally low. 4. It may be inaccurate in infants. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: E A pneumotachograph is a rapid response, fixed orifice/variable pressure device for measuring either constant or intermittent gas flows. It incorporates a flow chamber, resistance component, pressure transducer, and thermostat. The principle is that laminar flow across the resistance component will cause a pressure drop across the resistance which is determined by the flow and the resistance. When the resistance is known, the flow is directly related to the pressure gradient (this is an analog of Ohm's Law). The transducer may be associated with a microprocessor, amplifier, display, and recording facility. These would be seen in units located within pneumotachographs used in respiratory function testing, or in modern spirometers. The pressure drop is kept to a minimum by anticipating the range of flows and adjusting the resistance accordingly. It is usually of the order of 1-2 mm Hg. This is necessary in order to preserve laminar flow (and hence the direct relationship between pressure and flow ), and to minimize any additional resistance in the unit which may cause inaccuracies in measurement. The dead space is of the order of 16 mls which may cause inaccuracies at low tidal volumes (ie. neonates) References

76

SYKES, M.K. VICKERS, M.D. & HULL, C,J; Principles of Measurement and Monitoring in Anaesthesia and Intensive Care, 3rd Ed., Blackwell, 1991, pp 201-2. Number: 159 What arterial-end tidal CO2 tension difference would be expected to exist in a fit, young patient undergoing general anaesthesia? A. 0 mm Hg. B. 5 mm Hg. C. 10 mm Hg. D. 15 mm Hg. E. No single value can be expected; it is highly variable in this population. Select the single best answer ABCDE Correct Answer: B In a healthy awake subject, the end-tidal CO2 tension (ETCO2) is an indirect measure of arterial CO2 tension (PaCO2). The theoretical basis for this is that gas sampled at endexpiration represents alveolar gas which is in equilibrium with pulmonary end-capillary (arterial) blood. An "arterial-end expiratory PCO2 difference" has been observed to occur during anaesthesia in otherwise healthy, young subjects. This is generally of the order of 3-4 mm Hg. It is attributed to an increase in dead space ventilation during anaesthesia. In elderly subjects and those with preexisting lung disease, it has been recorded as high as 18 mmHg. Other causes include the supine position, positive pressure ventilation, and surgery. Paradoxically, in some patients (eg pregnant women at term), the ETCO2 can exceed the arterial CO2. References ROGERS, M.C ET AL (EDS); Principles and Practice of Anesthesiology, Mosby, 1993, pp 786. Number: 160 The safety coding features existing for all enflurane vapourizers and refill bottles are: A. A single pin and groove. B. Two pins and one groove. C. A groove only. D. An individualized shape for the block. E. None of the above. Select the single best answer

77

ABCDE Correct Answer: A Three identification devices exist to prevent inadvertent use of the wrong volatile anaesthetic agent. These are: (1) Colour coding- Trichloroethylene is coloured blue. In addition to this, all agents are packaged with individualized coloured labels. (2) Special key or pin filling devices- The commonly used agents are poured by specific key filling devices. In these, the pouring tube has a special block on the end of it, and a square cavity on the vapourizer to receive the filling block. Specificity is achieved by the position of the special groove on one side of the block. This groove mates with a short pin protruding from the wall of the square socket. The lower face of the block has liquid and air holes which allow the vapourizer to fill when the liquid agent in the bottle is inverted. (3) Individualized bottle necks and threads- There is a common agreement amongst manufacturers that the bottles for each agent have necks with the same screw thread regardless of which company produces them. Each agent has a different size neck and thread. References RUSSELL, W.J; Equipment for Anaesthesia and Intensive Care, 1983, pp 81-2. Number: 161 A Semi-rigid oxygen mask receiving an oxygen flow of 10 L/min will deliver what concentration of oxygen to the patient? A. 30%. B. 40%. C. 50%. D. 60%. E. 70%. Select the single best answer ABCDE Correct Answer: D A semi-rigid oxygen mask is an example of a variable performance system. Here, the fractional inspired oxygen concentration is dependent on the flow rate, patient ventilation, and device factors, including the fit of the mask. These devices will only be able to deliver 100% oxygen if the flow rate exceeds the patient's peak inspiratory flow rate. This is generally five times the resting minute volume or 25-35 L/min.

78

References T.E. OH; Intensive Care Manual, 3rd Ed., p 131. T.E. OH & DUNCAN, A.W; " Oxygen Therapy ", The Medical Journal of Australia, vol 149, August 1, 1988. (REVIEW) Number: 162 In an " in-series ", twin system soda lime, what is the most reliable sign of exhaustion (the "break point") of the upstream canister? A. Mixed expired CO2 concentration of 4%. B. Colour change throughout canister. C. Cooling of the first (upstream) canister. D. Warming of the second (downstream) canister. E. None of the above. Select the single best answer ABCDE Correct Answer: D Generally, a soda lime is considered at the end of its useful life when about 0.5% of CO2 is leaking through, with a mixed expired gas concentration of 4%. This is called the "break point". This is reached gradually, as the efficiency of the soda lime decreases with time. The "break point" of a single canister is of less importance when it is used in series with a second canister. This is because the first or upstream canister will absorb CO2 preferentially and be exhausted before there is significant utilization of the second or downstream canister. In this situation, exhaustion of the first will not be realized as an increasing mixed expired concentration of CO2. Exhaustion of the upstream canister will be suggested by its cooling or colour change, but the most reliable indication is probably warming of the downstream canister which is now receiving a larger load of CO2. References RUSSELL, W.J; Equipment for Anaesthesia and Intensive Care, 1983, pp 11-12. Number: 163 Which is the most efficient breathing system during controlled ventilation? A. Mapleson A. B. Mapleson B. C. Mapleson C. D. Mapleson D. E. Mapleson E. Select the single best answer

79

ABCDE Correct Answer: D The Mapleson A circuit is the only circuit which has the fresh gas flow distally located near the reservoir bag, The pressure release valve is located near the patient. The performance of this circuit differs dramatically between situations of spontaneous and controlled ventilation. During spontaneous ventilation with the valve fully open, the patient inhales only fresh gas flow. During exhalation, all expired gases are directed out the valve, and the reservoir/expiratory limb is again filled with fresh gas flow. This circuit provides the least amount of rebreathing in this situation. During controlled ventilation with the valve fully closed, expired gases will be directed into the reservoir limb so that on inspiration rebreathing will occur. To prevent rebreathing in this situation, very large gas flows are required and the valve must be partially open. In the Mapleson B circuit, the fresh gas flow and pressure release valve are located close to the patient; the reservoir limb is not the source of fresh gas as in the type A circuit. This circuit is less efficient than the A in spontaneous breathing and also allows rebreathing in controlled ventilation. In the Mapleson C circuit, fresh gas flow, valve, and reservoir bag are all located close to the patient, hence rebreathing is reduced in both situations. It provides less rebreathing than the A during controlled ventilation. The Mapleson D circuit features a fresh gas flow which is located close to the patient and a pressure release valve and reservoir bag which are located distally. During spontaneous ventilation, the fresh gas flow is directed toward the patient, and any overflow is directed into the expiratory limb. During expiration, expired gas is directed up the expiratory limb and is diluted with fresh gas flow. If the fresh gas flow is sufficiently high to fill the expiratory limb, or when the fresh gas volume in the expiratory limb is equal to the tidal volume, then no rebreathing of expired gas occurs during inspiration. During controlled ventilation, the expiratory limb is pressurized by occlusion. Fresh gas and some expiratory gas flow toward the patient. The greater the fresh gas flow, the less rebreathing occurs. During spontaneous ventilation, the Mapleson D circuit requires higher fresh gas flow than the Mapleson A circuit to ensure no rebreathing; however, this is the most efficient circuit for CO2 elimination during controlled ventilation. References: ROGERS, M.C ET AL (EDS); Principles and Practice of Anesthesiology, Mosby, 1993, pp 2157-9. Number: 164 When a sphygmomanometer is attached to the common gas outlet of an anaesthetic machine and the oxygen flow meter is turned on, in the absence of leaks upstream: A. A flow of 100 ml/min maintains a pressure of 25 mm Hg. B. A flow of 500 ml/min maintains a pressure of 25 mm Hg. C. A flow of 100 ml/min maintains a pressure of 50 mm Hg.

80

D. A flow of 500 ml/min maintains a pressure of 50 mm Hg. E. None of the above. Select the single best answer ABCDE Correct Answer: A The Australian protocol for checking leaks upstream from the common gas outlet recommends the use of a sphygmomanometer attached to the common gas outlet. The oxygen flow meter is turned on to a flow of 100 ml/min. In the absence of significant leaks, this should maintain a pressure of 25 mm Hg. References ANDREWS, J; " Checking Anaesthesia Machines ", Australian Anaesthesia 1990, pp 162-3. Number: 165 During the use of uncuffed endotracheal tubes in paediatric patients, a gas leak should ideally be elicited with an inspiratory pressure of: A. 10 cm H2O. B. 20 cm H2O. C. 30 cm H2O. D. 40 cm H2O. E. 50 cm H2O. Select the single best answer ABCDE Correct Answer: B The air leak test around an endotracheal tube is performed by slowly increasing airway pressure while noting the airway pressure at which audible air begins to leak around the endotracheal tube into the glottis. The ideal range is considered 15-20 cm H2O, with a safe range of 10-30 cm H2O. References ROGERS, M.C. ET AL (EDS); Principles and Practice of Anesthesiology, Mosby, 1993, pp 2162. Number: 166 Which of the following materials are flammable in air? 1. Polyethylene. 2. Polyvinylchloride (PVC). 3. Polymethylmethacrylate. 4. Polytetrafluoroethylene (Teflon).

81

A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: B Polyethylene and polymethylmethacrylate are flammable in air. Teflon requires 100% oxygen for flammability. PVC requires 26.3% oxygen in nitrogen to support combustion. One implication of the latter is that if an inspired oxygen concentration of 25% is used, then a sustained flame from an ignited PVC endotracheal tube is not possible. This is of particular relevance to laser surgery of the oral cavity. References WOLF, G.L.; " Flammability of Medical Equipment in Oxygen Enriched Atmospheres ", Australian Anaesthesia 1990, pp 149-50. Number: 167 A filling ratio is used when filling cylinders of : 1. CO2. 2. Cycloproprane. 3. N2O. 4. Entonox. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: A Filling ratios are used in the filling of cylinders whose contents are liquified under pressure. Cylinders containing oxygen, nitrogen, argon, helium, and air are filled under pressure to a nominal pressure of about 13,700 kPa. Because they remain in the gaseous state, cylinder pressure alone can be used as a guide to filling. N2O, CO2, and cycloproprane are liquifiable gases. When these cylinders are filled under pressure, gas entering the cylinder will form liquid, with the vapour pressure remaining unchanged. Pressure cannot be used as a guide to filling. These cylinders are thus weighed. The nominal weight at which the cylinder is considered " filled " is given by the filling ratio. The filling ratio of the gas is defined as the

82

weight of the gas in the cylinder to the water capacity at 15 degrees celsius. The filling ratio is an arbitrary value based on the expected behaviour of the agent. For instance, the filling ratio of N2O is 0.67 in tropical and sub-tropical climates (Australia), and 0.75 in temperate climates (United Kingdom). The filling of Entonox requires a special procedure because oxygen will remain as a gas and N2O will liquify under pressure. The mixture is manufactured by compressing the correct amount of N2O by weight in a cylinder. The pressure (about 5,000 kPa) causes some of it to liquify. Oxygen is then introduced into the cylinder and bubbles through the N2O. Initially, N2O is vapourized and oxygen dissolves into this mixture. Gradually, the cylinder pressure rises and the liquid evaporates. A cylinder pressure of about 12,000 kPa will be reached when the oxygen concentration reaches 50%. References RUSSELL, W.J.; Equipment for Anaesthesia and Intensive Care, 1983, p 16. Number: 168 What is the maximum allowable negative pressure applied across the interface of an active scavenging system? A. 0.1 cm H2O. B. 0.5 cm H2O. C. 1 cm H2O. D. 5 cm H2O. E. 10 cm H2O. Select the single best answer ABCDE Correct Answer: B An active scavenging system uses vacuum to remove waste gases. Interfaces are essential in active scavenging systems to ensure that the suction is not directly applied to the patient. An interface should ensure that no more than 0.5 cm H2O of negative pressure, nor 3.5 cm H2O of positive pressure are applied to the patient's circuit at any time. References RUSSELL, W.J.; Equipment for Anaesthesia and Intensive Care, 1983, p 123. Number: 169 What is the most important determinant of CO2 elimination during ventilation with an anaesthetic circuit not using a CO2 absorber? A. The type of circuit (Mapleson A,B,C,D,E,F) B. The mode of ventilation (spontaneous versus controlled).

83

C. The minute ventilation. D. The fresh gas flow. E. All of the above are equally important and must be considered within context. Select the single best answer ABCDE Correct Answer: D The elimination of CO2 during ventilation with a circuit which does not incorporate a CO2 absorber is determined by the extent of rebreathing which occurs. The type of circuit is important but this is usually dependent upon the mode of ventilation; the Mapleson A circuit ia associated with the least amount of rebreathing during spontaneous ventilation, but is inefficient during controlled ventilation. Under these conditions the D circuit is considered most efficient. In relation to this, the mode of ventilation is also important but variable. Respiratory rate, peak inspiratory flow rate, and tidal volume all influence elimination of CO2. The minute ventilation is the primary determinant of CO2 elimination when a CO2 absorber is in the circuit ( a reciprocal relationship exists which is independent of fresh gas flow), but is not a major determinant in the absence of CO2 absorption. In this situation, the fresh gas flow is the most important determinant of rebreathing, and hence, CO2 elimination. References ROGERS, M.C. ET AL (EDS); Principles and Practice of Anesthesiology, Mosby, 1993, pp 2159. Number: 170 Which of the following traces require a prompt response during the continuous measurement of intracranial pressure (ICP)? 1. Flattened trace. 2. C waves. 3. A waves. 4. B waves. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: B Pulsations from the choroid plexus are transmitted to the CSF in the ventricular and subarachnoid spaces and produce a waveform similar, but of lower amplitude, to the arterial pressure. A normal waveform rises sharply initially, then slopes toward the baseline. The

84

amplitude remains under 15 mm Hg. Several abnormal waveforms may be observed whilst monitoring a patient with intracranial pathology. (1) A waves- vary in intensity and amplitude, range from 50-100 mm Hg, and last 5-20 minutes. These are also known as "plateau" waves and occur when ICP rises rapidly above 50 mm Hg. They should be interpreted as a deterioration in the patient's condition which requires immediate treatment. (2) B waves-these are sharp rhythmic fluctuations that can occur in conjunction with changes in respiration and/or blood pressure. They sometimes precede A waves. They may rise as high as 50 mmHg, and usually occur every 50 seconds to 2 minutes. Whilst they may herald serious rises in ICP, B waves generally do not require prompt treatment. (3) C waves- these are also rhythmic fluctuations that correlate with changes in respiration and blood pressure, but are not as sharp or as rapid as B waves. They are small and rapid; usually occurring at a rate of four to eight per minute, and are not clinically significant. Flattening of the trace usually represents excessive damping which will reduce the usefulness of the measurement. References LUCHKA, S.; " Working with ICP monitors ", RN, April, 1993, pp 34-7. Number: 170 Which of the following traces require a prompt response during the continuous measurement of intracranial pressure (ICP)? 1. Flattened trace. 2. C waves. 3. A waves. 4. B waves. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: B Pulsations from the choroid plexus are transmitted to the CSF in the ventricular and subarachnoid spaces and produce a waveform similar, but of lower amplitude, to the arterial pressure. A normal waveform rises sharply initially, then slopes toward the baseline. The amplitude remains under 15 mm Hg. Several abnormal waveforms may be observed whilst monitoring a patient with intracranial pathology.

85

(1) A waves- vary in intensity and amplitude, range from 50-100 mm Hg, and last 5-20 minutes. These are also known as "plateau" waves and occur when ICP rises rapidly above 50 mm Hg. They should be interpreted as a deterioration in the patient's condition which requires immediate treatment. (2) B waves-these are sharp rhythmic fluctuations that can occur in conjunction with changes in respiration and/or blood pressure. They sometimes precede A waves. They may rise as high as 50 mmHg, and usually occur every 50 seconds to 2 minutes. Whilst they may herald serious rises in ICP, B waves generally do not require prompt treatment. (3) C waves- these are also rhythmic fluctuations that correlate with changes in respiration and blood pressure, but are not as sharp or as rapid as B waves. They are small and rapid; usually occurring at a rate of four to eight per minute, and are not clinically significant. Flattening of the trace usually represents excessive damping which will reduce the usefulness of the measurement. References LUCHKA, S.; " Working with ICP monitors ", RN, April, 1993, pp 34-7. Number: 171 With respect to storage of medical gases: 1. Air cylinders have black and white shoulders on grey bodies. 2. Some oxygen cylinders are painted green. 3. Nitrous oxide cylinders cool more quickly than oxygen cylinders. 4. Helium cylinders are painted orange. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: A Orange coloured cylinders are used for cycloproprane and mid brown cylinders are used for helium. Both air and nitrogen cylinders have a grey body; air has quartered black and white shoulders and nitrogen has all black shoulders. Although the Australian standard for oxygen is as described above, cylinders held on aircraft originating in the USA may actually be green. Adiabatic cooling occurs as a gas expands. It occurs in cylinders of both oxygen and nitrous oxide, however additional cooling occurs in nitrous oxide due the latent heat of vapourization as liquid enters the vapour phase.

86

References RUSSELL, W.J.; Equipment for Anaesthesia and Intensive Care, 1983. Number: 172 With regard to vacuum insulated evaporators (VIE) used in the storage of bulk oxygen: 1. Oxygen is stored mainly as a gas. 2. A temperature of about -150 degrees exists in the tank. 3. The oxygen content can be calculated by measuring the tank pressure. 4. The tanks are insulated with concentric steel shells and an evacuated space between. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: C The oxygen is stored mainly as a liquid by cooling. This cooling is achieved through the latent heat of vapourization generated as oxygen enters the gas phase on leaving the cylinder, and through insulation of the cylinder walls. If oxygen leaves too rapidly, rapid cooling occurs which may result in a pressure fall within the tank. This is regulated by a separate liquid oxygen drain which vapourizes in an external heat exchanger connected to the gas distribution system. The tank contents can be calculated from the weight but not the pressure, as the oxygen is mainly in the liquid form. References RUSSELL, W.J.; Equipment for Anaesthesia and Intensive Care, 1983, pp 24-6. Number: 173 Which of the following are true of rotameters? 1. There is generally a pressure drop across the rotating bobbin. 2. Temperature changes may cause inaccuracy. 3. Changes in density are more likely to cause inaccuracy in cyclopropane than viscosity. 4. Changes in density are more likely to cause inaccuracy in oxygen than viscosity. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct

87

ABCDE Correct Answer: C Temperature alters the rotameter mainly by its effect on viscosity and density. An increase in temperature from 10-35 degrees will, for most common medical gases, increase viscosity by 7%, and decrease density by 8%. The influence of viscosity is greatest at low flow, and of density at high flow. This is because of their respective effects on laminar and turbulent flow which occur at these ranges. At low flow, when viscosity is important, an increase in temperature causes an increase in viscosity and therefore a tendency to overread. The effects on density result in a tendency to underread at high flow. Normally, however, a change in temperature of a few degrees has no effect on accuracy. The range of flow for cyclopropane is within that of laminar flow, and that of air and oxygen is in turbulent flow. Rotameters are examples of variable orifice/constant pressure flowmeters. They are calibrated for a specific gas and have an accuracy of 3% at 1 ATM atmospheric pressure. References RUSSELL, W.J.; Equipment for Anaesthesia and Intensive Care, 1983, p 54. Number: 178 With regard to electrical safety in the operating room: 1. An isolated circuit provides total protection against microshock. 2. The minimum current applied externally that will cause VF is 1 ampere. 3. A core balance relay (ground fault detector) will alarm if an appliance has a broken ground wire. 4. Alternating current is at its most dangerous between 10-200 Hz. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: D The isolated circuit is powered by an additional transformer, but the return (neutral) wire is not connected to ground. In other words, there will be no potential difference between the live wire and ground. Therefore, the ideal isolated circuit would permit no current to flow if a bridge were to be created between the live wire and earth. This imparts a margin of safety to an individual who accidentally touches a live wire - such as may occur with a faulty appliance with a broken live wire which contacts the instrument casing. However, the ideal isolated circuit does not exist. Any appliance powered by alternating current will develop a small current in its casing due to the to and fro movement of electrons

88

in the circuitry. (Capacitance Current). A small potential difference is thus generated between the the circuit case and by default, between the circuit and ground since the casing is connected to a ground wire. As appliances are added to the circuit, the potential difference between the circuit and ground will increase, decreasing the isolation of the circuit. The leakage current under these circumstances may be enough to cause microshock if applied directly to the heart through conductors such as external pacemaker wires or saline filled central lines although the current will be too small to be detectable to the touch of the hand. Protection against microshock - which can occur with currents as small as 100 microamperes lies in the design of appliances that are to be attached to the patient. Macroshock requires significantly larger currents to cause VF. This is usually of the order of 100 millamperes. A core balance relay is designed to detect a difference in the current between the active and neutral wires and will shut off the current and/or alarm when the threshold difference is exceeded. Any difference will be due to current leaking to ground, such as may occur when a fault exists and the active wire contacts the casing of the appliance. Therefore, to function properly, such a relay requires an intact ground wire and will not function correctly if this wire is broken. Alternating current is most dangerous between 10-200 Hz, requiring significantly greater currents to cause VF outside these limits. References: BUCZKO, G.B. & MCKAY, W.P.S; " Electrical Safety in the operating room. ", Can. An. Soc. J. Anesth. 1987;34: pp 315-322. Number: 198 When using anaesthetic vaporisers: 1. The pumping effect is most marked at low flow rates. 2. In series, an ethrane vaporiser should be upstream of a halothane one. 3. With Vaporiser in Circle (VIC) as FGF is increased at a constant setting, the circuit concentration falls. 4. At high altitude a variable bypass vaporiser must be set to a higher dialled concentration to achieve the same delivered partial pressure compared to sea level. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: A

89

The pumping effect tends to increase the concentrations delivered by a vaporiser during IPPV. It is most marked with increasing back pressure, low FGF (cf pressurising effect which is converse) and lower dial setting of the vaporiser. It is minimised by modifications such as reducing the volume of the vaporising chamber relative to the bypass and increasing the volume of the inflow to the vaporising chamber. In series, the vaporiser delivering the agent with the lowest vapour pressure and highest MAC should be placed upstream. This will reduce the amount of cross contamination between the vaporisers. With VIC at low FGF, gas is recirculated more frequently through the vaporiser and takes up more agent with each passage. As the FGF is increased, so this effect becomes less marked and the concentration of the agent in the circuit falls. The effect of volatile agents on the brain is determined by their alveolar partial pressure, not the concentration. Because vapour pressure is independent of ambient pressure, the partial pressure of vapour delivered by a vaporiser at altitude will be the same as at sea level, although the concentration will rise since the partial pressure of the carrier gas will be lower. Therefore no adjustment to the dial setting is needed at altitude. Number: 202 When considering the detection of anaesthetic incidents: 1. Monitors are far more effective than anaesthetists at the initial detection of the impending incident. 2. A stethoscope is more cost:effective than a capnograph. 3. The ECG is useful at detecting an event before organ damage has occurred. 4. The capnograph and oximeter equally effective at initial detection. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: C References: Which Monitor? An analysis of 2000 incident reports. Webb RK et al. Anaesth. Intens Care 1993; 21: 529-542 This paper is one of several important papers in an issue of Anaesthesia and Intensive Care which was devoted to critical incident analysis. The net effect of the issue was (to say the least!) overwhelming and the creator of this question is still plodding dutifully through it.

90

Of the first 2000 incidents examined in the Australian Incident Monitoring Study, about half of the incidents were first detected by humans (48%) and half (52%) by one or other monitor. In the same study, the authors attempted to predict the likelihood of an individual monitor detecting an incident had it been allowed to evolve and the likelihood of this detection occurring before the potential for organ damage had occurred. On this basis, a stethoscope was virtually as effective as a capnograph, although the former was not as effective at early detection. Bearing in mind the cost differential, it must represent a more cost:effective instrument. An ECG was surprisingly deemed to be virtually ineffective at detecting critical incidents before the potential for organ damage had occurred - notwithstanding the fact that it apparently first detected 19% of monitor detected incidents. The capnograph first detected 24% of monitor detected incidents whereas the oximeter first detected 27%.

Number: 240 During the insertion of a pulmonary artery catheter, the incidence of ventricular arrhythmias can be reduced if: 1. The patient is placed 5 degrees head up. 2. The Internal Jugular route is used to insert the catheter. 3. The patient is rolled slightly to the right. 4. Lignocaine is given prior to passage of the catheter. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: B Positioning the patient 5 degrees head up with slight right lateral tilt during flotation of the catheter facilitates rapid transit of the catheter through the right ventricular outflow tract and reduces the likelihood of ventricular arrhythmias. The route of insertion and the 'prophylactic' administration of lignocaine has no effect on the incidence of arrhythmias. Keusch DJ, Winters S, and Thys DM. The patient's position influences the incidence of dysrhythmias during pulmonary artery catheterization. Anesthesiology 70:582-584, 1989.

91

Number: 243 A pulmonary artery catheter is contraindicated in a patient with:

1. A prosthetic Tricuspid Valve. 2. Tetralogy of Fallot. 3. Latex Allergy. 4. Type II Heparin Induced Thrombocytopenia. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: A The use of Heparin-bonded catheters is contraindicated in patients with Type II Heparin Induced Thrombocytopenia, but unbonded catheters can be safely used for short periods. 'Latex Free' catheters are not yet generally available for use in patients with latex allergy. As the balloons of all the manufacturers' catheters are made from latex, they should not be used in those with a history of allergy. Number: 249 The risk of pulmonary artery rupture associated with the use of a pulmonary artery catheter is higher in the presence of: 1. Advanced age. 2. Female gender. 3. Pulmonary hypertension. 4. Mitral stenosis, A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE

92

Correct Answer: E The risk factors which have been identified as increasing the likelihood of rupture include: Advanced age, female gender, pulmonary hypertension, mitral stenosis, anticoagulation and peripheral placement of the catheter tip. Most reported cases of rupture occur in association with balloon inflation or catheter manipulation. The incidence of pulmonary artery rupture may be reduced by: Staff training - in particular, teaching the importance of gradual balloon inflation, of watching the PA waveform continuously during balloon inflation and of stopping balloon inflation immediately a 'wedged' trace is observed. The use of a 'pilot' balloon which has a slightly lower compliance than that of the catheter balloon. If abnormal resistance is ignored during balloon inflation, a pilot balloon reduces the maximum attainable pressure within the catheter balloon from 1700 mm Hg to about 1000 mm Hg. Number: 250 Score: The incidence of sepsis related to the use of central venous catheters ('CRS') is increased if: 1. The line is left in place more than three days. 2. The internal jugular rather than the subclavian route is used. 3. A multi- rather than single lumen catheter is used. 4. Antibiotic prophylaxis is not used. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: A The longer a catheter is in place, the more likely it is to become infected. Furthermore, the risks of infection increase sharply if the PAC is in place for more than 3 days. If the risk of bacteraemia is expressed in terms of 'risk per catheter day', an incidence of 6-8 cases per 1000 catheter days is typical. The internal jugular route is associated with a fourfold increase in the risk of CRS as compared to the subclavian route.

93

Antibiotic prophylaxis has little effect on the incidence of CRS. Mermel LA; McCormick RD; Springman SR; Maki DG. The pathogenesis and epidemiology of catheter-related infection with pulmonary artery Swan-Ganz catheters: a prospective study utilizing molecular subtyping. Am J Med, 91(3B):197S-205S 1991 Number: 297 The likelihood of radial artery thrombosis complicating radial artery cannulation is increased if: 1. An 18G rather than a 20G catheter is used. 2. A polypropylene catheter has been used. 3. The patient suffers from Raynaud's phenomenon. 4. Aspirin has been administered preoperatively. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: A The incidence of radial artery thrombosis after cannulation has been extensively studied. Thrombosis has been found to correlate with the following factors: prolonged duration of cannulation, larger catheters, and smaller radial artery size (that is, a greater proportion of the artery is occupied by the catheter). Other factors associated with thrombosis in adults (but not in children) include polypropylene catheters and tapered catheters. The incidence of thrombosis is not affected by the technique of cannulation but is lowered with aspirin before treatment. Bedford RF: Radial arterial function following percutaneous cannulation with 18- and 20gauge catheters, Anesthesiology 47:37-39, 1977. Davis FM and Steward JM: Radial artery cannulation, BR J Anaesth 52:674-684, 1980. Bedford RF and Ashford TP: Aspirin pretreatment prevents post-cannulation radial-artery thrombosis, Anesthesiology 51:176-178, 1979. Number: 301 If holding a live electrical wire, what is the maximum current flow which an adult can tolerate before it becomes impossible to let go?

94

A. 1 mA. B. 5 mA. C. 10-20 mA. D. 50 mA. E. 100-300 mA. Select the single best answer ABCDE Correct Answer: C Following a 1-second contact with a 60-Hz source in an adult, a current level of: 1 mA will be just perceptible. 5 mA is accepted as the maximum harmless current. 10-20 mA is the maximum "Let-go" current before sustained muscle contraction occurs. 50 mA causes pain, possible fainting, but allows cardio-respiratory function to continue. 100-300 mA causes ventricular fibrillation, but the respiratory centre remains intact. Number: 320 Dead-space and alveolar gas flowing through standard anaesthetic circuit tubing will be completely mixed at a point: A. 0.25 metres along the tube. B. 0.50 metres along the tube. C. 1.0 metres along the tube. D. 1.25 metres along the tube. E. 1.50 metres along the tube. Select the single best answer ABCDE Correct Answer: C Spoerel WE: Rebreathing and carbon dioxide elimination with the Bain circuit, Can Anaesth Soc J 27:357-361, 1980. The pattern of gas flow through the circuit is almost always turbulent because of the corrugations in the tubing. This promotes both radial mixing and longitudinal mixing. In documenting performance of one circuit, Spoerel has demonstrated complete mixing of dead space and alveolar gas after gas has passed through one meter of such tubing.

95

Number: 398 With regard to an oxygen rotameter calibrated in the range 0 - 10 lpm at an indicated flow of 0.5 lpm: 1. The flow rate will still be 0.5 lpm if Nitrous Oxide is substituted for Oxygen. 2. The flow rate will still be 0.5 lpm if Helium is substituted for Oxygen. 3. Gas flow in the device will be orificial. 4. Gas flow in the device will be laminar. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: C Rotameters are examples of constant pressure, variable orifice flowmeters. At low flow rates, gas flow is essentially laminar and Poiseuille's law applies. When the flow rate is greater, turbulence occurs and flow becomes orificial. Flowmeters are not interchangeable among gases, and if a gas is passed through a rotameter for which it has not been calibrated, the flows shown are likely to be incorrect. However, at low flows, flow rates of gases with similar viscosities are read identically (e.g., oxygen and helium, 202 and 194 micropoise, respectively); and at high flows, gases of similar density (e.g., nitrous oxide and carbon dioxide, both of which have molecular weights of 44) are read identically. Number: 457 The most accurate measure of LVEDP on a wedged pulmonary artery pressure trace is: A. The mean value of the PAOP at the end of expiration. B. The peak of the 'A' wave at the end of expiration. C. The peak of the 'V' wave at the end of expiration. D. The peak of the 'A' wave at the end of inspiration. E. The mean value of the PAOP at the end of inspiration. Select the single best answer ABCDE

96

Correct Answer: B The peak of the 'A' wave at the end of expiration. - This point corresponds to the point of maximal distension of the ventricle and is the best measure of LVEDP (The 'Z' point). All intrathoracic intravascular pressure measurements should be made at the same phase of respiration. The end-expiratory point is generally agreed to be the most appropriate. Number: 464 A paralysed patient, under general anaesthesia is undergoing IPPV at a fixed rate and constant tidal volume. 200 mls of apparatus deadspace are inserted at the endotracheal tube connector. Which of the following statements are true? 1. End-tidal PCO2 will increase. 2. End-tidal to arterial PCO2 difference will increase. 3. Arterial PCO2 difference will increase. 4. Alveolar deadspace will increase. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: B The addition of apparatus ('serial') deadspace under these circumstances will increase the arterial and end-tidal PCO2, but there is no reason why alveolar ('Parallel') deadspace should change. Similarly, there is no reason why the difference between End-tidal to arterial PCO2 should be altered. Number: 495 To prevent rebreathing during spontaneous ventilation, the 'Bain' co-axial circuit requires a fresh gas flow of: A. 70 ml/kg/min. B. 100 ml/kg/min. C. 2.5 to 3 times minute ventilation.

97

D. 2.5 to 3 times alveolar ventilation. E. None of the above. Select the single best answer ABCDE Correct Answer: C Several studies have evaluated the fresh gas flow (FGF) requirements of the Bain system. When interpreting these data it is important to distinguish the FGF which can sustain normocarbia as opposed to the FGF which will effectively prevent rebreathing. (The latter being greater than the former). It has been found that during spontaneous ventilation, a FGF of 100 ml/kg/min produces normocarbia at the cost of increased minute ventilation. The FGF required to prevent rebreathing during spontaneous ventilation is 2.5 to 3 times the minute ventilation. During controlled ventilation the Bain circuit behaves more as a Mapleson D, and a FGF flow of 70 ml/kg/min results in normocarbia, provided that minute ventilation is adequate. See: Bain JA, Spoerel WE: A streamlined anaesthetic system, Can Anaesth Soc J 19:426, 1972. Conway CM, Seeley HF, and Barnes PK: Spontaneous ventilation with the Bain anaesthetic system, Br J Anaesth 49:1245, 1977. Bain JA, Spoerel WE: Flow requirements for a modified Mapleson D system during controlled ventilation, Can Anaesth Soc J 20:629, 1973. Number: 497 Score: The Mapleson 'A' circuit: 1. Is more efficient during spontaneous (SV) than controlled ventilation (IPPV). 2. Is available in coaxial form. 3. Can be safely used at a fresh gas flow equal to the alveolar ventilation during SV. 4. Is more efficient than the 'Bain' circuit during IPPV. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct

98

ABCDE Correct Answer: A The Mapleson 'A' circuit is the most efficient circuit available for use during spontaneous respiration and the least efficient during IPPV. A coaxial version of it (The 'Lack' circuit) is available. See also: Br J Anaesth 1998 Feb;80(2):263-9 Mapleson WW The elimination of rebreathing in various semi-closed anaesthetic systems. 1954. Number: 498 A variable bypass vaporiser set to deliver 1% halothane is in use at an altitude of ~ 10000 feet (Ambient pressure of 500 mm Hg). Which of the following statements are true? A. The delivered concentration of halothane will be about 0.66%. B. The delivered concentration of halothane will be about 1.33%. C. The delivered concentration represents a lower MAC value than would be delivered at sea level. D. The delivered concentration represents a higher MAC value than would be delivered at sea level. E. None of the above. Select the single best answer ABCDE Correct Answer: D Suppose that the vaporiser is set to deliver 1% halothane (1.33 MAC at 760 mm Hg atmospheric pressure), and is being used at an ambient pressure of 500 mm Hg and at a temperature of 20 C. In the vaporising chamber, halothane has an SVP of 243 mm Hg which represents 48.6 volumes percent (243/500) of the chamber flow. The vaporiser, set to deliver 1% at one atmosphere, creates a splitting ratio of 46:1 between bypass and vaporising chamber flows. If the total gas flow to the vaporiser is 4700 ml/min, then 100 ml/min of carrier gas passes through the vaporising chamber. This now represents 51.4% of the volume there because halothane represents the other 48.6 volumes percent (100 - 51.4). Emerging from the vaporising chamber is 100 ml/min of carrier gas plus 95 ml/min of halothane vapor ([100/51.4] 48.6). When the vaporising chamber and bypass flows merge, the 95 ml/min of halothane vapor are diluted in a total volume of 4795 ml/min (4600 + 100 + 95 ml), giving a halothane concentration of 1.98 volumes percent, or approximately 2% of the (hypobaric) atmosphere by volume. This appears to be double the dialed-in concentration in terms of volumes percent.

99

However, partial pressures must be considered because it is the tension of the anesthetic agent that is important. If halothane represents 1.98% of the gas mixture by volume, its partial pressure in the emerging mixture is 1.98% 500, or 9.90 mm Hg. In terms of anesthetic potency, this represents 1.74 MAC (9.90/5.7), because the MAC of halothane is 5.7 mm Hg. Thus, in theory, a halothane vaporiser used at a pressure of 500 mm Hg (10,000 feet) set to 1% (vol/vol) delivers twice the set concentration in terms of volumes percent but only 1.3 times the anesthetic potency in MAC (1.74/1.33). See Eisenkraft JB: Vaporizers and vaporization of volatile anesthetics. In 'Progress in anesthesiology', vol 2, San Antonio, Texas, 1989 Number: 505 The Jackson Rees modification of Ayre's 'T' piece used during spontaneous ventilation: 1. Is effective at conserving heat and moisture. 2. Offers little resistance to ventilation. 3. Will effectively eliminate rebreathing if the fresh gas flow (FGF) is twice the minute ventilation. 4. Requires a higher fresh gas flow than during controlled ventilation A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: C 1. Because the circuit needs a high FGF it is not effective at conserving heat and moisture. 2. It is a very low resistance circuit. 3. When the fresh gas flow is less than the peak inspiratory flow, some inspired gas will be entrained from the expiratory limb. Thus rebreathing can only be avoided completely if FGF exceeds the peak inspiratory flow. For most patients this usually requires a fresh gas flow that is in excess of three times the minute ventilation. 4. During IPPV a lower FGF can be selected. Rebreathing will occur, but normocarbia can still be achieved. As FGF is reduced, arterial PCO2 becomes less dependent on minute ventilation and more dependent on fresh gas flow. See also: Rees GJ: Anaesthesia in the newborn, Br Med J 1:1419, 1950.

100

Number: 506 A gas mixture which is fully saturated with water vapour at 37 degrees centigrade, 1 atmosphere absolute has a water content of: A. 22 mgs/L. B. 33 mgs/L. C. 44 mgs/L. D. 55 mgs/L. E. 66 mgs/L. Select the single best answer ABCDE Correct Answer: C Air fully saturated with water vapour at 37C contains 44 mgs/L of water. The content can be calculated on the basis of Avogadro's law. (1 g molecular weight of any gas or vapour occupies 22.4 L at standard temperature and pressure.)

Number: 524 Laser radiation is: 1. Monochromatic. 2. Coherent. 3. Collimated. 4. Confined to the visible portion of the spectrum. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: A The word "laser" is an acronym for Light Amplification of the Stimulated Emission of Radiation. Laser light is produced when energy is directed at a "lasing medium." The medium lends its name to the laser, for instance in the case of the CO2 laser, electrical energy is aimed at carbon dioxide molecules. When the lasing medium is stimulated electrically, the electrons in the molecular orbit are excited and change orbital patterns in such a way as to emit energy in the form of light. Light

101

produced in this fashion is known as "coherent radiation" because it is spatially and temporally coherent, collimated (the beam does not diverge), and monochromatic. Coherent light can be focused into spots in which the power density is so great that the concentrated light can cut and vapourise tissue. Number: 526 Soda lime: 1. Is mainly composed of calcium hydroxide. 2. Can produce carbon monoxide if dry. 3. Requires the presence of water to absorb carbon dioxide. 4. Can be used to absorb sevoflurane. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: A "Wet" soda lime is composed of calcium hydroxide (about 80%), sodium hydroxide and potassium hydroxide (about 5%), water (about 15%), and small amounts of inert substances such as silica and clay for hardness. The potassium hydroxide and sodium hydroxide function as 'catalysts' to speed the initial absorption of carbon dioxide - forming sodium and potassium carbonate. The sodium and potassium carbonates then react with the calcium hydroxide to form calcium carbonate and water, thereby regenerating sodium and potassium hydroxides. Soda lime is exhausted when all the hydroxides have become carbonates. Soda lime can absorb 19% of its weight in carbon dioxide. Both soda lime and baralyme can produce carbon monoxide if flushed with dry gases for long periods of time. (Moon RE, Ingram C, Brunner EA, et al: Spontaneous generation of carbon monoxide within anesthesia circuits, Anesthesiology 75:A873, 1991) Soda lime does not absorb volatile anaesthetic agents. The relevant chemical reactions for soda lime are: CO2 + H2O -> H2CO3 H2CO3 + 2NaOH -> Na2CO3 + 2H2O H2CO3 + 2KOH -> K2CO3 + 2H2O Na2CO3 + Ca(OH)2 -> 2NaOH + CaCO3

102

or NK2CO3 + Ca(OH)2 -> 2KOH + CaCO3 Sevoflurane is unstable in the presence of soda lime, but is not usefully absorbed by it. (Tanifuji Y, Takagi MS, Kobayashi K, et al: The interaction between sevoflurane and soda lime or Baralyme, Anesth Analg 68:S285, 1989) Number: 527 With regard to the monitoring of non-depolarising neuromuscular blockade (NMB): 1. A post-tetanic count of 5 correlates with a train-of-four ratio of approximately 0.7. 2. A post-tetanic count of greater than 10 is generally considered suitable for extubation. 3. The ability to sustain head lift for 5 seconds corresponds < 50% of receptor occupancy by the relaxant. 4. The ability to sustain head lift for 3 seconds is a reliable sign of the adequacy of reversal of NMB. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: D The post-tetanic count is used for the assessment of profound NMB. Its use is only appropriate when the response to single twitch, train-of-four (ToF) and tetanic stimuli are all absent. The fourth twitch of ToF does not appear until 12-15 post-tetanic twitches are present. When the ToF ratio is about 0.6, patients can sustain a head lift for 3.0 seconds (See : Ali HH, Utting JE, and Gray TC: Quantitative assessment of residual antidepolarizing block (part I), Br J Anaesth 43:473, 1971. and Ali HH, Wilson RS, Savarese JJ et al: The effect of tubocurarine on directly elicited train-offour muscle response and respiratory measurements in humans, Br J Anaesth 47:570, 1975.) 70-80% of receptors have to be occupied by neuromuscular blocking drug before the response to nerve stimulation is affected. Accordingly, during recovery from neuromuscular blockade even with normal inspiratory force, vital capacity, protrusion of the tongue and sustained head lift for 3 seconds, 70-80% of all receptors can still be occupied by the neuromuscular blocker. The ability to sustain head lift for 3 seconds is a good sign of the adequacy of reversal of NMB

103

Number: 550 The following capnograph trace was obtained from an intubated patient who was ventilated using a circle system with the absorber on. The trace is most compatible with: A. A correctly positioned tube. B. Inspiratory valve malfunction. C. Oesophageal intubation. D. Expiratory valve malfunction. E. Right main bronchial intubation. Select the single best answer

ABCDE Correct Answer: E The tube is in the right main bronchus. - Under these circumstances the left lung is poorly ventilated (ie has a low overall V:Q ratio) and a long overall time constant. Thus the initial plateau represents gas exchange in the right lung and the later plateau that in the left.

Number: 553 Which statement is true concerning medical gas cylinders: A. They are made of titanium / aluminium alloy. B. The colour and shape of the plastic disc around the neck of the cylinder identifies the gas it contains. C. The tare weight is the weight of the cylinder when full. D. The filling ratio is the weight of the fluid in the cylinder divided by the weight of the cylinder and fluid together. E. The cylinders attached to the anaesthetic machine are usually size E. Select the single best answer 104

ABCDE Correct Answer: E Cylinders are made of lightweight molybdenum steel (a chromium : steel alloy). The year when the cylinder was last tested can be identified from the shape and colour of the disc. The body and shoulder of the cylinder are colour-coded to identify the gas it contains. Tare weight is the weight of the cylinder when empty. The filling ratio is the weight of the fluid in the cylinder divided by the weight of water required to fill the cylinder. The cylinders attached to the anaesthetic machine are usually size E.

Number: 554 Which statements are true regarding the desflurane 'TEC 6' vapouriser? 1. It is a 'plenum' type vapouriser. 2. It has a warm-up period of about 3 minutes. 3. It can be used at a fresh gas flow of 500 mls/min. 4. It can provide desflurane at a concentration of up to 18%. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: E All statements are correct. Desflurane liquid is held within the vaporising chamber and is heated to 39 C by two 100W electrical heater elements. Two further heater elements warm the upper part of the vapouriser to prevent condensation. When operating temperature has been reached, the upper part of the

105

vaporising chamber contains desflurane vapour under pressure and solenoidoperated locks on the concentration dial and vapourising chamber outflow are released. Fresh gas from the flowmeters enters the vapouriser and passes through a fixed flow restrictor, to generate backpressure, sensed by two independent pressure sensors. Desflurane vapour passes through a shutoff valve and a pressure regulating valve to the concentration selection dial. The pressure of the vapour is detected also by these pressure sensors and by control of the pressureregulating valve the pressure may be matched to the backpressure generated by the fresh gas flows. This allows one single dial setting to deliver fixed concentrations of desflurane vapour on the output side of the vapouriser at varying fresh gas flows; higher flowmeter flows produce a larger measured backpressure, matched by a larger pressure of desflurane vapour, with a resultant greater flow of desflurane vapour from the vapouriser matching the increase in fresh gas flow. The concentration selector has a dial release bar on the back, which is compressed when initially setting a desired concentration. The dial is graduated in increments of 1% between 0 and 10%, and in increments of 2% between 10 and 18%. An interim stop is located at 12%, which requires depression of the dial release bar to bypass, in a manner similar to that used on the 7% Enfluratec 3 vaporizer. The desflurane Tec 6 vaporizer Br. J. Anaesth. 1994; 72:470-473: G Stephen. Number: 555 Which of the following techniques are absolutely contraindicated in a patient with an automatic implantable cardioverter defibrillator (AICD)? 1. Radiotherapy. 2. Extracorporeal shock wave lithotripsy. 3. Electroconvulsive therapy. 4. Magnetic resonance imaging. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: D Magnetic resonance imaging is contraindicated in patients with AICD as strong magnetic fields produced can exert mechanical forces causing physical pain and damage to the generator, or cause inappropriate delivery of a shock. Radiotherapy (linear accelerator, betatron, radioactive cobalt) may damage the complementary metal oxide semiconductor circuits of the AICD, especially with cumulative

106

doses. Therefore, shielding of the generator should be undertaken and the device evaluated after its exposure to radiation. Theoretically, extracorporeal shock wave lithotripsy can produce mechanical and electromagnetic forces which can damage the piezoelectric crystal timing device of the AICD or cause inappropriate delivery of a discharge. However, bench analysis and a case report suggest that contralateral lithotripsy can be performed safely in patients with an AICD in situ. The safety of lithotripsy applied ipsilateral to the AICD is unknown. As electroconvulsive therapy (ECT) frequently induces transient arrhythmias, the AICD should be deactivated just before treatment and reactivated immediately after ECT. Grounding of the patient should be avoided as the delivered current may be rerouted to the heart via the defibrillator electrodes resulting in VF. Anaesthetic management of a patient with an automatic implantable cardioverter defibrillator in situ. Br. J. Anaesth. 1997; 78:102-106: P. C. A. Kam. Number: 556 Which of the following solutions would be suitable for transcervical endometrial ablation (TCEA) using electrodiathermy? 1. 1.5% Glycine. 2. Normal Saline. 3. 5% Sorbitol. 4. Distilled Water. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: B Electrodiathermy requires the use of solutions which do not conduct electricity. These include 1.5% glycine, 5% sorbitol and 5% mannitol. The most commonly used irrigation fluid is 1.5% glycine. It has good optical qualities but is hypotonic (osmolality of 1.5% glycine is 188 mosmol kg-1) and absorption into the circulation may cause fluid overload, hyponatraemia, pulmonary oedema and cerebral oedema. Sorbitol 5% is isotonic with a short half-life of 35 min but it causes toffee-like deposits on the electrode and this may make the resection technically difficult. Consequently, it is seldom used.

107

Mannitol 5%, although isotonic, has a long half-life and is also seldom used; it may cause visual distortion and crystallization on instruments. Normal saline may be used only when laser treatment is contemplated and there is no danger of electrical conduction. It is isotonic and optically clear but it may also lead to fluid overload and pulmonary oedema if absorbed in large quantities. Distilled water should never be used. Complications of hysteroscopic treatments of menorrhagia. Br. J. Anaesth. 1996; 77:305-8: Williamson, K.M.; Mushambi, M.C. Number: 564 The Raman spectrometer cannot be used to measure the partial pressure of which of the following gases? A. Oxygen. B. Helium. C. Carbon Dioxide. D. Nitrogen. E. Nitrous Oxide. Select the single best answer ABCDE Correct Answer: B When light strikes gas molecules, most of the energy scattered is absorbed and re-emitted in the same direction and at the same wavelength as the incoming beam (Rayleigh scattering). At room temperature, about 1/1,000,000 of the energy is scattered at a longer wavelength, producing a so called red-shifted spectrum. This Raman scattering can be used to measure the constituents of a gas mixture. Unlike infrared spectroscopy, Raman scattering is not limited to gas species that are polar. Carbon dioxide, oxygen, nitrogen, water vapour, nitrous oxide, and all of the volatile anaesthetic agents exhibit Raman activity. Only monatomic gases such as helium, xenon, and argon, which lack intramolecular bonds, do not exhibit Raman activity.

108

Number: 566 Which of the following nerve:muscle combinations may be used for monitoring a 'Train-offour'? 1. Ulnar nerve:Abductor pollicis brevis 2. Common peroneal nerve:Tibialis anterior 3. Ulnar nerve:Opponens pollicis 4. Facial nerve:Orbicularis oculi A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: C Abductor pollicis brevis and opponens pollicis are supplied by the median nerve. The 'appropriate' combination in the hand is the ulnar nerve and Adductor pollicis. Number: 624 In this capnograph of a patient breathing spontaneously through a 'Bain' circuit there is evidence of: 1. Hypoventilation. 2. Segmentation of gas in the outer limb. 3. Rebreathing. 4. Disconnection of the inner limb at the machine end. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct

109

ABCDE Correct Answer: A The end-tidal CO2 is elevated which confirms hypoventilation. The 'blip' in the inspiratory phase of the trace reflects segmentation of gas in the outer limb as dead-space, alveolar and fresh gas fail to mix in the outer limb. - During inspiration the patient is sequentially ventilated with fresh gas which has entered the outer limb durin the expiratory pause, alveolar gas and then anatomical dead-space gas (which has less CO2 in it than the expired alveolar gas). Clearly there is re-breathing. Disconnection of the inner limb at the machine end produces almost complete re-breathing by adding a large, serial dead-space. There is no evidence of this. Number: 627 Regarding the desflurane sump in a 'TEC 6' vapouriser: 1. It is heated to 39 degrees centigrade. 2. The operating pressure in the sump is about three atmospheres absolute. 3. The vapour pressure in the sump is about 1500 mm Hg. 4. Up to 18% of the fresh gas flow passes through the sump. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: B The vapour circuit originates at the desflurane sump, which is electrically heated and thermostatically controlled to 39C. This circuit is completely separate from the fresh gas circuit and none of the fresh gas enters the sump. At 39C, the vapour pressure in the sump is approximately 1500 mm Hg absolute, or approximately 2 atmospheres.

110

Number: 628 Concerning the measurement of oxygen by a paramagnetic device: 1. The technique utilises the fact that oxygen is strongly attracted to a magnetic field. 2. The glass spheres in the device usually contain nitrogen. 3. No anaesthetic gases exhibit paramagnetism. 4. Water vapour must be removed from the sample before the measurement is made. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: E The two glass spheres are filled with a weakly diamagnetic gas such as nitrogen. Paramagnetic analysers are affected by the presence of high concentrations of diamagnetic background gases such as nitrous oxide, carbon dioxide or water vapour. The only other paramagnetic gas of occasional importance to anaesthetists is nitric oxide. For an explanation of the difference between paramagnetism and diamagnetism, visit the website at http://www.sci.kun.nl/hfml/. Number: 632 Concerning arterial PCO2 (PaCO2) and End-Tidal CO2 : Arterial CO2 tension difference (DCO2), this capnograph of a patient breathing spontaneously through a circle-absorber system suggests that: A. PaCO2 is high and DCO2 is normal. B. PaCO2 is high and DCO2 is high. C. PaCO2 is high and DCO2 is low. D. PaCO2 is normal and DCO2 is high. E. PaCO2 is normal and DCO2 is normal. Select the single best answer

111

ABCDE Correct Answer: B The End-Tidal CO2 is high (~46 mm Hg) and therefore the PaCO2 must also be high (unless DCO2 is negative which is an extremly unusual finding). Note also that the plateau phase (phase III) is still upsloping at the end of expiration. This suggests that a true end-tidal sample has not been measured and also that the patient has an increased dispersion of alveolar V/Q ratios with widely varying time constants. For all these reasons DCO2 is also likely to be increased. Number: 641 The elective use of a laryngeal mask airway has been advocated for: 1. Ventilation of children undergoing closure of an atrial septal defect. 2. Airway management for anaesthesia in the prone position. 3. Ventilation of fresh cadavers. 4. Ventilation of adults undergoing coronary artery grafting. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: A The things people do!! - Just because it's possible that surely doesn't make it right. As far as I can tell, the LMA has not yet been used (electively) in the context of coronary artery grafting in adults. Sooner or later I suppose that someone will tell me I'm wrong.

112

Number: 649 This tracing was recorded from the distal lumen of a Swan-Ganz catheter inserted to a distance of 52 cms via the left subclavian vein with balloon inflated. The waveform shown below most probably represents: A. An unwedged pulmonary artery pressure trace. B. A wedged pulmonary artery pressure trace in a patient with mitral incompetence. C. A right ventricular pressure trace. D. 'Cannon' waves in a right atrial pressure trace. E. A coronary sinus pressure trace. Select the single best answer

ABCDE Correct Answer: B This is, in fact, a wedged pulmonary artery pressure trace from a patient with severe mitral incompetence and large 'V' waves. The key to the diagnosis is the timing of the wave in relation to the 'T' wave. The normal pulmonary artery systolic peak occurs at about the time of the 'T' wave, whereas a 'V' wave occurs after the 'T' wave. This trace illustrates the dangers of using pulmonary artery catheters in patients with 'V' waves. - It is easy to imagine that someone could go on inflating the balloon in the presence of this waveform and thus rupture the pulmonary artery. Similarly, the systolic peaks of the right ventricular and coronary sinus pressure waves approximate to the 'T' wave. Cannon waves do not occur in patients (such as this) who are in normal sinus rhythm.

113

Number: 670 The value of the bispectral index which will prevent 50% of patients responding to a verbal command is: A. > 90. B. > 80 <= 90. C. > 65 <= 80. D. > 50 <= 65. E. <= 50. Select the single best answer ABCDE Correct Answer: C The BIS that prevents 50% of subjects from responding to verbal command ranges from 67 to 79. The BIS that prevents implicit memory is between 8491. Recovery of consciousness is expected as BIS rises above 90. References: Glass, PS, Bloom, M, Kearse, L, Rosow, C, Sebel, P & Manberg, P. Bispectral analysis measures sedation and memory effects of propofol, midazolam, isoflurane, and alfentanil in healthy volunteers. Anesthesiology 1997; 86, 836-847. Katoh, T, Suzuki, A & Ikeda, K. Electroencephalographic derivatives as a tool for predicting the depth of sedation and anesthesia induced by sevoflurane. Anesthesiology 1998; 88, 642650. Leslie, K, Sessler, DI, Schroeder, M & Walters, K. Propofol blood concentration and the Bispectral Index predict suppression of learning during propofol/epidural anesthesia in volunteers. Anesth Analg 1995; 81, 1269-74. Iselin-Chaves, IA, Flaishon, R, Sebel, PS et al. The effect of the interaction of propofol and alfanianil on recall, loss of consciousness, and the Bispectral Index. Anesth Analg 1998; 87, 949-955. Kearse, LA, JrC Rosow, Zaslavsky, A, Connors, P, Dershwitz, M & Denman, W. Bispectral analysis of the electroencephalogram predicts conscious processing of information during propofol sedation and hypnosis. Anesthesiology 1998; 88, 25-34. Liu, J, Singh, H & White, PF. Electroencephalogram bispectral analysis predicts the depth of midazolam-induced sedation. Anesthesiology 1996; 84, 64-69.

114

Number: 697 The International Standards Organization recommendation for the minimum humidity generated by a heat and moisture exchanger is: A. 44 mg H2O/L. B. 20 mg H2O/L. C. 25 mg H2O/L. D. 30 mg H2O/L. E. 33 mg H2O/L. Select the single best answer ABCDE Correct Answer: D At 37 degrees C, fully humidified gas contains 44 mg/L of water at a partial pressure of 47 mm Hg. Surprisingly, there are no really clear guidelines for what constitutes an 'acceptable' or 'ideal' water content of gases used in the ventilation of patients in the operating theatre or the intensive care unit. The British Standard Institution recommended in 1970 that optimum tracheal temperature and absolute humidity should be 35C and 33 mg H2O/L respectively. In 1988, the International Standards Organization (ISO) presented a draft standard for heat and moisture exchangers. They set a minimum humidity of 30 mgH2O/L for safe and effective use. The optimal humidity of the inspired gases during mechanical ventilation has been reported in adults as anywhere between 17 - 44 mgH2O/L. Number: 698 A gas which has a relative humidity (RH) of 70% at 37 degrees C is cooled to 30 degrees C, its RH at this temperature will be: A. 60%. B. 70%. C. 80%. D. 90% E. 100%. Select the single best answer

115

ABCDE Correct Answer: E An RH of 70% at 37 degrees C corresponds to an Absolute Humidity of 30 mg/L. At 30 degrees C, this water content corresponds to an RH of 100%. Thus it is never possible to attain an RH of 70% at the airway unless the ventilating gas is warmed to at least 30 degrees C. Number: 699 A 20-year-old, negro male is undergoing an exploratory laparotomy and partial hepatectomy following a motor vehicle accident. General anaesthesia is maintained with isoflurane in 100% oxygen and paralysis with vecuronium. His vital signs are: blood pressure 100/65 mmHg, temperature 34.7 C, Hb 80 gm/L. His oxygen saturation is noted to be only 85% by pulse oximetry, but is calculated at 98% on subsequent blood gas analysis. This discrepancy might be due to: 1. Anaemia. 2. Sickle Cell Disease. 3. Interference by ambient light. 4. Hypoperfusion. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: D Provided that a good waveform is present, anaemia does not significantly affect the accuracy of a pulse oximeter. See, for example: Jay GD, Hughes L, Renzi FP. Pulse oximetry is accurate in acute anemia from hemorrhage. Ann Emerg Med. 1994 Jul;24(1):32-5. In a recent study, Ortiz et al (Ortiz FO, Aldrich TK, Nagel RL, Benjamin LJ. Accuracy of pulse oximetry in sickle cell disease. Am J Respir Crit Care Med. 1999 Feb;159(2):447-51.) have concluded that "as long as strong and regular photoplethysmographic waves are present, pulse oximeters can be relied upon not to misdiagnose either hypoxemia or normoxemia in Sickle Cell Disease." Interference by ambient light tends to raise (not lower) the reading obtained by pulse oximetry.

116

Number: 703 With regard to the laminar flow of a fluid through a tube, the flow rate is directly proportional to: 1. The length of the tube. 2. The fourth power of the radius of the tube. 3. The viscosity of the fluid. 4. The pressure difference between the ends of the tube. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: C The Hagen-Poiseuille equation describes the determinants of the laminar flow of a fluid through a tube. The equation is: V = (Delta P*Pi*r4)/(8*L*mu): Where V is the flow rate, Delta P is the pressure difference between the ends of the tube, Pi is Pi, r4 is the fourth power of the radius of the tube, L is the length of the tube and mu is the viscosity of the fluid. Thus flow rate is inversely related to the length of the tube and the viscosity of the fluid. Number: 736 The average distance from skin puncture site to atrio-caval junction when the left subclavian (infraclavicular) approach is used for central venous access in an adult is: A. 12 cms. B. 15 cms. C. 18 cms. D. 21 cms. E. 24 cms. Select the single best answer

117

ABCDE Correct Answer: D The most effective way to induce arrhythmias during the insertion of a central venous (or PA) catheter is to pass the guide wire too far into the vein. Andrews et al have recently measured the distance to the atrio-caval junction from skin puncture site for various approaches to the central circulation. For the left subclavian vein the distance in adults is about 21 cms. Andrews RT, Bova DA, Venbrux AC. How much guidewire is too much? Direct measurement of the distance from subclavian and internal jugular vein access sites to the superior vena cava-atrial junction during central venous catheter placement. Crit Care Med 2000 Jan;28(1):138 - 42. Number: 741 The average distance from skin puncture site to atrio-caval junction when the right internal jugular approach is used for central venous access in an adult is: A. 10 cms. B. 13 cms. C. 16 cms. D. 19 cms. E. 22 cms. Select the single best answer ABCDE Correct Answer: C The most effective way to induce arrhythmias during the insertion of a central venous (or PA) catheter is to pass the guide wire too far into the vein. Andrews et al have recently measured the distance to the atrio-caval junction from skin puncture site for various approaches to the central circulation. For the right internal jugular vein the distance in adults is about 16 cms. Andrews RT, Bova DA, Venbrux AC. How much guidewire is too much? Direct measurement of the distance from subclavian and internal jugular vein access sites to the superior vena cava-atrial junction during central venous catheter placement. Crit Care Med 2000 Jan;28(1):138 - 42.

118

Number: 826 An adult patient is quietly breathing supplemental oxygen from a '24%' venturi mask supplied with oxygen at 2 litres per minute. The delivered oxygen concentration (FiO2) will be significantly affected if: A. The patient doubles his tidal volume. B. The patient doubles his peak inspiratory flow rate (PIFR). C. The fresh gas flow to the mask is doubled. D. The fit of the mask to the patient's face is loosened. E. None of the above. Select the single best answer ABCDE Correct Answer: E HAFOE (High Air Flow Oxygen Enrichment) masks are designed to deliver a constant inspired oxygen at a flow rate which considerably exceeds the patient's own PIFR. Thus, even if mask fit is relatively poor, the achieved FiO2 will not be affected. Doubling the fresh gas flow through the venturi will not alter the entrainment ratio of the mask, but will obviously increase the delivered gas flow to the patient. Number: 827 The completeness of pre-oxygenation is best reflected by measurement of: A. Arterial Oxygen Saturation (SaO2). B. Arterial Oxygen Partial Pressure (PaO2). C. End-tidal Oxygen concentration (ETO2). D. End-tidal Nitrogen concentration (ETN2). E. None of the above. Select the single best answer ABCDE Correct Answer: D The purpose of pre-oxygenation is the replacement of alveolar nitrogen with oxygen. This is best reflected by the ETN2. The 'next best' would be ETO2 - if your monitoring system cannot measure the former. A SaO2 of 100% merely reflects the fact that PaO2 is something over ~ 100 mm Hg and PaO2 itself is obviously affected by the proportion of venous admixture.

119

Number: 827 The completeness of pre-oxygenation is best reflected by measurement of: A. Arterial Oxygen Saturation (SaO2). B. Arterial Oxygen Partial Pressure (PaO2). C. End-tidal Oxygen concentration (ETO2). D. End-tidal Nitrogen concentration (ETN2). E. None of the above. Select the single best answer ABCDE Correct Answer: D The purpose of pre-oxygenation is the replacement of alveolar nitrogen with oxygen. This is best reflected by the ETN2. The 'next best' would be ETO2 - if your monitoring system cannot measure the former. A SaO2 of 100% merely reflects the fact that PaO2 is something over ~ 100 mm Hg and PaO2 itself is obviously affected by the proportion of venous admixture.

Number: 829 A hypothetical volatile anaesthetic agent with a saturated vapour pressure of 152 mmHg at 20C is placed in a copper kettle vapouriser. Gas flow into the vapouriser is 0.2 l/min. The patient flowmeter is delivering oxygen at 1.75 l/min. At 20C the concentration of the volatile anaesthetic agent delivered in the final mixture is: A. 0.5% B. 1% C. 2.5% D. 5% E. 10% Select the single best answer ABCDE Correct Answer: C Copper kettle vapourisers are obviously little used devices nowadays, but they do illustrate some important principles. First calculate the total volume of (fully saturated) vapour leaving the kettle each minute. We're told that the SVP of the agent is 20% of an atmosphere, so the volume leaving the kettle must be 250 mls (200mls oxygen + 50 mls of agent).

120

Now add in the fresh gas coming from the patient flow meters (1.75 l) to get a total gas volume of 2.0 l. This volume contains 50 mls of agent, so the final concentration is 50/2000 (or 2.5) %. Number: 830 The vapouriser of an ADU (Anesthesia Delivery Unit; Datex-Ohmeda, Helsinki, Finland) is loaded with a sevoflurane 'Aladin' cassette. The dial setting of the agent is 4%. The total fresh gas flow into the circuit is 5 l/minute. The delivered concentration of sevoflurane will remain within 10% of the dial setting if: 1. The fresh gas flow is changed to a 50:50 mixture of O2:N2O. 2. The fresh gas flow is reduced to 1 l/min. 3. The ambient temperature rises from 20c to 25c. 4. The fresh gas flow is increased to 10 l/min. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: A Refer to the paper by Hendrickx et al for a comprehensive review of this vapouriser. If the fresh gas flow is changed to a mixture of O2:N2O and the total flow remains at 5 l/min, the delivered concentration of sevoflurane will remain within 10% of the dial setting - as the effect of changes in gas composition only become apparent at relatively high fresh gas flows. The delivered concentration of sevoflurane remains within 10% of the dial setting down to a flow rate of about 0.5 l/min. The vapouriser is well temperature compensated within this range. At high fresh gas flows, the vapouriser tends to deliver a lower concentration of agent. Anesth Analg 2001 Aug;93(2):391-5 The adu vaporizing unit: a new vaporizer. Hendrickx JF, De Cooman S, Deloof T. In their discussion, these authors remarked "Vaporizer output also depended on carrier gas composition, dial setting, and the anesthetic used. As fresh gas flow increases, vaporizer output decreases despite the use of a fan to facilitate heat transfer to the vaporizer, probably because the amount of heat transfer to the vaporizing chamber becomes insufficient, and hence output decreases. The effect of higher fresh gas flows on vaporizer output was highly dependent on the duration of the high fresh gas flow and may have obscured the effects of carrier gas composition. Despite the use of anemometers and algorithms that electronically

121

control vaporizer output, vaporizer output was not independent of carrier gas composition. Changing carrier gas composition changes the viscosity and hence the flow rate across the anemometer: the viscosities of oxygen, air, and 70% N2O in oxygen are 210, 190, and 171 micropoises, respectively. These very same physical principles explain the effect of carrier gas composition on vaporizer output in conventional vaporizers. The performance of the Aladin cassettes is not the same for different anesthetics. Because the cassette design for the three anesthetics is similar, the effect might in part be related to differences in the relative quantities of liquid anesthetic that need to be vaporized to attain the desired concentration. " Number: 835 Xenon concentration in an anaesthetic gas mixture may be measured using: 1. Mass spectrometry. 2. Piezoelectric adsorption. 3. Thermal conductivity. 4. Infra red absorption spectroscopy. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: A According to Dingley et al "Being a noble gas, conventional methods cannot be used and only methods based on its physical properties can be applied. The Drager Physioflex device initially used a mass spectrometer. This was effective but far too expensive. Other lower cost devices have included piezoelectric adsorption, thermal conductivity and ultrasound. The piezoelectric method depends on adsorption of gas into an oil film on an oscillating quartz crystal, so changing its frequency of oscillation. The thermal conductivity method exploits the fact that xenon conducts heat far better than any other gas likely to be found in the breathing system. The ultrasonic method has been successfully used recently for the first time and exploits the fact that xenon as a very dense gas will conduct sound faster than any other gas likely to be found in the breathing system." Infra red absorption spectroscopy is only applicable to the measurement of polyatomic molecules such as CO2 or N2O.

122

Number: 875 With regard to electroencephalograph (EEG): 1. Voltages are generally in the range of 10 -100 microvolts. 2. Spontaneous EEG activity is lost when body temperature drops below ~22 centigrade. 3. Beta activity is accentuated by sedative-hypnotic drugs. 4. Theta waves occur at frequency of 3.5 - 7.5 Hz. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: E EEG voltages are generally in the range of 10 -100 microvolts. Electro-cerebral silence occurs at a temperature below 22 - 25 degrees C. Beta activity is 'fast' activity. It has a frequency of 14 and greater Hz. It is usually seen on both sides in symmetrical distribution and is most evident frontally. It is accentuated by sedative-hypnotic drugs especially the benzodiazepines and the barbiturates. It may be absent or reduced in areas of cortical damage. It is generally regarded as a normal rhythm. It is the dominant rhythm in patients who are alert or anxious or who have their eyes open. Theta activity has a frequency of 3.5 to 7.5 Hz and is classed as "slow" activity. It is abnormal in awake adults but is perfectly normal in children up to 13 years and in sleep. It can be seen as a focal disturbance in focal subcortical lesions; it can be seen in a generalised distribution in diffuse disorders, metabolic encephalopathy, deep midline disorders and some instances of hydrocephalus. Number: 941 A small air bubble in radial artery catheter system will consistently reduce the: A. Resonant frequency of the system. B. Damping of the system. C. Recorded systolic blood pressure. D. Recorded diastolic blood pressure. E. Recorded mean blood pressure. Select the single best answer

123

ABCDE Correct Answer: A Air bubbles in such a system will consistently reduce its resonant frequency and increase its damping. This will have an unpredictable effect on the final accuracy of the systolic and diastolic measurements and little (if any) effect on the accuracy of the mean measurement. Hipkins SF, Rutten AJ, Runciman WB. Experimental analysis of catheter-manometer systems in vitro and in vivo. Anesthesiology. 1989 Dec;71(6):893-906. Kleinman B, Powell S, Gardner RM. Equivalence of fast flush and square wave testing of blood pressure monitoring systems. J Clin Monit. 1996 Mar;12(2):149-54. Number: 944 Which of the following units are BASIC SI units of measurement? 1. Gram. 2. Second. 3. Watt. 4. Meter. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: C There are seven basic units of measurement in the SI system. These are: Unit of length: meter: The meter is the length of the path travelled by light in vacuum during a time interval of 1/299 792 458 of a second. Unit of mass: kilogram: The kilogram is the unit of mass; it is equal to the mass of the international prototype of the kilogram. Unit of time: second: The second is the duration of 9 192 631 770 periods of the radiation corresponding to the transition between the two hyperfine levels of the ground state of the cesium 133 atom. Unit of electric current: ampere: The ampere is that constant current which, if maintained in two straight parallel conductors of infinite length, of negligible circular cross-section, and

124

placed 1 meter apart in vacuum, would produce between these conductors a force equal to 2 x 10-7 newton per meter of length. Unit of thermodynamic temperature: kelvin: The kelvin, unit of thermodynamic temperature, is the fraction 1/273.16 of the thermodynamic temperature of the triple point of water. Unit of amount of substance: mole: 1. The mole is the amount of substance of a system which contains as many elementary entities as there are atoms in 0.012 kilogram of carbon 12; its symbol is "mol." 2. When the mole is used, the elementary entities must be specified and may be atoms, molecules, ions, electrons, other particles, or specified groups of such particles. Unit of luminous intensity: candela: The candela is the luminous intensity, in a given direction, of a source that emits monochromatic radiation of frequency 540 x 1012 hertz and that has a radiant intensity in that direction of 1/683 watt per steradian. Number: 954 Which of the following lung volumes CANNOT be measured by simple spirometry? A. Vital Capacity. B. Inspiratory Reserve Volume. C. Expiratory Reserve Volume. D. Tidal Volume. E. Residual Volume. Select the single best answer ABCDE Correct Answer: E Vital capacity, tidal volume, inspiratory reserve and expiratory reserve can all be measured with a simple spirometer. Total lung capacity, functional residual capacity and residual volume all contain a fraction (the residual volume) which cannot be measured by simple spirometry. However, if one of these volumes is measured (most commonly the FRC), the others can easily be derived. Three techniques are available for the measurement of FRC. The first employs nitrogen washout by breathing 100% oxygen. Total quantity of nitrogen eliminated is measured as the product of the expired volume collected and the concentration of nitrogen. If, for example, 4 litres of nitrogen are collected and the initial alveolar nitrogen concentration was 80%, then the initial lung volume was 5 litres. The second method uses the wash-in of a tracer gas such as helium, the concentration of which may be conveniently measured by catharometry. If, for example, 50 mI of helium is introduced into the lungs and the helium concentration is then found to be 1%, the lung volume is 5 litres.

125

The third method uses the body plethysmograph. The subject is totally contained within a gastight box and he attempts to breathe against an occluded airway. Changes in alveolar pressure are recorded at the mouth and compared with the small changes in lung volume, derived from pressure changes within the plethysmograph. Application of Boyle's law then permits calculation of lung volume. This method would include trapped gas which might not be registered by the two previous methods. Number: 955 Which of the following gases is paramagnetic? A. Nitrous Oxide. B. Nitric Oxide. C. Carbon Dioxide. D. Nitrogen. E. Helium. Select the single best answer ABCDE Correct Answer: B An atom with all of its orbitals filled, and therefore all of its electrons paired with an electron of opposite spin, will be very little affected by magnetic fields. Such atoms are called diamagnetic. Conversely, paramagnetic atoms do not have all of their electrons spin-paired and are affected by magnetic fields. In the context of anaesthesia, the two important paramagnetic gases are oxygen and nitric oxide. Number: 956 The most sensitive method available for the detection of venous air-embolism (VAE) occuring during anaesthesia is: A. Electrocardiography. B. Capnography. C. Two dimensional, trans-oesophageal echocardiophy. D. M-Mode, trans-oesophageal echocardiophy. E. Pre-cordial Doppler monitoring. Select the single best answer ABCDE Correct Answer: C Two dimensional, trans-oesophageal echocardiography provides by far the most sensitive and specific indication of VAE. In addition, it can also be used to examine the integrity of the atrial septum - which may be of considerable importance should VAE occur. However, the

126

use of the technique requires considerable skill and it is clinically inappropriate in many situations. M-Mode, trans-oesophageal echocardiophy is of no practical use in the detection of VAE. Both capnography and pre-cordial Doppler monitoring have an important role to play in the detection of clinically significant VAE. ECG changes are relatively insensitive and non-specific. Number: 965 Which of the following muscles is LEAST sensitive to the effects of a non-depolarising muscle relaxant? A. Lateral Cricoarytenoid. B. Adductor Pollicis. C. Abductor Digiti Minimi. D. Flexor Hallucis Brevis. E. Gastrocnemius. Select the single best answer ABCDE Correct Answer: A The laryngeal adductors (Lateral Cricoarytenoid and Interarytenoid) are amongst the muscles which are least sensitive to the effects of neuro-muscular blocking drugs (NMBD's). In contrast, Adductor Pollicis (AP) is relatively sensitive to the NMBD's. Thus, if it is imperative that a patient not cough or buck during a procedure, simple train-of-four monitoring of the AP may not be sufficient to guarantee 'peace and tranquility' and a technique such as post-tetanic counting should be used. Torda has recently published an excellent review entitled "Monitoring Neuromuscular Transmission". See: Torda TA. Monitoring Neuromuscular Transmission. Anaesth. Int. Care. 2002, April (30): 123-133. Number: 968 With regard to a central venous catheter: 1. The tip of the catheter should be above the level of the carina on chest X-Ray. 2. The risk of line colonisation is greater if the jugular rather than subclavian route is used. 3. The risk of catheter perforation is greater if the catheter is inserted using a peripheral route. 4. At the time of insertion, the catheter tip can be reliably positioned using electrocardiography. A: 1,2,3 Correct

127

B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: E 1. Conventional wisdom dictates that the catheter tip should lie outside the pericardial reflection - in order to obviate the risk of tamponade should vascular perforation occur. This point has been found to be consistently at or below the level of the carina in a cadaveric study by Schuster et al. 2. Several studies have found that the risk of line colonisation and / or infection is significantly increased if the jugular rather than subclavian route is used for line insertion. See for example, Mermel et al. 3. The risk of catheter perforation is widely believed to be greater if the catheter is inserted using a peripheral rather than central approach - due to the greater propensity for movement by the catheter tip. This seems to be a reasonable proposition, although there does not appear to be any evidence to support it. 4. Catheter tip localisation can be reliably achieved if the catheter itself is used as an intravascular electrode. Typical changes in the morphology of the 'P' wave are observed as the catheter passes the atrio-caval junction. ('The equivalence point'). Special kits - which incorporate a suitable electrode as a guide wire are available from some manufacturers See: Schuster M, Nave H, Piepenbrock S, Pabst R, Panning B. The carina as a landmark in central venous catheter placement. Br J Anaesth. 2000 Aug;85(2):192-4. Mermel LA, McCormick RD, Springman SR, Maki DG. The pathogenesis and epidemiology of catheter-related infection with pulmonary artery Swan-Ganz catheters: a prospective study utilizing molecular subtyping. Am J Med 1991 Sep 16;91(3B):197S-205S Watters VA, Grant JP. Use of electrocardiogram to position right atrial catheters during surgery. Ann Surg. 1997 Feb;225(2):165-71.

128

Number: 977 A Bispectral Index (BIS) monitor: 1. Will reliably predict the likelihood of a haemodynamic response to a noxious stimulus. 2. Will generate a BIS index of zero in the presence of an iso-electric EEG. 3. Will reliably predict the likelihood of movement in response to a noxious stimulus. 4. Incorporates the burst suppression ratio in its analysis of the EEG signal. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: C It is important to understand that the BIS index is a statistical function that has been tuned to correlate with the degree of sedation. It does not correlate with the 'depth' of anaesthesia as judged by somatic or autonomic responses to noxious stimuli and there is abundant evidence to support this view. For example see: Driessen, JJ, Harbers, JIBM, van Egmond, J & Booij, LHDJ. Evaluation of the electroencephalographic bispectral index (BIS) during fentanyl-midazolarn anaesthesia for cardiac surgery. Does it predict haemodynamic responses during endotracheal intubation and sternotomy? Eur J Anaesthesiol 1999; 16, 622627. The EEG waveforms is analysed according to three features: 1. Burst suppression ratio - A time-domain feature that quantifies the extent of electrical silence during deep anaesthesia. 2. Relative alpha/beta ratio. This is a frequency-domain feature and contributions from these frequency bands are seen during light sedation. 3. Bicoherence of the EEG - which describes the phase coupling relations between individual waves. In simple terms, a signal with strong phase relations and a high bicoherence value implies a common generator and may be associated with moderate sedation. A flat EEG generates a BIS index of zero.

129

CARDIORESPIRATORY PHYSIOLOGY TESTS Number: 18 A morbidly obese, non-smoking patient who is otherwise well is likely to have a significant reduction in: 1. Functional Residual Capacity (FRC). 2. Forced Expiratory Volume in 1 second (FEV1). 3. Expiratory Reserve Volume (ERV). 4. Diffusing Capacity for Carbon Monoxide (DLCO). A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: A Biring et al have recently examined pulmonary physiological changes of morbid obesity and concluded that "Forced vital capacity, forced expiratory volume in 1 second, expiratory reserve volume, functional residual capacity, maximum voluntary ventilation, and forced expiratory flow during midexpiratory phase were all significantly reduced." However, no abnormality in DLCO was found. See:Biring MS, Lewis MI, Liu JT, Mohsenifar Z. Pulmonary physiologic changes of morbid obesity. Am J Med Sci. 1999 Nov;318(5):293-7. Number: 30 An acclimatised mountaineer, breathing air on the summit of Mount Everest (barometric pressure 253 Torr), will have an arterial PCO2 (PaCO2) of approximately: A. 24 mm Hg. B. 20 mm Hg. C. 16 mm Hg. D. 12 mm Hg. E. 8 mm Hg. Select the single best answer ABCDE

130

Correct Answer: E See the classic study by West. - "Pulmonary gas exchange was studied on members of the American Medical Research Expedition to Everest at altitudes of 8,050 m (barometric pressure 284 Torr), 8,400 m (267 Torr) and 8,848 m (summit of Mt. Everest, 253 Torr). Thirty-four valid alveolar gas samples were taken using a special automatic sampler including 4 samples on the summit. Venous blood was collected from two subjects at an altitude of 8,050 m on the morning after their successful summit climb. Alveolar CO2 partial pressure (PCO2) fell approximately linearly with decreasing barometric pressure to a value of 7.5 Torr on the summit. For a respiratory exchange ratio of 0.85, this gave an alveolar O2 partial pressure (PO2) of 35 Torr. In two subjects who reached the summit, the mean base excess at 8,050 m was -7.2 meq/l, and assuming the same value on the previous day, the arterial pH on the summit was over 7.7. Arterial PO2 was calculated from changes along the pulmonary capillary to be 28 Torr. In spite of the severe arterial hypoxemia, high pH, and extremely low PCO2, subjects on the summit were able to perform simple tasks. The results allow us to construct for the first time an integrated picture of human gas exchange at the highest point on earth." West JB, Hackett PH, Maret KH, Milledge JS, Peters RM Jr, Pizzo CJ, Winslow RM. Pulmonary gas exchange on the summit of Mount Everest. J Appl Physiol. 1983 Sep;55(3):678-87. Number: 31 A patient in an intensive care unit has the following haemodynamic measurements made: Mean Systemic Arterial Pressure (MAP) 80 mm Hg. Mean Central Venous Pressure (CVP) 10 mm Hg. Cardiac Output (CO) 5.0 l/min. Mean Pulmonary Arterial Pressure (MPAP) 35 mm Hg. Pulmonary Artery Occlusion Pressure (PAOP) 20 mm Hg. The pulmonary vascular resistance (PVR) is: A. 14 dynes.sec.cm-5. B. 120 dynes.sec.cm-5. C. 240 dynes.sec.cm-5. D. 400 dynes.sec.cm-5. E. 1120 dynes.sec.cm-5. Select the single best answer ABCDE Correct Answer: C PVR= 80 x (MPAP-PAOP)/CO.

131

This equation is the hydraulic equivalent of Ohm's Law ie: Flow = Driving pressure / Resistance. The constant '80' being a conversion factor to convert the pressures (in mm Hg) to SI units. (More accurately the value is 79.9). The normal range for PVR in an adult is 150 - 250 dynes.sec.cm-5. The MAP and CVP are not needed for calculation of the PVR but can be used in the calculation of systemic vascular resistance according to the equation: SVR= 80 x (MAP-CVP)/CO. Number: 94 In the left lateral position, blood flow to the non-dependant lung is: A. 25%. B. 35%. C. 45%. D. 55%. E. 65%. Select the single best answer ABCDE Correct Answer: C The distribution of perfusion in the lungs varies regionally and is under the influence of posture, mode of ventilation, and type of anaesthesia. In general, a hydrostatic head of pressure exists which decreases with vertical height above the heart. In the upright position, the absolute pressure in the pulmonary artery decreases by 1 cm water/cm vertical distance up the lung. Distribution of blood flow can be summarized as follows: Normally, in the upright position, the right lung receives 55% of blood flow and the left receives 45%. In the lateral decubitus position, when the right lung is up, it receives 45% and the dependant left lung receives 55%. When the left lung is up, it receives 35% and the right dependant lung receives 65%. These values are for an awake, spontaneously breathing patient. With respect to the left lateral position only, blood flow to the non-dependant lung is: (1) 41% in an awake, spontaneously breathing patient. (2) 43% in an anaesthetised, spontaneously breathing patient. (3) 44% in a paralyzed patient, ventilated with IPPV. (4) 70% in a paralyzed patient, ventilated with IPPV, with the chest wall open. MARTIN, J; Positioning the Patient for Anaesthesia and Surgery, 1978, p138. ROGERS, M.C ET AL (EDS); Principles and Practice of Anesthesiology, Mosby, 1993, pp 1748.

132

Number: 96 What is the rate of rise of PaCO2 during breath holding? A. 1 mmHg/min. B. 3 mmHg/min. C. 5 mmHg/min. D. 7 mmHg/min. E. 10 mmHg/min. Select the single best answer ABCDE Correct Answer: B The rise of PaCO2 is most rapid in the first minute of breath holding. This felt to be due to the additional effects of equilibration between the venous and arterial blood. Thereafter a steady rise of ~ 3mmHg/min occurs. NUNN, J; Applied respiratory Physiology,3rd Ed., Butterworths, 1987. Number: 97 Which of the following are true with respect to increasing oxygen reserves through preoxygenation with 100% oxygen: 1. It is well reflected by the arterial oxygenation saturation. 2. It requires longer when using a Bain circuit. 3. It is achieved equally as well with 4 vital capacity breaths or 3 minutes of tidal volume breathing. 4. Oxygen reserves are reduced in pregnancy. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: D Arterial oxygen saturation does not reflect the amount of oxygen contained within the functional residual capacity- the major reservoir utilized during preoxygenation. This is reflected by the end-tidal N2. Non-rebreathing circuits generally achieve denitrogenation rapidly. Vital capacity breathing reduces end-tidal N2O to 6% as compared with conventional tidal volume breathing in which it is reduced to 1%. In ASA I patients, this will still prevent desaturation for up to 6 minutes of apnoea, but may cause significant reductions in the tolerated apnoeic intervals in obstetric or elderly patients. Arterial oxygen saturation falls to a mean of 75% within 1 minute of suxamethonium when oxygen is not administered prior to induction of anaesthesia. Maximizing oxygen reserve has

133

been advocated as a means of delaying this event. The major oxygen stores of the body are shown after equilibration when breathing 21% and 100% oxygen: 21% functional residual capacity = 0.21 x 2.4 L ~450 mls chemical combination with haemoglobin ~850 mls dissolved in plasma ~50 mls chemical combination with myoglobin ~200 mls 100% ~3000 mls ~950 mls ~100 mls ~200 mls

Thus, increasing oxygen reserve by " preoxygenation " is achieved predominantly through denitrogenation of the FRC and to a lesser extent through increasing saturation of arterial blood. This will be manifested using pulse oximetry as an elevation of baseline SAO2 and a delayed fall in SAO2 during apnoea. The best method of preoxygenation has been studied. The options include: (1)Preoxygenation with tidal volume breaths for 2-10 minutes. (2) " 4 vital capacity breaths. (3)Postoxygenation by assisted ventilation after apnoea has occured. (4)Any combination of the above. (1)Recommendations vary between 2 and 10 minutes. Earlier studies showed that in normal subjects, breathing 100% achieved > 98% denitrogenation in 7 minutes. Reducing alveolar N2 to 4% was felt to be acceptable however, and allowed 5-6 minutes of apnoea without desaturation. The difference in oxygen stores at 0% and 4% N2 were negligible (2.53L v 2.61L). More recently, it has been shown that in ASA I patients, tidal breathing of 100% oxygen reduced alveolar N2 to 1% after 3 minutes, and to 6% after 2 minutes. The time required will however vary with different breathing circuits. Circuits using low fresh gas flows require longer to complete denitrogenation. Non-rebreathing systems generally achieve this rapidly. Three minutes has been recommended with the Magill (Mapleson A) system using 8 L/min flow rate. One minute using 10 L/min will allow 3 minutes of apnoea before desaturation > 6% SAO2 occurs. When a circle system is used with 5 L/min flow rate, an adequate level of denitrogenation is achieved within 5 minutes. Note that these times assume a tight seal with the face mask. (2)More recently, it has been shown that four voluntary, maximal breaths of 100% oxygen over 30 seconds produced a similar level of oxygenation as 3 minutes of tidal breathing. It would appear that this technique would require a non-rebreathing circuit with a large reservoir bag and a large fresh gas flow. Satisfactory results have been obtained however, with a circle system with 5 L/minute flows and a Magill circuit with 8 L/min flows despite this observation. Here, the patient was instructed to inhale slowly to prevent the reservoir bag from collapsing. A study published in 1989 has challenged the second method on the basis that most studies performed measured oxygen content of the blood rather than actual N2 content of the lungs. This was following an earlier study which showed the maximal breath technique to be associated with a significantly shorter time to desaturation than tidal breathing for 3 minutes.The implication was that whilst they both fully saturate haemoglobin, only the latter provides adequate denitrogenation. One of the reasons suggested was that the maximal breath

134

method was assumed to represent vital capacity breathing where in reality, many patients achieved inspiratory capacity or smaller volumes. In the study cited, 3 minutes of tidal breathing was compared with eight inspiratory capacity breaths (TLC with passive exhalation) and four vital capacity breaths (exhaling to residual volume then maximal breaths). The study showed that N2 washout to 1% was achieved with 3 minutes of tidal breathing and to 6% with 2 minutes of tidal breathing, 8 inspiratory breaths or 4 vital capacity breaths. It should be noted that whilst 6% residual N2 may be adequate in an ASA I patient, it may only allow a shorter apnoeic time before desaturation in a patient with a less favourable relationship between closing capacity and FRC as seen in pregnancy, obesity and age > 44. (3)Oxygenation after induction is practiced widely however is felt to be less effective than preoxygenation because the volume of the reservoir bag is limited and the FRC is often reduced. LATTO, I.P & ROSEN, M (EDS); Difficulties in Tracheal Intubation, Balliere Tindall, pp 2023. Number: 130 Which of the following typically result from the application of an aortic cross clamp? 1. Stroke volume decreases. 2. Systemic blood pressure increases. 3. Myocardial contractility decreases. 4. Venous return decreases. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: E The anticipated consequences of application of an aortic cross-clamp include an increased ventricular afterload, a decreased venous return, and a decreased velocity and shortening of myocardial muscle fibres. Clinical reports consistently report a 15-35% reduction in stroke volume and cardiac index, coupled with an increased arterial blood pressure and up to 40% increase in systemic vascular resistance. The effect of cross-clamping on venous return is a composite of complimentary and opposing factors- diminished venous return due to exclusion of blood flow to the pelvis and lower extremities; a possible redistribution of blood flow from the inferior vena cava to the superior vena cava; and an increase in left ventricular end systolic and end-diastolic volumes. CUNNINGHAM, A.J; " Anaesthesia for abdominal aortic surgery- a review (Part 1) ", Can J Anaesth, vol 36, no 4, 1989, pp 426-44.

135

Number: 183 Pulmonary Surfactant: 1. Is produced by type II alveolar cells. 2. Is turned over so rapidly that a reduction in pulmonary blood flow can cause a decrease in surfactant production. 3. Synthesis is stimulated by thyroxine and glucocorticoids. 4. Is partly recycled by endocytosis into the synthesising cell. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: E The role of surfactant in the aetiology of respiratory distress syndrome has been recently reviewed. ARDS includes a complex series of events leading to alveolar damage, high permeability pulmonary edema, and respiratory failure. The endogenous pulmonary surfactant system is crucial to maintaining normal lung function, and only recently has it been appreciated that alterations in the surfactant system significantly contributed to the pathophysiology of the lung injury of patients with ARDS. Through a combination of analyzing broncho-alveolar lavage samples from patients with ARDS and extensive animal studies, there have been significant insights into the variety of surfactant abnormalities that can occur in injured lungs. These include altered surfactant composition and pool sizes, abnormal surfactant metabolism, and inactivation of alveolar surfactant by serum proteins present within the airspace. Positive effects of exogenous surfactant administration on acute lung injury have been reported. There is now a prospective, randomized clinical trial evaluating the efficacy of aerosolized exogenous surfactant in patients with ARDS. This trial has demonstrated improvements in gas exchange and a trend toward decreased mortality in response to the surfactant. Despite these encouraging results, there are multiple factors requiring further investigation in the development of optimal surfactant treatment strategies for patients with ARDS. Such factors include the development of optimal surfactant delivery techniques, determining the ideal time for surfactant administration during the course of injury, and the development of optimal exogenous surfactant preparations that will be used to treat these patients. With further clinical trials and continued research efforts, exogenous surfactant administration should play a useful role in the future therapeutic approach to patients with ARDS. References: NUNN, J.F; Applied Respiratory Physiology, 3rd edition , Butterworths, 1987. LEWIS. J.F; Am Rev Respir Dis, vol 147, no 1, Jan. 1993, pp 218-33.

136

Number: 183 Pulmonary Surfactant: 1. Is produced by type II alveolar cells. 2. Is turned over so rapidly that a reduction in pulmonary blood flow can cause a decrease in surfactant production. 3. Synthesis is stimulated by thyroxine and glucocorticoids. 4. Is partly recycled by endocytosis into the synthesising cell. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: E The role of surfactant in the aetiology of respiratory distress syndrome has been recently reviewed. ARDS includes a complex series of events leading to alveolar damage, high permeability pulmonary edema, and respiratory failure. The endogenous pulmonary surfactant system is crucial to maintaining normal lung function, and only recently has it been appreciated that alterations in the surfactant system significantly contributed to the pathophysiology of the lung injury of patients with ARDS. Through a combination of analyzing broncho-alveolar lavage samples from patients with ARDS and extensive animal studies, there have been significant insights into the variety of surfactant abnormalities that can occur in injured lungs. These include altered surfactant composition and pool sizes, abnormal surfactant metabolism, and inactivation of alveolar surfactant by serum proteins present within the airspace. Positive effects of exogenous surfactant administration on acute lung injury have been reported. There is now a prospective, randomized clinical trial evaluating the efficacy of aerosolized exogenous surfactant in patients with ARDS. This trial has demonstrated improvements in gas exchange and a trend toward decreased mortality in response to the surfactant. Despite these encouraging results, there are multiple factors requiring further investigation in the development of optimal surfactant treatment strategies for patients with ARDS. Such factors include the development of optimal surfactant delivery techniques, determining the ideal time for surfactant administration during the course of injury, and the development of optimal exogenous surfactant preparations that will be used to treat these patients. With further clinical trials and continued research efforts, exogenous surfactant administration should play a useful role in the future therapeutic approach to patients with ARDS. References: NUNN, J.F; Applied Respiratory Physiology, 3rd edition , Butterworths, 1987. LEWIS. J.F; Am Rev Respir Dis, vol 147, no 1, Jan. 1993, pp 218-33.

137

Number: 284 Acidosis may result in: 1. Potassium retention 2. A rise in plasma chloride 3. A low pCO2 4. Tetany A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: A Alkalosis enhances and acidosis depresses renal potassium secretion, probably by inducing corresponding changes in tubular cell potassium. Chloride is required for bicarbonate secretion in the collecting duct via a bicarbonate-chloride exchanger. In acute metabolic acidosis, hyperventilation is usual and may be intense (Kussmaul respiration). Alkalosis directly enhances neuromuscular excitability; this effect, rather than the modest decrease in ionized plasma calcium induced by alkalosis, is probably the major cause of tetany. Number: 324 Concerning the membrane potential of cardiac muscle: 1. Phase 2 is associated with efflux of calcium ions 2. Phase 3 is produced by an efflux of potassium ions 3. Slowing of phase 3 decreases the QT interval 4. Verapamil blocks slow calcium currents A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE

138

Correct Answer: C Phase 2 is the plateau phase of the action potential. The slow calcium channel is open during this time. During phase 3 membrane repolarisation occurs as a result of the continued flow of potassium out of the cell. Number: 325 The gas transfer (DLCO) depends on: 1. The volume of the pulmonary capillary bed. 2. Ventilation perfusion matching 3. Haemoglobin concentration 4. Residual volume A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: A The ability of gas to diffuse across the alveolar-capillary membrane is ordinarily assessed by the diffusing capacity of the lung for carbon monoxide (DLCO). In this test, a small concentration of carbon monoxide (0.3%) is inhaled, usually in a single breath that is held for approximately 10 s. The carbon monoxide is diluted by the gas already present in the alveoli and is also taken up by haemoglobin as the erythrocytes course through the pulmonary capillary system. The concentration of carbon monoxide in exhaled gas is measured, and DLCO is calculated as the quantity of carbon monoxide absorbed per minute per mmHg pressure gradient from the alveoli to the pulmonary capillaries. The value obtained for DLCO depends on the alveolar-capillary surface area available for gas exchange and on the pulmonary capillary blood volume. In addition, the thickness of the alveolar-capillary membrane, the degree of ventilation-perfusion ratio mismatching, and the patient's haemoglobin level will affect the measurement. Because of this effect of haemoglobin levels on DLCO, the measured DLCO is frequently corrected to take the patient's haemoglobin level into account. The value for DLCO can then be compared with a predicted value, based either on age, height, and gender or on the alveolar volume (VA) at which the value was obtained. Alternatively, the DLCO can be divided by VA and the resulting value for DLCO/VA compared with a predicted value.

139

Number: 334 The features of chronic mountain sickness include: 1. A decreased ventilatory response to carbon dioxide. 2. Extreme polycythaemia. 3. A decreased ventilatory response to hypoxia. 4. Thromboembolism A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: E This uncommon disorder affects long-time, high-altitude residents and is known as Monge's disease. It is characterised by fatigue, dyspnoea, aches and pains, excessive polycythaemia, and thromboembolism. Hypoventilation is a prominent feature of the disorder. The condition is well recognized in miners living above 4000 metres in the Andes. Number: 342 The cardiovascular response to cooling to 31 degrees centigrade in a healthy 20 year old is likely to include: 1. Bradycardia. 2. Prolongation of the PR interval. 3. Prolongation of the QT interval. 4. Ventricular fibrillation. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: A Heart rate slows as temperature decreases to less than 33 C. This slowing results from prolongation of systole, unlike physiologic bradycardia in which diastole is prolonged.

140

Conduction velocity decreases throughout the hypothermic heart, yielding prolonged PR and QT intervals as well as a widening of the QRS complex on the electrocardiogram. Both Jpoint elevations, termed "Osborn waves," and T-wave flattening or inversions occur. Atrial fibrillation is common. It results from atrial stretching because of increased central blood volume. Ventricular fibrillation develops between 26 and 30 C . Hypothermia-induced ventricular fibrillation is refractory to pharmacologic therapy. Number: 404 A fit twenty year old male has been thoroughly preoxygenated, rendered apnoeic with thiopentone and suxamethonium and now has oxygen being insufflated into the upper airway at 500 mls/min. Given this scenario, which of the following statements are true? 1. The PCO2 will rise more in the first minute of apnoea than in the second. 2. Oxygen will be drawn into the apnoeic lung at a rate equal to the difference between O2 utilisation and CO2 production. 3. The arterial PCO2 will exceed the venous PCO2 by about 2 mm Hg after three minutes of apnoea. 4. Apnoea can be safely sustained for no longer than ten minutes. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: B The PCO2 rises more in the first minute than subsequent minutes because there is a rapid equilibration of CO2 between the alveolar and mixed venous blood. Thus in the first minute, the rise in PCO2 is about 6 mm Hg, thereafter it rises at about 3 mm Hg per minute. Oxygen is drawn into the lung ('apnoeic oxygenation') at a rate equal to the difference between the uptake of oxygen (~250 mls/min) and the rate at which CO2 is being added to the FRC. - The catch is that this rate does NOT equal CO2 production. - Because the body has a large capacity for buffering CO2, PCO2 only climbs at about 3 mm Hg per minute during apnoea. Thus the partial pressure of CO2 in the Functional Residual Capacity climbs at the same rate - which corresponds to a volume change of about 10 mls. As a result, oxygen is drawn into the lung at a rate just a little less than that of oxygen utilisation. Oxygen is transferred into the blood in the absence of CO2 exchange. The Haldane effect now operates and raises the PCO2 of the blood (without changing carbon dioxide content).

141

Properly performed, the limiting factor in apnoeic oxygenation is the maximum acceptable PCO2. In an otherwise healthy 20 year old this is likely to be more than 100 mm Hg, which would correspond to an apnoeic period of about 20 minutes. Number: 485 With regard to the Inspiratory (FiO2) to End-tidal Oxygen (FeO2) concentration difference (Fi-eO2). A. FeO2 is a good measure of the completeness of pre-oxygenation. B. (FetO2) can exceed (FiO2) during the first few minutes of Nitrous Oxide:Oxygen anaesthesia C. Fi-eO2 increases during the first hour of Nitrous Oxide:Oxygen anaesthesia. D. Fi-eO2 correlates with the rate of uptake of oxygen in the steady state. E. All of the above. Select the single best answer ABCDE Correct Answer: E Br J Anaesth 1994 Jan;72(1):116-8 Berry CB, Myles PS Preoxygenation in healthy volunteers: a graph of oxygen "washin" using end-tidal oxygraphy. Anaesth Intensive Care 1993 Aug;21(4):409-13 Machlin HA, Myles PS, Berry CB, Butler PJ, Story DA, Heath BJ End-tidal oxygen measurement compared with patient factor assessment for determining preoxygenation time. Time to adequate preoxygenation was assessed in 200 elective surgical patients, using measurement of end-tidal oxygen concentration. A variety of patient factors were assessed as to their ability to predict the time required to preoxygenate a patient. Of the 200 patients, 23 (11.5%) were unable to be adequately preoxygenated; most of these cases were due to a poor mask fit. The average time for preoxygenation was 154 seconds (range 43-364 seconds). Of those patients who could be preoxygenated, 46 (23%) required more than three minutes. Although a regression equation could be constructed to calculate time required for preoxygenation, the wide standard errors of the coefficients preclude a clinically useful predictive equation. We thus found that we could not accurately predict time required for preoxygenation and that a routine three minutes preoxygenation may not be sufficient for many patients. However, the measurement of end-tidal oxygen concentration is a very useful method of determining the end-point for preoxygenation.

142

Number: 492 The component of the pulmonary artery wedged pressure (PAWP) trace which most accurately reflects the left ventricular end-diastolic pressure is: A. The peak of the 'V' wave. B. The trough of the 'X' descent. C. The peak of the 'A' wave. D. The trough of the 'Y' descent. E. The mean value of the PAWP. Select the single best answer ABCDE Correct Answer: C The peak of the 'A' wave corresponds to the maximal end-diastolic pressure of the ventricle. Number: 520 With regard to lung volumes and capacities: A. Vital capacity represents the total lung volume. B. Inspiratory capacity is the sum of the tidal volume and the inspiratory reserve volume. C. FEV1 is typically about 90% of the vital capacity. D. Residual volume can be measured by the spirometry. E. Vital capacity is the sum of the inspiratory and the expiratory reserve volumes. Select the single best answer ABCDE Correct Answer: B Total lung volume is the vital capacity plus the residual volume. FEV1 is approximately 75-85% of the vital capacity. The functional residual capacity and residual volume can only be measured by plethysmography or indicator-dilution (eg Helium). Vital capacity is the sum of the inspiratory reserve volume, expiratory reserve volume and tidal volume.

143

Number: 522 Functional residual capacity: 1. Can be measured by the Helium dilution technique. 2. Decreases with age. 3. Decreases following prolonged exposure to 100% oxygen. 4. Exceeds closing capacity in a fit 20 year old in the supine position. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: B FRC can be measured by plethysmography or indicator-dilution (eg Helium, Oxygen). FRC remains the same or increases slightly with increasing age. Removal of the 'Nitrogen Splint' is associated with absorption atelectasis and a reduction in FRC. (The 'Critical VQ Hypothesis'). Closing capacity usually exceeds FRC in the supine position after 40 years and in the erect position after 60 years. Number: 525 The partial pressure of oxygen in the 'ideal' alveolar gas during air breathing: 1. Varies with atmospheric pressure. 2. Varies with ambient humidity. 3. Will transiently rise during induction of anaesthesia with a mixture of 21% oxygen in nitrous oxide. 4. Is greater than in the mixed expired air. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: B

144

Whatever the ambient humidity, air drawn into the respiratory tract becomes fully saturated in the alveoli at 37 degrees C. The SVP of water at this temperature is 47 mm Hg which corresponds to a concentration of 44 mg/L or a fractional concentration of 6.2%. During induction of anaesthesia with 21% oxygen in nitrous oxide, the initial rate of uptake of nitrous oxide is very rapid in comparison to oxygen, so the alveolar oxygen tension (PAO2) transiently rises in proportion to the decrease in alveolar volume. (Severinghaus JW: The rate of uptake of nitrous oxide in man, J Clin Invest 33:1183, 1954.) Expired air is a mixture of alveolar and dead space gas. By definition, dead space gas has not participated in gas exchange and therefore has a higher percentage of oxygen than alveolar air. Number: 587 A volunteer sits with his left arm in a water bath maintained at 42 centigrade and his right arm in a bath at 4 centigrade. 1. The arterial PO2 is higher in his left arm than in his right. 2. The arterial PO2 is lower in his right arm than in his aortic root. 3. The arterial O2 content is the same in both arms. 4. The arterial PO2 will be the same in both arms if temperature corrections are not applied to the measurements. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: E There is effectively no change in arterial oxygen content between the aortic root and the right and left arms. However, the arterial PO2 (measured at the actual blood temperature) will vary according to the temperature-induced shift in the haemoglobin dissociation curve. Thus, if the blood is cooled, the curve is left-shifted, haemoglobin binds oxygen more avidly and the arterial PO2 falls. The converse applies in the limb which has been warmed. Number: 600 Which of the following methods can be used to measure functional residual capacity (FRC)? 1. Helium dilution. 2. Bohr's method. 3. Body plethysmograph. 4. Fowler's method.

145

A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: B FRC can be measured by plethysmography or indicator-dilution (eg Helium, Nitrogen, or Oxygen). Fowler's method is used to measure the anatomical dead space, while Bohr's method is used to measure physiological dead space. Number: 617 Which of the following conditions is least likely to be associated with an increased end-tidal to arterial CO2 tension difference? A. Fat embolism. B. Chronic Obstructive Pulmonary Disease. C. Air embolism. D. Cardiogenic shock. E. Lobar pneumonia. Select the single best answer ABCDE Correct Answer: E Conditions which are characterised by an increase in alveolar (parallel) deadspace increase the end-tidal to arterial CO2 tension difference much more markedly than conditions which are characterised by increased intrapulmonary shunting (such as lobar pneumonia), Number: 619 After 5 minutes of air breathing in a hypobaric chamber at a chamber altitude of 10,000 feet, a fit 25 year old will demonstrate: A. A reduced PaCO2 with an increased ETCO2 : Arterial CO2 tension difference. B. A reduced PaCO2 with an unchanged ETCO2 : Arterial CO2 tension difference. C. An unchanged PaCO2 with an increased ETCO2 : Arterial CO2 tension difference. D. An unchanged PaCO2 with an unchanged ETCO2 : Arterial CO2 tension difference. E. No change in end-tidal or arterial CO2 tension. Select the single best answer

146

ABCDE Correct Answer: B During air-breathing at this altitude, hyperventilation (in response to hypoxia) occurs and hence PaCO2 is reduced. However, this is not accompanied by any increase in alveolar deadspace and accordingly there will be no change in the end-tidal to arterial tension difference. (In fact alveolar deadspace might actually decrease slightly which would tend to reduce the ETCO2 : Arterial CO2 tension difference.) At the low FiO2, ventilation:perfusion mismatch in any low V/Q units would be accentuated and venous admixture will tend to increase. Number: 668 The rate of transfer of oxygen from the alveolar gas to the alveolar capillary blood increases if there is an increase in: 1. Cardiac output. 2. Mixed venous PCO2. 3. Haemoglobin. 4. Mixed venous PO2. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: A Cardiac output. An increased cardiac output increases haemoglobin flow through the lungs, and, as a result produces an almost linear increase in oxygen transfer from alveolar gas to the blood. Mixed venous PCO2. When more CO2 is presented to the lungs the Haldane effect becomes more marked and more oxygen is transferred. Haemoglobin concentration. At normal levels of alveolar PO2 haemoglobin is about 98% saturated, and the absolute amount of oxygen is proportional to the rate of flow of haemoglobin through the lungs. Mixed venous PO2. The higher the venous O2 content, the less can be taken up in approaching saturation as the blood traverses the alveolar capillaries.

147

Number: 685 With regard to this flow:volume loop (blue), which of the following diagnoses is most likely? (For comparison, a normal loop is shown in black.) A. Acute asthma. B. Chronic Obstructive Pulmonary Disease. C. Intrathoracic tracheal obstruction. D. Laryngeal carcinoma. E. Pulmonary fibrosis. Select the single best answer

148

ABCDE Correct Answer: E Pulmonary Fibrosis. - This is a classic flow:volume loop for a patient with a restrictive lung defect. The five major types of abnormal flow:volume loops are: 1. Obstructive pattern the loop is left shifted (towards the TLC) due to hyperinflation and air trapping (increased RV). Decreased expiratory flows show up in the top half of the loop with a typical "scooped out" appearance. 2. Restrictive pattern a small volume loop that is shifted towards the right. Both volumes and, to a lesser extent, flow are decreased. 3. Fixed Upper Airway Obstruction - both inspiratory and expiratory flows are decreased. The FVC is nearly normal. 4. Variable Intrathoracic Obstruction Peak expiratory flow is markedly decreased in the presence of a nearly normal FVC. 5. Variable Extrathoracic Obstruction - Peak inspiratory flow is markedly decreased in the presence of a nearly normal FVC.

Number: 715 Acclimatisation to altitude commonly results in a: 1. Decreased red cell 2,3 diphosphoglycerate concentration. 2. Decreased affinity of haemoglobin for oxygen. 3. Decreased ventilatory response to CO2. 4. Decreased arterial PCO2. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: C

149

The erythrocyte content of 2,3-DPG is INCREASED by both anaemia and arterial hypoxaemia (such as occurs following ascent to altitude). The effect of 2,3-DPG is to decrease the affinity of haemoglobin for oxygen (by shifting the oxyhaemoglobin dissociation curve to the right), causing oxygen to be released to the tissues at a higher PaO2 than would otherwise be the case. In cases of Chronic Mountain Sickness (Monge's disease), the ventilatory response to CO2 is diminished, but this is unusual. Otherwise, the ventilatory response to CO2 is unchanged. The immediate response to altitude is an increase in alveolar ventilation, caused by hypoxic stimulation of the carotid body chemoreceptors. Arterial PCO2 is decreased as a result.

Number: 763 The Left Ventricular End-Diastolic Volume (LVEDV) of an adult at rest is approximately: A. 25 - 50 mls. B. 51 - 75 mls. C. 76 - 100 mls. D. 101 - 125 mls. E. 126 - 150 mls. Select the single best answer ABCDE Correct Answer: D Wahr et al estimated the mean LVEDV (in a group of 52 normal volunteers using echocardiography) to be 112 ml +/- 27 ml. Number: 764 The Left Ventricular End-Systolic Volume (LVESV) of an adult at rest is approximately: A. 0 - 10 mls. B. 11 - 25 mls. C. 26 - 50 mls. D. 51 - 75 mls. E. 76 - 100 mls. Select the single best answer ABCDE

150

Correct Answer: C Wahr et al estimated the mean LVESV (in a group of 52 normal volunteers using echocardiography) to be 35 +/- 16 ml. Number: 765 The effect of the loss of atrial systole on cardiac output is to reduce ouput by about: A. 0 - 5% B. 6 - 10% C. 11 - 20% D. 21 - 40% E. 41 - 60% Select the single best answer ABCDE Correct Answer: D Most of the work in this area is produced from research into the effects of DDD vs VVI cardiac pacing. Typically, there is a 30% reduction in cardiac output when such a switch is made. See, for example, Am J Cardiol 1988 Feb 1;61(4):323-9. Clinical and hemodynamic comparison of VVI versus DDD pacing in patients with DDD pacemakers. Rediker DE, Eagle KA, Homma S, Gillam LD, Harthorne JW Number: 768 Which of the following conditions would be associated with the greatest alveolar deadspace in an otherwise fit 20 year old? A. Major pulmonary embolism. B. Tension pneumothorax. C. Lobar collapse. D. Morbid obesity. E. Status Asthmaticus. Select the single best answer ABCDE Correct Answer: A Remember that 'Deadspace' respresents 'wasted' ventilation or 'ventilation without perfusion'. The initial 'lesion' in pulmonary embolism is the development of unperfused but still ventilated areas of lung. - Hence the large increase in alveolar deadspace.

151

A tension pneumothorax markedly increases right-to-left shunt together with a reduction in cardiac output. Thus hypoxaemia features strongly, but alveolar deadspace (and CO2 exchange) may not be greatly changed. Lobar collapse and morbid obesity are also associated with increases in right-to-left shunt but for different reasons. In status asthmaticus there are disturbances in the distribution of ventilation (in particular, the effect of anatomical deadspace may become relatively more significant if alveoalr hypoventilation occurs) but the most important effects are caused by the mal-distribution of perfusion acting in concert with alveolar hypoventilation. Number: 773 The (absolute) rate of uptake of oxygen into the blood from the alveolar gas will increase with an increase in: 1. Haemoglobin concentration. 2. Alveolar ventilation. 3. Cardiac output 4. 2,3 diphosphoglycerate. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: A 1. At normal levels of alveolar PO2 (about 100 mm Hg or 13.3 kPa) haemoglobin will become 96% saturated, and the absolute amount of oxygen taken up will therefore be proportional to the rate of flow of haemoglobin through the lungs. 2. An increase of alveolar ventilation will raise the PO2 of alveolar gas, and therefore increase the uptake of oxygen by blood. This will be slight if the haemoglobin is already nearly saturated, but there will always be an increase. 3. Like an increase in haemoglobin concentration, an increase in cardiac output increases haemoglobin flow through the lungs, which results in a nearly proportional increase in oxygen transfer from the alvolus to blood. 4. The effect of raising 2,3-DPG is to shift the oxyhaemoglobin dissociation curve to the right, which is advantageous for the transfer of O2 from blood to tissue, but not for uptake in the lungs.

152

Number: 781 With regard to the normal heart: 1. Atrial systole contributes to about 20 - 25% of ventricular filling. 2. Coronary blood flow comprises about 5% of the cardiac output at rest. 3. Blood flow in the left anterior descending coronary artery occurs primarily during diastole. 4. Left Ventricular dP/dT max is dependent on changes in preload. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: E Number: 782 The application of Positive End-Expiratory Pressure (PEEP) to a patient with normal lungs will tend to: 1. Increase right ventricular afterload. 2. Increase left ventricular afterload. 3. Increase alveolar deadspace. 4. Reduce the end-tidal to arterial carbon dioxide tension difference. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: B Under these circumstances, PEEP tends to increase right ventricular afterload and alveolar deadspace. As a result of the increase in deadspace, the end-tidal to arterial carbon dioxide tension difference also increases. PEEP increases in intrathoracic pressure, reduces left ventricular transmural pressure during systole, and, as a direct consequence, decreases left ventricular afterload.

153

See, for example: Circulation 1995 Mar 15;91(6):1725-31: Effect of continuous positive airway pressure on intrathoracic and left ventricular transmural pressures in patients with congestive heart failure. Naughton MT, Rahman MA, Hara K, Floras JS, Bradley TD Number: 811 Which of the following conditions would inevitably be associated with a lower-than-normal arterial PO2? A. Anaemia B. Carbon monoxide poisoning C. The presence of a high oxygen-affinity haemoglobin in the red cells. D. The presence of a low oxygen-affinity haemoglobin in the red cells. E. Lung disease with intra-pulmonary shunting. Select the single best answer ABCDE Correct Answer: E The presence of anaemia only affects only oxygen content, but not saturation or PO2. In contrast, the presence of CO or an abnormal oxygen-affinity haemoglobin affects oxygen saturation and content, but not PO2. The first demonstration of a high oxygen-affinity haemoglobin was by Charache in 1966, who was investigating a patient with erythrocytosis. The patients Hb level was 19.9 g/dl and an abnormal Hb band was observed on electrophoresis. The oxygen dissociation curve (ODC) of the patient's blood was found to be significantly shifted to the left. It was therefore suggested that the patient's erythrocytosis might be a secondary compensation to a primary defect in oxygen unloading. A family study revealed 15 other members with both erythrocytosis and the abnormal Hb. This Hb was then isolated and confirmed to have a marked increased oxygen affinity. A structural analysis revealed that it was an alpha-chain variant carrying the Arg->Lys substitution at position 92. This variant was named Hb Chesapeake. There are now over 200 high oxygen-affinity haemoglobins described. Number: 812 With regard to hyper- or hypo- baric conditions: 1. The 'cabin altitude' of commercial aircraft is maintained at sea-level pressure. 2. The PO2 of a scuba diver breathing compressed air at a depth of 66 feet is higher than at sea level. 3. At an altitude of 10,000 feet, the arterial PO2 of a climber remains normal due to hyperventilation. 4. The fractional inspired concentration of oxygen is the same at the summit of Mt. Everest as it is at sea level.

154

A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: C The 'cabin altitude' of commercial aircraft is maintained at 7-8000 feet. This can be an important consideration when transporting patients with 'bends' or arterial hypoxaemia. Breathing compressed air at this depth will approximately treble the sea level arterial PO2. Number: 813 The pH of a blood sample with a bicarbonate of 24 mmol/L and a PaCO2 80 mm Hg is: A. 7.10 B. 7.30 C. 7.40 D. 7.50 E. 7.60 Select the single best answer ABCDE Correct Answer: A This is calculated from the Henderson-Hasselbalch equation. pH = pK + log(HCO3-/0.03*PCO2). Even without doing the calculation, it should be apparent that a very high PaCO2 and normal bicarbonate will lead to a very low pH. Number: 814 'Shallow water blackout' occurring during a breath-holding dive is principally due to: A. Hypercarbia. B. Hypocarbia. C. Hypoxia.

155

D. The 'diving reflex'. E. None of the above. Select the single best answer

ABCDE Correct Answer: C I think this is correct!! Certainly hypoxia is the main cause of the problem, although it is possible that the diving response contributes as well. Shallow-water blackout is a sudden unconsciousness from resulting from lack of oxygen during a breath-hold dive. It can occur at any depth, but the risk is greatest during ascent. At this time, decompression is lowering an already low arterial PO2. The risk of shallow-water blackout is further increased if the diver hyperventilates just prior to the dive. Refer to the web link for a good explanation of the subject. Number: 815 Given that the barometric pressure on the summit of Mount Everest has been measured at about 253 mm Hg, the arterial PO2 of an acclimatised mountaineer at the summit without supplemental oxygen will be about: A. 20 mm Hg. B. 25 mm Hg. C. 30 mm Hg. D. 40 mm Hg. E. 50 mm Hg. Select the single best answer ABCDE Correct Answer: C The alveolar air equation tells us that: Alveolar PO2 = PAO2 = .21(253-47) - 1.2 (40). An acclimatised mountaineer is able to hyperventilate to a PCO2 of about 7.5 mm Hg under these circumstances. If ones assumes an A-a difference of 5 mm Hg, he or she will achieve a PaO2 of about 30 mm Hg.

156

Number: 866 The best indicator of the adequacy of systemic oxygen delivery in a patient with haemorrhagic shock is: A. Oxygen flux. B. Arterio-venous oxygen content difference (Ca-vO2). C. Arterial partial pressure of oxygen (PaO2). D. True mixed venous partial pressure of oxygen (PvO2), E. True mixed venous oxygen content (CvO2). Select the single best answer ABCDE Correct Answer: D This is a difficult one! The main contenders for the correct answer being options 'B', 'D' and 'E'. Oxygen flux - is clearly incorrect as it simply gives you a measure of oxygen delivery and tells you nothing about oxygen utilisation. Similarly, PaO2 gives you even less information about oxygen delivery and again tells you nothing about oxygen utilisation. Ca-vO2 gives you an insight into oxygen utilisation, but because you don't know the partial pressure of oxygen in either the arterial or venous sample (or the haemoglobin), you don't know where they are are on Hb dissociation curve and therefore don't know if arterial (and therefore tissue) hypoxaemia is present. PvO2 in the steady state will always reflect 'average' tissue PO2. Thus, a high PvO2 will always reflect an O2 supply that is adequate for the current utilisation and a low PvO2 one that is inadequate. CvO2 (like Ca-vO2) gives you no estimate of blood or tissue PO2. See, also, the interesting paper by Siggaard-Andersen et al. Siggaard-Andersen O, Ulrich A, Gothgen IH. Classes of tissue hypoxia. Acta Anaesthesiol Scand Suppl. 1995;107:137-42.

157

Number: 906 An acclimatised mountaineer, breathing air on the summit of Mount Everest (barometric pressure 253 Torr), will have an arterial PO2 (PaO2) of approximately: A. 50 mm Hg. B. 45 mm Hg. C. 40 mm Hg. D. 35 mm Hg. E. 30 mm Hg. Select the single best answer ABCDE Correct Answer: E See the classic study by West. - "Pulmonary gas exchange was studied on members of the American Medical Research Expedition to Everest at altitudes of 8,050 m (barometric pressure 284 Torr), 8,400 m (267 Torr) and 8,848 m (summit of Mt. Everest, 253 Torr). Thirty-four valid alveolar gas samples were taken using a special automatic sampler including 4 samples on the summit. Venous blood was collected from two subjects at an altitude of 8,050 m on the morning after their successful summit climb. Alveolar CO2 partial pressure (PCO2) fell approximately linearly with decreasing barometric pressure to a value of 7.5 Torr on the summit. For a respiratory exchange ratio of 0.85, this gave an alveolar O2 partial pressure (PO2) of 35 Torr. In two subjects who reached the summit, the mean base excess at 8,050 m was -7.2 meq/l, and assuming the same value on the previous day, the arterial pH on the summit was over 7.7. Arterial PO2 was calculated from changes along the pulmonary capillary to be 28 Torr. In spite of the severe arterial hypoxemia, high pH, and extremely low PCO2, subjects on the summit were able to perform simple tasks. The results allow us to construct for the first time an integrated picture of human gas exchange at the highest point on earth." West JB, Hackett PH, Maret KH, Milledge JS, Peters RM Jr, Pizzo CJ, Winslow RM. Pulmonary gas exchange on the summit of Mount Everest. J Appl Physiol. 1983 Sep;55(3):678-87. Number: 917 An awake patient, with normal lung function, is breathing spontaneously in the lateral decubitus position with the right side dependent. The proportion of blood flowing to the right lung will be approximately: A. 25% of total pulmonary flow. B. 35% of total pulmonary flow. C. 45% of total pulmonary flow. D. 55% of total pulmonary flow. E. 65% of total pulmonary flow.

158

Select the single best answer

ABCDE Correct Answer: E According to Benumof: "Thus, when the right lung is nondependent, it should receive approximately 45 per cent of total blood flow, as opposed to the 55 per cent of the total blood flow that it received in the upright and supine positions. When the left lung is nondependent, it should receive approximately 35 per cent of total blood flow, as opposed to the 45 per cent of the total blood flow that it received in the upright and supine positions." Anesthesia for Thoracic Surgery.2nd ed.Jonathan L. Benumof. ISBN: 0721644678. Publisher: WB Saunders. See also: Wulff KE, Aulin I. The regional lung function in the lateral decubitus position during anesthesia and operation. Acta Anaesthesiol Scand. 1972;16(4):195-205. Rehder K. Postural changes in respiratory function. Acta Anaesthesiol Scand Suppl. 1998;113:13-6. Number: 925 A patient in an intensive care unit has the following haemodynamic measurements made: Mean Systemic Arterial Pressure (MAP) 80 mm Hg. Mean Central Venous Pressure (CVP) 10 mm Hg. Cardiac Output (CO) 5.0 l/min. Mean Pulmonary Arterial Pressure (MPAP) 35 mm Hg. Pulmonary Artery Occlusion Pressure (PAOP) 20 mm Hg. The systemic vascular resistance (SVR) is: A. 14 dynes.sec.cm-5. B. 300 dynes.sec.cm-5. C. 350 dynes.sec.cm-5. D. 960 dynes.sec.cm-5. E. 1120 dynes.sec.cm-5. Select the single best answer ABCDE Correct Answer: E SVR= 80 x (MAP-CVP)/CO.

159

This equation is the hydraulic equivalent of Ohm's Law ie: Flow = Driving pressure / Resistance. The constant '80' being a conversion factor to convert the pressures (in mm Hg) to SI units. (More accurately the value is 79.9). The normal range for SVR in an adult is 900-1500 dynes.sec.cm-5. The MPAP and PAOP are not needed for calculation of the SVR but can be used in the calculation of pulmonary vascular resistance according to the equation: PVR= 80 x (MPAP-PAOP)/CO.

CLINICAL INVESTIGATIONS TESTS Number: 207 The Pressure:volume loop below is of: A. Acute Aortic Incompetence. B. Aortic Stenosis. C. Mitral Incompetence. D. Chronic Aortic Incompetence. E. Ventricular Septal Defect. (A normal loop - shaded - is shown for comparison) Select the single best answer

ABCDE Correct Answer: D The loop is of Chronic Aortic Incompetence. - Note the large increase in End-Diastolic volume which is associated with little increase in End-Diastolic pressure. 160

Number: 239 The following blood gas was taken 10 minutes into routine cardio-pulmonary bypass in an adult: PaO2:35 mmHg; PaCO2:34 mm Hg; pH:7.28; BXS -6.3; For the blood gas analysis shown above, the most likely diagnosis is: A. Oxygenator failure. B. Gas Blender Failure. C. Malignant Hyperpyrexia. D. Disconnection of the gas line from oxygenator. E. None of the above. Select the single best answer ABCDE Correct Answer: B There is an isolated failure of oxygen transfer. This is most probably due to the delivery of fresh gas with an inappropriately low FiO2 - ie blender failure. If the gas line has become disconnected from the oxygenator, or the oxygenator has failed, there will be a failure of both oxygen and carbon dioxide transfer. Malignant hyperpyrexia on bypass is extremely uncommon. It can cause arterial hypoxaemia, but this would inevitably be associated with extreme hypercarbia, metabolic acidosis and hyperkalaemia. Number: 559 The blue (expiratory) flow pattern is superimposed on a black flow:volume loop for a normal patient of the same height, age and weight. Both expire from vital capacity to residual volume. On the basis of this test, which statements are true of the blue patient? 1. He has a greater residual volume. 2. He has an abnormal FEV (1 sec) : VC Ratio. 3. His vital capacity is less than the black patient. 4. He will have a reversible component to his mid-expiratory flow impairment. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct

161

ABCDE Correct Answer: B 2. Although it is highly likely that this is true, a measure of time on the X axis is necessary to confirm this. 4. The reversibility (or otherwise) of expiratory flow impairment can only be measured by testing pre- and post-exposure to a bronchodilator. The five major types of abnormal flow:volume loops are: 1. Obstructive pattern the loop is left shifted (towards the TLC) due to hyperinflation and air trapping (increased RV). Decreased expiratory flows show up in the top half of the loop with a typical "scooped out" appearance. 2. Restrictive pattern a small volume loop that is shifted towards the right. Both volumes and, to a lesser extent, flow are decreased. 3. Fixed Upper Airway Obstruction - both inspiratory and expiratory flows are decreased. The FVC is nearly normal. 4. Variable Intrathoracic Obstruction Peak expiratory flow is markedly decreased in the presence of a nearly normal FVC. 5. Variable Extrathoracic Obstruction - Peak inspiratory flow is markedly decreased in the presence of a nearly normal FVC.

162

Number: 565 Which of the following diagnoses is most likely for a patient with this flow:volume loop? A. Acute bronchospasm. B. Chronic Obstructive Pulmonary Disease. C. Intrathoracic tracheal obstruction. D. Extrathoracic tracheal obstruction. E. None of the above. Select the single best answer

ABCDE Correct Answer: C Intrathoracic tracheal obstruction. The five major types of abnormal flow:volume loops are: 1. Obstructive pattern the loop is left shifted (towards the TLC) due to hyperinflation and air trapping (increased RV). Decreased expiratory flows show up in the top half of the loop with a typical "scooped out" appearance. 2. Restrictive pattern a small volume loop that is shifted towards the right. Both volumes and, to a lesser extent, flow are decreased. 3. Fixed Upper Airway Obstruction - both inspiratory and expiratory flows are decreased. The FVC is nearly normal.

163

4. Variable Intrathoracic Obstruction Peak expiratory flow is markedly decreased in the presence of a nearly normal FVC. 5. Variable Extrathoracic Obstruction - Peak inspiratory flow is markedly decreased in the presence of a nearly normal FVC. Number: 643 A junior colleague calls you into his operating theatre because he is a little bit worried about his patient. The patient is a 20 year old with Down's syndrome who is undergoing a dental clearance under relaxant general anaesthesia. The patient has been intubated with a size 8 cuffed endotracheal tube (ETT) and is being ventilated with isoflurane in 100% oxygen. 30 minutes into the procedure, the patient is noted to be a little bit dusky. A blood gas analysis (ABG) has been performed, and is reported as: PaO2: 54 mm Hg; PaCO2: 30 mm Hg; pH: 7.48 Given the scenario above, what is the most likely cause for desaturation? A. Oesophageal intubation. B. Intubation of the right main bronchus. C. Endocardial cushion defect. D. Absorption atelectasis. E. Inhalation. Select the single best answer ABCDE Correct Answer: B Common things occur commonly! The ABG is unlikely to be due to oesophageal intubation in this scenarion because the PaCO2 is low. Nevertheless, as part of your management, you must visualise the ETT and confirm that it is passing through the cords. An endocardial cushion defect is a possibility - The incidence of endocardial cushion defects in patients with Down's syndrome is about 40% and it is certainly possible that a right-to-left shunt is causing (or contributing) to hypoxia in this patient.. Absorption atelectasis cannot produce this degree of right to left shunting unless other pathology is present.

164

Number: 702 These two blood gases were taken at a temperature of 26 degrees centigrade, 15 minutes apart, during cardiopulmonary bypass for aortic valve replacement. Both are reported at the analyser temperature of 37 dgrees centigrade. Note that the first gas was taken using a much HIGHER fresh gas flow (sweep gas) rate than the second. Blood Gas 1: Fresh Gas Flow: 3.6 L/min; Pump Flow: 3.5 L/min Hb: 77 G/L PaO2: 670 mm Hg. PaCO2: 46 mm Hg. pH: 7.32. Blood Gas 2: Fresh Gas Flow: 2.7 L/min; Pump Flow: 3.5 L/min Hb: 76 G/L PaO2: 640 mm Hg. PaCO2: 33 mm Hg. pH: 7.44. The most likely explanation of the change between blood gas 1 and blood gas 2 is: A. That CO2 flooding of the open chest was stopped. B. That a muscle relaxant was administered. C. That malignant hyperpyrexia was treated. D. That a large dose of thiopentone was administered. E. That the blood gas analyser was recalibrated. Select the single best answer ABCDE Correct Answer: A CO2 flooding of the open chest was stopped. The first blood gas is quite typical for a patient in whom CO2 flooding (for the purpose of minimising the risks of air embolism) is in use. In such cases, much higher than normal Fresh Gas Flows may be required in order to achieve normocarbia. CO2 is more dense than air and therefore accumulates in the open chest wound. As such, it tends to get preferentially sucked into the cardiotomy reservoir (where again it accumulates), either through the hand-held sucker or through a vent line. Once in the cardiotomy reservoir it raises the PCO2 of the incoming venous blood significantly - the reservoir being a surprisingly good gas-exchanging device. See, for example: Nadolny EM, Svensson LG. Carbon dioxide field flooding techniques for open heart surgery. Perfusion 2000; 15: 151-153. The effects of muscle relaxants and profound anaesthesia on metabolic rate at this temperature are minimal.

165

Malignant hyperpyrexia on bypass is virtually undescribed during cardiopulmonary bypass. The pH change is consistent with the change in PCO2 which means that it is unlikely that the gas analyser was recalibrated. Number: 767 A fit young man suffers a large, left-sided, spontaneous pneumothorax with no clinical evidence of tension. If an arterial blood gas (ABG) analysis were performed on the patient while breathing room air, which of the following results would be most likely? A. PaO2 70; PaCO2 35. B. PaO2 60; PaCO2 40. C. PaO2 50; PaCO2 40. D. PaO2 40; PaCO2 30. E. PaO2 50; PaCO2 30. Select the single best answer ABCDE Correct Answer: E Option 'E' corresponds to about a 40% right-to-left shunt - which is the sort of value you might expect in this scenario. The degree of hypoxia is sufficient to provoke a ventilatory response - hence option 'C' cannot be correct. Option 'D' corresponds to a 70% right-to-left shunt which is unlikely. Download the calculator (which is included in the pulmonary artery catheter simulator) if you want to examine the effect of right-to-left shunting on arterial oxygenation. Number: 791 A previously fit 50 year old lady undergoes an uneventful laparoscopic cholecystectomy. On the first post-operative day, the intern takes a blood specimen for 'routine' biochemistry. The patient is well. The result is reported as: Sodium 110 mmol/L (Normal Range 135 -145 mmol/L) Potassium 2.6 mmol/L (Normal Range 3.5 - 5.0 mmol/L) Chloride 79 mmol/L (Normal Range 98 - 106 mmol/L) Bicarbonate 20 mmol/L (Normal Range 22 - 32 mmol/L) Osmolality 291 mosm/L (Normal Range 270 - 290 mmol/L) Glucose 60 mmol/L (Normal Range 3.5 - 7.0 mmol/L) Urea 0.04 mmol/L (Normal Range 3.0 - 8.0 mmol/L)

166

The most likely diagnosis is: A. Syndrome of Inappropriate Anti-Diuretic Hormone secretion (SIADH). B. Hypothyroidism. C. Over-administration of 5% dextrose. D. Sampling from the 'Drip' arm. E. Hypoaldosteronism. Select the single best answer ABCDE Correct Answer: D There are three important causes of hyponatraemia resulting from hormonal abnormalities SIADH, adrenal insufficiency and hypothyroidism. All of such cases of hyponatraemia are associated with a low plasma osmolality. Adrenal insufficiency and hypothyroidism may present with hyponatraemia but should not be confused with SIADH. Although decreased mineralocorticoids may contribute to the hyponatraemia of adrenal insufficiency, it is the cortisol deficiency that leads to hypersecretion of ADH both indirectly (secondary to volume depletion) and directly (cosecreted with corticotropin-releasing factor). The mechanisms by which hypothyroidism leads to hyponatraemia include decreased cardiac output and GFR and increased ADH secretion in response to haemodynamic stimuli. Given the scenario, it is very unlikey that hormonal excess or deficiency is the cause of hyponatraemia in this case. Inappropropiate prescription of free water (in the form of 5% dextrose) is a relatively common peri-operative complication, but, again given the scenario seems unlikely. This is the typical result of sampling from the 'Drip' arm in a patient receiving 5% dextrose. Note that the blood is still iso-osmolar - in contrast to most of the 'real' causes of extreme hyponatraemia. Number: 793 An 85 year old lady is brought to the emergency room having been found unconscious at home. No other history is available. A biochemical screen performed at that time shows: Sodium 144 mmol/L (Normal Range 135 -145 mmol/L) Potassium 5.0 mmol/L (Normal Range 3.5 - 5.0 mmol/L) Chloride 99 mmol/L (Normal Range 98 - 106 mmol/L) Bicarbonate 17 mmol/L (Normal Range 22 - 32 mmol/L) Osmolality 391 mosm/L (Normal Range 270 - 290 mmol/L) Glucose 65 mmol/L (Normal Range 3.5 - 7.0 mmol/L) Urea 16 mmol/L (Normal Range 3.0 - 8.0 mmol/L) Creatinine 0.2 mmol/L (Normal Range 0.05 - 0.12 mmol/L) Urinary ketones absent.

167

The most likely diagnosis is: A. Neurogenic Diabetes Insipidus. B. Primary Hypodipsia. C. Hyperosmolar, nonketotic diabetic coma. D. Simple Dehydration. E. Diabetic Ketoacidosis. Select the single best answer ABCDE Correct Answer: C This is the classic picture of hyperosmolar, nonketotic diabetic coma. Hyperosmolar, nonketotic diabetic coma is usually a complication of NIDDM. It is a syndrome of profound dehydration resulting from a sustained hyperglycaemic diuresis under circumstances in which the patient is unable to drink enough water to keep up with urinary fluid losses. Commonly, an elderly diabetic patient, often living alone or in a nursing home, develops a stroke or infection that worsens hyperglycaemia and prevents adequate water intake. The full-blown syndrome probably does not occur until volume depletion is severe enough to decrease urine output. Number: 803 The following blood gas was taken 60 minutes into routine cardio-pulmonary bypass in an adult. Sodium Nitroprusside (SNP), administered at a rate of 2 mcg/kg/min has been running for 15 minutes to assist in re-warming. PaO2: 375 mm Hg; PaCO2: 40 mm Hg; pH: 7.08; BXS: -16.3 Blood Sugar: 27.2 mmol/L; Given the scenario above, the most likely diagnosis is: A. Malignant hyperpyrexia. B. Diabetic ketoacidosis. C. Lactic acidosis. D. Acute renal failure. E. Cyanide toxicity. Select the single best answer ABCDE Correct Answer: B Diabetic Ketoacidosis. The diagnosis should be confirmed by looking for ketonuria.

168

During high infusion rates of nitroprusside, cyanide toxicity may occur. This appears to be a particular problem when doses greater than 10 mcg/kg/min (0.6 mg/kg/hour) are used. Cyanide ion combines with cytochrome C, an enzyme required for aerobic metabolism. The impairment of aerobic metabolism results in a shift to anaerobic metabolism which is manifested as metabolic acidosis, with elevated plasma lactate concentrations. Number: 804 A 65 year old woman presents to the emergency department complaining of generalised weakness. On examination she has suffered obvious weight loss (her skin creases are quite prominent) and has a blood pressure of 90/60. She has no peripheral oedema or other evidence of malnutrition. A biochemical screen performed at that time shows: Sodium 120 mmol/L (Normal Range 135 -145 mmol/L) Potassium 6.2 mmol/L (Normal Range 3.5 - 5.0 mmol/L) Chloride 87 mmol/L (Normal Range 98 - 106 mmol/L) Bicarbonate 17 mmol/L (Normal Range 22 - 32 mmol/L) Osmolality 273 mosm/L (Normal Range 270 - 290 mmol/L) The most likely diagnosis for her hyponatraemia is: A. 'Factitious' hyponatraemia. B. Addison's disease. C. Syndrome of Inappropriate Anti-diuretic Hormone Secretion (SIADH). D. Cushing's syndrome. E. Nephrotic syndrome. Select the single best answer ABCDE Correct Answer: B A. 'Factitious' hyponatraemia (such as occurs with hyperlipidaemia) does not explain the serum potassium. B. Addison's original description was of "general languor and debility, feebleness of the heart's action, irritability of the stomach and a peculiar change of the colour of the skin". The condition results from progressive destruction of the adrenals - which must involve more than 90 percent of the glands before adrenal insufficiency appears. Historically the most important cause was chronic granulomatous disease - in particular tuberculosis (but also histoplasmosis, coccidioidomycosis, and cryptococcosis). Nowadays the most frequent cause in developed countries is 'idiopathic atrophy' with necrotising adrenalitis (due to cytomegalovirus) in AIDS patients running a close second. Hyperpigmentation in Addison's disease may be striking or absent. It commonly appears as a diffuse brown, tan, or bronze darkening of parts such as the elbows or creases of the hand and

169

of areas that normally are pigmented such as the areolae about the nipples. Bluish-black patches may appear on the mucous membranes. C. The diagnosis SIADH should be suspected in patients who have hyponatraemia and a concentrated urine (osmolality >300 mmol/kg) associated with lethargy - in the absence of oedema, orthostatic hypotension and features of dehydration. It may be reasonable to suspect SIADH (secondary to a malignancy) in this woman, but the diagnosis is inconsistent with the hyperkalaemia. D. The clinical picture is not one of Cushing's syndrome. E. The absence of peripheral oedema excludes the possibility of nephrotic syndrome. Number: 810 The following blood gas was obtained 15 minutes after initiation of cardio-pulmonary bypass in an otherwise fit 60 year old man undergoing elective aortic valve replacement. At the time the measurement was made, carbon dioxide was being continually insufflated into the chest wound in order to reduce the likelihood of air embolism. pH: 7.41. pCO2: 72.5 mm Hg. pO2: 504 mm Hg. HCO3-: 41.7 mmol/L K+: 5.2 mmol/L Given this scenario, the most likely cause of the hypercarbia is: A. Oxygenator failure. B. Partial disconnection of the fresh gas supply from the oxygenator. C. Malignant hyperpyrexia (MH). D. The carbon dioxide insufflation. E. Malfunction of the blood-gas electrode. Select the single best answer ABCDE Correct Answer: E Malfunction of the blood-gas electrode. - the combination of a normal pH and large base excess is incompatible with any pathological condition. If a partial disconnection of the fresh gas supply from the oxygenator had occurred, the pH would be much lower. Similarly, MH would be associated with a base deficit and hyperkalaemia. Carbon dioxide insufflation can result in hypercarbia, but usually not of this magnitude. If the insufflated CO2 were the cause, one would expect the pH to be much lower and the base excess to be in the normal range.

170

Number: 920 A 40 year old woman with a DVT has the following coagulation profile: INR 0.9 (Normal range 0.8-1.2) APPT 90 sec (Normal range < 35 sec) Platelet count 250 x 10^6 (Normal range 150-450.) Which of the following could explain these findings? 1. Disseminated intravascular coagulation. 2. Presence of lupus anticoagulant. 3. Antithrombin III deficiency. 4. Heparin therapy. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: C Abnormal coagulation studies may be the result of anticoagulation therapy or it may be a disorder of coagulation. The latter may be congenital or acquired. In this scenario, there is an isolated rise in the APPT. This may occur in the presence of the lupus anticoagulant, however, paradoxically, thrombosis is more common than coagulopathy. The cornerstone of monitoring heparin therapy is serial measures of APPT. The standard coagulation screen includes INR, APPT, TT, and FBC to assess platelet count. In addition a skin bleeding time and ACT may be indicated in some situations. INR (correlates with Prothrombin time (PR)): involves adding the source of thromboplastin (animal brain usually) and calcium to plasma thus activating Factor VII which activates Factor X. Sequentially, Xa and Va convert prothrombin to thrombin, fibrinogen to fibrin. Thus , the INR bypasses the intrinsic pathway and is abnormal with deficencies of Factors VII, X, V, prothrombin, fibrinogen or if a coagulation inhibitor is present, for example, warfarin. APPT (Activated Partial Thromboplastin Time): contact Factors XII and XI are activated by kaolin, and phospholipid accelerates the reactions involving VIII and V. Thus Factor X is activated leading to the formation of thrombin and fibrin. The only factor not involved in this pathway is VII. This test gives prolonged times with deficencies of XII, XI, IX, X, V, prothrombin & fibrinogen or by inhibitors such as Heparin. TT (Thrombin time):involves adding a source of thrombin to plasma thus bypassing intrinsic, extrinsic and common pathways to the level of conversion of fibrinogen to fibrin. It is

171

prolonged with deficiency of fibrinogen or by inhibitors of the conversion of fibrinogen to fibrin, for example: Heparin, FDPs DISSEMINATED INTRAVASCULAR COAGULATION (DIC): in DIC a triggering event occurs which disturbs the normal balance between intravascular coagulation and fibrinolysis and leads to activation of the coagulation system with widespread deposition of fibrin and platelets and secondary activation of the fibrinolytic system. Laboratory diagnosis involves: HB - low - bleeding/hemolysis PLATELET COUNT - low - consumption/ may be normal in chronic. INR - high - markedly prolonged in acute/ may be normal in chronic. APPT - high - markedly prolonged in acute/ may be normal in chronic. TT - high - may be normal depending on the level of fibrinogen. FIBRINOGEN - low - may be normal/increased. FDPs/D-DIMER - high - reflecting fibrinolysis Some disorders associated with DIC include:infection, obstetric complications, neoplasia, shock, hepatic disease, intravascular hemolysis, vasculitis, snake venom, burns, extracorporeal circulation, metabolic diseases eg: severe diabetes, hyperlipoproteinaemia. LUPUS ANTICOAGULANT: These are inhibitors which are directed against phospholipids and inhibit the interaction between the complex of Xa, V, phospholipid and calcium, and prothrombin. They may be found in SLE, other autoimmune disorders and some haematological malignancies, but often no underlying disease state can be found. In screening the most common finding is prolonged APPT which is not corrected by the addition of plasma. Despite this, bleeding is a rare event in the absence of other haemostatic defects for example, thrombocytopenia or hypoprothrombinaemia. The most common clinical manifestations are thrombotic events and recurrent abortions. ANTITHROMBIN III: This is one of the endothelial cell factors and has an anticoagulant role. The mechanism and control of its release are poorly understood. It is the main physiological inhibitor of thrombin and Factor Xa. It reacts irreversibly with thrombin to form a complex in which both components are inactivated. This reaction is greatly enhanced in the presence of heparin, and antithrombin III is an essential cofactor in its anticoagulant effect. As a serine protease inhibitor, it is also capable of inhibiting the activity of XIIa, XIa,and IXa. As a serine protease inhibitor, it is also capable of inhibiting the activity of XIIa, XIa,and IXa. The importance of antithrombin III in the normal inhibition of clotting activation is emphasised by the high incidence of venous thrombosis found in patients with congenital antithrombin III deficiency. A patient with a DVT may have antithrombin III deficiency but heparin therapy will be limited in effectiveness as reflected by an APPT which does not rise with therapy. HEPARIN: There are several ways in which heparin can influence the coagulation system. Predominantly,it potentiates the inhibition of Factors XIIa, XIa, IXa, Xa and thrombin through its interaction with Antithrombin III. As a result the APPT and TT will be prolonged as isolated findings unless it is complicated by bleeding or HITS. Low molecular weight heparin is produced by depolymerization of the parent compound. It has an equipotent effect on thrombogenesis but a reduced effect on platelets. It is a potent inhibitor of Factor X but has a weak effect on thrombin. Subsequently, the APPT cannot be used to measure activity; instead the more complex anti Factor Xa assay is used.

172

References International Anesthesiology Clinics, vol 23, no 2, Coagulation Disorders and the Hemoglobinopathies, 1985, pp 8-9, 34 NUNN, UTTING & BROWN; Anaesthesia, Ch. 79; Acquired Haemostatic Failure. Number: 1007 The bleeding time is increased in: 1. Haemophilia. 2. Idiopathic Thrombocytopenic Purpura (ITP). 3. Coumarin overdose. 4. Vitamin C deficiency. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: C The bleeding time (BT) is a very sensitive measure of platelet function and is thus normal in both haemophilia and coumarin overdosage. In both ITP and scurvy the bleeding time is prolonged. In ITP it is prolonged because of the reduction in platelet numbers (There is effectively a linear relationship between BT and platelet count once the count is less than ~ 80,000 platelets / microlitre of blood.), while in scurvy, there is a functional platelet defect associated with impairment of prostaglandin E1 synthesis. See: Johnson GJ, Holloway DE, Hutton SW, Duane WC. Platelet function in scurvy and experimental human vitamin C deficiency. Thromb Res. 1981 Oct 1-15;24(1-2):85-93. Horrobin DF, Oka M, Manku MS. The regulation of prostaglandin E1 formation: a candidate for one of the fundamental mechanisms involved in the actions of vitamin C. Med Hypotheses. 1979 Aug;5(8):849-58. LA Harker, Hemostasis Manual, 2d ed. Philadelphia, FA Davis Company, 1974

173

GENERAL ANAESTHESIA TESTS Number: 1 With regard to explicit awareness during general anaesthesia: 1. It occurs in about 0.2% of a heterogenous population of cases. 2. It is about twice as common in those given muscle relaxants compared to those who are not. 3. About 20% of those who suffer explicit awareness feel pain. 4. About 50% of those who suffer explicit awareness manifest cardiovascular changes.

A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct Correct Answer: A Awareness during anaesthesia can be classified as either 'explicit' or 'implicit'. Explicit awareness refers to the specific recall of intra-operative events, whereas implicit memories can only be recalled when special techniques (such as hypnosis) are used to demonstrate 'awareness'. The incidence of explicit awareness in a heterogenous population of cases in the United Kingdom has been reported at about 0.2% and in Sweden at 0.18% (Liu D, Thorp S, Aitkenhead AR. Incidence of awareness with recall during general anaesthesia. Anaesthesia 1991; 46:435-437. Sandin RH, Enlund G, Samuelsson P, Lennmarken C: Awareness during anaesthesia: a prospective case study. Lancet 2000 Feb 26;355(9205):707-11 ). In particular risk groups, the incidence of explicit awareness may be considerably higher - for example in cardiac surgical cases it has been reported as about 1%. Awareness is usually thought to be extremely uncommon in those who have not been paralysed, but a recent study suggests that this might not be so. (Sandin RH, Enlund G, Samuelsson P, Lennmarken C: Awareness during anaesthesia: a prospective case study. Lancet 2000 Feb 26;355(9205):707-11 ) Schwender et al recently described 45 patients who had reported explicit awareness. 8 of these patients complained of painful awareness. (Schwender D, Kunze-Kronawitter H, Dietrich P, et al; Conscious awareness during general anaesthesia: patients' perceptions, emotions, cognition and reactions. Br J Anaesth 1998; 80:133 - 139.) The traditional cardiovascular signs of awareness only occur in about 25% of cases. Auditory awareness is almost always present in those who have been aware. 174

Number: 7 In patients undergoing laparoscopy, there is a association between the incidence of POSTOPERATIVE nausea and vomiting (PONV) and a high INTRA-OPERATIVE arterial partial pressure of which of the following gases: 1. Oxygen. 2. Carbon dioxide. 3. Nitrogen. 4. Nitrous oxide A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct Correct Answer: E This is a bit of a trick question as all are probably correct! 1. Oxygen. In a recent study by Goll et al, the surprising efficacy of intra-operative hyperoxia in combatting PONV was demonstrated.The authors speculated that "The efficacy of oxygen may be related to ameliorating subtle intestinal ischemia with its consequent release of emetogenic substances, including serotonin. Intestinal ischemia seems more likely during surgery than postoperatively because that is when the bowel is manipulated and compressed by retractors. To the extent that this theory is correct, intraoperative oxygen presumably contributed more to reducing the incidence of PONV than the 2 h of postoperative oxygen." See: Goll V, Akca O, Greif R, Freitag H, Arkilic CF, Scheck T, Zoeggeler A, Kurz A, Krieger G, Lenhardt R, Sessler DI. Ondansetron is no more effective than supplemental intraoperative oxygen for prevention of postoperative nausea and vomiting. Anesth Analg. 2001 Jan;92(1):112-7. 2. Carbon dioxide. Although intra-operative PaCO2 measurements have not been correlated with the incidence of PONV, there seems little doubt that 'Gasless' laparoscopy (which is associated with a lower end-tidal PaCO2) is associated with a lower incidence of PONV. See, for example: Br J Anaesth 1996 Nov;77(5):576-80: Gasless laparoscopic cholecystectomy: comparison of postoperative recovery with conventional technique. Koivusalo AM, Kellokumpu I, Lindgren L 3. Nitrogen. - This is a natural consequence of '1' above if nitrous oxide is not the balancing gas. 4. Nitrous oxide. There seems little doubt that the use of N2O increases the incidence of PONV. See, for example: Anesthesiology 1996 Nov;85(5):1055-62: Omission of nitrous

175

oxide during anesthesia reduces the incidence of postoperative nausea and vomiting. A metaanalysis. Divatia JV, Vaidya JS, Badwe RA, Hawaldar RW Kovac has recently reviewed the whole area of PONV. See: Drugs 2000 Feb;59(2):213-43: Prevention and treatment of postoperative nausea and vomiting. Kovac AL Number: 8 Mild, accidental hypothermia during the course of major surgery may lead to significant increases in: 1. The requirement for peri-operative blood transfusion. 2. The duration of stay in the anaesthetic recovery room. 3. The incidence of post-operative wound infection. 4. The incidence of post-operative myocardial ischaemia. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct Correct Answer: E Mild, accidental hypothermia (<35 centigrade) is emerging as a major cause of perioperative morbidity. It is a potent cause of coagulopathy (Johnson TD, Chen Y, Reed RL: Functional equivalence of hypothermia to specific clotting factor deficiencies. J Trauma 37:413, 1994.) which can be easily overlooked as laboratory testing is carried out at 37 centigrade. It has also been demonstrated to cause a significant increase in post-operative blood loss (Schmied H, Kurz A, Sessler DI, Kozek S, Reiter A. Mild hypothermia increases blood loss and transfusion requirements during total hip arthroplasty. Lancet. 1996 Feb 3;347(8997):289-92.). The incidence of post-operative wound infection is at least doubled in those whose body temperature falls to less than 35 centigrade (Kurz A, Sessler DI, Lenhardt R. Perioperative normothermia to reduce the incidence of surgical-wound infection and shorten hospitalization. Study of Wound Infection and Temperature Group. N Engl J Med. 1996 May 9;334(19):120915.). Similarly, duration of stay in the recovery ward is virtually doubled (Lenhardt R, Marker E, Goll V, Tschernich H, Kurz A, Sessler DI, Narzt E, Lackner F. Mild intraoperative hypothermia prolongs postanesthetic recovery. Anesthesiology. 1997 Dec;87(6):1318-23.). In a study of patients undergoing peripheral vascular surgery (Frank SM et al: Unintentional hypothermia is associated with postoperative myocardial ischemia. The Perioperative Ischemia Randomized Anesthesia Trial Study Group. Anesthesiology. 1993 Mar;78(3):46876.), it was found that the incidence of postoperative angina was greater in the hypothermic group (18%, 6 of 33) than in the normothermic group (1.5%, 1 of 67, P = 0.002). The

176

incidence of PaO2 < 80 mmHg in the arterial blood was greater in the hypothermic group (52%, 17 of 33) than in the normothermic group (30%, 20 of 67, P = Number: 14 Of the following possible complications of electro-convulsive therapy (ECT) the most common is: A. Dental damage. B. Aspiration pneumonitis. C. Bronchospasm. D. Laryngospasm. E. Hypertension Select the single best answer Correct Answer: E Tecoult and Nathan reviewed 612 electroconvulsive therapy procedures carried out under propofol anaesthesia on 75 patients. In their series, hypertension was the most common complication (15%). Laryngospasm occurred in about 5% of patients while aspiration pneumonitis, dental damage and bronchospasm complicated less than 2% of cases. Of complications not listed above, confusion and headache were reported by 33% and 10% of patients respectively. See: Tecoult E, Nathan N. Morbidity in electroconvulsive therapy. Eur J Anaesthesiol. 2001 Aug;18(8):511-8. The haemodynamic response to ECT (hypertension, tachycardia) is well-recognised, although the exact mechanism remains uncertain. See, for example, Petrides G, Maneksha F, Zervas I, Carasiti I, Francis A. Trimethaphan (Arfonad) control of hypertension and tachycardia during electroconvulsive therapy: a double-blind study. J Clin Anesth. 1996 Mar;8(2):104-9 and Weinger MB, Partridge BL, Hauger R, Mirow A. Prevention of the cardiovascular and neuroendocrine response to electroconvulsive therapy: I. Effectiveness of pretreatment regimens on hemodynamics. Anesth Analg. 1991 Nov;73(5):556-62. Number: 17 Which of the following drugs are believed to be effective in the treatment of post-operative shivering? 1. Clonidine. 2. Tramadol. 3. Pethidine. 4. Paracetamol

177

A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct Correct Answer: A With the exception of paracetamol, all of these drugs may be of some use in the treatment of post-operative shivering. In a recent study, Bhatnagar et al demonstrated that tramadol was a remarkably effective form of therapy. In their discussion, they commented that "Although the aetiology of postoperative shivering is inadequately understood, various risk factors have been suggested. These include hypothermia, stress, uncontrolled pain, uninhibited spinal reflexes and decreased sympathetic activity. Many drugs have been used to treat shivering, including opioids, doxapram, tramadol, ketanserin, clonidine, propofol, physostigmine and nefopam, with opioids being the most extensively evaluated. Amongst the opioids, pethidine has been found to be most efficacious. Evidence suggests that kappa-opioid receptors play an important role in the modulation of postoperative shivering. This explains the greater efficacy of pethidine compared with equi-analgesic doses of mu-receptor opioid agonists such as morphine, fentanyl, alfentanil and sufentanil. The analgesic potential of tramadol is believed to be mediated weakly through its effect on the mu-opioid receptor, for which it has a low affinity. Of greater importance may be its effect on 5-HT3 and noradrenergic receptors, with activation of descending inhibitory pathways producing antinociception. The R (+) enantiomer of tramadol inhibits 5-HT3 uptake and enhances its release, while the L (-) enantiomer inhibits nonadrenaline uptake. Electrophysiologic, neurophysiologic and neuropharmacologic experiments in animals have established the role of noradrenaline and 5-HT3 in the control of body temperature. Activation of the nucleus raphe magnus, where 5-HT3 acts as a neurotransmitter, has an inhibitory effect on shivering. It is thus possible that the antishivering effect of tramadol is mediated by its effect on these receptors. We postulated that it was likely to have better clinical utility compared with pethidine for the management of postoperative shivering." See: Bhatnagar S, Saxena A, Kannan TR, Punj J, Panigrahi M, Mishra S. Tramadol for postoperative shivering: a double-blind comparison with pethidine. Anaesth Intensive Care. 2001 Apr;29(2):149-54. Number: 22 The prevalence of the use of 'alternative' medicines in an unselected group of adults presenting for surgery in California is approximately: A. 10%. B. 20%. C. 30%. D. 40%. E. 50%. 178

Select the single best answer Correct Answer: D Leung et al found that 39% of a group of 2560 patients awaiting surgery in the San Francisco area admitted to taking alternative medicine supplements. In about 2/3rds of these cases the supplement was a herbal medicine. Many herbal medicines (Garlic, Ginger, Ginko and Ginseng) are believed to impair platelet function and St John's Wort may have monoamine oxidase inhibitory activity. See: Leung JM, Dzankic S, Manku K, Yuan S. The prevalence and predictors of the use of alternative medicine in presurgical patients in five california hospitals. Anesth Analg. 2001 Oct;93(4):1062-8. Number: 23 The relationship between increasing age and the Minimum Alveolar Anaesthetic Concentration (MAC) of the volatile agents is best described as one that: A. Increases by 6% per decade of life. B. Does not vary with decade of life. C. Decreases by 6% per decade of life. D. Decreases by 12% per decade of life. E. Decreases unpredictably per decade of life. Select the single best answer Correct Answer: C Both Mapleson and Eger have undertaken meta-analyses which suggest that MAC decreases by 6% per decade of life in a more or less linear fashion. See: Eger EI 2nd. Age, minimum alveolar anesthetic concentration, and minimum alveolar anesthetic concentration-awake. Anesth Analg. 2001 Oct;93(4):947-53. And: Mapleson WW. Effect of age on MAC in humans: a metaanalysis. Br J Anaesth. 1996;76: 179-185. Number: 46 Which of the following significantly increase the risk of peri-operative myocardial infarction.? 1. Untreated Hypertension in the absence of Coronary Artery Disease. 2. Signs of Congestive Cardiac Failure. 3. Previous Coronary Artery Grafting.

179

4. Unstable Angina A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct Correct Answer: C Preoperative findings that correlate with perioperative myocardial infarction (PMI) include severe CCF (associated with S3 or raised JVP) and unstable angina. Hypertension does not correlate despite its prevalence in this population. Several studies have concluded that prior coronary artery bypass grafting lowers the risk of PMI. Peri-operative myocardial infarction remains a major cause of morbidity and mortality associated with surgery. Many occur on the third postoperative day. Many contributing factors not directly related to anaesthesia have been suggested. These include the hypercatabolic and hypercoaguable responses to surgery, anaemia, and pain. The period of anaesthesia often accounts for a limited portion of the perioperative period, however, the separation of anaesthesia and events occurring postoperatively has not been achieved. The correlation between preoperative factors and perioperative myocardial ischaemia in cardiac and non-cardiac surgery has been extensively studied. The issue is not wholly resolved. The major studies involving cardiac surgery have looked at anaesthetic technique and intraoperative haemodynamic instability and outcome. Slogoff and Keats, and Tuman could not find any correlation between different agents or anaesthetic techniques and intraoperative ischaemia or postoperative MI. Mangano provides editorial comment highlighting the difficulty separating anaesthetic from surgical factors. In non-cardiac surgery, the highest risk occurs in thoracic, major vascular, and upper abdominal surgery. Of the extensive literature available, studies by Goldman, Rao, and Steen are prominent. Many of the studies incorporate a scoring system which correlates the presence of preoperative factors with PMI. Those factors which appear consistently in the studies are: (1) Previous MI:Numerous studies have shown that if previous AMI precedes surgery by less than 6 months, the perioperative reinfarction rate is 5-86% and mortality rate is 23-86%. After 6 months the reinfarction rate stabilizes at 2-6%. (Goldman, Steen, Rao, Tarhan, Eerola, Schoeppel, Fraser, Topkins, Sapala). A commonly quoted figure is: 5% overall reinfarction rate; 15-30% if previous MI is within 3 months; 10-15% within 3-6 months . The study by Rao is of special interest because it proposes to show a major reduction in perioperative reinfarction rate (7.7% to 1.9% overall and 36% to 5.8% within the 0-3 month group). This was attributed to invasive monitoring and rapid treatment of cardiovascular variables both intraoperatively and within the first 72 hours postoperatively. (2) Congestive Cardiac Failure.-Master, Skinner & Pearce, Goldman, Rao and Mangano all describe CCF as a risk factor for surgery. It is associated with a high rate of reinfarction. More specifically, signs of poorly controlled or decompensated left ventricular failure, such as

180

an elevated JVP, S3 or pulmonary oedema are associated with a 20% mortality from cardiovascular complications, including myocardial infarction. (3) Unstable or poorly controlled angina. (4) Aortic stenosis is the only valve lesion which has been identified as a factor which increases cardiac risk for non-cardiac surgery. It appears low on the Goldman Index and high on Detsky's Modified list. Early work by Skinner & Pearce evaluating patients with rheumatic heart disease in non-cardiac surgery found a 10% mortality in aortic valve disease versus 6% for mitral valve disease. This difference was more pronounced in intra-abdominal and intrathoracic procedures (20% v 0%). (4)Prior CABG surgery. In general, authors have reported a reduction in risk. Maher has compared outcomes from non-cardiac surgery in patients who have had prior CABG surgery versus medically treated, angiographically proven coronary artery disease (CAD). Patients with a history of previous CABG had a PMI rate of 0% compared with 5% for the latter group. Repeat revascularization is sometimes needed and this protection probably diminishes as the time from surgery increases. (5) Long standing hypertension is a marker for CAD, and is clearly associated with cardiac hypertrophy, changes in cerebral blood flow, autoregulation and baroreceptor responsiveness, and renal function. Cardiovascular responses to anaesthesia are pronounced in hypertensive patients. However, the literature does not clearly show that preoperative hypertension increases cardiac risk. In Goldman's study it was found not to correlate; whereas in Steen's it did. Antihypertensive therapy has not demonstrably reduced the incidence of PMI. (6) Therapy for ventricular dysrhythmias has not greatly reduced the incidence of sudden death . Much of the early work evaluating cardiac risk concentrated on clinical risk factors as predictors of outcome. Later work evaluated the usefulness of monitoring techniques and preoperative investigations in identifying high risk groups, and the efficacy of improved control of CAD through pharmacological intervention perioperatively. A summary of the literature available on this topic follows: Barter, 1930 - recognized that patients who underwent surgery after an AMI had a high mortality. Master, 1937,1938 - described age > 60, prior CAD, cardiomegaly and preoperative ECG abnormalities as predictive indicators of PMI; that PMI typically occurred on day 3 and had a 65% mortality. Knapp, 1962 - Topkins & Artuso 1964 demonstrated previous AMI or CVA to predispose to further events. Arkins, 1964 - found that recent AMI, poor physical condition and emergency surgery predisposed to PMI which had a mortality of 69%.

181

Skinner & Pearce, 1964 - characteristics associated with increased mortality included intraperitoneal and intrathoracic surgery, severe hypertension , aortic valve disease, cor pulmonale, poor functional class, advanced age >75, ECG abnormality including AF, BBB, and multiple surgical procedures. MAYO Clinic report, 1972 - PMI more likely after upper abdominal and intrathoracic surgery; most frequent on 3rd postoperative day; associated with high mortality and not related to type of anaesthesia. AMI within 3 months was associated with 37% reinfarction rate, 16% within 3-6 months and 4-5% after 6 months. Goldman, 1977 - Cardiac risk index compiled 9 preoperative factors as independent predictors of postoperative cardiac complications including PMI, CCF and VT. Each factor was weighted such that multiple factors were summated to give an overall score of risk. This study suggested that history and physical examination account for 29 of 53 points in assessing cardiac risk. Patients were further segregated into classes which correlated with cardiac complications. Ambiguity arose in patients intermediate scores. In 1978, he suggested that the index be used to select 'intermediate' risk patients who could proceed with further evaluation.(ie: ambulatory ECG, Dipyridamole thallium scanning and/or coronary angiography). This was widely adopted despite criticisms of the use of sample groups which were too small , operator dependence on eliciting the more significant factors, and insufficient monitoring of postoperative ischaemia. Moreover, a number of studies evaluated the predictive value of the Goldman index. One (Waters, 1981) found it to be no better than the ASA Physical Status Classification and others found it to underestimate risk especially in major vascular surgery. Non-predictive factors included smoking, diabetes, hypertension, stable angina, BBBs and stable CCF (ie: absence of S3 or raised JVP) Steen, 1978 - confirmed that recent AMI was associated with high reinfarction rate. Predictive factors of PMI in Steen's study which had not correlated well in Goldman's study included preoperative hypertension, intraoperative hypotension, and duration of anaesthesia. Predictive factors common to both studies included intra-thoracic, intra-abdominal or major vessel surgery. Non-predictive factors common to both were diabetes, preoperative angina or anaesthetic technique. Of note was the high incidence of PMI in patients with 'old' AMIs (10.8%). The conclusion drawn was that in addition to old AMIs, these patients had experienced recent silent AMIs. Statistically, this group represented 1/4 of all reported previous AMIs. Detsky, 1986 - performed one of the studies which concluded that Goldman's Cardiac Index Score underestimated actual risk. In response, he compiled the Modified Multifactorial Index. In brief, this dropped uncontrolled LVF and added class 4 angina and symptomatic aortic stenosis to the list of risk factors. It was more complicated to apply and never proved to be of greater predictive value. Gerson, 1985 - found that poor performance on exercise ECG provided greater predictive data that was available from either Goldman data or radionucleotide ventriculograms. References

182

ROGERS,M.C ET AL (EDS); Principles and Practice of Anesthesiology, Mosby, 1993, pp 168-95 -an excellent review of the topic! MILLER,R (Ed), Anesthesia, Churchill Livingstone, 3rd Ed., pp 733-4, 165-178.

Number: 47 Which of the following clinical predictors of a difficult intubation is postulated to be responsible for a grade III Mallampati view of the oral cavity? A. Temporomandibular joint disease. B. Hypognathism. C. Restricted neck extension. D. A large tongue. Select the single best answer Correct Answer: D Many investigators have attempted to determine clinical signs which could be used as predictors of subsequent difficult intubation.The Mallampati classification attempts to grade the difficulty of intubation on the preoperative ability to visualize the faucial pillars, soft palate, and base of uvula. The postulate is that the size of the base of the tongue is an important factor determining the degree of difficulty of laryngoscopy. Since it is not possible to determine the volume or size of the base of the tongue relative to the capacity of the oropharyngeal cavity, it is inferred that the base of the tongue is disproportionately large when it is able to mask the visibility of the faucial pillars and uvula. The original classification involved three grades which described visibility of pharyngeal structures when the patient protruded the tongue maximally through the open mouth in the sitting position (nb: without saying Arrrrgh!). This was later modified to describe four classes: Class 1- Faucial pillars, soft palate and uvula can be visualized. Class 2- Faucial pillars and soft palate can be visualized, but uvula is masked by the base of the tongue. Class 3-Only the soft palate can be visualized. Class 4-The soft palate cannot be visualized. (Modified) The degree of difficulty of intubation is determined by laryngoscopic findings: Grade 1- Glottis (including anterior and posterior commissures) can be exposed. Grade 2- Glottis can be partly exposed (anterior not visualized). Grade 3- Glottis can not be exposed (corniculate cartilages only can be visualized). Grade 4- Glottis including corniculate cartilages can not be exposed. Grades 1 and 2 are considered " adequate exposure ", and grades 3 and 4 " inadequate exposure ".

183

In the original paper, all class 1 views correlated with either a grade 1 or 2 larynx. Conversely, of class 3 patients, 93% were either a grade 3 or 4 larynx. See: Mallampati SR, Gatt SP, Gugino LD, Desai SP, Waraksa B, Freiberger D, Liu PL. A clinical sign to predict difficult tracheal intubation: a prospective study. Can Anaesth Soc J. 1985 Jul;32(4):429-34.

Number: 49 Which of the following may confer difficulty in anaesthetising a patient with rheumatoid arthritis? 1. Reduced mouth opening. 2 .Oedematous larynx. 3. Atlantoaxial instability. 4. Hypognathism. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct Correct Answer: E Temporo-mandibular, crico-arytenoid, and cervical spine synovitis may all contribute to difficulty in airway management in a patient with rheumatoid arthritis (RA). Hypognathism is found in juvenile onset RA. Rheumatoid arthritis typically involves diarthritic joints. These contain two opposing cartilages with a synovial lined joint space and capsule. The cervical spine, temporomandibular and cricoarytenoid joints are examples of these. Synovitis of these joints often results in a constellation of changes which render the airway increasingly difficult to manage as the disease progresses. Temporo-mandibular joint ankylosis may manifest as limited mouth opening and an obscured view of the fauces. This may make oro-tracheal intubation difficult. The jaw may be tender and difficult to 'thrust' during mask anaesthetics. Crico-arytenoid joint ankylosis has been suggested to occur in up to 26% of patients with RA.(Funk). When the cricoarytenoid joint is involved, the patient may complain of recent changes in voice, dysphagia, dysarthria, hoarseness, stridor, and a sense of fullness in the oropharynx. Visualization shows oedematous, hyperaemic arytenoid mucosa with swollen aryepiglottic folds and false cords. The cords may show decreased movement. During anaesthesia, abrupt airway obstruction may be precipitated by the anaesthetic agent or by adjunctive drug-induced diminution in tone of the laryngeal musculature.

184

Cervical spine instability may present problems during anaesthesia even in the early stages of the disease. Synovial destruction and vertebral erosion, along with ligamentous changes at the atlas/odontoid or subaxial vertebral structures, may result in subluxation or cord compression. Knowledge of the degree instability becomes critical, particularly with attempts to manipulate the neck for airway management or positioning. Because of the immobility and shortening of the neck associated with advanced disease, the trachea becomes increasing rotated with an anterolateral displacement, which rotates the larynx, making laryngoscopy increasingly difficult. Cervical joint involvement has been reported in 15-86% of patients with RA. Higher incidence occurs in those sero-positive for rheumatoid factor, those with severe erosive polyarthropathy of peripheral joints and in patients on long term steroid therapy. Whereas RA has a female predeliction, males seem to be at greater risk of cervical spine involvement. Juvenile onset RAs are not at risk. Atlanto-axial (C1-C2) are most commonly involved (1535%). They do not correlate with disease duration. Depending on the particular supporting element which is destroyed, the atlas may sublux in relation to the axis in one of four directions: (1) Anterior AAS- comprises 80% of AAS. C1 moves forward on C2 due to transverse ligament destruction. Best seen by examining the flexion view of the lateral XR. Subluxation is said to exist when the distance between the atlas and odontoid peg in the lateral flexion view is > 3mm in patients > 44 or > 4mm in those < 44 years old. (2) Posterior AAS-rare, accounting for only 3-7% AAS. C1 moves backward on C2 due to peg destruction. Best demonstrated on lateral extension XR. (3) Vertical AAS-Comprises 10-20%. The lateral masses of C1 are destroyed. The odontoid peg may then sublux up through the foramen magnum to compress the cervicomedullary junction.Lateral XR views reveal that the process is superior to MacGregor's line by > 8mm in men and > 9.5mm in women. MacGregor's line joins the upper surface of the posterior edge of the hard palate and the most caudal point on the occiput. (4) Lateral/Rotatory AAS-rare, occurring in 2-5%. C1 moves laterally or rotationally due to facet joint destruction. Seen on lateral and open mouth views. Subaxial subluxation occur in 10-20% of the RA population and correlate with disease duration. It is caused by facet joint destruction and becomes symptomatic early causing cervical column and spinal root compression because of the smaller diameter at these lower levels. The commonest level is C5-C6. Lateral views may show a step deformity >2mm. While synovial joint destruction initially leads to subluxation, it is important to bear in mind that cervical spine ankylosis may develop as a final pathological state which results in a flexion deformity of the neck. See: ROGERS,M.C ET AL (Eds); Principles and Practice of Anesthesiology, Mosby, 1993, pp 219-20. Macarthur A, Kleiman S. Rheumatoid cervical joint disease--a challenge to the anaesthetist. Can J Anaesth. 1993 Feb;40(2):154-9.

185

Funk D, Raymon F. Rheumatoid arthritis of the cricoarytenoid joints: an airway hazard. Anesth Analg. 1975 Nov-Dec;54(6):742-5. Keenan MA, Stiles CM, Kaufman RL. Acquired laryngeal deviation associated with cervical spine disease in erosive polyarticular arthritis. Use of the fiberoptic bronchoscope in rheumatoid disease. Anesthesiology. 1983 May;58(5):

Number: 51 Abnormal preoperative pulmonary function tests in a patient with severe kyphoscoliosis might include: A. Increased RV/TLC. B. Reduced FEV1/FVC. C. Reduced FEV25-75. D. Increased FRC. E. All of the above. Select the single best answer Correct Answer: A Respiratory dysfunction associated with severe kyphoscoliosis primarily involves abnormalities in lung volumes and capacities. Total lung capacity and vital capacity are reduced. This occurs at a greater rate than reductions in residual volume and functional residual capacity, hence RV/TLC increases. Airways and lung parenchyma are essentially normal as are tests reflecting these. Scoliosis refers to lateral deviation of the spine and consists of the initiating curve and a compensatory curve attempting to restore postural balance. Kyphosis refers to posterior angulation of the spine. Respiratory and cardiac compromise associated with these conditions are most common when they occur together. They correlate with the severity of the deformity. In general , they would be unexpected in the presence of < 20 degree kyphosis and < 10 degree scoliosis but may appear with milder disease. Severe kyphoscoliosis may be associated with dyspnoea, cyanosis, somnolence and corpulmonale. Alterations in lung function involve lung volumes and capacities. TLC and FRC are reduced. VC is markedly reduced with a smaller reduction in TV. The RV/TLC increases as does TV/VC. Because chest wall compliance is reduced, augmenting TV requires large increases in the work of breathing resulting in a tendency to employ shallow , rapid breathing when minute ventilation needs to be augmented. The patient's reserve may be quite limited and decompensation may occur during anaesthesia, sedation or infection. A restrictive pattern is observed with a normal FEV1/FVC. Typically, airways disease is not present, therefore tests of this should be normal (FEV25-75%, FEF50%, MEF etc.)

186

Pulmonary hypertension may develop. Compression and kinking of pulmonary vessels may cause an increase in PVR but this is more typically related to chronic hypoxaemia. There is some evidence that disordered sleep patterns and nocturnal hypoxaemia occur which contribute to this as in sleep apnoea. Cor pulmonale is a not uncommon sequel. See: Pehrsson K, Bake B, Larsson S, Nachemson A. Lung function in adult idiopathic scoliosis: a 20 year follow up. Thorax. 1991 Jul;46(7):474-8. BORDOW,R.A & MOSER,K.M (EDS);Manual of Clinical Problems in Pulmonary Medicine, Little Brown and CO, London, 3rd Ed, 1991, pp 335-6. Kafer ER. Respiratory and cardiovascular functions in scoliosis and the principles of anesthetic management. Anesthesiology. 1980 Apr;52(4):339-51. Number: 52 Which of the following has been shown to offer protection from gastric aspiration syndrome in a patient with symptoms of reflux ? 1. Cimetidine. 2. Metoclopramide. 3. Sodium citrate. 4. Atropine. Number: 53 Which of the following are true of adrenal suppression due to steroid therapy? 1. It is associated with atrophy of the adrenal glands. 2. It does not occur in patients receiving inhaled steroids. 3. It should be expected in anyone receiving > 5mg prednisolone daily. 4. Following cessation, the stress response normalises after 8 weeks. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct

Correct Answer: B

There are three components in the regulation of cortisol production. These are the basal production of cortisol by the adrenal cortex; negative feedback control of ACTH produced by 187

the hypothalamic-pituitary axis in response to plasma cortisol; and the augmented adrenal response to plasma ACTH. The administration of high doses of exogenous adrenocorticoids for prolonged periods may result in suppression of all components and atrophy of the adrenal cortex. In these cases, full function may not return for up to 9 months. The individual response to exogenous steroids is unpredictable. Many consider that suppression of adrenocortical function does not occur below a maintenance dose of 5mg of prednisolone daily or a duration of therapy less than 2 weeks regardless of maximal dosage. It has been observed after inhaled therapy. Despite these observations, however, there exists only a few reports of hypotension attributable to omission of replacement therapy in the perioperative period. Suppression of secretion of cortisol by the adrenal gland caused by exogenous steroids involves normal mechanisms of feedback inhibition. Responsiveness of the axis remains normal after a single dose and normalizes over a period of days if a short course has been given. When steroids have been given for a slightly longer period, suppression becomes a function of the duration of therapy as well as the total dose. If the dosage is high enough, adrenal atrophy and suppression of the entire axis may occur, hence even exogenous ACTH may not stimulate adrenal secretion. With lower doses, basal levels of cortisol may be low, but response to stimulation may be normal (ie:stress). Long term high dose therapy can cause profound and prolonged suppression of basal adrenal gland function, the axis, and responsiveness of the gland to ACTH. High dose therapy (50mg daily) for only 5 days may cause adrenal-pituitary-axis dysfunction. Adrenal response is better preserved with alternate day therapy. Both inhaled and topical steroids may impair the pituitary-adrenal response. Patients receiving the equivalent of 30mg/day for longer than 1-2 weeks may have impairment for up to 1 year. 9 months after discontinuation of therapy, most patients should have a normal stress response and normal basal secretion of cortisol. In general, any patient who has been receiving steroids for more than a day or two before surgery, or who has received steroids for prolonged periods within the last year, should be considered for replacement. See: Rogers, M.C et al (Eds); Principles and Practice of Anesthesiology, Mosby, 1993, pp 68-70, 1584-85. Udelsman R, Ramp J, Gallucci WT et al. Adaptation during surgical stress. A reevaluation of the role of glucocorticoids. J Clin Invest. 1986 Apr;77(4):1377-81. Number: 55 Which of the following is true of the immediate postoperative period in a young patient with previously normal lungs having upper abdominal surgery? A. Arterial oxygen tension will typically be reduced by an average of 10 mm Hg when breathing room air. B. Arterial oxygen tension will normalize after 15 minutes. C. Diffusion hypoxia is the major determinant of arterial hypoxaemia. D. The CXR will typically reveal no abnormalities. E. All of the above. Select the single best answer

188

Correct Answer: D Pulmonary dysfunction extending for a variable time into the postoperative period occurs invariably after upper abdominal surgery with the exception of young patients who have been anaesthetized for only a few minutes. It is most pronounced in the first two hours and may continue for 3-4 days. More commonly, it will begin to normalize after the first postoperative day in the absence of evolving complications. In the immediate postoperative period, arterial PaO2 will be reduced by up to 30 mm Hg when breathing room air. Many factors contribute to this event, however, intrapulmonary shunting secondary to atelectasis and exaggerated ventilation/perfusion inequality in general are felt to be the primary cause. In most cases, increasing the FIO2 to 35-40% will restore PaO2 to preoperative values. The CXR will typically appear normal unless frank pathology has developed like aspiration or CCF. After the first hour of recovery from anaesthesia, previously well patients who have undergone surgery to the limbs or body surface normally exhibit little deterioration of lung function and any apparent deterioration in lung function suggests intraoperative events including aspiration. In contrast, when the same patients undergo abdominal surgery, there is impairment of arterial oxygenation for at least 48 hours postoperatively. Exceptions include young patients anaesthetized for only a few minutes. The magnitude of the hypoxaemia is related to the size and site of the incision. Typically, if the patient breathes air, the PaO2 is reduced by up to 30 mm Hg. It has been shown that 30% of patients breathing air on the way to recovery will have SAO2 < 90% and 12% < 85%. Multiple factors contribute including low FIO2 and hypoventilation. Diffusion hypoxia contributes in the first 10 minutes.The main cause however, is an increase in intrapulmonary shunt The causes may be considered as an extension of intraoperative factors and the development of new factors. The intraoperative factors include redistribution of ventilation and perfusion in the supine, anaesthetised, and paralysed patient resulting in a decrease in FRC, encroachment of closing capacity upon FRC and an increase in scatter of V/Q relationships. Central respiratory depression, and dyscoordinate activity of respiratory muscles from residual effects of anaesthetic agents compounds this in the early postoperative period. The fall in FRC increases postoperatively and is maximal on the first to second postoperative day. Reasons include diaphragmatic splinting due to pain, abdominal distension associated with ileus and retained pneumoperitoneum and prolonged rest in the supine position. Hypoxaemia will be most severe in the first 2 hours postoperatively but will remain impaired until FRC normalizes. If the fall in FRC is complicated by sputum retention and bacterial colonization of collapsed segments , infection may prolong recovery and hypoxaemia. A CXR performed at this time will often appear within normal limits See: SPENCE, A; " Postoperative Pulmonary Complications ", in GRAY, NUNN & BROWN; Anaesthesia, pp 1149-59. Schwieger I, Gamulin Z, Suter PM. Lung function during anesthesia and respiratory insufficiency in the postoperative period: physiological and clinical implications. Acta Anaesthesiol Scand. 1989 Oct;33(7):527-34.

189

Simonneau G, Vivien A, Sartene R, Kunstlinger F, Samii K, Noviant Y, Duroux P. Diaphragm dysfunction induced by upper abdominal surgery. Role of postoperative pain. Am Rev Respir Dis. 1983 Nov;128(5):899-903. Brown LT, Purcell GJ, Traugott FM. Hypoxaemia during postoperative recovery using continuous pulse oximetry. Anaesth Intensive Care. 1990 Nov;18(4):509-16. Mitchell C, Garrahy P, Peake P. Postoperative respiratory morbidity: identification and risk factors. Aust N Z J Surg. 1982 Apr;52(2):203-9. Number: 56 With regard to diffusion hypoxia: 1. It is likely to occur during emergence from Xenon anaesthesia. 2. It is a common mechanism of hypoxia when entonox is used in labour 3. It may contribute to hypoxaemia present 1 hour following cessation of administration of N2O. 4. It may cause alveolar hypoventilation A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct Correct Answer: D This term is applied to a transient decrease in Pa02 of about 5-10 mmHg associated with a return to breathing air after the use of N2O in O2. The primary cause is a dilution of the alveolar O2 content as the more soluble N2O leaves the tissues at a faster rate than N2 returns. It does not occur when a relatively insoluble gas (such as Xenon) is administered. A secondary factor, which prolongs and aggravates the effect, is alveolar hypoventilation, consequent upon dilution of the alveolar PCO2. At worst, the reduction in Pa02 attributable to this effect lasts for not more than 10 mins. Because N2O is relatively insoluble in blood, brain and muscle, discontinuation of N2O is followed by a 50% decrease in brain levels in less than 5 minutes regardless of the length of anaesthesia. Supplemental 02 given for 10 minutes after the discontinuation of N2O will prevent this effect. See: Einarsson S, Stenqvist O, Bengtsson A, Noren H, Bengtson JP. Gas kinetics during nitrous oxide analgesia for labour. Anaesthesia. 1996 May;51(5):449-52. Fink BR, Diffusion Anoxia, Anesthesiology, 16,pp 511-19, 1955.

190

Schwieger I, Gamulin Z, Suter PM. Lung function during anesthesia and respiratory insufficiency in the postoperative period: physiological and clinical implications. Acta Anaesthesiol Scand. 1989 Oct;33(7):527-34. Calzia E, Stahl W, Handschuh T, Marx T, Froba G, Georgieff M, Rademacher P. Continuous arterial P(O2) and P(CO2) measurements in swine during nitrous oxide and xenon elimination: prevention of diffusion hypoxia. Anesthesiology. 1999 Mar;90(3):829-34. Number: 57 Which of the following surgical incisions is associated with the highest risk of postoperative pulmonary complications? A. Vertical laparotomy. B. Horizontal laparotomy. C. Lateral thoracotomy. D. Median sternotomy. E. Cholecystectomy Select the single best answer Correct Answer: C Postoperative pulmonary complications as measured by impairment of oxygenation correlate strongly with the type of surgery. In decreasing order are lateral thoracotomy, median sternotomy, vertical midline and paramedian abdominal, upper lateral abdominal and lower abdominal incisions. With respect to falls in FRC, a reduction of 30% following upper abdominal surgery compared with 15% following inguinal hernia repair have been shown. Alternatively, a pulmonary complication rate of: 30-40%-upper abdominal ; 10-16% lower abdominal; <10% -non-thoracic, non-abdominal surgery SPENCE, A.; " Postoperative pulmonary complications ", chapter 96 NUNN, UTTING & BROWN, Anaesthesia. Number: 58 The following are true of Mendelson's Syndrome: 1. Critical volume of aspirate is 30 mls. 2. Critical pH of gastric aspirate is 1.5. 3. Onset of symptoms generally occurs within 30 minutes. 4. Steroids have been shown to improve outcome. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct

191

Correct Answer: B A patient is thought to be at risk when > 25-30 mls (0.4 ml/Kg) of gastric aspirate of a pH <2.5 is regurgitated. Higher volumes are thought to be tolerated if the pH is higher. It s felt that the pH is a more critical determinant of lung injury. Several studies indicate that corticosteroid therapy may provide some modification of the inflammatory response early after aspiration, but in essence, does not alter the course of the illness. Bordrow, R.A & Moser, K.M; Manual of Clinical Problems in Pulmonary Medicine, Little Brown & Co., 3rd Ed., 1991, pp 72-75. Mendelson, C.L; " The aspiration of stomach contents into the lungs during obstetric anaesthesia. ", Am J Obstet Gynecol, 52, 1946, pp 191-204. Number: 61 With respect to cardiac arrests occurring during anaesthesia: 1. Most occur during induction of anaesthesia. 2. The most common cause is failure of ventilation. 3. The most common preceding arrhythmia is bradycardia. 4. Most are considered unpreventable and untreatable A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct Correct Answer: B With respect to cardiac arrest due to anaesthetic factors, most occur during the induction phase. Whilst failure of ventilation is the sequelae of many intraoperative complications, the most common cause is inappropriate drug administration; either frank overdose or patient intolerance to 'normal' dosages. Greater than 90% are heralded by bradycardia, however it was not specified whether this was solely sinus bradycardia or other bradyarrhythmias (slow idioventricular for example). Most of the arrests considered due to anaesthetic causes were also deemed preventable. Cardiac arrests due solely to anaesthesia were studied over a 20 year period. During this time, 798 arrests occurred. Most were ascribed to patient illness or surgical factors but 36 were considered to result from the anaesthesia. Contributing factors included: (1)Age - the incidence was three fold in children < 12 years. No correlation was found for advancing years.

192

(2)Time of day - no correlation was found between incidence and anaesthesia outside of normal working hours. (3)Phase of anaesthesia - the majority occurred induction. (4)ASA physical status - this comes under patient illness and not anaesthesia related. (5)Emergency surgery correlates with a sixfold increase in incidence. The causes may be considered as respiratory or non-respiratory. Respiratory causes culminate in hypoxaemia secondary to failure to ventilate for a number of reasons. The most common cause was related to the inappropriate use or overdose of an anaesthetic agent. Half of these were 'relative', occurring during induction in patients who were haemodynamically unstable with doses of anaesthetic within the usual clinical ranges. Absolute overdosage occurred in the rest.The latter group tended to have improved outcome. Cardiac arrest was preceded by bradycardia in 26/27 patients KEENAN, R.L; " Cardiac arrest due to anesthesia- a study of incidence and causes ", JAMA, vol 253, no 16, April 26, 1985, pp2373. KEENAN, R.L; " Decreasing frequency of anesthetic cardiac arrests ", J Clin. Anesth., vol 3, Sept/Oct, 1991, pp 354-7. Number: 62 Which of the following should be considered as the cause of generalized convulsions 20 minutes postoperatively? 1. Local anesthetic toxicity after use of lignocaine. 2 .Enflurane. 3. Propofol. 4. Preexisting grand mal epilepsy. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct Correct Answer: E Anaesthetic agents may have a role in the genesis of perioperative seizures. Several agents produce intraoperative EEG and clinical evidence of intraoperative seizures, but evidence that they produce postoperative seizures is comparatively weak. Enflurane produces epileptiform activity that is influenced by the depth of anaesthesia and the PaCO2. In healthy normocapnic people, EEG spiking is maximal at end-tidal concentrations of 2-3%, and grand mal seizure patterns occur at 3-6%. At a given enflurane concentration, hyperventilation increases seizure activity such that minimum epileptiform activity is approximately 1% lower at a PaCO2 of 20 mm Hg and is 1% higher at a PaCO2 of 60 mm Hg than it is at 40 mmHg. Even though

193

seizures have been reported days after enflurane anaesthesia in non-epileptic patients, EEG documentation of postoperative seizure activity is rare. Halothane, isoflurane, and N2O have also been the subject of isolated case reports of seizure like activity during exposure, but none are believed to cause postoperative seizures. It is known that propofol may activate preexisting seizure foci, but has until recently been considered not to precipitate epileptiform activity in patients without a seizure disorder. It is known to decrease the seizure duration in electroconvulsive therapy, and has been used successfully to treat status epilepticus. A growing number of reports describing convulsions, twitching, or opisthotonos has led to a challenge to its use in epileptics recently. By February, 1993, 105 reports had been received by the Australian Adverse Drug Reaction Committee. 45 of these were considered serious and included convulsions (32/45), twitching (14/45), or opisthotonos (5/45). 14 cases occurred immediately, during, or shortly after induction, and 17 cases occurred within 30 minutes to 6 hours. Symptoms lasted 20 seconds to three minutes in 16 cases, 45-180 minutes in 5 cases, and one case of status epilepticus occurred in a well controlled epileptic. Another patient continued to experience seizures intermittently for 48 hours. 5 of the patients had a history of epilepsy, 2 had had similar experiences with other drugs, and one patient had had an episode of seizures after a previous anaesthetic. References BENUMOF ,J.L & SAIDMAN, L.J; Anesthesia and Perioperative Complications, Mosby, 1992, pp 360-1. Australian Adverse Drug Reactions Bulletin, 1991, 10:8. Number: 63 With regard to laryngeal trauma associated with the placement of an endotracheal tube (ETT) 1. It is most likely to occur at the arytenoid cartilage. 2. Trauma to the vocal cords usually involves the left. 3. Vocal cord paralysis is caused by injury to the anterior branch of the recurrent laryngeal nerve. 4. Postoperative hoarseness greater than one week is likely to represent transient nerve injury. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct Correct Answer: A Laryngeal trauma due to the placement of an ETT occurs most commonly at the posterior arytenoids and involve sore throat secondary to pressure effects. Trauma found on examination most commonly involves haematomas of the vocal cords, which are likely to occur on the left as a result of placement by right handed anaesthetists. True cord paralysis is

194

generally due to a neuropraxia of the anterior branch of the recurrent laryngeal nerve as it passes between the laryngeal mucosa below and thyroid cartilage above. Postoperative hoarseness usually represents a haematoma which resolves over a period of 2-4 weeks. The placement of endotracheal tubes carries with it a number of complications. They may be classified temporally. Early (0-24 hrs)- transient sore throat and hoarseness -damage to hypoglossal or lingual nerves -glottic oedema -supraglottic oedema -retroarytenoid oedema -subglottic oedema -vocal cord paralysis Medium (24-72 hrs)-infection Late (72+ hrs)-laryngeal ulcer, granuloma and polyp -synechia of vocal cords -laryngotracheal membranes and webs -laryngeal fibrosis -tracheal fibrosis -stricture of the nostril Sore throat postoperatively is relatively common. The majority of cases are probably caused by pressure induced injury of the arytenoid mucosa. The arytenoid mucosa contacts the ETT at its point of maximal curvature and therefore exerts significant pressure in this area. Sore throat correlates with the size of the ETT(32% in 8.5-9.00mm ETTs; 18% in 6.5-7.00mm ETTs); length of intubation and variably with the use of succinylcholine. It does not correlate with the use of lignocaine ointment or spray. Several large studies of laryngeal injury after short term intubation have shown an incidence of laryngeal injury of 6-7%. The majority of these are haematomas of the vocal cords, usually the left, since the ETT is usually inserted by a right handed anaesthetist and rotated to the left. The vocal process of the arytenoid is the most likely site of damage as it sits between the cords. In one of these studies, laryngoscopy was performed immediately after extubation. Haematoma occurred in 4.5% of these. It was more common in patients suffering allergic laryngitis or when the cords were not fully relaxed at intubation This is generally a benign lesion that resolves over 2-4 weeks. It would be likely to manifest as a resolving postoperative hoarseness. Persistent postoperative hoarseness may represent granuloma or polyp formation. These are rare complications of ulceration secondary to pressure on the posterior commissure. Persistent hoarseness and odynophagia has also been reported in arytenoid dislocation and responds to reduction. Persistent hoarseness is an indication for otolaryngeal evaluation. In the study described above, laceration of the mucosa of the vocal cord occurred in only 0.8%, and subluxation of the arytenoid in only 0.1% Vocal cord paralysis is an uncommon sequelae following tracheal intubation. It is most often attributed to thyroid, carotid or head and neck surgery where direct or indirect injury to the recurrent laryngeal nerve has occurred, however,it has been reported in 3% of non-head and

195

neck cases. Additionally, it is possible to cause lasting voice changes from damage to the external laryngeal nerves. True vocal cord paralysis may be related to endotracheal intubation. One review found only 32 cases that could plausibly be attributed to the ETT and in common with other complications of intubation, is possibly associated with a known difficult intubation. The most likely cause of vocal cord paralysis, exclusive of traumatic or difficult intubation, is pressure by the cuff on the vulnerable portion of the anterior branch of the recurrent laryngeal nerve, 6-10mm below the cords as it runs between the cuff and the overlying thyroid cartilage. In this injury, cord adductors are paralyzed so that hoarseness rather than airway obstruction is produced. The latter would result from paralysis of the cord abductors which are not innervated by this nerve. These injuries are generally caused by a neuropraxia which resolves in 2-4 weeks without specific intervention. It may be prevented by positioning the cuff lower in the trachea such that it can be felt in the suprasternal notch, and by monitoring cuff pressures. The recurrent laryngeal nerve has an anterior branch which innervates the lateral cricoarytenoid muscles (vocal cord adductors), and posterior branch which innervates the posterior cricoarytenoid and interarytenoid muscles. Other causes of nerve damage during endotracheal intubation include damage to lingual or hypoglossal nerves due to pressure from the laryngoscope blade in the vallecular region behind the tongue. Right sided lingual nerve damage is more common and usually resolves over a few months. Some inconsistency exists in the literature with regard to this issue. Atkinson says that laryngeal or supraglottic haematomas usually clear up in a few days (rather than 2-4 weeks), and that the occurrence of this complication bears no relation to the difficulty of intubation. Additionally, bilateral cord paralysis occurring from pressure of the cuff on the laminae of the thyroid cartilage may result in airway obstruction requiring CPAP or reintubation. This is in contrast to the earlier statement that hoarseness is the most serious sequelae. Permanent voice changes have been reported in 3%. Laryngoscopy is recommended for hoarseness persisting greater than 1 week. References ROGERS, M.C ET AL (EDS); Principles and Practice of Anesthesiology, Mosby, 1993, p 2392-4. LATTO, I.P & ROSEN, M (Eds); Difficulties in Tracheal Intubation, Balliere Tindall, Sydney, p38, 43-6 - an excellent book covering anatomy, equipment and procedural aspects of intubation! ATKINSON, R.S; Lee's Synopsis of Anaesthesia, 11th Ed., p 231. Number: 64 Which of the following positions will prevent damage to the ulnar nerve in an anaesthetised patient. A. Supine, arm resting by side with forearms folded across chest. B. Supine, arm resting by side in supination. C. Supine, arm resting by side in pronation.

196

D. Supine, arm abducted 45 degrees in supination. E. None of the above. Select the single best answer Correct Answer: E Whilst supination of the forearm theoretically rotates the cubital tunnel away from the underlying surface, there is no evidence to confirm that any form of positioning will decrease the incidence of postoperative ulnar nerve palsy Ulnar neuropathy represents 1/3 of all claims related to nerve injury in the USA. The most common site of injury is in the cubital tunnel. Some types of surgery are associated with an exceptionally high incidence of nerve damage. One study found a 61% incidence of ulnar nerve conduction velocity slowing in cardiac surgery. Most commonly, the position of the patient during anaesthesia allows compression or elongation of the nerve in the cubital tunnel. Some positions are particularly prone to injury. For example,when the arm is tethered to the supine patient's side or abducted with the arm pronated, the elbow is rotated such that the cubital tunnel is in contact with the flat supporting surface. As a result of this rotation, the nerve is theoretically vulnerable to external compression. Conversely, supination of the forearm rotates the cubital tunnel away from the flat surface. Flexion of the elbow to greater than 90 degrees causes the arcuate ligament which forms the roof of the cubital tunnel , to become tense, thereby decreasing available space and increasing risk of compression. Despite the theoretical advantages, there is no proof that supination decreases the risk of postoperative palsy. In fact, there is evidence that ulnar nerve palsy may still occur despite accepted positioning practices. One revealing study (Kroll), examined the American Society of Anesthesiologists Closed Claims Study database to define the role of nerve damage in the overall spectrum of anesthesia-related injury that leads to litigation. Of 1,541 claims reviewed, 227 (15%) were for anesthesia-related nerve injury. Ulnar neuropathy represented one-third of all nerve injuries and was the most frequent nerve injury. Less-frequent sites of nerve injury were the brachial plexus (23%) and the lumbosacral nerve roots (16%). In a large proportion of cases, the exact mechanism of injury was unclear despite evidence of intensive investigation in the claim files. Median payment for nerve damage claims involving disabling injury was $56,000, which was significantly lower than the $225,000 median payment for claims for disabling injury not involving nerve damage (P less than 0.01). The closed claims reviewers judged that the standard of care had been met significantly more often in claims involving nerve damage than in claims not involving nerve damage. The authors conclude that nerve damage is a significant source of anesthesia-related claims but that the exact mechanism of nerve injury is often unclear. In particular, ulnar nerve injuries seemed to occur without identifiable mechanism. References STOELTING, R.K; " Postoperative ulnar nerve palsy- is it a preventable complication? ", Anesth Analg, 76, 1993, pp 7-9. PERREAULT, L ET AL;" Ulnar nerve palsy at the elbow after general anaesthesia ", Can J Anaesth, 39, 5, 1992, pp 499-503.

197

KROLL, D.A. CAPLAN, R.A. POSNER, K & CHENEY, F.W;" Nerve injury associated with anesthesia. ", Anesthesiology, vol 73, no 2, 2Aug, 1990, pp 202-7. Number: 65 Which of the following is consistent with return of muscle tone adequate to protect the airway from aspiration? A. TOF ratio of 0.7. B. No fade detectable on Double Burst Tetanic Stimulation. C. Return of normal resting minute ventilation. D. 5 sec sustained head lift. E. None of the above. Select the single best answer Correct Answer: D With respect to the assessment of recovery from muscle relaxants, tests employing the peripheral nerve stimulator are used to quantify recovery of postsynaptic receptors at the neuromuscular junction, and yield information throughout the range of recovery of 50-90% of receptors. This is consistent with considerable diminution in muscle tone. Clinical tests may support return of muscle tone adequate to support ventilation, which correlates with a maximum inspiratory effort generating -20 cmH2O. Power required to protect the airway from aspiration has been found to correlate with a generatable inspiratory pressure of -40 cmH2O. This corresponds with a sustained head lift of 5 seconds. Criteria which suggest adequate ventilatory function which may be used to determine appropriateness of extubation after anaesthesia include: (1)resting minute ventilation < 10L. (2)the ability to voluntarily double the resting minute ventilation. (3)peak negative pressure on maximal inspiration > 30cm H2O. (4)FVC >10-15 ml/Kg. A patient may however be able to maintain adequate ventilation in the presence of residual muscle weakness that is inadequate to protect the airway from aspiration. A recent study compared the requirement for both events. In it, subjects were given d-tubocurarine to cause different levels of inspiratory muscle weakness as measured by the mean inspiratory pressure (MIP) generated by a maximal inspiratory effort. Four levels of power were evaluated: -90 cmH2O (control), -60, -40, and -20 cm H2O. At each level, vital capacity (VC), ETCO2, and hand grip strength were measured and muscles of airway protection were evaluated. These comprised ability to swallow, perform a Valsalva manoeuvre, prevent obstruction of the airway and approximate the teeth. These were compared with sustained head lift and straight leg lift. At MIP - 20cmH2O, VC was 2 L, and ETCO2 was normal. Hand grip strength was 0 and muscles of airway protection were still incapacitated.

198

Swallowing returned at a MIP> -43 cm H2O, approximation of the teeth at >-42 cmH2o, airway obstruction at > -39 cm H2O, and Valsalva at > -33 cm H2O. All subjects who could perform a sustained head lift could perform the airway protective manoeuvres. Tests employing PNSs are not sensitive with respect to assessing the adequacy of ventilation and airway protection, as for most the degree of receptor blockade is profound before they become abnormal (ie:~50-90% ) Thus, although ventilation may be adequate at -25 cm H2O, the muscles of airway protection are still non-functional and further reversal of neuromuscular blockade is required. References PAVLIN, E.G; " Recovery of Airway Protection Compared with Ventilation in Humans after Paralysis with Curare ", Anesthesiology, 70, 381-85, 1989. ROBBINS,M.C ET AL (EDS); Principles and Practice of Anesthesiology, Mosby, 1993, pp 2363. MILLER,R (ED); Anesthesiology, Churchill Livingstone, 3rd Ed., 1990, p 392. Number: 66 When comparing general versus regional anaesthetic techniques, the following is/are true of regional anaesthesia: 1. Urinary nitrogen is reduced postoperatively. 2. Intraoperative blood loss is reduced. 3. GIT motility is increased. 4. Perioperative cardiac complications are reduced A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct Correct Answer: A When comparing the benefits of regional over general anaesthesia, the major issues can be summarized as: - Pain relief - Postoperative morbidity - Modification of metabolic response to surgery - Pulmonary complications - Blood loss - Thromboembolic complications - Cerebral function - Cardiac complications - Gastrointestinal function and complications - Mortality

199

- Length of hospital stay Most of these parameters are considered to benefit from regional anaesthetic techniques. Whilst theoretically it would appear that perioperative myocardial ischaemia and other cardiac complications would be decreased, no proof has yet appeared in the literature. The metabolic response to surgery is characterized by an increased secretion of catabolically acting hormones (cortisol, glucagon, catecholamines), whereas the anabolically acting hormones (insulin, testosterone, growth hormone) are mainly inhibited. The resulting effect is hypermetabolism and release of substrate from peripheral stores. This is reflected in an increase in urinary nitrogen.There is a tendency to suppression of immune function and changes in coagulation and fibrinolysis resulting in a hypercoaguable state are other features. The effect of general anaesthesia on the intraoperative metabolic response to surgery is either slight or nil and there is no effect on postoperative catabolism with the exception of high dose opioid anaesthesia which reduces a major part of the response intraoperatively; etomidate, which causes intraoperative suppression of adrenocortical responses; and hypothermia, which may inhibit catabolism. In contrast, the effect of regional anaesthesia is extensive. Much of the research has been conducted with intrathecal or extradural anaesthesia. The major mechanisms involved are inhibition of nociceptive signal from the surgical area to the CNS; Blockade of reflexes involving efferent autonomic and somatic pathways, and suppression of sensitization of nociceptors and other events involved in " wind-up " phenomena. This effect is most pronounced with procedures involving the lower part of the body (gynaecologic, urologic, orthopedic) whereas the effect is less pronounced with major abdominal and thoracic procedures. Reasons for this may include insufficiently blocked vagal, phrenic, sympathetic and somatic afferents. The timing and duration of blockade are important for magnitude and duration of the modification of the postoperative stress response. Post-traumatic blockade has less effect than a block instituted before the surgical incision. A single dose has only a short inhibitory effect whereas preliminary studies suggest that blockade for 24 hours will have a prolonged effect for up to 4 days on indices of the stress response. More than 20 studies have compared intraoperative blood loss and the subsequent need for blood transfusions during general and regional anaesthesia. Most studies were undertaken during elective hip surgery and show a reduction in intraoperative blood loss of approximately 30% in patients receiving regional anaesthesia. Similar results have been obtained in studies during prostatectomy and lower limb vascular surgery. Abdominal procedures show a similar trend but results have been statistically insignificant. Seven studies have shown that regional anaesthesia reduces postoperative DVTs by approximately 50% as compared with general anaesthesia without prophylaxis.These studies usually employed continuous epidural techniques in hip surgery.The effect after abdominal surgery is less and suggests that thoracic epidural techniques may not be as effective in altering components of Virchow's Triad as lumbar, however it should be noted that in this group low dose heparin prophylaxis was utilized. No data is available on graft patency rates with patients having distal vascular procedures, however , physiologic data show increased

200

lower extremity and graft blood flow. In all studies suggest greater efficacy of continuous epidural versus single shot techniques. The most important factor leading to postoperative ileus is activation of sympathetic inhibitory reflexes. Addition of N2O to Isoflurane has been shown to impair operative working conditions and to delay passage of flatus and faeces. The effects of systemic opioids are well documented. Continuous epidural bupivacaine appears to be the most effective measure to improve postoperative ileus. It is more effective than epidural opioids alone. Few studies are available comparing mixtures of epidural local anaesthetics and opioids with the former. Intraoperatively, intraluminal pressures are elevated but evidence of increased anastomotic breakdown have not been shown, in the wake of three case reports. Colonic peristaltic activity and blood flow are increased. Despite well documented physiologic advantages, the few studies that have evaluated clinically important cardiac complications only show an insignificant trend toward a beneficial effect in patients receiving regional anaesthesia.Thus it is not possible to draw conclusions. This is of particular relevance to major abdominal vascular surgery where outcome is highly associated with cardiac complications. References ROGERS, M.C. ET AL (EDS); Principles and Practice of Anesthesiology, Mosby, 1993, pp 1218-25. Number: 101 Which of the following signs of congestive cardiac failure constitute a major risk to the surgical patient? 1. Jugular venous distension. 2. Cardiomegaly. 3. Third heart sound. 4. Basal crepitations on auscultation. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct Correct Answer: B

Congestive cardiac failure has been identified as a major risk factor for cardiovascular complications following abdominal aortic aneurysm repair and other major vascular surgery. Studies have shown that in adults undergoing non-cardiac surgery, the presence of a S3 gallop and/or jugular venous distension are associated with about a 20% incidence of fatal cardiovascular complications. Decompensated congestive failure remains a stronger predictor

201

of perioperative cardiac mortality than recent myocardial infarction. Cardiomegaly and basal crepitations alone are consistent with stable, compensated heart failure and are associated with a significantly smaller risk (5%). Other conditions that are associated with an increased incidence of fatal cardiac complications are pulmonary oedema (14%), and cardiac related dyspnoea, orthopnoea, or peripheral oedema (6%). These findings suggest that the surgical patient with congestive cardiac failure can be stratified into two groups. Patients with decompensated heart failure, as manifested by S3, raised JVP, or pulmonary oedema comprise a high risk group with a 15-20% mortality from cardiorespiratory complications. Pulmonary venous congestion in these patients causes peribronchiolar oedema and areas of airway closure, resulting in intrapulmonary shunting. This further impairs cardiac function. Decreased cardiac output can also promote a rapid increase in the depth of anaesthesia and concomitant changes in circulatory dynamics and vital organ perfusion during induction of anaesthesia. The combined cardiopulmonary dysfunction predisposes to intraoperative hypoxaemia, hypotension, overt pulmonary oedema, metabolic acidosis and malignant arrhythmias. Finally, limited reserve results in poor tolerance of increased afterload as seen with surgically induced sympathetic stimulation, aortic cross clamping, etc. In contrast, patients with stable, haemodynamically compensated heart failure make up a relatively low risk group in which the incidence of fatal complications approaches 5%. These patients may exhibit one or more signs of diminished cardiac reserve, such as orthopnoea, basilar crepitations, or cardiomegaly. However, they are adequately compensated at rest. Operative mortality in these patients is determined less by existing haemodynamic compromise than by underlying cardiac pathology or associated medical conditions. In exception, if ejection fraction is documented to be < 35% in patients undergoing major vascular procedures, then the risk of perioperative myocardial infarction is significantly increased regardless of whether signs of decompensated heart failure are present. References MILLER, R. (ED); Anesthesiology, 3rd Ed., Churchill Livingstone, 1990, pp 1699-1700. Number: 104 A neurological assessment is required in the recovery room to exclude an intraoperative cerebrovascular accident. Which of the following are consistent with the normal postoperative state? 1. Hyperreflexia in the biceps muscles. 2. Fixed dilated pupils. 3. Bilaterally upgoing toes (positive Babinski reflex). 4. The presence of primitive reflexes (grasp, snout, palmomental). A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct

202

Correct Answer: A 40%-100% of neurologically normal patients have an absent pupillary response to light 20 minutes after anaesthesia, and in 10% this can be absent for 40 minutes. Biceps and quadriceps hyperreflexia, unsustained ankle clonus and a positive Babinski reflex occur in a large number of patients recovering from anaesthesia, and in , many cases, abnormalities are present when the patients are fully awake. Abnormal reflexes occur more commonly after enflurane or halothane than N2O/opiate anaesthesia. A variety of other transient abnormalities have been reported during recovery from anaesthesia; opisthotonus and difficulty with eye opening have been associated with propofol, extrapyramidal reactions with droperidol, and seizures with several agents. Certain findings should be considered abnormal. These include unilateral reflex changes, and primitive reflexes- grasp, snout, palmomental, and Hoffman's. Ophthalmoplegia may represent basilar artery thrombosis. BENUMOF, J.L. & SAIDMAN, L.J.; Anesthesia and Perioperative Complications, Mosby, 1992, p 361. Number: 105 Which of the following conditions require endocarditis antibiotic prophylaxis ? 1. Mitral valve prolapse. 2. Presence of a permanent pacemaker. 3. Ventricular septal defect. 4. Previous coronary artery bypass graft surgery. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct Correct Answer: B Patients who have any form of valvular heart disease, intracardiac or intravascular shunts should have antibiotic prophylaxis against endocarditis. Endocarditis has occured in a sufficiently significant number of patients with hypertrophic cardiomyopathy (subvalvular aortic stenosis, asymmetric septal hypertrophy), and mitral valve prolapse to include such patients in a prophylaxis regime. Previous coronary artery bypass graft surgery or ligation of a patent ductus arteriosus arteriosus greater than 6 months previously, or presence of a pacemaker are considered to be associated with a low risk of endocarditis and do not require prophylaxis. In summary: Endocarditis prophylaxis recommended:

203

prosthetic cardiac valves most congenital cardiac malformations surgically constructed systemic-pulmonary shunts rheumatic and other acquired valvular dysfunction idiopathic hypertrophic subaortic stenosis past history of endocarditis mitral valve prolapse Endocarditis prophylaxis not recommended: Isolated secundum atrial septal defect patent ductus arteriosus ligated more than six months earlier postoperative coronary artery bypass graft pacemaker SHULMAN, S.T. ET AL; " Prevention of Bacterial Endocarditis ", Circulation, vol 70, no 6, Dec. 1994, 1123A-1127A. Number: 106 A patient with myasthenia gravis who is managed on oral neostigmine can be expected to have a prolonged response to which of the following agents during anaesthesia: A. Succinylcholine. B. Atracurium. C. Lignocaine. D. Vecuronium. Select the single best answer Correct Answer: A Anticholinesterases can inhibit plasma cholinesterase activity with a subsequent decrease in the metabolism of ester local anaesthetic agents, and the hydrolysis of succinylcholine. As in non-myasthenic patients, the duration of succinylcholine activity is inversely related to the plasma cholinesterase activity. In MG there is a decrease in the number of functional acetylcholine receptors available. This can decrease the response to the neurotransmitter and other depolarizing agents like succinylcholine and decamethonium, and cause marked sensitivity to non-depolarizing agents secondary to a with a decrease in the " safety " margin. These events are typically manifest as a need to increase the amount of available acetylcholine with neostigmine during general therapy, and atropinization during anaesthesia; a larger paralyzing dose of succinylcholine as compared with the normal patient; and smaller doses of non-depolarizing agents compared with the normal patient. Because of the decreased number of receptors, succinylcholine may not effectively depolarize the endplate resulting in " resistance ". The ED50 and ED95 in myasthenic patients is 2.0 and

204

2.6 times that of the normal patient. Thus, high doses of succinylcholine may be required for rapid sequence intubation. The endplate potential may not reach the threshold required for inducing a depolarizing " phase 1 " block and may readily induce a " phase 2 " block. Also if plasma cholinesterase has been inhibited, then hydrolysis may be decreased. Both of these events may result in potentiation and prolongation of its activity. The reduction of the number of receptors at the neuromuscular junction, and consequent reduction in the " safety margin " makes these patients extremely sensitive to nondepolarizing muscle relaxants. One tenth of the normal paralysing dose may be sufficient to paralyse a patient with MG, however, this varies with the severity of the disease. Also, this may not apply to intermediate acting agents, vecuronium and atracurium. Both of these are eliminated normally, and their short half lives allow the initial dose to be titrated against need with the expectation of full reversal at the end of the procedure as normal. References BAKARA, A; " Anaesthesia and Myasthenia Gravis ", Can J Anaesth, vol 39, no 5, 1992, pp 476-86. Number: 210 Which of the following are true of Latex allergy: 1. The incidence in Health Care Workers is a least three times that in those not exposed to latex. 2. Type IV reactions are more common than Type I reactions. 3. Is four times as common in women as opposed to men. 4. Is more common in those allergic to bananas. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct

Correct Answer: E Number: 302 A 75 year old patient with stable angina whose exercise capacity is limited to walking 200 metres before angina supervenes is in the ASA class of: A. I B. II C. III D. IV E. V

205

Correct Answer: C The American Society of Anesthesiologists classification is: I. No organic disease II. Mild or moderate systemic disease without functional impairment III. Organic disease with definite functional impairment IV. Severe disease that is life-threatening V. Moribund patient, not expected to survive Dripps RD, Lamont A, and Eckenhoff JE: The role of anesthesia in surgical mortality, JAMA 178:261, 1961. Number: 303 The most common intraoperative complication reported during anaesthesia in ASA I or II patients is: A. Dysrhythmia. B. Hypotension. C. Hypertension. D. Syringe Swap. E. Airway Obstruction Select the single best answer Correct Answer: A In 1986 Cohen et al. described the findings of a large prospective survey that identified major and minor complications in 112,721 patients over a 9-year period. More than 80% of the patients were healthy American Society of Anesthesiologists (ASA) physical status class I or II. All types of surgery and anesthetic techniques were included. The study indicated that 9% of all patients had at least one intraoperative complication. The two most common complications encountered in adults were dysrhythmias (3.9%) and hypotension (2.7%). The next most common were respiratory problems (1%), followed by incidents related to the drugs administered or to the surgical procedure performed. Cardiac arrest was very uncommon. It is of interest that during the period 1975 to 1978, 7.6% of patients experienced some intraoperative complication, whereas during the period 1979 to 1983, the incidence had increased to 10.6%. The authors of this study suggested that at least part of this increase was a result of improved monitoring, which permitted better detection of problems, rather than reflecting an actual increase in the overall incidence of intraoperative complications. In a similar study conducted to determine the incidence of intraoperative anesthetic complications in children, Cohen, Cameron, and Duncan found that 35% of pediatric patients experienced adverse perioperative events, of which 8.5% occurred during the intraoperative period. Cohen MM, Duncan PG, Pope WDB et al: A survey of 112,000 anaesthetics at one teaching hospital (1975-83), Can J Anaesth 33:22, 1986.

206

Cohen MM, Cameron CB, and Duncan PG: Pediatric anesthesia morbidity and mortality in the perioperative period, Anesth Analg 70:160, 1990. Number: 332 The appropriate size of laryngeal mask airway for a 40 kg patient is likely to be: A. 1. B. 2. C. 3. D. 4. E. 5. Select the single best answer Correct Answer: C The manufacturer recommends: Size 1: up to 6.5kgs. Size 2. 6.5 - 20 kgs. Size 2.5. 20 - 30 kgs. Size 3. 30 - 50 kgs. Size 4. 50 - 75 kgs. Size 5. Over 75 kgs. Number: 341 A healthy 20 year old is to be anaesthetised in a hospital at an altitude of 10,000 feet: 1. Nitrous oxide can be expected to be a useful component of a general anaesthetic. 2. The concentration of halothane delivered by a 'Tec' type vapouriser will be accurate. 3. His resting PCO2 is likely to be 40 mm Hg. 4. His arterial PO2 breathing air will be about 65 mm Hg. Select the single best answer Correct Answer: D At an altitude of 10,000 feet, the inspired PO2 is reduced to 110 mm Hg and PaO2 to 65 mm Hg in air. At this hypoxic level, alveolar ventilation increases and PaCO2 is steadily reduced (34 mm Hg at rest). The effective anesthetic power of nitrous oxide is also reduced as total barometric pressure decreases. It has been shown that analgesia induced by 50% nitrous oxide is reduced by nearly 50% at 5000 feet and it becomes insignificant at 10,000 feet. Therefore, nitrous oxide is not a useful anesthetic gas at altitude. Safar and Tenicela and James and White condemn the use of nitrous oxide for anesthesia at altitude.

207

The saturated vapor pressure of a volatile anesthetic agent depends only on temperature and is practically independent of total environmental pressure. Consequently, for a given vapouriser temperature, the concentration of a given mass of vapor increases as the barometric pressure is reduced, because the same mass of volatile agent is vaporized in less and less dense carrier gas. However, the partial pressure (expressed in mm Hg) of the agent remains unchanged, and so does its biological effect on the neural tissue where the anesthetic effect is produced. Safar P, Tenicela R: High altitude physiology in relation to anesthesia and inhalation therapy, Anesthesiology 25:515-531, 1964. James MFM, White JF: Anesthetic considerations at moderate altitude, Anesth Analg 63:1097-1105, 1984. Number: 397 Nerve injury in relation to anaesthesia is most likely to occur in the distribution of the: A. Supraorbital nerve. B. Mental nerve C. Ulnar nerve. D. Radial nerve E. Median nerve Select the single best answer Correct Answer: C Ulnar nerve injury is by far the most commonly reported neurological deficit reported in 'closed claims' analyses. For example, the percentage incidence in a survey of 227 cases by Kroll was: Ulnar 34 Brachial plexus 23 Lumbosacral nerve root 6 Spinal cord 6 Sciatic 5 Median 4 Radial 3 Femoral 3 Multiple nerves 2 Other nerves 5 Overall the risks of major neurologic deficits after any form of anesthesia are exceedingly rare. In a recent review of nerve injury in 227 patients associated with anesthesia, the mechanisms of injury often remained unclear despite extensive analysis.

208

The sensitivity of the ulnar nerve to damage is because of its superficial position as it passes behind the epicondyle of the humerus. Injury can occur because of hyperflexion of the elbow, which overstretches the nerve in a comatose patient, direct compression of the nerve against a hard object such as an armboard or side rail of the operating room table, or in relation to the use of automatically cycled blood pressure cuffs. Alexander GD: Mechanism of ulnar nerve injury, Anesthesiology 73:1294-1295, 1990. Kroll DA et al: Anesthesiology 73:202-207, 1990 Number: 399 The most likely adverse outcome of anaesthesia in closed claim studies is: A. Nerve damage. B. Airway trauma. C. Aspiration. D. Myocardial infarction E. Stroke. Select the single best answer In the American Society of Anesthesiologists Closed Claims Project, nerve damage was far more common than the other outcomes listed here. The percentage incidence of some adverse outcomes of 1541 settled claims is shown below. Death 37 Nerve damage 15 Brain damage 12 Low-severity injuries 11 Airway trauma 4 Pneumothorax 3 Eye damage 3 Aspiration 3 Pulmonary edema 3 Stroke 2 Hepatic dysfunction 2 Myocardial infarction 1 Number: 406 Intraneural pressure in the ulnar nerve at the elbow is highest if the arm is positioned: A. Elbow at side and extended, wrist supinated. B. Elbow at side and extended, wrist pronated. C. Elbow at side and flexed. D. Elbow flexed and above shoulder. E. None of the above.

209

Select the single best answer Correct Answer: D The intraneural pressure in the ulnar nerve is at its highest when the shoulder is fully abducted and the elbow is flexed. With the elbow at the side and extended, intraneural pressure is about 7 mm Hg. With the elbow at the side and flexed, intraneural pressure is about 11 mm Hg. With the elbow above the shoulder and flexed, intraneural pressure is about 47 mm Hg. Pechan J; Julis I: Pressure measurement in the ulnar nerve. A contribution to the pathophysiology of the cubital tunnel syndrome. J. Biomech 8: 75-79, 1975. Pronation and / or extension of the wrist tend to further increase intraneural pressure. It seems reasonable to assume that measures which minimise the rise of intraneural pressure during anaesthesia will reduce the risk of ulnar neuropathy, although, as yet, there is no clear evidence to support this view. Number: 409 With regard to critical incidents in the recovery ward: 1. They are associated with significantly more adverse outcomes than those occurring in theatre. 2. Reintubation is necessary in ~ 0. 1% of critical respiratory incidents in the recovery room. 3. The complication rate for removal of artificial airways in recovery is about 15%. 4. About 70% of critical incidents in the recovery room are circulatory problems. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct Correct Answer: A Van der Walt JH, Webb RK, Osborne GA, et al. Recovery room incidents in the first 2000 incident reports. Anaesthesia Intensive Care 1993; 21 :650-652. Vaughan RS. Airway Management in the recovery room. Anaesthesia 1997; 52:617-618. Number: 441 Which of the following statements are true regarding Broncho - Alveolar Lavage for a patient with pulmonary alveolar proteinosis?

210

1. A double-lumen endotracheal tube is absolutely indicated. 2. The right lung should be lavaged first. 3. Pre-oxygenation of the lavaged lung will improve the effectiveness of the procedure. 4. Lavage can be safely performed with isotonic saline infused at a height of 70 cm above the midaxillary line. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct Correct Answer: B Pulmonary Alveolar Proteinosis (PAP) is a condition in which the alveoli are filled with granular material that stains with Periodic Acid Schiff reagent, but there is no evidence of inflammation and septal architecture is relatively normal. The intra-alveolar material is a combination of surfactant phospholipid produced by alveolar type II pneumocytes and of other proteins and immunoglobulins found in alveolar lining fluid. The cytoplasm of alveolar macrophages appears engorged with inclusions (lamellar bodies). Whole-lung lavage provides relief from both the dyspnoea and the progressive deterioration in arterial oxygenation which affects many patients. It may also may provide long-term benefit. Broncho - Alveolar Lavage (BAL) is performed under general anaesthesia using warm, isotonic saline infused by gravity from a height of 30 cm above the midaxillary line. The resultant hydrostatic pressure of the lavage fluid with this setup is 30 mm Hg - a pressure at which the seal on the endobronchial cuff can still remain effective. The left lung, being smaller, should be lavaged first so that during the first period of one lung ventilation the largest lung is responsible for gas transfer. Pre-oxygenation is recommended in order to remove insoluble nitrogen from the alveoli and enhance distribution of the saline. The non- lavaged lung is ventilated with 100% O2. When lavage fluid ceases to flow (usually after 1000 ml in an adult), drainage is accomplished by clamping the inflow line and unclamping the drainage line, which runs to a collection bottle placed 20 cm below the midaxillary line. The application of mechanical chest percussion and vibration to the lavaged hemithorax before drainage enhances the yield of each lavage and thus shortens the time required for the procedure. Initially the lavage fluid is cloudy, turbid, and has a light-brown colour. Sediment collects at the bottom of the drainage bottle. The cycle of filling and drainage is then repeated until the lavage effluent becomes clear. It is extremely important to record accurately volumes delivered to and retrieved from each tidal lavage. Total lavage fluid volumes of 10 to 20 L are usually employed. After the effluent

211

lavage fluid becomes clear, the procedure is terminated, the lavaged lung thoroughly suctioned, and ventilation reestablished. The compliance of the lavaged lung is much less than that of the nonlavaged lung at this time. Large tidal volumes of 15 to 20 ml/kg to the lavaged side alone are necessary to reexpand the alveoli. The non-lavaged side is temporarily clamped after a large inspiration of 100% O2. Number: 443 The maximum amount of air recommended for use in a size 2 laryngeal mask airway is: A. 2 mls. B. 5 mls. C. 7 mls. D. 10 mls. E. 15 mls. Select the single best answer Correct Answer: D The manufacturer recommends: Size 1.0 1.5 2.0 2.5 3.0 4.0 5.0 Weight Air in Cuff under 5 kg 4 ml 5 to 10 kg 7 ml 10 to 20 kg 10 ml 20 to 30 kg 14 ml 30 kg to small adult 20 ml adult 30 ml big adult 40 ml

Number: 444 With regard to aspiration risk and the use of the laryngeal mask airway (LMA). 1. It has an overall incidence of about 1:5000 cases. 2. Gastric reflux to the level of the mid-oesophagus is greater when an LMA as opposed to face mask is used. 3. The risk may be increased by the effect of the mask on lower oesophageal sphincter tone. 4. The incidence Is increased if extubation is delayed until the patient is awake. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct

212

Correct Answer: A The incidence of aspiration associated with the laryngeal mask airway: a meta-analysis of published literature. Brimacombe JR; Berry A. J Clin Anesth, 7(4):297-305 1995 Jun STUDY OBJECTIVE: To determine the incidence of pulmonary aspiration with the laryngeal mask airway (LMA). Number: 478 With regard to latex-induced anaphylaxis: 1. A 'Neoprene' reservoir bag can be safely used in a patient who has had a previous reaction to latex. 2. Anaphylaxis is more likely to occur in a patient who is allergic to bananas. 3. Allergy is usually IgE-mediated. 4. RAST testing is more sensitive than intradermal testing in confirming the allergy. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct Correct Answer: A 'Neoprene' is completely synthetic and can be safely used in the breathing circuit. Allergic manifestations commonly depend on the route of exposure to latex: Cutaneous exposure causes contact pruritus, urticaria, eczema and dermatitis, whereas airborne exposure causes rhinitis, conjunctivitis and asthma. Mucosal or intravenous exposure results in angioedema and anaphylaxis. - However, any route of exposure may cause anaphylaxis. Ask about a history of atopy (hay fever, asthma) and multiple drug allergies as these patients are more likely to be allergic also to latex. Patients with certain food allergies (e.g.avocado, banana, chestnut) are also more likely to be allergic. The reaction is IGE-mediated. Skin-prick testing is less sensitive than intradermal test but more sensitive than RAST. Radioallergosorbent test (RAST) - an in-vitro test for IgE antibodies in the patient's serum is positive in 65 - 95% of cases. The Allergenicity of Latex Gloves:

213

Allergenicity of latex gloves is related to both the quantity, and the type of protein antigens they contain. Allergenicity can be suppressed by washing and steam sterilising the gloves during manufacture. Cornstarch powder is the most common lubricant and is associated with reactions due to the adsorption of antigens to the cornstarch particles, producing aerosolized latex antigen. Powder-free gloves are less allergenic. Note that the powder itself does not cause allergy. "Hypoallergenic" gloves are usually made from latex and should not be used to manage latexallergic patients. There is no standard for "hypoallergenic" latex gloves, which are often mistakenly assumed to be non-latex. Read the labelling carefully! Number: 486 With regard to desflurane: A. It has a boiling point of 29.2 Deg. C. B. Has a blood:gas partition coefficient higher than isoflurane. C. Has been reported as a triggering agent for malignant hyperthermia. D. Is associated with a low incidence of airway reflex responses when used for gaseous induction. E. None of the above. Select the single best answer Correct Answer: C ADesflurane is a volatile anaesthetic that combines low blood gas solubility (blood/gas partition coefficient = 0.42 at 37 degrees C), moderate potency (MAC = 6-7%), and high volatility (vapour pressure = 681 mmHg at 20 degrees C, boiling point = 23.5 degrees C). Anesthesiology 1999 Apr;90(4):1208-9 Garrido S, Fraga M, Martin MJ, Belda J Malignant hyperthermia during desflurane-succinylcholine anesthesia for orthopedic surgery. nesth Analg 1998 Jun;86(6):1328-31 Allen GC, Brubaker CL Human malignant hyperthermia associated with desflurane anesthesia Number: 487 Sevoflurane: 1. Is a halogenated ether. 2. Is flammable. 3. Has a MAC of about 2 vol%. 4. Has a blood/gas partition coefficient of about 3.

214

A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct Correct Answer: B Sevoflurane is a halogenated methyl isopropyl ether. It is potent, non explosive and non flammable. It reacts with soda lime to form traces of a related ether which has not been shown to have any toxic effect on animals chronically exposed to it in a closed system. Induction of anaesthesia with sevoflurane is rapid and smooth, as predicted by a blood/gas partition coefficient of about 0.6 and an acceptable odour which allows the use of concentrations of up to 10%. Its MAC has been reported to vary between 1.7 and 2.3 vol %. Sevoflurane causes dose-dependent cardiovascular and respiratory depression. Its effect on the cerebral circulation is similar to that of isoflurane. The extent of biotransformation is similar to that of enflurane, but its low solubility and rapid elimination confine this to the period of inhalation. No toxic effects on the kidneys, liver and haematopoietic system have been found. Br J Hosp Med 1997 Jan 15-Feb 5;57(1-2):43-6 Grounds RM, Newman PJ 'Sevoflurane.' Number: 488 Carbon Monoxide (CO) is more likely to be produced by carbon dioxide absorbent in a circle system if: 1. Enflurane rather than sevoflurane is the volatile agent in use. 2. High concentrations of volatile agents are in use. 3. The carbon dioxide absorbent is 'baralyme' rather than soda lime. 4. The carbon dioxide absorbent is very moist A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct Correct Answer: A Anesth Analg 1995 Jun;80(6):1187-93 Fang ZX, Eger EI 2nd, Laster MJ, Chortkoff BS, Kandel L, Ionescu P Carbon monoxide production from degradation of desflurane, enflurane, isoflurane, halothane, and sevoflurane by soda lime and Baralyme.

215

Anecdotal reports suggest that soda lime and Baralyme brand absorbent can degrade inhaled anesthetics to carbon monoxide. We examined the factors that govern CO production and found that these include: 1) The anesthetic used: for a given minimum alveolar anesthetic concentration (MAC)multiple, the magnitude of CO production (greatest to least) is desflurane > or = enflurane > isoflurane >> halothane = sevoflurane. 2) The absorbent dryness: completely dry soda lime produces much more CO than absorbent with just 1.4% water content, and soda lime containing 4.8% or more water (standard soda lime contains 15% water) generates no CO. In contrast, both completely dry Baralyme and Baralyme with 1.6% water produce high concentrations of CO, and Baralyme containing 4.7% water produces concentrations equaling those produced by soda lime containing 1.4% water. Baralyme containing 9.7% or more water and standard Baralyme (13% water) do not generate CO. 3) The type of absorbent: at a given water content, Baralyme produces more CO than does soda lime. 4) The temperature: an increased temperature increases CO production. 5) The anesthetic concentration: more CO is produced from higher anesthetic concentrations. These results suggest that CO generation can be avoided for all anesthetics by using soda lime with 4.8% (or more) water or Baralyme with 9.7% (or more) water, and by using inflow rates of less than 2-3 L/min. Such inflow rates are low enough to ensure that the absorbent does not dry out. See also: Anesth Analg 1995 Jul;81(1):144-6 Baum J, Sachs G, v d Driesch C, Stanke HG Carbon monoxide generation in carbon dioxide absorbents. Number: 502 Ulnar nerve injury occurring in association with anaesthesia is: 1. More common when regional rather than general anaesthesia is used. 2. More common in patients with an 'extreme' body habitus. 3. More common in women rather than men. 4. The most common single nerve injury. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct

216

Correct Answer: C Ulnar nerve injury is by far the most common nerve injury reported in association with anaesthesia. It occurs predominantly in men (75:25), who are either fat or thin and who have undergone general anaesthesia. See: Anesthesiology 1999 Apr;90(4):1062-9 Cheney FW, Domino KB, Caplan RA, Posner KL Nerve injury associated with anesthesia: a closed claims analysis. Anesthesiology 1994 Dec;81(6):1332-40 Warner MA, Warner ME, Martin JT Ulnar neuropathy. Incidence, outcome, and risk factors in sedated or anesthetized patients. Number: 504 Which of the following can be considered a 'normal' reaction to suxamethonium given to a child? 1. Masseter spasm. 2. Myoglobinuria. 3. Elevation of creatine phosphokinase (CPK). 4. Myalgia A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct Correct Answer: E Masseter spasm is no longer thought to be an early sign of malignant hyperthermia. It is more likely that it reflects relative 'underdosing' of the drug. See: Br J Anaesth 1990 Apr;64(4):488-92 Leary NP, Ellis FR Masseteric muscle spasm as a normal response to suxamethonium. Succinylcholine, particularly in infants and small children, will result in damage to the muscle cell as evidenced by increased levels of creatine phosphokinase (CPK) and by myoglobinaemia and in some cases myoglobinuria. This is a normal response to succinylcholine. It can be minimized or prevented by the pretreatment with nondepolarizing muscle relaxants (curare or atracurium 0.05 mg/kg). This pretreatment will result in a pronounced reduction in the levels of CPK and so on and a considerable reduction in myalgias. Number: 510 The following exist as liquids at room temperature when stored in pressurised cylinders:

217

1. Helium 2. Nitrous oxide 3. Entonox 4. Carbon dioxide A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct Correct Answer: C The critical temperature of a gas is the temperature above which the gas cannot be liquefied by pressure alone. In the case of both carbon dioxide and nitrous oxide this temperature exceeds room temperature at 31 and 36.5 degrees C respectively. Therefore when cylinder pressure is higher than critical pressure, these compounds exists in the cylinder as a mixture of gas and liquid. Under these circumstances the cylinder pressure gauge will not give a true indication of cylinder content. Number: 511 With regard to the pin index system of medical gas cylinders: 1. There are seven possible pin positions. 2. Air and oxygen share a common pin position. 3. The positions for oxygen are two and five. 4. Keying is permitted using either one or two pins. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct Correct Answer: A The Pin Index Safety System has two (5-mm) stainless steel pins on the cylinder yoke connector just below the fitting for the valve outlet port. There are seven different pin positions, depending on the type of gas in the cylinder. The yoke connector for an oxygen cylinder, for example, has pins at positions 2 and 5 whereas that for air is 1 and 5. Two pins must ALWAYS be present on the yoke.

218

Number: 519 Gastric emptying is enhanced by: A. The presence of fat in the duodenum. B. The presence of acid in the duodenum. C. Stress. D. An increase in vagal tone. E. The administration of atropine. Select the single best answer Correct Answer: D The presence of fat, acid or hypertonic solutions in the duodenum initiates a neurallymediated inhibitory enterogastric reflex, thus delaying the rate of gastric emptying. Gastric emptying is also under control of the autonomic nervous system such that a relative increase in vagal tone hastens gastric emptying while an increase in sympathetic tone will decrease it. Thus, anti-muscarinic agents delay gastric emptying. Number: 539 The value of the bispectral index which is thought to be most appropriate for the performance of minor, body-surface surgery, in a patient anaesthetised with propofol is: A. > 90. B. > 80 <= 90. C. > 70 <= 80. D. > 60 <= 70. E. <= 60. Select the single best answer Correct Answer: E During propofol-induced sedation, BIS values may be maintained above 75 to prevent airway obstruction and hypoxia. During propofol intravenous anaesthesia, BIS values from 40 to 60 have been proposed to maintain the desired level of hypnosis, with values below 50 associated with an insignificant probability of recall. Singh H : Eur J Anaesthesiol 1999 Jan;16(1):31-6 Bispectral index (BIS) monitoring during propofol-induced sedation and anaesthesia. Gajraj RJ, Doi M, Mantzaridis H, Kenny GN : Br J Anaesth 1998 Jan;80(1):46-52 Analysis of the EEG bispectrum, auditory evoked potentials and the EEG power spectrum during repeated transitions from consciousness to unconsciousness.

219

Number: 557 In the case of a 'typical' brachial plexus injury complicating cardiac surgery via a median sternotomy: 1. Sensory features are usually present. 2. Motor features are usually present. 3. The lower roots are usually affected. 4. The long-term prognosis is poor. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct

Correct Answer: B Brachial plexus injury occurring after cardiac surgery is a distinct entity from that which complicates other forms of surgery. The former is characterised by a predominance of sensory features confined to the lower roots of the plexus and the latter by a predominance of motor signs in the upper and middle roots. The former is far more frequent than the latter, with an excellent prognosis for recovery. The prognosis of brachial plexopathy after non-cardiac surgery may be worse in males, diabetics, those with injury to all roots of the plexus and when, in addition to the motor deficit, there is sensory loss and pain or dysaesthesia. Prognosis of intraoperative brachial plexus injury: a review of 22 cases. Br. J. Anaesth. 1997; 79:440-44: Ben-David, B.; Stahl, S Number: 567 Which of the following routine pre-operative laboratory tests have been shown to have a significant impact on the anaesthetic management of healthy patients scheduled for elective outpatient surgery? A. Serum electrolytes. B. Full blood count. C. Urinalysis. D. Coagulation studies. Select the single best answer Correct Answer: E

220

JAMA 1985 Jun 28;253(24):3576-81 The usefulness of preoperative laboratory screening. Kaplan EB, Sheiner LB, Boeckmann AJ, Roizen MF, Beal SL, Cohen SN, Nicoll CD We assessed the usefulness of routine laboratory screening of preoperative patients. Computer-readable laboratory, demographic, and discharge diagnostic data were assembled for 2,000 patients undergoing elective surgery over a four-month period, and randomly selected samples of patients were studied. Several tests ordered by protocol and performed by the laboratory at the time of admission were examined in these samples, including complete blood cell count, differential cell count, prothrombin time, partial thromboplastin time, platelet count, six-factor automated multiple analysis, and glucose level. Sixty percent of these routinely ordered tests would not have been performed if testing had only been done for recognizable indications, and only 0.22% of these revealed abnormalities that might influence perioperative management. Chart review indicated that these few abnormalities were not acted on nor did they have adverse surgical or anesthetic consequences. In the absence of specific indications, routine preoperative laboratory tests contribute little to patient care and could reasonably be eliminated Number: 568 Which statement is correct with regard to dantrolene sodium? A. It is a neuromuscular blocking agent. B. It causes phlebitis if administered into a peripheral vein.. C. It has an elimination half-life of 2-3 hours. D. It causes significant myocardial depression. E. It significantly enhances the effects of other neuromuscular blocking agents. Select the single best answer Correct Answer: B Unlike neuromuscular blocking agents, dantrolene acts within the muscle cell itself by reducing the level of intracellular ionised calcium. 'Minor' complications of dantrolene administration include nausea, phlebitis and transient (~24 hrs) muscle weakness. The half-life of intravenous dantrolene is approximately 12 hours. In clinical doses, this decrease in intracellular calcium has been shown to have little effect on myocardial contractility. The dosage of a neuromuscular blocking agent need not be changed significantly after dantrolene administration

221

Number: 578 With regard to ondansetron: 1. It increases gastric motility. 2. It has anti-dopaminergic activity. 3. It is relatively ineffective in the treatment of chemotherapy-induced nausea. 4. It is a 5-HT 3 receptor antagonist. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct Correct Answer: D In normal volunteers, single I.V. doses of 0.15 mg/kg of ondansetron had no effect on esophageal motility, gastric motility, lower oesophageal sphincter pressure, or small intestinal transit time. Ondansetron is a selective 5-HT 3 receptor antagonist. While ondansetron's mechanism of action has not been fully characterised, it is not a dopamine-receptor antagonist. Serotonin receptors of the 5-HT 3 type are present both peripherally on vagal nerve terminals and centrally in the chemoreceptor trigger zone of the area postrema. Ondansteron is extremely effective in the treatment of chemotherapy-induced emesis. It is not certain whether ondansetron's antiemetic action in chemotherapy-induced emesis is mediated centrally, peripherally, or in both sites. However, cytotoxic chemotherapy appears to be associated with release of serotonin from the enterochromaffin cells of the small intestine. In humans, urinary 5-HIAA (5-hydroxyindoleacetic acid) excretion increases after cisplatin administration in parallel with the onset of emesis. The released serotonin may stimulate the vagal afferents through the 5-HT 3 receptors and initiate the vomiting reflex. Number: 582 Drugs which are known to be triggering agents for malignant hyperthermia (MH) include: A. Haloperidol B. Ketamine C. Etomidate D. Atropine E. None of the above. Select the single best answer

222

Correct Answer: E The known triggering agents for MH comprise all the inhalational anaesthetic agents and suxamethonium. The drugs known to be safe include: atropine, benzodiazepines, bupivacaine, droperidol, lignocaine, nitrous oxide, non-depolarising muscle relaxants, opioids and the intravenous induction agents. Atropine can cause hyperpyrexia (particularly in children), but this is a feature of a central anticholinergic syndrome rather than malignant hyperthermia. Haloperidol can precipitate the neurolept malignant syndrome. In some of these patients the caffeine-contracture test may be positive for malignant hyperthermia susceptibility. This syndrome differs from malignant hyperthermia in that central dopamine depletion is responsible for the clinical picture. Number: 609 Which of the following therapies are probably effective in the treatment of post-operative nausea and vomiting (PONV)? 1. Ondansetron. 2. Acupuncture. 3. Droperidol. 4. Metoclopramide. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct Correct Answer: A With the exception of metoclopramide (which is emerging as a drug with little other than placebo effect in this regard), all have been found to be more or less effective therapies for PONV. Acupuncture (at the P6 acupuncture point which lies about four centimetres up the arm from the wrist creases) has been shown to reduce nausea and vomiting quite effectively in adults but not children. See: Lee A, Done ML. The use of non-pharmacologic techniques to prevent postoperative nausea and vomiting: a meta-analysis. Anesth Analg. 1999 Jun;88(6):1362-9.

223

Visit the 'Bandolier' website (www.jr2.ox.ac.uk/bandolier) and in particular pages www.jr2.ox.ac.uk/bandolier/band71/b71-9.html and www.jr2.ox.ac.uk/bandolier/band71/b718.html for comment on this topic. Number: 648 With regard to intravenous cannulation: 1. The use of local anaesthesia for cannulation diminishes pain on insertion even when a 20G cannula is used. 2. Antibiotic bonding of the cannula will reduce the rate of catheter infection. 3. Cannulation in the sitting position increases the likelihood of vasovagal symptoms. 4. Polyurethane cannulae are associated with a lower incidence of thrombophlebitis than teflon cannulae. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct Correct Answer: E Langham and Harrison have demonstrated that even when small cannulae (22G) are used, it is kinder to use local anaesthetic! See: Langham BT, Harrison DA Local anaesthetic: does it really reduce the pain of insertion of all sizes of venous cannula? Anaesthesia. 1992 Oct;47(10):890-1. As with central venous catheters, the incidence of catheter-related infection appears to be reduced when antibiotic bonded cannulae are used. See: Kamal GD, Pfaller MA, Rempe LE, Jebson PJ. Reduced intravascular catheter infection by antibiotic bonding. A prospective, randomized, controlled trial. JAMA. 1991 May 8;265(18):2364-8. The effect of posture on the likelihood of vasovagal symptoms has been explored by Rapp and Pavlin ( Rapp SE, Pavlin DJ, Nessly ML, Keyes H. Effect of patient position on the incidence of vasovagal response to venous cannulation. Arch Intern Med. 1993 Jul 26;153(14):1698-704.). Polyurethane cannulae are associated with a lower incidence of thrombophlebitis than teflon cannulae - see: Gaukroger PB, Roberts JG, Manners TA. Infusion thrombophlebitis: a prospective comparison of 645 Vialon and Teflon cannulae in anaesthetic and postoperative use. Anaesth Intensive Care. 1988 Aug;16(3):265-71. Number: 659 The incidence of anaesthesia-related dental trauma in a patient with 'good' dentition is about: A. 0.0001% B. 0.001% C. 0.01%

224

D. 0.1% E. 1.0% Select the single best answer Correct Answer: D This subject has recently been the subject of comprehensive review by Owen and WaddellSmith. Damage to teeth has long been associated with general anaesthesia and especially endotracheal intubation. Over sixty years ago, Magill recommended using a piece of adhesive plaster to protect the teeth when using the laryngoscope, and noted that with "blind (nasal) intubation" there was no risk of damage to teeth. Reviews of claims made to medical defence organisations in England, data from the Risk Management Foundations, closed claims analysis by the National Association of Insurance Examiners in the U.S.A and a review of anaesthesia-related claims in South Australian public hospitals between 1989 and 1998 confirm that dental injuries are the most common anaesthetic-related event reported, accounting for up to a third of incidents.Surveys of anaesthesia-related dental trauma show an incidence from 0.02% to 0.7%). The incidence of dental damage in patients with otherwise "good" dentition is approximately 0.08%. Macintosh described the curved blade most widely used today, observing that the straight blade occasionally "jeopardizes the patient's upper teeth". It was claimed that the open top of the curved blade decreased the risk of dental injury. The plethora of subsequent descriptions of devices and techniques to facilitate endotracheal intubation prompted Sykes to write "There is no living anaesthetist who holds the distinction of no having designed one or more! Despite the progress in intubation techniques, damage to teeth is still the commonest cause of complaint against anaesthetists. See: Anaesth Intensive Care 2000; 28: -133-145. Dental Trauma Associated with Anaesthesia. H. Owen, I. Waddell-Smith. Number: 660 The incidence of difficult intubation (> 2 attempts at laryngoscopy required) in a general surgical population (excluding obstetrics) is about: A. 0.05% B. 0.2% C. 1.0% D. 2.0% E. 5.0% Select the single best answer Correct Answer: D

225

Rose and Cohen determined the factors predictive of difficult intubation in a study of 18,205 patients scheduled for tracheal intubation under direct laryngoscopy. Tracheal intubation was difficult (> 2 laryngoscopies) in 1.8% and awkward (< or = 2 laryngoscopies) in 2.5%. This approach was a failure in 0.3%, and surgery was postponed in 0.05%. In this study an alternative approach to direct laryngoscopy, was the first choice in 353 patients. See: Rose DK, Cohen MM. The airway: problems and predictions in 18,500 patients. Can J Anaesth. 1994 May;41(5 Pt 1):372-83. Number: 682 Which of the following is most likely to occur within 5 minutes of the accidental insertion of an endotracheal tube into the right main bronchus of a ventilated patient: A. Hypotension. B. Severe hypercarbia. C. An increase in the requirement for the volatile agent. D. An increased inflation pressure. E. Collapse of the right upper lobe. Select the single best answer Correct Answer: D Hypotension, hypercarbia and increased requirements for volatile agents are not features of inadvertent bronchial intubation. RUL collapse usually takes longer than 5 minutes to occur. Number: 684 During the repair of idiopathic scoliosis in a 20-year-old, you decide to reduce blood loss by the combined use of isovolaemic haemodilution and induced hypotension with sodium nitroprusside. Your monitoring includes an arterial line and an oximetric pulmonary artery catheter. You are ventilating the patient with isoflurane in 30% oxygen. One hour into the procedure you note that the blood pressure is 85/60 mm Hg and the pulse rate is 115 bpm. You perform an arterial blood gas analyses which reveals, amongst other things: haemoglobin 61 G/L, PaO2 95 mm Hg, BXS -2.5. The mixed venous saturation is 59%. Given the scenario above, the most appropriate initial therapy is A. Institution of positive end-expiratory pressure at 10 crnH2O. B. Cessation of the sodium nitroprusside.

226

C. Administration of methylene blue for the treatment of possible cyanide toxicity. D. Retransfusion of some of the autologous blood. E. Ventilation with 100% oxygen. Select the single best answer Correct Answer: D Institution of positive end-expiratory pressure at 10 crnH2O is likely to reduce cardiac output and not be helpful at all. The sodium nitroprusside appears to be doing its job. The patient doesn't really have any signs of cyanide toxicity. The mixed venous oxygen saturation is unacceptably low. Given that it is not due to arterial hypoxaemia, the obvious option is to retransfusion of some of the autologous blood. Number: 689 A unit of Fresh Frozen Plasma (FFP): 1. Will tend to reverse the effect of warfarin. 2. Poses the same infection risk as a unit of packed cells. 3. Can prcipitate an anaphylactic reaction. 4. Contains the same concentration of factor VIII as a unit of cryoprecipitate A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct

Correct Answer: B FFP is an acellular product and therefore does not carry the risk of transmission of CMV (which is an intracellular infection). Otherwise, the infection transmission risk is the same as for a unit of packed cells. FFP contains stable coagulation factors and plasma proteins - that is: fibrinogen, antithrombin, albumin, protein C and protein S. Patients who are IgA-deficient and require plasma support should receive FFP collected from IgA-deficient donors because the risk of anaphylaxis is increased if normal donors are used. Cryoprecipitate contains about half the factor VIII activity of FFP in one-tenth the original volume.

227

Indications for FFP transfusion include correction of coagulopathies, including the rapid reversal of coumadin; supplying deficient plasma proteins; and treatment of thrombotic thrombocytopenic purpura. Although FFP is an excellent volume expander, it should not be routinely used in this role. FFP is an acellular component and therefore does not transmit intracellular infections, i.e., cytomegalovirus (CMV). Patients who are IgA-deficient and require plasma support should receive FFP collected from IgA-deficient donors because the risk of anaphylaxis is increased with normal donors. Number: 690 A unit of whole blood which has been stored for 24 hours will have normal levels of factor(s): 1. V. 2. VII. 3. X. 4. VIII. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct Correct Answer: A O'Neill et al recently examined the effect of 24 hours of storage on the clotting factors. They found that there were no significant changes in factors V, VII, and X; fibrinogen; antithrombin III; protein C; and protein S over the 24-hour storage period. At 8 hours, factor VIII activity was reduced by 13 percent, and it was reduced by a further15 to 20 percent after the 24 hours. See: O'Neill EM et al Transfusion 1999 May;39(5):488-91 Effect of 24-hour whole-blood storage on plasma clotting factors Number: 704 Which organ is at greatest risk of ischaemia under conditions of normovolaemic haemodilution? A. Brain B. Lung C. Liver D. Heart E. Kidney Select the single best answer

228

Correct Answer: D The heart is the organ at greatest risk as, under basal conditions, it has the highest oxygen extraction ratio. Number: 710 Generally accepted techniques for reducing the incidence of suxamethonium-induced muscle pains include pre-treatment with: 1. Pancuronium 0.3 mg/kg. 2. Lignocaine 1.5 mg/kg. 3. Suxamethonium 0.05 mg/kg. 4. Midazolam 0.1 mg/kg. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct Correct Answer: A Pretreatment with various non-depolarising relaxants, lignocaine and suxamethonium itself have all been shown to be effective in reducing the incidence of suxamethonium-induced muscle pains although the efficacy of a 'self-taming' dose of suxamethonium is questionable. In contrast, induction agents (thiopentone, propofol) and benzodiazepines are all ineffective. Number: 716 A 32 year old ex-heroin addict with hepatitis C requires an urgent laparotomy for oversewing of a perforated duodenal ulcer. The patient is undergoing treatment with naltrexone. The results of pre-operative coagulation studies include an International Normalised Ration for the prothrombin time of 1.8 and a platelet count of 85,000/cubic mm. Given this scenario, which of the following post-operative analgesic techniques would be most appropriate? A. Morphine-based patient-controlled analgesia (PCA). B. Local anaesthetic-based epidural analgesia. C. Ketamine PCA. D. Intramuscular Methadone. E. Fentanyl-based epidural analgesia. Select the single best answer

229

Correct Answer: C There are surprisingly few reports addressing the problems of providing anaesthesia and postoperative analgesia for patients undergoing treatment with naltrexone. Given the options listed here, a ketamine based analgesic technique would seem most appropriate (notwithstanding the fact that some effects of ketamine are mediated via opiate mu and delta receptors). See, for example: Latasch L, Freye E. Opioid receptors-mediated respiratory effects and antinociception after S(+)-ketamine. Acta Anaesthesiol Belg. 1993;44(3):93-102. The use of opiates in patients receiving naltrexone is likely to be ineffective and is probably also inappropriate. An epidural technique is contra-indicated given the presence of a coagulopathy Number: 717 A 75 year old lady weighing about 65Kgs, requires internal fixation of a fractured neck of femur. At your preoperative visit you ascertain that she is in good health and that her only significant medical condition is hypertension for which she takes captopril. Her blood pressure at the time of this visit is 140/85. You decide to give her a general anaesthetic. The patient receives her usual captopril prior to surgery and is premedicated with temazepam 10 mgs orally. Anaesthesia is induced with propofol 80 mgs, midazolam 2.5 mgs and fentanyl 50 mcgs. Muscle relaxation is secured with vecuronium 6mgs, the trachea is intubated and the patient ventilated with sevoflurane in oxygen. 3 minutes after induction the blood pressure has fallen to 80/50 and the monitor shows sinus rhythm at a rate of 80 bpm. You treat this by the administration of 500 mls of Hartmanns solution together with 1 mg of metaraminol. The blood pressure rises to 100/50 while the heart rate remains unchanged. You decide to commence 500 mls of Normal Serum Albumen (NSA). Five minutes later the blood pressure has fallen to 55/30 with a heart rate of 110 bpm. There is no evidence of bronchospasm or of a rash. Given this scenario, the most likely cause of her hypotension is: A. Hypovolaemia. B. Anaphylaxis. C. Fat embolism. D. Acute coronary ischaemia. E. Administration of albumen to a patient on an ACE inhibitor. Select the single best answer Correct Answer: E

230

Anaphylaxis and the administration of albumen to a patient on an ACE inhibitor are the most likely diagnoses in this case. Given the absence of respiratory or cutaneous manifestations of anaphylaxis, the latter is more likely. It should be remembered that patients on ACE inhibitors may demonstrate an exaggerated hypotensive response to induction of anaesthesia - unlike, say, a patient on beta blockers. (Coriat P et al; Influence of chronic angiotensin-converting enzyme Inhibition on anesthetic Induction; Anesthesiology 81:299-307, 1994.) In this case, the felony has been compounded by the concurrent administration of NSA! Albumen solutions contain low levels of Hageman Factor - a bradykinin activator. Bradykinin is an autocoid which stimulates the release of nitric oxide thereby inducing vasodilatation. It is normally very rapidly hydrolysed by ACE and usually has minimal systemic effects. However, in the presence of ACE inhibition, profound systemic effects commonly occur. Exaggerated hypotension in patients on ACE inhibitors has also been reported in response to the adminstration of colloid solutions and a similar mechanism has been suggested. See, for example: Powell CG, Unsworth DJ and McVey FK; Severe hypotension associated with Angiotensin-Converting Enzyme inhibition in anaesthesia. Anaesth. Intens. Care 1998; 26:107-109. Fat embolism is very unusual with this type of fracture. Hypovolaemia and primary coronary ischaemia seem equally unlikely given the scenario. Number: 726 The absorption of glycine during trans-urethral prostatectomy: 1. Can be detected by expired gas analysis. 2. Is a likely cause of confusion. 3. Is a likely cause of prolonged hypertension. 4. Is a likely cause of transient blindness. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct Correct Answer: C Glycine itself is not detectable in expired alveolar gas. However, if a trace amount of ethanol is added to the solution, the absorption can be measured by expired-breath testing. See: Hahn RG, Olsson J. Ethanol monitoring of the transurethral resection syndrome. J Clin Anesth. 1996 Dec;8(8):652-5. Absorption of glycine is suggested by the occurrence of either an acute confusional state or transient blindness. Surprisingly, the degree of visual disturbance does not appear to correlate

231

with the plasma level of glycine. See: Mizutani AR, Parker J, Katz J, Schmidt J. Visual disturbances, serum glycine levels and transurethral resection of the prostate. J Urol. 1990 Sep;144(3):697-9. Transient hypertension may occur in the early stages of glycine absorption, but hypovolaemia and hypotension then supervene. See: Hahn RG. Fluid and electrolyte dynamics during development of the TURP syndrome. Br J Urol. 1990 Jul;66(1):79-84. Number: 730 With regard to postobstructive (negative pressure) pulmonary oedema: 1. The oedema fluid has a protein content consistent with a transudate. 2. The syndrome complicates about one in a thousand general anaesthetics. 3. Follow-up echocardiography is generally worthwhile. 4. Haemoptysis may be a prominent feature. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct Correct Answer: C At the time of writing (July 2000) over a 100 cases of postobstructive pulmonary oedema have been reported in the world literature. The terms "postobstructive pulmonary oedema", "negative pressure pulmonary oedema" and "laryngospasm induced pulmonary oederna" have been used. The common pattern in these cases is the occurrence of an episode of airway obstruction at emergence from general anaesthesia, followed by the rapid onset of respiratory distress, haemoptysis and bilateral radiological changes consistent with pulmonary oedema. Oedema fluid analysis has consistently shown a high protein content (oedema: plasma albumin ratio). This suggests that the fluid is an exudate and is evidence for disruption of capillary integrity rather than transudation occurring as a result of simple rearrangement of Starling forces. The largest reported series is by Deepika who reviewed 30 cases in one institution and arrived at an incidence of 0.094%. See: Deepika K, Kenaan CA, Barrocas AM, Fonseca JJ, Bikazi GB. Negative pressure pulmonary edema after acute upper airway obstruction. J Clin Anesth. 1997 Aug;9(5):403-8. McConkey has also recently written a good review. See: McConkey PP. Postobstructive pulmonary oedema--a case series and review. Anaesth Intensive Care. 2000 Feb;28(1):72-6. Follow-up echocardiography is generally normal and therefore not worthwhile. When laryngospasm occurs in the recovery period from general anaesthesia, postobstructive pulmonary oedema will complicate 5-10% of such cases.

232

Number: 735 The incidence of ipsilateral phrenic nerve paralysis in patients undergoing carotid endarterectomy under combined superficial and deep cervical plexus block is: A. Less than 5%. B. 5 - 49% C. 50 - 70% D. 71% - 95% E. More than 95%. Select the single best answer Correct Answer: C The incidence of ipsilateral phrenic nerve paralysis following combined superficial and deep cervical plexus block seems to be about 55 - 60%. - See for example: G. EMERY, G. HANDLEY, M. J. DAVIES:, P. H. MOONEY Anaesth Intensive Care 1998; 26: 377-381 Incidenceof Phrenic Nerve Block and Hypercapnia in Patients Undergoing Carotid Endarterectomy Under Cervical Plexus Block. The incidence is similar when supraclavicular brachial plexus blockade is instituted. Number: 737 Which of the following food allergies in a patient scheduled for surgery coronary artery grafting are of potential concern to the anaesthetist? 1. Avocado. 2. Fish. 3. Bananas 4. Egg. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct Correct Answer: E Allergy to avocado, bananas or chestnuts has a significant correlation with allergy to latex ("Latex-fruit syndrome"). The antigens responsible for this have not been fully identified, but are probably class I chitinases. The ASA website (see website link) deals with this problem extensively.

233

Protamine is manufactured from fish roe and for this reason, patients who are allergic to fish are at increased risk of the development of protamine hypersensitivity. There is also an increased risk of an adverse reaction to protamine in patients treated with neutral protamine Hagedorn (NPH) insulin. 'Diprivan' is formulated with egg-lecithin and should probably not be administered to those with a proven allergy to eggs. Number: 755 In the management of an anaesthetised patient with severe anaphylaxis: 1. Treatment of hypovolaemia is of major importance. 2. H2 receptor antagonists may have a role as adjunctive therapy. 3. Adrenaline is the drug of choice for the treatment of bronchospasm. 4. Aminophylline is strongly indicated if bronchospasm is refractory to treament with adrenaline A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct Correct Answer: A Aggressive treatment of hypovolaemia and the administration of adrenaline are central to the successful management of anaphylaxis. The venodilatory response of histamine is mediated through both H1 and H2 receptor subtypes and for this reason, H2 receptor antagonists may have a role as adjunctive therapy. The role of aminophylline in the therapy of refractory bronchospasm is at best debatable. There is little evidence to support its use in anaphylaxis. If bronchospasm persists despite the use of large doses of adrenaline, it seems more reasonable to contemplate drug therapy with volatile agents, ketamine or magnesium and the use of other therapeutic techniques such as special modes of ventilation and even short term cardiopulmonary bypass. Number: 761 Which of the following drugs may precipitate myotonia in a patient with myotonic dystrophy? 1. Neostigmine. 2. Potassium chloride. 3. Suxamethonium 4. Vecuronium. A: 1,2,3 Correct B: 1,3 Correct

234

C: 2,4 Correct D: 4 Correct E: All Correct Correct Answer: A Neostigmine: Anticholinesterase drugs used to antagonise the effects of the nondepolarising neuromuscular blocking drugs may also precipitate myotonia, presumably because myotonic muscle has increased sensitivity to the stimulatory effects of acetylcholine. Potassium: The administration of potassium worsens clinical myotonia. Normal and myotonic muscle respond differently to increased serum concentrations of potassium. In normal muscle, an increase in serum potassium concentration increases muscular excitability and spontaneous discharges. Myotonic muscle shows a biphasic response. Initially, a decreased excitability can be demonstrated, but as serum potassium increases, increased sensitivity is seen. Durelli and colleagues have suggested that there is a differential effect of potassium on potassium channels on the muscle membrane surface and on the Ttubules of myotonic muscle. It would seem wise to avoid potassiumcontaining solutions. Suxamethonium: Although some authors have reported a normal response to suxamethonium, others report a generalised myotonic response resulting in difficulties in tracheal intubation and ventilation . The response appears to be dose dependent. Suxamethonium in the myotonic patient has a dual effect. It blocks neuromuscular transmission in the normal manner , but also acts directly on the muscle causing contraction . In addition, the increase in serum potassium concentration after administration of suxamethonium may further contribute to the development of myotonia. Several reports describing relaxation of myotonia after suxamethonium have appeared, but the mechanism is unclear. A typical generalised myotonic response to suxamethonium consists of the rapid development of jaw, abdominal and chest rigidity with arching of the cervical and lumbar spines. Ventilation and intubation may be difficult or impossible for 45 min. Furthermore, because the myotonia is caused by a primary defect of the muscle, nondepolarising neuromuscular blocking drugs do not abolish the generalised contractions. It is therefore recommended that suxamethonium is avoided in myotonic patients. Vecuronium: Nondepolarising neuromuscular blocking agents, when effective, appear to behave normally. Number: 790 The cost of a dose of a drug from societys perspective is equal to the purchase ('acquisition') cost of the drug plus the cost of treating the complications of the drug and the cost of treating any adverse outcomes. Dexter et al have recently analysed the 'true' cost of suxamethonium in this manner In the context of the statement above, the 'true' cost of a dose of suxamethonium, expressed as a proportion of acquisition cost is about: A. Equal to the acquisition cost. B. Ten times the acquisition cost. C. Twenty times the acquisition cost.

235

D. Two hundred times the acquisition cost. E. Five hundred times the acquisition cost. Select the single best answer Correct Answer: D In the report by Dexter et al, the 'true' or 'societal' cost of a drug was estimated using a pharmaco-economic measurement system which included the cost of treating complications and adverse outcomes. Suxamethonium was chosen as the drug for study, and the cost estimate included the cost of treating complications such as malignant hyperpyrexia, anaphylaxis, bradycardia causing cardiac arrest etc. Their estimate of true cost of a single dose of suxamethonium was that it was approximately two hundred times the acquisition cost (USD 0.19 compared to USD 37.00). There is no reason why the technique cannot be applied to any other drug (or therapeutic technique). See: Anesth Analg 2001 Mar;92(3):693-9: Cost identification analysis for succinylcholine. Dexter F, Gan TJ, Naguib M, Lubarsky DA. (Note that there is an arithmetic error in the published abstract of this paper). Number: 792 Since the earliest reports in 1982, there have been more than 24 reported cases of survival after failed attempts at cardio-pulmonary resuscitation. This phenomenon has been variously referred to as "spontaneous return of circulation" or "Lazarus syndrome". %The proportion of patients who survive this experience neurologically intact is about: A. 5%. B. 10%. C. 20%. D. 30% E. 50 Select the single best answer Correct Answer: D At the time of writing, (March 2001) there have been 26 case reports of Lazarus syndrome and 9 of these patients have survived to be neurologically intact. The mechanism of "spontaneous return of the circulation" is believed to be the removal of the effect of 'Auto PEEP' when the resuscitation attempt is abandoned.

236

The message is - If it happens to you it is probably worth re-commencing the resuscitation process! See: Ben-David B, Stonebraker VC, Hershman R, Frost CL, Williams HK. Survival after failed intraoperative resuscitation: a case of "Lazarus syndrome". Anesth Analg. 2001 Mar;92(3):690-2. Number: 809 The Chief Executive Officer of your local private hospital asks you for your advice on cost containment in the Post-Anaesthesia Care Unit (PACU). The strategy which is most likely to be effective is: A. The application of restrictions on the prescription of expensive drugs. B. The aggressive treatment of post-operative nausea and vomiting. C. Scheduling the distribution of admissions (ie.arranging the operating theatre schedule to optimise PACU admission patterns). D. The application of restrictions on the use of sophisticated monitoring equipment. Select the single best answer Correct Answer: C Cost containment and reduction have become major goals in health care. To decrease costs, hospital managers need to know the principal determinants of cost. However, these determinants are not always obvious, despite widespread beliefs. Dexter and Tinker recently analysed the costs of running a PACU and explored the effects of varying different cost inputs on overall running costs. Their principal findings are outlined below: Supplies and medications accounted for only 2% of PACU charges. Personnel costs, which depend on the peak number of patients in the PACU, accounted for almost all PACU costs. If nausea and vomiting could have been eliminated in each patient who suffered this complication, without causing sedation, the total time to discharge for all patients would have been decreased by less than 4.8% (95% confidence interval < 7.3%). Arrival rates to and times to discharge from the PACU followed triangular and log-normal distributions, respectively. Computer simulations, using published times to discharge for drugs with faster recovery, such as propofol, showed that the use of these drugs would only decrease PACU costs if operating rooms were consistently scheduled to run later each day. Such earlier discharge also might be beneficial if used at night, but only if the PACU could close after a single patient leaves. However, reasonably achievable decreases in the times to discharge for all patients undergoing general anesthesia are unlikely to substantively decrease PACU costs. In contrast, arranging an operating room schedule to optimize admission rates would greatly affect the number of PACU nurses needed. They concluded that "Anesthesiologists have little control over PACU economics via choice of anesthetic drugs. The major determinant of PACU costs is the distribution of admissions."

237

See: Anesthesiology Anesthesiology 82:94-101, 1995: Analysis of Strategies to Decrease Postanesthesia Care Unit Costs: Dexter F and Tinker JH. Number: 817 The most effective way to prevent pain on injection of propofol in an adult is to: A. Warm the drug to 37 centigrade before injection. B. Mix ~ 35 mg of lignocaine with the drug before injection. C. Cool the drug to 4 centigrade before injection. D. Inject ~ 35 mg of lignocaine as a 'Bier's Block' ~ 30-120 secs before injection of propofol. E. Inject 10 mg of metoclopramide through the same vein before injection of propofol. Select the single best answer Correct Answer: D A recent meta-analysis has been performed by Picard and Tramer. Their findings were that approximately 70% of all control patients reported some degree of pain or discomfort on injection with propofol alone. In some trials, all controls reported pain. The most effective analgesic method was IV lignocaine, given as a Biers block before the injection of propofol. Of 100 the patients treated with lignocaine 40 mg with a rubber tourniquet at the forearm for 30 to 120 s before the injection of propofol, approximately 60 (NNT 1.6) would not have any pain who would have had pain had they not received lignocaine. See: Picard P. and Tramr MR: Prevention of Pain on Injection with Propofol: A Quantitative Systematic Review Anesth Analg 2000 90: 963-969. Metoclopramide is also a surprisingly effective method for reducing pain on injection. This presumably reflects its structural similarity to the local anaesthetics. See: Pang WW, Mok MS, Chang DP, Huang MH. Local anesthetic effect of tramadol, metoclopramide, and lidocaine following intradermal injection. Reg Anesth Pain Med 1998;23:5803. Liaw WJ, Pang WW, Chang DP, Hwang MH. Pain on injection of propofol: the mitigating influence of metoclopramide using different techniques. Acta Anaesth Scand 1999;43:247. Number: 821 Which of the following drugs may be safely used in a patient with proven Acute Intermittent Porphyria? 1. Aminocaproic Acid. 2. Propofol. 3. Morphine. 4. Metformin.

238

A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct Correct Answer: E Patients with the acute forms of porphyrias are at risk of developing life-threatening attacks of porphyria on exposure to certain commonly prescribed drugs. All the acute porphyrias are inherited as mendelian autosomal dominants, and each may be linked to lowered activity of one of the enzymes of the haem biosynthetic pathway: in Acute Intermittent Porphyria - a decrease in porphobilinogen deaminase; in Variegate Porphyria - a decrease in protoporphyrinogen oxidase; and in Hereditary Coproporphyria - a decrease in coproporphyrinogen oxidase. My suggestion is that you specifically confirm the safety (or otherwise) of every drug you wish to use in any patient with the disease. See the excellent review by James and Hift entitled 'Porphyrias' in Br J Anaesth 2000 Jul;85(1):143-53 A couple of web-sites which may help you are: The Canadian Porphyria Foundation at http://www.cpf-inc.ca and The University of Queensland Porphyria Research Unit at http://www.uq.edu.au/porphyria/ Number: 834 With regard to Xenon: 1. It has a MAC of about 70%. 2. It is a potent analgesic. 3. It is an odourless gas. 4. It has a blood/gas partition coefficient similar to nitrous oxide. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct Correct Answer: A See: Dingley J, Ivanova-Stoilova TM, Grundler S, Wall T. Xenon: recent developments. Anaesthesia. 1999 Apr;54(4):335-46. Xenon is a colourless, odourless, tasteless monatomic gas. It has an atomic number of 54 and a molecular weight of 131.3. It has nine stable isotopes and many artificial isotopes. It freezes at -111.9 C and boils at -107.1 C. Xenon is four times as dense as air and 3.4 times as dense

239

as N2O. It is nonflammable and does not support combustion. Its oil/water solubility coefficient is 20.0 and it has the highest coefficient of any of the noble gases, being the only one with anaesthetic properties at atmospheric pressure. It has an extremely low blood/gas partition coefficient of 0.14, even compared to nitrous oxide (0.47) or sevoflurane (0.65). Xenon diffuses freely through rubber and there can be significant losses of gas by this route during anaesthesia. It has a MAC of about 70% and is a good analgesic. Number: 842 The force required during the application of cricoid pressure is in the range: A. < 20 Newtons. B. 20 - 45 Newtons. C. 45 - 60 Newtons. D. 60 - 85 Newtons. E. > 85 Newtons. Select the single best answer Correct Answer: B The force required during the application of cricoid pressure appears to be in the range of 20 45 Newtons. See: 1. Wraight WJ, Chamney AR, Howells TH. The determination of an effective cricoid pressure. Anaesthesia. 1983 May;38(5):461-6. 2. Skinner HJ, Bedforth NM, Girling KJ, Mahajan RP. Effect of cricoid pressure on gastrooesophageal reflux in awake subjects. Anaesthesia. 1999 Aug;54(8):798-800. 3. Vanner RG, Pryle BJ. Regurgitation and oesophageal rupture with cricoid pressure: a cadaver study. Anaesthesia. 1992 Sep;47(9):732-5. Number: 843 A force of 30 Newtons applied to the cricoid region is believed to be effective in preventing regurgitation when intra-oesophageal pressure rises to: A. 20 mm Hg. B. 40 mm Hg. C. 60 mm Hg. D. 80 mm Hg. E. 100 mm Hg. Select the single best answer Correct Answer: B

240

See: 1. Wraight WJ, Chamney AR, Howells TH. The determination of an effective cricoid pressure. Anaesthesia. 1983 May;38(5):461-6. 2. Skinner HJ, Bedforth NM, Girling KJ, Mahajan RP. Effect of cricoid pressure on gastrooesophageal reflux in awake subjects. Anaesthesia. 1999 Aug;54(8):798-800. 3. Vanner RG, Pryle BJ. Regurgitation and oesophageal rupture with cricoid pressure: a cadaver study. Anaesthesia. 1992 Sep;47(9):732-5. The latter authors reported that "The efficacy of cricoid pressure was studied in 10 adult cadavers. The oesophageal pressure that would result in regurgitation during measured values of cricoid pressure was determined. Oesophageal pressure, recorded by a 2 mm diameter oesophageal tube, was increased by oesophageal distension with saline, and incremental levels of cricoid force, 20, 30 and 40 Newtons, were applied with a cricoid yoke. With each 10 Newton increment of cricoid force there was a significant rise in the oesophageal pressure required to provoke regurgitation (p < 0.01). Thirty Newtons of cricoid force prevented regurgitation of saline in all cadavers with oesophageal pressures of up to 40 mmHg. Rupture of the oesophagus occurred in three cadavers: one at 30 and two at 40 Newtons of cricoid force, but there was no rupture at 20 Newtons of cricoid force. In the other seven cadavers oesophageal pressures were also studied with a 4.6 mm diameter (14 FG) oesophageal tube, which did not reduce the efficacy of cricoid pressure in preventing regurgitation." See also the report by Tournadre et al on the effect of cricoid force on lower oesophageal sphincter tone. Tournadre JP, Chassard D, Berrada KR, Bouletreau P. Cricoid cartilage pressure decreases lower esophageal sphincter tone. Anesthesiology 1997; 86: 79. Note the trade offs, - low range cricoid force is less effective in preventing regurgitation and has a disproportionately large effect in reducing lower oesophageal sphincter tone, whereas higher forces are more effective, but appear to increase the risk of oesophageal rupture. Number: 845 The incidence of pulmonary aspiration in the perioperative period in adults who have undergone general anaesthesia is approximately: A. 1 in a 100. B. 3 in a 1000. C. 1 in a 1000. D. 3 in 10000. E. 1 in 10000. Select the single best answer See: Ng A, Smith G: Anesth Analg 2001;93:494-513. Gastroesophageal Reflux and Aspiration of Gastric Contents in Anesthetic Practice. According to the authors of this excellent review: "Examination of the literature suggests that the incidence of pulmonary aspiration in the perioperative period is relatively infrequent and that there has been little change in the last few years. In 1986, a study of Scandinavian Teaching Hospitals suggested that the incidence of aspiration varied between 0.7 and 4.7 per

241

10,000 general anesthetics. A report published one decade later suggested that the incidence was 2.9 per 10,000 at a Norwegian hospital. Studies from the Mayo Clinic indicated that the incidence of aspiration is similar in adults (3.1 per 10,000) and children (3.8 per 10,000) although another study from the United States suggested that the incidence of aspiration in children was more frequent (10.2 per 10,000)." Number: 847 A 70 year old man is scheduled for elective repair of an inguinal hernia under general anaesthesia. Which of the following screening tests performed as part of the pre-operative assessment are most likely to be predictive of an adverse perioperative outcome? A. Haemoglobin < 10 g/ dL. B. Creatinine > 1.5 mg/dL (~0.13 mmol/L). C. Sodium > 147 mmol/L. D. Potassium < 3.5 mmol/L. E. Glucose > 200 mg/dL (~11 mmol/L). Select the single best answer Correct Answer: C All of these variables are associated with a higher than expected incidence of adverse perioperative outcomes - with a serum sodium of more than 147 mmol/L being the most powerful predictor. However, none of them are particularly useful or cost-effective investigations if used routinely. Refer to the important paper by Dzankic et al and the editorial by Fleisher in the same issue of Anesthesia & Analgesia. Both these groups of authors agree that "routine preoperative laboratory testing for hemoglobin, creatinine, glucose, and electrolytes based on age alone may not be indicated in geriatric patients." See: Dzankic S, Pastor D, Gonzalez C, Leung JM. The prevalence and predictive value of abnormal preoperative laboratory tests in elderly surgical patients. Anesth Analg. 2001 Aug;93(2):301-8. Fleisher LA. Routine laboratory testing in the elderly: is it indicated? Anesth Analg. 2001 Aug;93(2):249-50 Number: 880 Professional document P24 of the Australia and New Zealand College of Anaesthetists outlines the standards required for the safe conduct of sedation for endoscopy. Which of the following drugs is NOT required to be immediately available in an area where patients undergo such sedation?

242

A. Dextrose 50% B. Lignocaine C. Flumazenil D. Naloxone E. Calcium chloride Select the single best answer Correct Answer: E The document requires that immediately available emergency drugs should include at least: adrenaline, atropine, dextrose 50%, lignocaine, flumazenil and naloxone. Number: 881 Which of the following drugs is contraindicated in a patient with known malignant hyperpyrexia (MH)? A. Droperidol. B. Propofol. C. Bupivacaine. D. Ketamine. E. Chlorpromazine. Select the single best answer Correct Answer: E Droperidol, propofol, bupivacaine and ketamine can all be safely used in patients with MH. In a recent review, Wappler commented that "Further evaluation is required about the potency of certain psychotropic substances in triggering symptoms of MH, e.g. phenothiazines, monoamine oxidase inhibitors and tricyclic antidepressants. These substances should not be given to MHS individuals, as malignant neuroleptic syndrome might be induced, which presents with similar symptoms to MH (fever, muscle rigidity and tachycardia). This is caused by a deregulation of central dopamine receptors as opposed to MH where peripheral metabolism is deranged. However, there have been no reports of MH associated with usage of these drugs outside anaesthetic practice. Furthermore, no case of MH-like symptoms after phenothiazines, monoamine oxidase inhibitors or tricyclic antidepressants has been verified by an in vitro contracture test on the patient concerned." See: Wappler F. Malignant hyperthermia. Eur J Anaesthesiol. 2001 Oct;18(10):632-52 and Hopkins PM. Malignant hyperthermia: advances in clinical management and diagnosis. Br J Anaesth. 2000 Jul;85(1):118-28. Number: 882

243

An In Vitro Contracture Test (IVCT) on a muscle specimen obtained from a patient with suspected malignant hyperpyrexia (MH) is being conducted. Preparation and processing for IVCT are standardised according to the protocol of the European MH Group. Which of the following agents should the muscle be exposed to? 1. Caffeine. 2. Suxamethonium. 3. Halothane. 4. Dibucaine A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct Correct Answer: B "The muscle sample is split into separate bundles and spread out between two electrodes. It is then stimulated using a supramaximal current and the resulting muscle twitches measured. Only viable muscle preparations with a twitch response greater than 10 mN are used for IVCT. After equilibration, halothane is introduced into the system using a vapouriser, in increasing concentrations. The same procedure is carried out on a second muscle bundle but using cumulative concentrations of caffeine instead of halothane. Both tests are repeated with fresh muscle samples." (Wappler F. Malignant hyperthermia. Eur J Anaesthesiol. 2001 Oct;18(10):632-52). See also: Hopkins PM. Malignant hyperthermia: advances in clinical management and diagnosis. Br J Anaesth. 2000 Jul;85(1):118-28. Number: 883 Which of the following agents is a known trigger for Malignant Hyperthermia (MH) in a susceptible patient? A. Droperidol. B. Sevoflurane. C. Ketamine. D. Pancuronium. E. Ondansetron Select the single best answer Correct Answer: B

244

Although case reports of MH associated with the use of sevoflurane are few, there is little doubt that all volatile anaesthetics (including halothane, enflurane, isoflurane, sevoflurane and desflurane) can trigger MH. Number: 884 The incidence of Malignant Hyperthermia Susceptibility (MHS) in an unselected population of children and adolescents is in the order of: A. 1:1000. B. 1:5000. C. 1:15000. D. 1:50000. E. 1:100000. Select the single best answer Correct Answer: C The incidence of MHS is estimated to be 1:15 000 for children and adolescents and 1:50 000 150 000 for adults in North America and Europe. See: Gronert GA, Antognini JF, Pessah IN. Malignant Hyperthermia. In: Miller RD, eds. Anesthesia, 5th edn. New York: Churchill Livingstone, 2000: 10331052 Number: 885 Which of the following agents is LEAST likely to precipitate contracture in a muscle specimen obtained from a patient susceptible to Malignant Hyperthermia (MH)? A. Caffeine. B. Isoflurane. C. 4-chloro-m-cresol. D. Ryanodine. Select the single best answer Correct Answer: E Caffeine (and halothane) are used as triggering agents in the In Vitro Contracture Test protocol of the European MH Group. Isoflurane is the second most potent of the volatile agents at inducing contracture and there are numerous case reports of MH associated with the use of this drug. 4-chloro-m-cresol and ryanodine are emerging as important trigger agents in patients with equivocal responses to caffeine or halothane. Haloperidol may augment the response to trigger agents but is still probably safe for use in patients with MH.

245

Number: 887 A 50 year old woman, is scheduled for an emergency ovarian cystectomy. She reports that she regularly takes the herbal medicine Ginseng (Panax Ginseng) but is otherwise well. The patient is at increased risk of: 1. Intra-operative cardiac arrhythmias. 2. Intra-operative hypoglycaemia. 3. Prolongation of the effects of non-depolarising muscle relaxants. 4. Peri-operative bleeding. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct Correct Answer: C See the systematic review by: Ang-Lee MK, Moss J, Yuan CS. Herbal medicines and perioperative care. JAMA. 2001 Jul 11;286(2):208-16. Ginseng usage is associated with an increased incidence of hypoglycaemia and peri-operative bleeding. The use of garlic, ginger and ginko has also been associated with an increase in peri-operative bleeding. (It seems that herbs that begin with 'G' are anti-coagulant!) Number: 889 The incidence of persistent ulnar neuropathy complicating general anaesthesia in patients undergoing non-cardiac surgery is about: A. 1:100. B. 1:250. C. 1:2500. D. 1:5000. E. 1:10,000. Select the single best answer Correct Answer: C The definitive study is that by Warner et al who reviewed this complication in a study of 1,129,692 procedures undertaken at the Mayo clinic and found an incidence of 1:2729 cases.

246

However, it should be noted that the incidence of transient neuropathy (duration less than 3 months) is considerably higher than this - probably in the order of 1:250. Warner MA, Warner ME, Martin JT. Ulnar neuropathy. Incidence, outcome, and risk factors in sedated or anesthetized patients. Anesthesiology. 1994 Dec;81(6):1332-40. Warner MA, Warner DO, Matsumoto JY, Harper CM, Schroeder DR, Maxson PM. Ulnar neuropathy in surgical patients. Anesthesiology. 1999 Jan;90(1):54-9. Number: 890 A patient sustains a mixed motor and sensory ulnar neuropathy following the repair of an abdominal aortic aneurysm under general anaesthesia. Three months post-operatively the patient still has signs of the neuropathy. The likelihood of a complete recovery from this injury is about: A. 10% B. 20% C. 30% D. 40% E. 50% Select the single best answer Correct Answer: E Warner et al found that in a group of the 382 patients who sustained such an injury, "53% had regained complete motor function and sensation and were asymptomatic. An additional six percent had regained complete motor function and sensation but still had pain as a symptom. The remaining 41% of the patients had persistent deficits with or without pain at 1 yr. In general, pain was perceived in the ulnar nerve distribution; however, 23% of patients with persistent pain for more than 1 yr described intermittent episodes of generalized forearm and hand discomfort or aching. Early identification of ulnar neuropathy symptoms in these patients did not appear to result in a greater chance of improvement for these symptoms." See: Warner MA, Warner ME, Martin JT. Ulnar neuropathy. Incidence, outcome, and risk factors in sedated or anesthetized patients. Anesthesiology. 1994 Dec;81(6):1332-40. Number: 914 With regard to the relationship between hypothermia and the Minimum Alveolar Anaesthetic Concentration (MAC) of the volatile agents it is believed that MAC: A. Increases by ~5% per degrees centigrade decrease. B. Does not vary with body temperature. C. Decreases by ~5% per degrees centigrade decrease. D. Decreases by ~10% per degrees centigrade decrease. E. Decreases unpredictably with body temperature Select the single best answer

247

Correct Answer: C Surprsingly little is known about this subject - with most of the work having been undertaken in animals. According to Eger: "In animals, and presumably humans, MAC for potent inhaled anesthetics decreases with decreasing body temperature by approximately 4% to 5% per degrees centigrade decrease, doing so in a rectilinear manner, with complete elimination of the requirement for anesthesia at 20C. However, this relationship does not extend to N2O; MAC for N2O does not change materially with decreasing temperature. " See: Eger EI 2nd. Age, minimum alveolar anesthetic concentration, and minimum alveolar anesthetic concentration-awake. Anesth Analg. 2001 Oct;93(4):947-53. Number: 919 Recognised complications of the use of 6% Hydroxy Ethyl Starch (Hetastarch) include: 1. Suppression of the pituitary-adrenal axis. 2. Pruritus. 3. Hypercalcaemia 4. Increased perioperative bleeding. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct Correct Answer: C There is no suggestion that hetastarch interferes with the integrity of the pituitary-adrenal axis. Delayed pruritus is well recognised. - Kimme et al found that: "After Hetastarch treatment, we observed pruritus in 54% of the patients." and also noted that in other investigations the incidence has been found to vary between 20% and 64%. 6% hetastarch is calcium-free and, if anything, has a tendency to cause hypocalcaemia. Hetastarch inhibits platelet function by reducing the availability of the functional receptor for fibrinogen on the platelet surface. It may also impair coagulation by prolonging the partial thromboplastin times and decreasing factor VIII activity and fibrinogen levels. See: Kimme P, Jannsen B, Ledin T, Gupta A, Vegfors M. High incidence of pruritus after large doses of hydroxyethyl starch (HES) infusions. Acta Anaesthesiol Scand. 2001 Jul;45(6):686-9.

248

Wilkes MM, Navickis RJ, Sibbald WJ. Ann Thorac Surg 2001 Aug;72(2):527-33; Albumin versus hydroxyethyl starch in cardiopulmonary bypass surgery: a meta-analysis of postoperative bleeding Number: 930 The most common major complication of blood transfusion in the US and western Europe is: A. Transmission of Hepatitis A. B. Transmission of Hepatitis B. C. Transmission of Hepatitis C. D. Transmission of Human Immunodeficiency Virus (HIV). E. ABO incompatibility as a result of transfusion error. Select the single best answer Correct Answer: E See the case report and review by Krombach et al. According to these authors, "Human error has long been identified as a major source of ABO incompatibility-related transfusion fatalities. However, reports on this issue in the anesthesiology literature are sparse, and many anesthesiologists may be unaware that they are key players, as at least 50% of all blood units, by estimate, are transfused by anesthesiologists. In the United States, the frequency of avoidable transfusion fatalities attributable to misidentification of the pretransfusion blood sample, the blood unit, or the recipient has been reported to range from 1 per 600,000 to 1 per 800,000 transfusions. The estimated incidence of nonfatal transfusion errors in the United States ranges from 1 in 12,000 to 1 in 19,000 transfusions. The United Kingdoms Serious Hazards of Transfusion (SHOT) group, which tracks adverse events on a voluntary basis and currently covers more than 90% of all red cell usage in the United Kingdom, recently reported an error incidence of 1 in 16,000 (335 errors per 5.5 million units of red blood cells transfused between 1996 and 1999). Transfusion errors accounted for 54% of all transfusion-related complications, and ABO incompatibility as a possible life-threatening condition was reported 97 times, leading to 4 deaths (1 per 1,400,000 transfusions) and 29 cases of immediate major morbidity (1 per 200,000 transfusions). By contrast, the SHOT initiative recorded only 19 cases of confirmed transfusion-transmitted infection (1 per 300,000 transfusions), including four cases of hepatitis B, three cases of hepatitis C, and one case of HIV. Eleven cases (one hepatitis A infection, one malaria, and nine bacteremias) were attributable to infections for which no testing of donations is performed. In the United States, the aggregated risk of transmission of HIV, human T-cell lymphotropic virus, hepatitis C virus, and hepatitis B virus is 1 per 34,000 blood units transfused, or less than half the risk of transfusion error (1 in 12,000 to 1 in 19,000 transfusions). On the basis of current estimates of the risks of transfusion-transmitted infections and transfusion errors, an anesthesiologist of a major general hospital or trauma center who transfuses an average 500 U of packed red cells per year can be estimated to transmit HIV infection once in 1000 years, hepatitis C once in 200 years, hepatitis B once in 120 years, and

249

to administer blood to the wrong recipient once in 30 years, or once within his professional lifetime. In a university hospital with an annual volume of 20,000 blood transfusions or more, transfusion error is likely to occur once every year. " References: Krombach J, Kampe S, Gathof BS, Diefenbach C, Kasper SM. Human error: the persisting risk of blood transfusion: a report of five cases. Anesth Analg. 2002 Jan;94(1):154-6. Williamson L, Cohen H, Love E, Jones H, Todd A, Soldan K. The Serious Hazards of Transfusion (SHOT) initiative: the UK approach to haemovigilance. Vox Sang 2000;78 Suppl 2:291-5 Number: 933 When used as an anti-emetic for prophylaxis of Post-Operative Nausea and Vomiting (PONV), a single dose of dexamethasone: 1. Has no clinically relevant side-effects if administered to an otherwise healthy patient. 2. Exerts its effects for at least 12 hours. 3. Is more effective if administered with a 5HT3 antagonist. 4. Should be given to an adult in a dose of 0.5 mg/kg. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct Correct Answer: A Readers are referred to the excellent systematic review by Henzi et al. The drug appears to have no clinically relevant side-effects when used in otherwise healthy patients. It is more effective if used in combination with a 5HT3 antagonist and exerts its effects for about 24 hours. The appropriate dose in an adult seems to be either 8 or possibly 16 mgs. In their review, Henzi et al concluded that "In the surgical setting, a single prophylactic dose of dexamethasone is antiemetic compared with placebo without evidence of any clinically relevant toxicity in otherwise healthy patients. Late (i.e., up to 24 hours) efficacy seems to be most pronounced. It is likely that the best prophylaxis of PONV currently available is achieved by combining dexamethasone with a 5-HT3 receptor antagonist." References: Henzi I, Walder B, Tramer MR. Dexamethasone for the prevention of postoperative nausea and vomiting: a quantitative systematic review. Anesth Analg. 2000 Jan;90(1):186-94.

250

Number: 936 Which of the following drugs are believed to be effective in the treatment of post-operative shivering? 1. Clonidine. 2. Doxapram. 3. Pethidine. 4. Ketanserin. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct

Correct Answer: E All of these drugs are effective forms of treatment. The appropriate doses in an adult are: Clonidine 150 micrograms, doxapram 100 mg, pethidine 25 mg and ketanserin 10 mg. The topic of post-operative shivering has recently been subject to systematic review by Kranke et al. These authors noted that "Shivering, as nausea or vomiting, never becomes chronic and it is unlikely to kill a patient. However, in shivering postoperative patients, left ventricular systolic work index and oxygen consumption index may be increased (54). It is, therefore, encouraging that some simple and inexpensive interventions are effective in the treatment of this adverse effect of anesthesia and surgery. Two shivering patients need to be treated with meperidine 25 mg, clonidine 150 g, or doxapram 100 mg for one to stop shivering within five minutes who would have continued to shiver had they all received a placebo. This degree of efficacy relates to the "average" shivering adult patient in the postoperative period." See also the recent study Bhatnagar (who was investigating the effect of tramadol on shivering) - who observed that "Although the aetiology of postoperative shivering is inadequately understood, various risk factors have been suggested. These include hypothermia, stress, uncontrolled pain, uninhibited spinal reflexes and decreased sympathetic activity. Many drugs have been used to treat shivering, including opioids, doxapram, tramadol, ketanserin, clonidine, propofol, physostigmine and nefopam, with opioids being the most extensively evaluated. Amongst the opioids, pethidine has been found to be most efficacious. Evidence suggests that kappa-opioid receptors play an important role in the modulation of postoperative shivering. This explains the greater efficacy of pethidine compared with equi-analgesic doses of mu-receptor opioid agonists such as morphine, fentanyl, alfentanil and sufentanil." See: Kranke P, Eberhart LH, Roewer N, Tramer MR. Pharmacological Treatment of Postoperative Shivering: A Quantitative Systematic Review of Randomized Controlled Trials. Anesth Analg. 2002 Feb;94(2):453-460.

251

Bhatnagar S, Saxena A, Kannan TR, Punj J, Panigrahi M, Mishra S. Tramadol for postoperative shivering: a double-blind comparison with pethidine. Anaesth Intensive Care. 2001 Apr;29(2):149-54. Number: 940 Glucocorticoid cover may be required in patients with the following diseases: 1. Sarcoidosis. 2. Polyarteritis nodosa. 3. Systemic lupus erythematosus 4. Thrombocytopenic purpura. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct Correct Answer: E Short or long term therapy with steroids may be part of the management of all of these diseases. Glucocorticoid cover is required to replace the 'basal' level of cortisol if the patient's normal oral intake is disrupted, and to increase plasma cortisol levels to a level consistent with the expected 'stress' response to surgery. The magnitude of the response correlates to a degree with the magnitude of injury from trauma or the extent of surgery, inflammation etc. In general, after surgery, plasma cortisol increases 5-6x within 6 hours postoperatively, with levels falling by 24 hours unless the stress response continues. ROGERS, M.C ET AL (EDS); Principles and Practice of Anesthesiology, Mosby, 1993, pp 68-70, 1584-85. Jabbour SA. Steroids and the surgical patient. Med Clin North Am. 2001 Sep;85(5):1311-7. Udelsman R, et al. Adaptation during surgical stress. A reevaluation of the role of glucocorticoids. J Clin Invest. 1986 Apr;77(4):1377-81. Number: 947 Which of the following manoeuvres were included in Sellick's original description of cricoid pressure? 1. Extending the head 2. Applying one hand behind the neck to optimize traction of the oesophagus against the vertebral body of C5 3. Applying cricoid pressure with the thumb and the index finger 4. Applying pressure with the loss of the lash reflex.

252

A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct Correct Answer: B In Sellick's original description, the stomach was emptied first with an oro-gastric tube and the patient was preoxygenated. The patient lies supine with slight head down, so that if active vomiting occurs, gravity will direct it away from the airway. The head was extended in the tonsillectomy position. This increases the anterior convexity of the cervical spine, stretches the oesophagus, and prevents lateral displacement when pressure is applied to the cricoid cartilage. Before induction, the cricoid is palpated to establish landmarks by the assistant. It is lightly held whilst the patient is awake. As anaesthesia begins, moderate pressure is exerted with the thumb and second finger. As soon as consciousness is lost, firm pressure is applied and maintained until the cuff of the endotracheal tube is inflated. Sellick demonstrated that this manoeuvre could prevent passive regurgitation of contrast material from the stomach up to a pressure of 100 cm H2O. References SELLICK, B.A;" Cricoid pressure to control regurgitation of stomach contents during induction of anaesthesia", The Lancet, August 19th, 1961, pp 404-6. Number: 962 A 50 year old man with chronic renal failure (CRF) presents for creation of an arterio-venous fistula. He is receiving no drugs which are known to interfere with coagulation. His coagulation profile is reported as follows: Bleeding time 18 mins (3 - 5 mins). Platelet count: 110 (150 - 350 K/ml). APTT: 30 secs (30 - 40 secs). PT: 15 secs (11 - 14 secs). In this context, the most appropriate management of his bleeding diathesis is to: A. Transfuse 6 units of platelets immediately before surgery. B. Administer 50 mg of conjugated estrogen 1 hour before surgery. C. Transfuse 2 units of cryoprecipitate immediately before surgery. D. Administer DDAVP 0.3 mcg/kg immediately before surgery. E. Proceed with surgery as planned. Select the single best answer Correct Answer: D

253

There seems little doubt that the primary disorder of coagulation in CRF relates to platelet dysfunction, although the exact mechanism remains obscure. In this man, this is manifest as marked prolongation of his bleeding time (BT). Both the administration of a conjugated estrogen (such as 'Premarin') and DDAVP have been shown to reduce the likelihood of bleeding in the uremic patient, but the former requires hours (if not days) to achieve its maximal effect. The administration of a blood product such as platelets (or cryoprecipitate) - with its attendant risks, is probably not justified in this situation. Similarly, to proceed with surgery in the face of such a marked prolongation of the BT would be foolhardy - given the low morbidity associated with the use of DDAVP. An online review of coagulation has been recently publsihed by Triplett. With regard to the bleeding time, Triplett remarks "The BT has also been widely utilized as a means of accessing primary hemostatic response (platelet-injured vessel wall interaction). Unfortunately, the BT is relatively insensitive and, in many cases, nonspecific with respect to identifying abnormalities of primary hemostasis . The major variables are the inherent differences between individuals performing the BT and the various BT devices. The introduction of BT devices designed to decrease the variability of the depth of the induced wound was a major advance over the traditional Ivy BT test. Despite the introduction of the newer devices, there remains substantial variability between individuals performing BTs as well as the possible complication of scar formation at the test site (typically, the anteriorlateral aspect of the arm). There are several variables in the BT in addition to the technical aspects of performing the test. BTs tend to be longer in females and decrease with aging. One cosmetic complication frequently seen in elderly patients who have experienced extensive sun exposure is the formation of a somewhat symmetrical subepidermal hemorrhage, which is attributable to blood dissecting into the subepidermis as opposed to exiting onto the surface of the skin at the site of the BT incision. The BT is also affected by the hematocrit and platelet mass. Patients with chronic renal disease and decreased hematocrit often have a prolonged BT. Increasing the hematocrit to >30% often will correct a prolonged BT in a patient with chronic renal disease Number: 967 Which of the following is true of penicillin allergy? A. It occurs in 20% of hospitalized patients after exposure. B. It occurs more commonly following intravenous than intramuscular administration. C. Cross reactivity with cephalosporins is high. D. Premedication with antihistamines and steroids reduces the severity of an anaphylactic reaction. Select the single best answer

254

Correct Answer: B 10-20% of hospitalized patients report an allergy to penicillin. Between 1-10% of all patients treated with penicillins develop reaction to them. IgE mediated reactions are more common after intravenous administration. Initial reports suggested a cross reactivity with cephalosporins. This is felt to be overestimated. There are no figures to describe the actual incidence which is felt to be small, however, true anaphylactic cross reactivity has occurred. Premedication and 'test' doses have not been shown to reduce the severity of severe reactions The majority of reactions involve rashes. All four types of hypersensitivity reactions described by Gell & Coombs have been seen with penicillin. In addition, some reactions have an obscure pathogenesis and have been labelled as idiopathic. Among these are the common maculopapular rash, Stevens-Johnson's syndrome, exfoliative dermatitis, and toxic epidermal necrolysis. Ampicillin induce rashes with a greater frequency than penicillin. Pseudoanaphylactic reactions have been observed after IMI injections of procaine penicillin and are most likely caused by a combination of toxic and embolic phenomena from procaine Anaphylactic reactions occur in 0.004-0.015% of treatment cases. Anaphylactic reactions are mediated by IgE antibodies and include urticaria, laryngospasm, bronchospasm, and cardiovascular collapse. The most effective means of prevention is by identifying those who are destined to have a reaction and withhold the drug from them. Factors which are associated with increased risk are: (1) Second or more exposure. Allergic reactions can occur on initial exposure, however, it is more common to find a patient who has tolerated the penicillin on initial exposure and developed a reaction on subsequent exposure. Presumably sensitization has already occurred when the patient reacts to the initial exposure. Non-therapeutic exposure to environmental and occupational sources may account for this; for example, in utero exposure or occult sources of penicillin in foods. Cross sensitization with other drugs is another source; for example, cephalosporin sensitivity following previous penicillin allergy. (2) Age.Young and middle aged adults are most likely to develop penicillin allergy. (3) Route of administration. Adverse reactions are more common after IV than IMI or Oral administration. (4) History of allergy. A patient with a history of an earlier reaction to penicillin has a 6 fold risk of experiencing a reaction on subsequent exposure. However, the most serious and fatal reactions occur in individuals with no history of previous reaction. Occult sensitization as described above may have occurred. A history of allergy in general appears to have no bearing on a patients likelihood to react to skin tests with penicillin reagents. (5) Skin test reactions. 10-20% of hospitalized patients will disclose a history of allergic reaction to penicillin. The most useful single piece of information in assessing an individuals risk of experiencing an immediate IgE mediated reaction is the skin test. Greatest sensitivity is found with tests including " minor " determinants (penicilloyl-polylysine reagent or minor determinant mixtures) as compared with those testing " major " determinants (RAST). Approximately 1% of patients with negative skin tests will develop severe reactions compared with 50-70% who will develop them after positive skin tests.

255

References SHEFFER, A.;" Anaphylaxis, continuing medical education ", The Journal Of Allergy and Clinical Immunology, Nov 1986, pp 1051-2. FISHER, M.;" The Prevention of Second Anaphylactoid Reactions To Anaesthetic Drugs ", Anaesth Intens Care, 9, pp 242-6, 1981. ROGERS, M.C ET AL (EDS); Principles and Practice of Anesthesiology, Mosby, 1993, pp 2467-70. Number: 1003 An otherwise fit, 60kg, 25 year old, asthmatic patient requires an urgent appendicectomy. The patient uses a salbutamol inhaler frequently, but is otherwise on no regular medication. Following a rapid-sequence induction with 300 mg of thiopentone and l00 mg of suxamethonium, the patient is noted to have a sharply upward sloping phase 3 on the capnograph trace. Breath sounds are diminished bilaterally, but no wheezes are heard. Peak inspiratory pressures are 55 cm H2O and the pulse oximeter reads 90% with an FiO2 of 0.98. The most appropriate next step in management is: A. Hand-ventilation with a high concentration of volatile anaesthetic. B. The administration of a further 120 mg of thiopentone. C. The administration of a non-depolarising neuromuscular blockade to facilitate ventilation. D. The administration of aminophylline 300 mg intravenously and initiation of a maintenance infusion. E. The institution of 10 cmH2O positive end-expiratory pressure. Select the single best answer Correct Answer: A Hand-ventilation with a high concentration of volatile anaesthetic (?particularly sevoflurane) is the most appropriate initial response to a high airway resistance. See, for example: Rooke GA, Choi JH, Bishop MJ. The effect of isoflurane, halothane, sevoflurane, and thiopental / nitrous oxide on respiratory system resistance after tracheal intubation. Anesthesiology. 1997 Jun;86(6):1294-9. The administration of a further 120 mg of thiopentone is very unlikely to be effective. In view of the likely effect of 7 mgs/kg of thiopentone on the cardiac output, it could well make the hypoxia worse. Similarly, the administration of a non-depolarising neuromuscular blockade to facilitate ventilation in this situation is unlikely to be of any practical use, although relaxants may be indicated as part of a hypoventilation strategy in the therapy of acute, severe asthma. The role of theophylline derivatives in asthma is debatable, but they are certainly not first line therapy. See, for example: Beveridge RC, Grunfeld AF, Hodder RV, Verbeek PR. Guidelines for the emergency management of asthma in adults. CAEP/CTS Asthma Advisory

256

Committee. Canadian Association of Emergency Physicians and the Canadian Thoracic Society. The role of PEEP in asthma is controversial. Number: 1009 Which of the following may be associated with hyperthermia during anaesthesia. 1. Phaeochromocytoma. 2. Thyrotoxicosis. 3. Osteogenesis Imperfecta. 4. Neuroleptic Malignant Syndrome. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct

Correct Answer: E Hyperthermia in the anaesthetised patient may be secondary to : 1. Iatrogenic causes 2. Coexisting diseases - Phaeochromocytoma - Thyrotoxicosis - Osteogenesis imperfecta - Riley-Day syndrome - CNS pathology - Sepsis - Parkinson's Disease 3. Drugs - Malignant Hyperthermia - Neuroleptic Malignant Syndrome - Central Anticholinergic Syndrome - 'Tyramine-like' response to MAOI's 1. Iatrogenic-active warming, heated humidifiers, non-permeable drapes. Application of tourniquets for prolonged periods of time have been reported to induce hyperthermia. The mechanism is felt to be release of catecholamines. Injection of A-V malformation with sclerosing solutions may increase temperature for reasons not understood. 2. Secondary to diseases - Phaeochromocytoma secondary to catecholamine release. - Thyrotoxicosis and thyroid storm. Thyroid storm presents with hypertension, hyperthermia and tachycardia, but unlike MH, muscle rigidity and acidosis are unusual. Clinical observation indicates that thyroid gland surgery causes mild hyperthermia, perhaps 257

because of release of thyroid hormone with manipulation of the gland. The mechanism is Na/K ATPase mediated in contrast to MH in which intracellular Ca is elevated Alternatively, the increased temperature may occur independently, secondary to inadequate heat dissipation from a small operative site. - Osteogenesis Imperfecta-Hyperthermia occurs during anaesthesia in these patients. Although a few episodes of true MH have been reported in this population, in many cases clinical and laboratory testing reveal that MH was mistakenly diagnosed. - CNS dysfunction-Status epilepticus is associated with hyperthermia due to increased muscle activity. " Central " or " neurogenic " hyperthermia is associated with brainstem lesions. Patients who experience hypoxic encephalopathy characteristically develop hyperthermia. This may manifest with coma, seizures and abnormal posturing post resuscitation from cardiac arrest and differentiation from MH may be difficult. - Bacteremia/Sepsis- Body temperature characteristically falls when febrile patients are anaesthetized. However, hyperthermia recurrs after surgery, characterized by rigors and intense peripheral vasoconstriction. Bacteremia may be induced by surgical manipulation, leading to postoperative hyperthermia. Appendicectomy constitutes a common scenario for this occurrence , with fever engendered by the release of pyrogens consequent to handling of the septic organ. Surgery for head trauma especially when the oral cavity is disrupted is another example. - Riley-Day Syndrome-This syndrome involves a deficiency of dopamine B-hydroxylase. People with this exhibit profound instability of the autonomic nervous system with a wide variation in blood pressure, heart rate, and body temperature apparently unrelated to temperature. Parkinson's Disease. 3. Drug induced - Malignant Hyperthermia. - Neuroleptic Malignant Syndrome-This is characterized by hyperthermia, muscle rigidity, rhabdomyolysis, arrhythmia, acidosis and death. It is precipitated by haloperidol alone, or with phenothiazines, or occasionally with antidepressants. Despite the clinical similarity to MH, the mechanism is different. Most believe that NMS results from blockade of dopamine receptors in the CNS. The dopamine agonist, bromocriptine is one of the drugs effective in treatment. - Central anticholinergic syndrome - MAO inhibitors-Either alone or in association with pethidine or indirect acting sympathomimetic agents. BENUMOF, J.L & SAIDMAN,L.J; Anesthesia and Postoperative Complications, Mosby, 1991, pp 340-43. Number: 1010

258

Which of the following is / are specifically relevant in a patient with Ankylosing Spondylitis due to undergo anaesthesia ? 1. Aortic incompetence may exist. 2. Reduced lung compliance may make GA hazardous. 3. Maintaining anaesthesia with a face mask may be difficult. 4. Intubation should not pose any additional hazard. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct

Correct Answer: B Several of the articular and extra-articular manifestations of Ankylosing Spondylitis (AS) are of significance to the anaesthetist. Cardiovascular involvement occurs in 3.5% of patients over a 15 year period and usually manifests as aortic incompetence. Controversy exists with regard to pulmonary involvement; some sources state that lung function is well preserved, others describe abnormalities in pulmonary function testing as commonplace. Pulmonary dysfunction when it occurs is primarily due to decreased chest wall compliance, and even though upper lobe fibrosis is described, this is not generally associated with loss of lung compliance. Cervical spine, temporo-mandibular, and crico-arytenoid involvement can make airway management and intubation difficult. AS is a disease characterized by fibrosis and ossification of ligamentous insertions and joint capsules. Ossification occurs at the vertebral discs with progression to a degree of complete fusion of the cervicolumbar spine. A minority develop the full features of 'bamboo spine'. The fused spine may fracture even after trivial injury and necessitate vigilance during positioning , head manipulation and transport. In later stages, sensory and motor deficits associated with cauda equina lesions may appear constituting a greater risk for nerve damage. 10% have TMJ involvement. This together with an immobile cervical spine may make airway management difficult. Cervical spine involvement may range from a small degree of limitation of movement to complete ankylosis, usually in flexion with a rotational component. A small group of patients with advanced disease are at risk of sustaining a cervical fracture. Here, the anaesthetist will be confronted with a possibly difficult intubation, difficult airway and risk of fracture. Although rare, it would appear that crico-arytenoid arthritis may also occur in ankylosing spondylitis. In 1984, 5 patients had been reported with this. Three developed acute upper respiratory complications. One had cor-pulmonale felt to be due to narrowing of the glottis. Extra-articular involvement is common. Patients frequently suffer from fatigue, weight loss and low grade fever, associated with hypochromic anaemia and a raised ESR. 83% of males suffer prostatitis, and uveitis occurs in 35% during the course of the disease. Cardiovascular, pulmonary and neurological manifestations are relatively rare but correlate with long standing disease. CVS involvement is found in 3.5% of patients with a 15 year and 10% with a 30 year history and is frequently manifest as AI and cardiomegaly. Scarring of the adventitia and fibrous proliferation of the intima of the aorta and aortic valve cusps may give rise to aortitis 259

and aortic incompetence. Occasionally, the mitral valve is involved as well, and fibrosis may affect the purkinje fibres giving rise to persistent conduction defects. Involvement of the lungs as measured by reduced lung volumes is a known manifestation of the disease. This has suggested to be due to reduced mobility of the thoracic cage due to inflammation or ankylosis of the sternocostal or costoclavicular joints and adjacent syndondroses.This correlates with disease duration resulting in permanently reduced lung function. Asymptomatic patients with normal CXRs have undergone pulmonary function testing. The main abnormalities are reduced TLC and VC and increased ratio of closing capacity to VC. FRC and RV are spared (In this study the authors suggested this pattern is consistent with a restrictive defect. Note that WEST and other texts describe a restrictive pattern as one with reduction in all lung volumes and capacities, but with preservation of 'normal' proportions and flow ratios.) Flow patterns, static compliance and diffusion capacity are also normal. The observation that reduction in lung volumes is also related to the inflammatory intensity of the disease suggests also an inflammatory involvement of the lung parenchyma. Upper lobe fibrosis is known to be a late pulmonary manifestation and may mimic TB when associated with cyst formation. However, reduced chest wall compliance is felt to be the cause of significant reductions in total pulmonary compliance which creates hazard in these patients. Diaphragmatic activity should be normal. Neurological complications have been described in 22% of patients in one series of 45. Spinal cord compression, cauda equina lesions, focal epilepsy, vertebrobasilar insufficiency and peripheral nerve lesions have been described. Vertebral fractures are also more common. See: Feltelius N, Hedenstrom H, Hillerdal G, Hallgren R. Pulmonary involvement in ankylosing spondylitis. Ann Rheum Dis. 1986 Sep;45(9):736-40. Sinclair JR, Mason RA. Ankylosing spondylitis. The case for awake intubation. Anaesthesia. 1984 Jan;39(1):3-11. Salathe M, Johr M. Unsuspected cervical fractures: a common problem in ankylosing spondylitis. Anesthesiology. 1989 May;70(5):869-70.

OPIATES AND OTHER TESTS Number: 5 Clopidogrel: 1. Is a glycoprotein IIb/IIa inhibitor. 2. Is more likely to cause bleeding complications than aspirin. 3. Is an isomer of ticlopidine. 4. May rarely cause thrombocytopenia. A: 1,2,3 Correct

260

B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: D Kam and Nethery have recently published an excellent review on the thienopyridine platelet antagonists (Clopidogrel and Ticlopidine). According to these authors: "ADP is released from activated platelets, erythrocytes and endothelial cells, and induces platelet adhesion and aggregation. ADP activates platelets by binding to membrane-bound nucleotide receptors (purinoceptors) on the platelet surface called P2 receptors [4]. Human platelets possess two major G protein-coupled ADP receptors, the P2Y1 and P2Y12 receptors, and a third ionotropic receptor, P2X1. The human P2Y1 receptor is a Gq protein-coupled receptor that activates phospholipase C to form inositol triphosphate (IP3) and causes calcium to be released from intracellular stores. The P2Y1 receptor is necessary to trigger a response and initiates the formation of platelet pseudopodia in response to low concentrations of thromboxane A2 or thrombin, and transient platelet aggregation occurs. However, activation of the P2Y1 receptor is insufficient for a full platelet response. The P2Y12, formerly known as P(2T), P2T (AC), P2Y (ADP) or P2Y (cyc), receptor is a Gi protein-coupled receptor that inhibits adenylyl cyclase. This results in a decreased platelet cyclic adenosine monophosphate (AMP) level in response to ADP, activating platelet glycoprotein IIb/IIIa (IIb3 integrin) receptors that bind fibrinogen, leading to stabilisation of platelet aggregation and enhanced platelet secretion. Platelets also possess a third ADP receptor, P2X1, which is a ligand-gated ion channel that mediates rapid transient calcium ion influx. However, the P2X1 receptor does not contribute to platelet aggregation." The incidence of bleeding complications with clopidogrel is very similar to that which occurs with aspirin when used for similar indications (~ 9%). The currently available glycoprotein IIb/IIa inhibitors are: abciximab, tirofiban, and eptifibatide. The drug is structurally very similar to ticlopidine, but is not an isomer (it contains an additional carboxymethyl side group). The drug may rarely cause thrombocytopenia, but far less commonly than ticlopidine. See: Kam PC, Nethery CM. The thienopyridine derivatives (platelet adenosine diphosphate receptor antagonists), pharmacology and clinical developments. Anaesthesia. 2003 Jan;58(1):28-35. Number: 16 Which of the following drugs does NOT possess anti-platelet activity?

261

A. Sevoflurane. B. Tirofiban. C. Hydroxy Ethyl Starch (Hetastarch). D. Remifentanil. E. Dipyridamole. Select the single best answer ABCDE Correct Answer: D Sevoflurane alters platelet aggregation - possibly by suppression of thromboxane A2 formation. Tirofiban is a platelet GP IIb/IIIa receptor antagonist. Others in this class of drug are the human-murine chimeric monoclonal antibody Fab fragment abciximab, the peptide antagonist eptifibatide and the peptidomimetic lamifiban. Hetastarch inhibits platelet function by reducing the availability of the functional receptor for fibrinogen on the platelet surface. (It may also impair coagulation by prolonging the partial thromboplastin times and decreasing factor VIII activity and fibrinogen levels.) There is no evidence of anti-platelet activity for any of the synthetic opioids. Dipyridamole is a platelet adhesion inhibitor, although the mechanism of action has not been fully elucidated. The mechanism may relate to inhibition of red blood cell uptake of adenosine, itself an inhibitor of platelet reactivity, phosphodiesterase inhibition leading to increased cyclic-3,5-adenosine monophosphate within platelets, and inhibition of thromboxane A2 formation which is a potent stimulator of platelet activation. Number: 54 With regard to delta-9 tetrahydrocannabinol (THC): 1. It is the primary psychoactive component of cannabis. 2. It readily crosses the placental barrier. 3. It has clinically useful anti-emetic effects. 4. It has an analgesic efficacy roughly equivalent to codeine. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE

262

Correct Answer: E The pharmacological actions and therapeutic uses of cannabis and cannabinoids have recently been superbly reviewed by Kumar et al. According to these authors: 1. Although the term cannabis is used colloquially to describe a single entity, over 60 different compounds have been identified and collectively referred to as cannabinoids. These are largely derived from the female plant of Cannabis sativa. The most abundant cannabinoid and the primary psychoactive constituent is d-9 tetrahydrocannabinol (THC), which was isolated in 1964. Other natural cannabinoids are d-8THC, cannabinol and cannabidiol. The THC content is highest in the flowering tops, declining in the leaves, stem and seeds of the plant. Marijuana (THC content 0.55%) is prepared from the dried flowering tops and leaves; hashish (THC content 220%) consists of dried cannabis resin and ompressed flowers. 2. Cannabinoids also cross the placenta, enter the foetal circulation and penetrate into breast milk. Cannabinoids are highly lipid soluble and accumulate in fatty tissues from where they are released slowly back into the bloodstream. Because of this sequestration, elimination from the body is extremely slow and can take many days. With repeated dosage, cannabinoids accumulate and continue to reach the brain over a longer period. 3. Cannabinoids have been used in the prevention of nausea and vomiting caused by anticancer drugs. Nabilone and dronabinol (THC in sesame oil) have been shown to be as effective or more effective than phenothiazines, metoclopramide and domperidone for this indication, although they have not been tested against the 5-HT3 antagonist ondansetron. Nabilone is usually given in a dose of 48 mg per day in divided doses for a few days during cancer chemotherapy. There is a high incidence of adverse effects and 50100% of patients experience drowsiness, dizziness and lethargy. 4. The efficacy of THC appears to be approximately equivalent to codeine and an adjunctive role seems to be the most promising use of cannabinoids in the management of pain. See: Kumar RN, Chambers WA, Pertwee RG. Pharmacological actions and therapeutic uses of cannabis and cannabinoids. Anaesthesia. 2001 Nov;56(11):1059-68. Number: 92 Which of the following complications of amiodarone generally occur with acute therapy? 1 .Pulmonary fibrosis. 2. Thyrotoxic crisis. 3. Hepatitis. 4. Digoxin toxicity. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct

263

ABCDE Correct Answer: D The complications generally seen early after administration include rhythm disturbances and potentially, toxicity with other drugs whose plasma concentrations have been elevated as a result of interaction. Patients on long term oral therapy may also experience these side effects, but in addition, may develop pulmonary fibrosis, thyroid dysfunction and reversible abnormality of liver function. Amiodarone has a large side effect profile. Many of its side effects occur during chronic therapy. As a result, it is considered a useful short term agent for the treatment of refractory supraventricular tachyarrhythmias, and it has been replaced by sotalol as the first line agent for long term use. Amiodarone is a structural analog of thyroid hormone. Its electrophysiological effects include - prolonged action potential duration (Vaughan-Williams Class 3) in atria and ventricles. - increased effective refractory period in the AV node, His Purkinje system, and ventricular conducting system. - depression of SA node activity. Haemodynamic effects include powerful systemic and coronary vasodilation with moderate, non-competitive adrenergic receptor antagonism. It does not cause clinically significant myocardial depression in patients with normal ventricular function but may aggravate existing heart failure in patients dependent upon augmented sympathetic drive. Cardiac output should be increased or preserved as a result of afterload reduction. Toxicity is dose dependent, cumulative with time, and not predictable from serum assays. Moreover, due to a half life of 14-04 days, toxicity once manifest, may take months to resolve. Toxic effects which manifest early include: (1)Sinus bradycardia, sinus arrest, AV block, prolongation of the QT interval, and Torsades de Pointes. The effect is additive with other drugs which depress the sinus node including lignocaine and halothane. Two case reports of sinus arrest refractory to atropine under general anaesthesia exist and some sources advocate prophylactic temporary pacing in this scenario. (2)Drug interactions include an elevation of serum levels of digoxin and warfarin. Effects which tend to occur with chronic oral treatment include: (3)Thyroid dysfunction. Hypo- or hyperthyroidism may occur. Hyperthyroidism is sometimes fulminant and refractory to medical treatment, requiring thyroidectomy under " toxic " conditions. (4)Pulmonary fibrosis occurs in 1-13%, and has a mortality of 20-25%. (5)Hepatotoxicity- transient elevation of transaminases occurs. (6)Corneal deposits - Iodine containing microdeposits occur throughout the body. Whilst generally considered asymptomatic, they have led to blurring of vision when in the cornea. (7)Photosensitivity and a characteristic slate grey pigmentation of the face occurs. (8)Neurotoxicity-10-74% develop ataxia and tremor which is not always reversible. HOLT,A.W; " Supraventricular tachyarrhythmias in Critically Ill Patients ", Australasian Anaesthesia 1992, pp 78-85.

264

Number: 176 Regarding this compound: catechol ring and substitutions ( no figure) 1. It is the parent compound of the catechol amines. 2. Substitution on the alpha carbon blocks oxidation by MAO. 3. Substitution on the Beta carbon increases peripheral agonist activity. 4. Substitution on the Beta carbon generally increases central stimulant action. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: A Beta Phenylethylamine is the parent compound of the Catechol Amines. Substitutions can be made on the Benzene ring as well as the Alpha and Beta positions on the ethylamine side chain with retention of sympathomimetic activity. Adrenaline, Noradrenaline, dopamine and isoprenaline all have hydroxy groups subtituted onto positions 3 & 4 of the ring. Since o-dihydroxybenzene is also known as 'Catechol' these compounds are also known as catechol amines. Substitution on the beta carbon generally decreases central stimulant activity by lowering the lipid solubility of the compound, but generally greatly enhances alpha and beta potency. Potency of the compounds is reduced markedly when more than two carbons separate the aromatic and amine groups. Number: 177 The parent compound illustrated below: 1. Is Pethidine if R1 = B and R2 = A 2. Is Fentanyl if R1 = C and R2 = D 3. Will have Atropine like qualities 4. Is a Phenylpiperidine A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct

265

ABCDE Correct Answer: E The phenylpiperidine analgesics (Pethidine and Fentanyl family) were first developed in 1939 by Eisleb and Schaumann who were looking for Atropine like agents. Morphine is a Phenanthrene derivative. Pethidine is partially metabolised by (30%) by N-demethylation to Norpethidine which is responsible for many of the toxic effects of chronic pethidine administration. Number: 211 Sodium nitroprusside A. Promotes fluid and sodium retention B. Decreases venous return C. Causes CNS depression D. Increases cardiac work E. None of the above Select the single best answer ABCDE Correct Answer: B Nitroprusside is the most potent 'mixed' vasodilator - acting on both the arterial and venous side of the circulation. This, results in reduced peripheral vascular resistance and venous return. Nitroprusside does not cause CNS depression and tends to reduce cardiac work. In the presence of ischaemic heart disease the drug can occasionally precipitate acute myocardial ischaemia. This may occur if: 1. Diastolic blood pressure is reduced in the presence of critically stenotic lesions, 2. Reflex tachycardia is precipitated or, 266

3. Coronary 'Steal' has occurred. Number: 212 The side-effects of Enalapril include: A. Drowsiness B. Excess fluid retention C. Hyperglycaemia D. Urinary retention E. Hyperkalemia Select the single best answer ABCDE Correct Answer: E The adverse effects that are common to ACE inhibitors include acute renal failure, hyperkalaemia, angioedema and dry cough, sometimes accompanied with wheezing. Plasma creatinine should be routinely monitored in patients undergoing treatment with ACE inhibitors - particularly at the start of therapy. Renal artery stenosis can come to light under these circumstances. Number: 264 A patient with a type 'B' aortic dissection being treated with sodium nitroprusside(SNP) for the control of arterial blood pressure. The patient develops a lactic acidosis and cyanide toxicity is suspected. Appropriate resuscitation includes the administration of: 1. Sodium thiosulfate. 2. Sodium bicarbonate. 3. Sodium nitrite. 4. Vitamin B12. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: A When life-threatening tissue hypoxia is present, ventilating with 100% oxygen, correcting metabolic acidosis with sodium bicarbonate, and administering 3% sodium nitrite (46 mg/kg

267

very slowly intravenously), and sodium thiosulfate (150200 mg/kg IV over 15 min) is the usual treatment for suspected cyanide toxiicty. Sodium nitrite converts haemoglobin to methaemoglobin which competes with cytochrome oxidase for cyanide radicals. Some clinicians will withhold sodium nitrite therapy in anaemic patients, particularly when oxygen delivery is already compromised while others consider its vasodilating effects to be problematic. Hydroxocobalamin (vitamin B12a) may also have a role in the treatment of cyanide toxicity. Hydroxocobalamin binds CN- forming cyanocobalamin which acts as a nontoxic reservoir and can be excreted in the urine. The vitamin can be infused at 25 mg/h to a total of 100 mg or more during and after SNP infusion. Infusion of vitamin B12 (cyanocobalamin) is considered ineffective in removing CN- due to poor binding, thus is not a substitute for hydroxocobalamin . The principal toxic effect of hydroxocobalamin is reddish discoloration of the skin and mucous membranes. The evidence that hydroxocobalamin administration is either needed or efficacious is controversial. See: Anesth Analg 1995 Jul;81(1):152-62: Sodium nitroprusside: twenty years and counting. Friederich JA, Butterworth JF 4th - for an excellent, comprehensive review of the problem. Number: 300 For acute short-term use, (eg hypotensive anaesthesia lasting a few hours) the total intraoperative dose of sodium nitroprusside (SNP) should be limited to a total dose of: A. 0.5 mg/kg. B. 1.5 mg/kg. C. 3.0 mg/kg. D. 5.0 mg/kg. E. 10.0 mg/kg. Select the single best answer ABCDE Correct Answer: B Possible cyanide poisoning has been reported over a wide range of SNP infusion rates and total doses; deaths clearly linked to cyanide toxicity appear to have occurred at infusion rates in excess of, 30120 mcg/kgmin. Blood cyanide concentrations required for clinical toxicity appear to exceed 40 microM/L ; deaths have been reported with blood concentrations exceeding 77, 100, or 1309 microM/L. There appears to be a discrepancy between the maximum 'safe-dosage' recommended by some textbooks of anaesthesia and that recommended in the anaesthetic literature. Conventional wisdom (See, for example 'Drugs and Anesthesia' Ed: Wood and Wood) appears to be that for acute short-term use, as during hypotensive surgery, the total intraoperative dose of SNP should be limited to 1.0 to 1.5 mg/kg administered over a 1 to 3

268

hour period. If the initial dose requirements are such that it seems likely this figure will be exceeded, alternate methods of inducing hypotension should be used. More recently, Friederich and Butterworth have suggested the use of alternative drugs to reduce the dose or shorten the duration of infusion when a dose of 2 micrograms/kg/min (0.12 mg/kg/hr) is exceeded. This is a much lower figure and corresponds to the rate of spontaneous detoxification of SNP in humans as reported by Schulz. I have arbitrarily chosen the 'textbook' answer as the correct answer because it appears to me that the lower dose can generally be quite safely exceeded. However, prolonged or high-dose infusions of nitroprusside should be minimised in critically ill patients, especially if hepatic and / or renal dysfunction is present. See: Anesth Analg 1995 Jul;81(1):152-62: Sodium nitroprusside: twenty years and counting. Friederich JA, Butterworth JF 4th - for an excellent, comprehensive review of the problem. Clin Pharmacokinet 1984 May-Jun;9(3):239-51: Clinical pharmacokinetics of nitroprusside, cyanide, thiosulphate and thiocyanate. Schulz V Number: 311 The risk of intoxication during digoxin treatment is increased by: 1, Hypercalcaemia 2. Hypokalaemia 3. Hypomagnesaemia 4. Hypoalbuminaemia A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: A The most common precipitating cause of digitalis intoxication is depletion of potassium stores. Advanced age, acute myocardial infarction or ischemia, hypoxemia, magnesium depletion, renal insufficiency, hypercalcemia, electrical cardioversion, and hypothyroidism also reduce the tolerance of the patient to the digitalis glycosides and may provoke latent digitalis intoxication. The calcium channel antagonist verapamil and the antiarrhythmic agent amiodarone also appear to raise serum digoxin levels and can precipitate toxicity if administered to a patient who is already digitalised.

269

Number: 330 Adenosine: 1. Is an endogenous nucleotide. 2. Is a vasodilator. 3. Has a half-life of about 10 seconds. 4. Will successfully revert at least 80% of supraventricular tachycardias. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: E Adenosine is an endogenous nucleotide natural to all cells of the body. In pharmacologic doses, it slows conduction through the AV node and has proved highly efficacious as acute IV therapy for patients with paroxysmal supraventricular tachycardia in both reentry and accessory pathway (Wolff-Parkinson-White) dysrhythmias. After IV administration, adenosine undergoes rapid redistribution to erythrocytes and cells of the vascular endothelium, with a half-life estimated at less than 10 seconds. Subsequently, it is metabolized to inosine or adenosine monophosphate. After a bolus of 6 mg, about 60% of patients with paroxysmal supraventricular tachycardia will convert to sinus rhythm within 1 minute. If the initial bolus is unsuccessful, 12 mg given intravenously will convert most of the remaining patients, for a cumulative effectiveness of 92%. Transient high-grade blocks and even asystole may be seen following adenosine administration. These usually resolve rapidly and without therapy. Lerman BB, Belardinelli L Cardiac electrophysiology of adenosine, basic and clinical concepts. Circulation 83:1499, 1991 Number: 343 Phenytoin: 1. Is a Vaughan-Williams Class 1B anti-dysrhythmic. 2. Can precipitate Stevens-Johnson Syndrome. 3. Can be used for the treatment of digoxin toxicity. 4. Can precipitate lupus erythematosus. A: 1,2,3 Correct B: 1,3 Correct

270

C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: E Although mainly used as an anticonvulsant, phenytoin has been used in patients with atrial and ventricular dysrhythmias, digitalis toxicity, and chronic ventricular dysrhythmias. It can be used alone or in combinations. Its action is similar to the other class IB agents. A usual loading dose is 1000 mg given at a rate that does not exceed 50 mg/min, and the ECG and blood pressure are monitored to prevent hypotension and cardiovascular collapse. Rarer but more serious reactions include severe dermatitis and Stevens-Johnson syndrome, a lupus-like syndrome, and possibly even hematologic malignancies. Number: 364 With regard to adverse reactions to the administration of protamine: 1. They are more likely to occur in diabetics. 2. Previous exposure to heparin increases the risk of a reaction 3. Previous exposure to protamine increases the risk of a reaction 4. Pulmonary vasodilation is usually a feature. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: B Adverse reactions to intravenous protamine administration include rash, urticaria, bronchospasm, pulmonary vasoconstriction, and/or systemic hypotension leading at times to cardiovascular collapse and death. Diabetic patients receiving daily subcutaneous injections of insulins containing protamine have a 40- to 50-fold increased risk for life-threatening reactions when given protamine intravenously. Another group putatively at increased risk for protamine reactions are men who have undergone vasectomies. With disruption of the blood-testis barrier, studies have shown that

271

20% to 33% of such men develop hemaglutinating autoantibodies against protamine-like compounds. Previous exposure to intravenous protamine given for reversal of heparin anticoagulation may increase the risk for a reaction on subsequent protamine administration. Sharath MD, Metzger WJ, Richerson HB et al: Protamine-induced fatal anaphylaxis, J Thorac Cardiovasc Surg 90:86, 1985. There is evidence that some protamine reactions are mediated through protamine-specific IgG antibody. Weiss ME, Nyhan D, Zhikang P et al: Association of protamine IgE and IgG antibodies with life-threatening reactions to intravenous protamine, N Engl J Med 320:886, 1989. Adverse reactions to intravenous protamine administration include rash, urticaria, bronchospasm, pulmonary vasoconstriction, and/or systemic hypotension leading at times to cardiovascular collapse and death. - It is the combination of pulmonary vasoconstriction with systemic vasodilation which can make the reactions so devastating. Pulmonary hypertension has been associated with the generation of thromboxane, a known pulmonary vasoconstrictor. Number: 364 With regard to adverse reactions to the administration of protamine: 1. They are more likely to occur in diabetics. 2. Previous exposure to heparin increases the risk of a reaction 3. Previous exposure to protamine increases the risk of a reaction 4. Pulmonary vasodilation is usually a feature. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: B Adverse reactions to intravenous protamine administration include rash, urticaria, bronchospasm, pulmonary vasoconstriction, and/or systemic hypotension leading at times to cardiovascular collapse and death. Diabetic patients receiving daily subcutaneous injections of insulins containing protamine have a 40- to 50-fold increased risk for life-threatening reactions when given protamine intravenously.

272

Another group putatively at increased risk for protamine reactions are men who have undergone vasectomies. With disruption of the blood-testis barrier, studies have shown that 20% to 33% of such men develop hemaglutinating autoantibodies against protamine-like compounds. Previous exposure to intravenous protamine given for reversal of heparin anticoagulation may increase the risk for a reaction on subsequent protamine administration. Sharath MD, Metzger WJ, Richerson HB et al: Protamine-induced fatal anaphylaxis, J Thorac Cardiovasc Surg 90:86, 1985. There is evidence that some protamine reactions are mediated through protamine-specific IgG antibody. Weiss ME, Nyhan D, Zhikang P et al: Association of protamine IgE and IgG antibodies with life-threatening reactions to intravenous protamine, N Engl J Med 320:886, 1989. Adverse reactions to intravenous protamine administration include rash, urticaria, bronchospasm, pulmonary vasoconstriction, and/or systemic hypotension leading at times to cardiovascular collapse and death. - It is the combination of pulmonary vasoconstriction with systemic vasodilation which can make the reactions so devastating. Pulmonary hypertension has been associated with the generation of thromboxane, a known pulmonary vasoconstrictor. Number: 372 Remifentanil: 1. Has a similar lipid solubility to alfentanil. 2. Relies on pseudocholinesterase for its metabolism. 3. Does not need dose modification in the presence of renal failure. 4. Can be used for induction of anaesthesia when spontaneous respiration is planned. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: B Remifentanil is a potent esterase-metabolised opioid (EMO) characterized by rapid clearance and lack of accumulation following repeated or prolonged dosing. This profile results in the rapid dissipation of respiratory depressant and analgesic effects (within 5 to 10 minutes) after the infusion of Remifentanil is discontinued.

273

Remifentanil has a short duration of action (t1/2 = 3 to 10 minutes) because of the rapid esterase metabolism. Steady-state conditions can be achieved in 5 to 10 minutes without a loading or bolus dose of Remifentanil. The esterase metabolism of remifentanil allows higher relative doses (ED90) of Remifentanil to be administered. This flexibility for higher doses of Remifentanil results in superior control of intraoperative stress responses, compared to alfentanil and fentanyl, without delaying recovery. The pharmacokinetic and pharmacodynamic profile of remifentanil allows rapid titration to attenuate signs of light anaesthesia and rapid, predictable recovery when its analgesic effects are no longer needed. The esterase metabolism and rapid blood-brain equilibration result in a rapid onset (approximately 1 minute) and offset of action. Rapid offset of effect requires that early postoperative analgesia be established as part of the anaesthesia plan when postoperative pain is anticipated. The drug does not need dose modification in the presence of renal impairment. No dosage adjustment is recommended in patients with hepatic impairment. The pharmacokinetics of remifentanil are not changed in patients with severe hepatic impairment awaiting liver transplant, or during the anhepatic phase of liver transplant surgery. Individuals with severe hepatic impairment demonstrated statistically significant, reduced sensitivity to carbon dioxide simulation of minute ventilation, which may indicate an increased sensitivity to the respiratory depressant effects of remifentanil. These patients should be closely monitored and the dose of remifentanil should be titrated to the individual patient's need. It must never be administered rapidly for induction of anaesthesia and is not indicated for use as an induction agent when spontaneous respiration is planned. Number: 403 Phenothiazines: 1. Lower the seizure threshold. 2. Possess anticholinergic activity. 3. Possess local anaesthetic activity. 4. Characteristically have small distribution volumes. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: A Phenothiazines differ structurally but have similar pharmacologic activity. These agents block postsynaptic dopamine receptors, exhibit anticholinergic activity, and inhibit reuptake of norepinephrine and 5HT in the CNS.

274

They also have peripheral alpha-adrenergic blocking and anticholinergic activity and lower the seizure threshold. Some phenothiazines have a quinidine-like effect on the heart. These agents are efficiently absorbed from the GIT, are highly protein bound, and have large apparent volumes of distribution. They are slowly eliminated by hepatic metabolism with half-lives of 20 to 40 h. Number: 426 Rapid bolus intravenous adenosine could be expected to terminate the following arrhythmias: 1. Atrial flutter with 2:1 atrioventricular block 2. Atrioventricular nodal re-entry tachycardia (AVNRT). 3. Paroxysmal atrial fibrillation 4. Orthodromic atrioventricular re-entry tachycardia A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: C 1. It would increase the degree of AV block which might aid the diagnosis but would not usually stop the atrial flutter. 2. AVNRT is a re-entry circuit within the AV node which is terminated by adenosine. 3. It might slow the AV conduction but not stop the atrial fibrillation. 4. This is the commonest tachycardia associated with WPW syndrome. The circuit is from atria to ventricles via the AV node and back to the atria via the accessory pathway. Number: 445 Lithium therapy can result in: 1. Inappropriate ADH secretion. 2. Sinus node dysfunction. 3. Hyperglycaemia. 4. Hypothyroidism. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct

275

ABCDE Correct Answer: C Several medical complications can develop during lithium therapy. About 25 percent of patients develop some degree of vasopressin-resistant nephrogenic diabetes insipidus with polyuria and polydipsia. The lithium inhibition of adenylate cyclase activity is responsible for the disruption of renal tubular transport. These symptoms are usually completely reversible by lithium withdrawal and often can be ameliorated by a reduction in dosage. Lithium may induce the following ECG changes especially in older patients: T-wave depression, sinus node dysfunction, and, very rarely, sinoatrial block and ventricular irritability. The drug tends to have an 'insulin-like' effect and for this reason may lower blood sugar. Because of its effect on adenylate cyclase activity, lithium inhibits the thyroid gland's secretory function; non-toxic goitres and hypothyroidism can develop, which can be readily corrected during lithium therapy by thyroid supplement. Number: 446 Which statement(s) is/are true with regard to Dantrolene: 1. It has muscle relaxant properties. 2. It has a role in the treatment of neuroleptic malignant syndrome. 3. It lowers intracellular calcium levels. 4. Its solubility increases with increasing pH. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: E Dantrolene relaxes skeletal muscle by inhibiting the calcium influx induced by electrical stimulation or potassium-induced depolarisation and inhibtiing augmented caffeine-induced contracture in MH Susceptible muscle. The mechanism and site of action of dantrolene is not completely understood, but it is postulated that it depresses the rate and amount of calcium release from the sarcoplasmic reticulum or increases calcium uptake into the sarcoplasmic reticulum.

276

Dantrolene is packaged in lyophilised form at 20 mg/vial and is reconstructed with 50 ml of sterile water in which it is relatively insoluble. Sodium hydroxide and 3 g of mannitol are added to the vial to allow the dantrolene to dissolve in 2 to 3 minutes. The resulting pH of the solution is 9.5, so care must be taken to prevent extravasation and to monitor for thrombophlebitis. See also: Lancet 1998 Oct 3;352(9134):1131-6 Denborough M Malignant hyperthermia. Number: 473 The anticoagulant effect of warfarin may be enhanced by 1. Carbamazepine 2, Metronidazole 3. Vitamin K 4. Aspirin A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: C Drugs may affect the activity of warfarin in at least three important ways. Drugs which alter the activity of the heaptic microsomal mixed-function oxidase system which is responsible for warfarin elimination in humans will alter plasma warfarin concentration and effect. Enzyme inducers increase the rate of metabolism and, hence, result in reduced warfarin effect whereas enzyme inhibitors result in increased warfarin effect. Carbamazepine is an enzyme inducer and will increase the metabolism of warfarin leading to a reduced anticoagulant effect. Metronidazole is an enzyme inhibitor and will reduce the metabolism of warfarin leading to an increased anticoagulant effect. Vitamin K will reduce the anticoagulant effect - Warfarin interferes with vitamin K metabolism and prevents the caroboxylation of glutamic residues in factors II, VII, IX and X. Aspirin competes for protein binding with warfarin.

277

- In vitro protein binding interactions have been frequently described with warfarin. However, the clinical significance of many of these reported interactions was not critically evaluated. Warfarin is an example of a low-clearance drug whose clearance is dependent on the free fraction of drug in plasma. Increasing the free fraction will result in a transient increase in the free concentration (and possibly increased effect); however, as the clearance is increased, the total level will fall, restoring the free concentration to pretreatment levels. Number: 475 Metabolic acidosis characteristically occurs in poisoning with 1. Aspirin 2. Ethylene glycol 3. Methanol 4. Phenobarbitone A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: A Salicylate intoxication is common. It results in impaired generation of adenosine triphosphate and produces a primary respiratory alkalosis. In adults the clinical manifestations may closely simulate a cerebrovascular event or alcoholic ketoacidosis. Central nervous system dysfunction, fever, glycosuria, ketonuria, respiratory alkalosis with an elevated anion gap, tinnitus, dehydration, hypokalaemia and haemostatic defects are common. Ethylene glycol is rapidly absorbed. Peak levels occur approximately 2 h following ingestion. Ethylene glycol has a volume of distribution of 0.6 to 0.8 L/kg of body weight. It is oxidized by alcohol dehydrogenase to glycoaldehyde, which is then metabolized to glycolic acid, glyoxylic acid, and oxalic acid. Effects begin 30 min following ingestion and include nausea, vomiting, slurred speech, ataxia, nystagmus, and lethargy. A faint, sweet aromatic odor may be detected on the breath. Coma, seizures, respiratory depression, cardiovascular collapse, and death may occur. Effects caused by metabolites begin 4 to 12 h following ingestion. At this stage the patient appears more ill than intoxicated. Manifestations include tachypnea, hypotension, agitation, confusion, lethargy, coma, and seizures. Hypocalcemia occurs in a third of patients. Leukocytosis is present in the majority. In severe cases, adult respiratory distress syndrome, cyanosis, pulmonary edema, and cardiomegaly may be seen. In this stage the diagnosis is suggested by metabolic acidosis, an increased anion gap (low bicarbonate and chloride), and an abnormal urinalysis (crystalluria). In patients who survive the early stages, acute tubular necrosis manifested by proteinuria, oliguria, and anuria ensues 12 to 24 h following ingestion. Renal failure may be permanent but typically lasts days to weeks. In early intoxication, osmolality is elevated. Later, an elevated anion gap and decreased serum bicarbonate and chloride are

278

observed. Signs of alcohol-like intoxication suggest a serum ethylene glycol level greater than 8 to 16 mmol/L (50 to 100 mg/dL). Survival has been reported with levels as high as 100 mmol/L (650 mg/dL). Methanol intoxication, a rare and potentially lethal form of poisoning, usually results from ingestion and occasionally inhalation of methanol. Initial symptoms are of blurred vision, elongated anion gap and metabolic acidosis which are typically delayed in onset and may not at first be recognised as methanol-related complaints. Number: 477 Chlorpromazine: 1. Can precipitate cholestatic jaundice. 2. Has alpha-blocking activity. 3. Can produce a photosensitivity rash. 4. Lowers seizure threshold. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: E Azer SA, Stacey NH J Gastroenterol Hepatol 1996 Apr;11(4):396-407 Current concepts of hepatic uptake, intracellular transport and biliary secretion of bile acids: physiological basis and pathophysiological changes in cholestatic liver dysfunction. Eberlein-Konig B, Bindl A, Przybilla B Dermatology 1997;194(2):131-5 Phototoxic properties of neuroleptic drugs. - Most neuroleptics are strongly phototoxic in vitro indicating a potential risk for photoinduced reactions also to occur in patients treated with these drugs. Aguglia U, Gambardella A, Le Piane E, De Sarro GB, Zappia M, Quattrone A J Neurol 1994 Oct;241(10):605-10 Chlorpromazine versus sleep deprivation in activation of EEG in adult-onset partial epilepsy. - EEG activation by either sleep deprivation or Chlorpromazine is highly specific in the diagnosis of adult-onset partial epilepsy.

279

Number: 483 Amiodarone: 1. Enhances the peripheral transformation of T4 to T3 2. Inhibits TSH release 3. Rarely causes corneal microdeposits 4. Readily crosses the placenta A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: C 1. Amiodarone inhibits the peripheral transformation of T4 to T3. 2. Amiodarone inhibits TSH release and decreases pituitary sensitivity to T4 and T3. 3. Most patients develop (reversible) corneal microdeposits. 4. Amiodarone is contraindicated in pregnancy and breast feeding. Number: 491 Remifentanil: 1. Will prevent the rise in intraocular pressure associated with the administration of suxamethonium. 2. Will diminish cerebral vasoreactivity to carbon dixoide. 3. Tends to cause a bradycardia. 4. Provokes histamine release. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: B 1. Br J Anaesth 1998 Oct;81(4):606-7 Alexander R, Hill R, Lipham WJ, Weatherwax KJ, elMoalem HE Remifentanil prevents an increase in intraocular pressure after succinylcholine and tracheal intubation.

280

2. Anesthesiology 1998 Aug;89(2):358-63 Ostapkovich ND, Baker KZ, Fogarty-Mack P, Sisti MB, Young WL Cerebral blood flow and CO2 reactivity is similar during remifentanil/N2O and fentanyl/N2O anesthesia. 3. Br J Anaesth 1998 Apr;80(4):467-9 Thompson JP, Hall AP, Russell J, Cagney B, Rowbotham DJ Effect of remifentanil on the haemodynamic response to orotracheal intubation. 4. Anesth Analg 1995 May;80(5):990-3 Sebel PS, Hoke JF, Westmoreland C, Hug CC Jr, Muir KT, Szlam F Histamine concentrations and hemodynamic responses after remifentanil. Number: 499 Acetazolamide: 1. Is used in the management of renal tubular acidosis 2. Causes hypokalaemia 3. Causes metabolic alkalosis 4. Inhibits the action of carbonic anhydrase A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: C 1. Acetazolamide is a cause of renal tubular acidosis. 3. Acetazolamide enhances renal bicarbonate excretion thereby causing a metabolic acidosis. K Number: 508 Hepatic first-pass metabolism: 1. Is avoided by giving a drug intranasally. 2. Is avoided by giving a drug rectally. 3. Is avoided by giving an intramuscular injection of a drug. 4. Is seen when a drug has a low hepatic extraction ratio. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct

281

D: 4 Correct E: All Correct ABCDE Correct Answer: B Transdermal, sublingual, intranasal and parenteral (IV, IM, SC) routes avoid the portal circulation and hence first-pass metabolism. A variable proportion of a drug given rectally will be absorbed into the portal circulation, therefore first-pass metabolism is not totally avoided. Drugs with high hepatic extraction ratios undergo substantial first-pass metabolism. Number: 512 Epileptiform activity may be seen with: 1. Propofol 2. Neostigmine 3. Etomidate 4. Ketamine A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: B There is now no doubt that propofol can cause epileptic fits in those who are susceptible. These fits may be considerably delayed in onset. Paradoxically, the drug may also be used in the treatment of status epilepticus that is resistant to other forms of therapy. Etomidate can induce convulsion-like EEG potentials in epileptic patients without the appearance of myoclonic or convulsion-like motor activity. Opitz A, Marschall M, Degen R et al: General anesthesia in patients with epilepsy and status epilepticus. In Delgado-Escueta AV, Wastedain CG, Treiman DM et al, eds: Status epilepticus: mechanisms of brain damage and treatment, New York, 1983, Raven Press. Ketamine is not epileptogenic but enhanced skeletal muscle tone may be manifested by tonic and clonic movements which may resemble fits. The drug may lower seizure threshold.

282

Number: 513 Hyperglycaemia may result from the administration of: 1. Adrenaline 2. Thyroid stimulating hormone 3. Thiazide diuretics 4. Beta blockers A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: A Adrenaline increases glucagon and stimulates gluconeogenesis. The adverse metabolic effects of thiazide diuretics include hypokalaemia, hypomagnesaemia, hyperglycaemia, and hypercholesterolaemia. Increases in plasma insulin and glucose levels have been observed in thiazide-treated hypertensive patients and have been attributed to a diminished insulin sensitivity induced by diuretic therapy. Patients on beta blockers are at risk of hypoglycaemia under general anaesthesia. Number: 528 Which of the following drugs readily cross the placenta? 1. Physostigmine 2. Suxamethonium 3. Naloxone 4. Heparin A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: B The transplacental passage of drugs is dependent on several important factors:

283

lipid solubility; degree of drug ionisation molecular weight; protein binding; drug concentration gradients; maternal and foetal blood pH; and placental and foetal drug metabolism. Drug transfer across the placenta occurs mostly by diffusion, which is governed by the Fick diffusion equation. Physostigmine, being a tertiary amine readily crosses the placenta. Naloxone, because of its high lipid solubility, is easily transferred to the foetus and can be administered to the mother to counteract anticipated respiratory depression in the infant. Suxamethonium and heparin are highly ionised and therefore do not readily cross the placenta. Number: 530 Droperidol: 1. Has alpha blocking activity. 2. Is extensively metabolised by the liver. 3. Causes extrapyramidal side effects. 4. Is a phenothiazine. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: A Droperidol acts by interfering with dopaminergic transmission in the brain. Because it blocks dopamine receptors, it may cause extrapyramidal side effects. The drug also has some (competitive) alpha-blocking activity. It is a butyrophenone and is extensively metabolised by the liver. Number: 558 With regard to tramadol: 1. Its effects can be largely reversed by naloxone. 2. It is a potent respiratory depressant. 3. It suppresses EEG activity at typically-used dosages. 4. It is supplied as a racemic mixture of D and L forms. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct

284

E: All Correct ABCDE Correct Answer: D In volunteer studies only 30% of the effect of tramadol could be antagonised by naloxone. The drug has been found both in vivo and in vitro to have a low activity at mu opioid receptors, and also to inhibit both noradrenaline and 5hydroxytryptamine (5HT) neuronal reuptake, and to facilitate 5HT release . The drug has little respiratory depressant effect, but post-operative nausea is a significant problem. EEG frequencies are significantly increased in patients treated with the drug. Tramadol is supplied as a racemic mixture of the dextro- and laevo-rotatory forms. The effects of tramadol on opioid receptors, noradrenaline and 5HT are now attributed to the separate activities of these enantiomers. (+)Tramadol has a greater affinity at mu receptors and inhibits 5HT uptake and enhances its release, whereas (-) tramadol inhibits noradrenaline uptake. Number: 569 With regard to benzodiazepines which statements are correct? 1. They inhibit release of gamma-aminobutyric acid. 2. When used in premedicant doses,cardiovascular depression is uncommon. 3. They possess analgesic properties. 4. Nausea and vomiting are uncommon side effects. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: C The sedative action of benzodiazepines is said to result from their facilitation of gammaaminobutyric acid-mediated inhibitory neurotransmission. The muscle-relaxant effects of the drugs may be due to glycine-mimetic effects in the spinal cord and brainstem. Benzodiazepines cause little depression of either the cardiovascular or respiratory systems.

285

Benzodiazepines are not analgesic agents. Nausea and vomiting are not associated with the administration of benzodiazepines. In fact, in some situations the drugs have useful anti-emetic effects. For example: Anaesth Intensive Care 1999 Feb;27(1):38-40 The effect of midazolam on persistent postoperative nausea and vomiting. Di Florio T, Goucke CR Number: 569 With regard to benzodiazepines which statements are correct? 1. They inhibit release of gamma-aminobutyric acid. 2. When used in premedicant doses,cardiovascular depression is uncommon. 3. They possess analgesic properties. 4. Nausea and vomiting are uncommon side effects. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: C The sedative action of benzodiazepines is said to result from their facilitation of gammaaminobutyric acid-mediated inhibitory neurotransmission. The muscle-relaxant effects of the drugs may be due to glycine-mimetic effects in the spinal cord and brainstem. Benzodiazepines cause little depression of either the cardiovascular or respiratory systems. Benzodiazepines are not analgesic agents. Nausea and vomiting are not associated with the administration of benzodiazepines. In fact, in some situations the drugs have useful anti-emetic effects. For example: Anaesth Intensive Care 1999 Feb;27(1):38-40 The effect of midazolam on persistent postoperative nausea and vomiting. Di Florio T, Goucke CR

286

Number: 597 During the administration of Sodium Nitroprusside (SNP), there will be a tendency for: 1. Intra-cranial pressure to rise. 2. Platelet aggregation to be inhibited. 3. Hypoxic pulmonary vasoconstriction to be inhibited. 4. Coronary 'steal' to occur. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: E SNP is a direct cerebral vasodilator, leading to increased cerebral blood flow and cerebral blood volume. These changes, when they occur in patients with reduced intracranial compliance, may cause an undesirable elevation of intracranial pressure. Infusion rates of SNP of more than 3 microgram / kg / minute may result in a dose-related decrease in platelet aggregation. The mechanism of this effect is uncertain. All peripheral vasodilators attenuate the hypoxic pulmonary vasoconstrictive response presumably as a result of inappropriate release of constriction to poorly ventilated areas of the lung. SNP has been demonstrated to cause coronary 'steal' in various situations. In the context of acute coronary ischaemia, it probably results from dilation of resistance vessels in nonischaemic myocardium, resulting in diversion of blood flow from ischaemic areas where vessels are already maximally dilated. Any reduction in diastolic blood pressure which occurs as a result of afterload reduction may also contribute to the occurrence of coronary ischaemia. Number: 598 Which of the following drugs increases gastrointestinal motility? A. Fentanyl. B. Atropine. C. Neostigmine. D. Rocuronium. E. Glycopyrrolate. Select the single best answer ABCDE

287

Correct Answer: C By enhancing cholinergic activity, neostigmine increases gastrointestinal motility. Fentanyl, like the endorphins, has several important effects on the enteric nervous system. Within myenteric neurones, the opioids exert inhibitory influences and reduce intestinal motility. Within submucosal neurones they act to decrease mucosal secretion. Atropine, and glycopyrrolate both decrease gut motility. Rocuronium has no effect. Number: 613 With regard to remifentanil: 1. It has a histamine-releasing effect equivalent to an equianalgesic dose of morphine. 2. It has an elimination half-life of approximately 10 minutes. 3. Its effect is prolonged in patients with pseudocholinesterase deficiency. 4. It has a comparable potency to fentanyl. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: C 1. It produces no detectable histamine release when administered in doses of up to 30 mcgs/kg over 60 seconds. 2. Using a 3 compartment model, the drug has an initial distribution half-life of about 1 minute, a slower distribution half-life of about 6 minutes and an elimination half-life of approximately 10 minutes. Less than 10% of the AUC is contained within the terminal elimination component 3. The drug is hydrolysed by non-specific esterases in blood and tissues. It is not a substrate for pseudo-cholinesterase and its action is therefore not prolonged in patients with pseudocholinesterase deficiency. 4. The drug has a comparable potency to fentanyl. The pharmacokinetic profile of the drug is such that it is ideally suited to use by continuous infusion. The typical dose range for the drug in an intubated, ventilated patient is 0.1 - 0.5 mcg/kg/min. Hypotension and bradycardia are the most troublesome side-effects in such patients.

288

Number: 620 Which of the following are features of digoxin toxicity? 1. Nausea. 2. Gynaecomastia. 3. Xanthopsia. 4. Hypokalaemia. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: A Anorexia, nausea, and vomiting, are among the earliest signs of digoxin intoxication, and are caused by direct stimulation of centres in the medulla. The most typical dysrhthmia is ventricular ectopy either bigeminy, ventricular tachycardia, or, rarely, ventricular fibrillation. Atrioventricular block of varying degrees of severity is also characteristic. Gynaecomastia is a well-recognised complication of digoxin therapy which presumably reflects the affinity (but low potency) of the drug at androgen receptors. Chronic digoxin intoxication may be insidious in onset and characterised by weight loss, cachexia, neuralgias, gynaecomastia, Xanthopsia (yellow vision), and delirium. Hypokalaemia predisposes to toxicity but is not a cause by digoxin overdosage. Number: 629 In the case of a drug which exhibits first-order kinetics: 1. A constant proportion of it is metabolised in a given period of time. 2. It undergoes the most metabolism when plasma concentration is greatest. 3. It has a constant elimination half-life - irrespective of plasma concentration. 4. There is a linear relationship between plasma concentration and time. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct

289

ABCDE Correct Answer: A Option 4 describes, in part, the behaviour of a drug which exhibits zero-order kinetics. Zero-order kinetics are observed when the enzyme system responsible for the elimination of the drug is saturated. Some compounds (such as alcohol) are always eliminated by zero order processes, while many drugs (such as phenytoin, salicylates, thiopentone and theophylline derivatives) switch from first-order to zero-order as dosage is increased and the enzyme systems responsible for the elimination of the drug become saturated. Number: 630 Magnesium: 1. Can be used to control hypertension during surgery for phaeochromocytoma. 2. Is an N-methyl-D-aspartate antagonist. 3. Potentiates neuromuscular blockade. 4. Is a pulmonary vasoconstrictor. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: A Magnesium is an underused and underrated therapeutic compound. In addition to its important anti-dysrhythmic properties, it is an effective pulmonary and systemic vasodilator, has a role in chronic pain management because of its NMDA receptor blocking properties and potentiates the neuromuscular blocking effects of non-depolarising relaxants. For its use in phaeochromocytoma see: James MF. Use of magnesium sulphate in the anaesthetic management of phaeochromocytoma: a review of 17 anaesthetics. Br J Anaesth. 1989 Jun;62(6):616-23. For NMDA receptor blockade see: Antonov SM, Johnson JW. Permeant ion regulation of N-methyl-D-aspartate receptor channel block by Mg(2+). Proc Natl Acad Sci U S A. 1999 Dec 7;96(25):14571-6. For pulmonary effects see: Fullerton DA, Hahn AR, Agrafojo J, Sheridan BC, McIntyre RC Jr. Magnesium is essential in mechanisms of pulmonary vasomotor control. J Surg Res. 1996 Jun;63(1):93-7.

290

Number: 640 Which of the following agents inhibit adenosine diphosphate (ADP) induced platelet aggregation when administered at typical clinical concentrations? 1. Halothane. 2. Sevoflurane 3. Nitric Oxide. 4. Isoflurane. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: A The effects of anaesthetic agents on platelet function are complicated. Basically, two aspects have been examined. First, researchers have looked at the effect of volatile agents on induction of platelet aggregation by triggers such as ADP, collagen or thromboxane A2. Halothane has been found to inhibit this at clinically-used MAC levels. Sevoflurane probably exerts a similar effect, but the effect of isoflurane is only demonstrable at very high MAC (> 20) levels (Can J Anaesth 1997 Nov;44(11):1157-6. Platelet aggregation is impaired during anaesthesia with sevoflurane but not with isoflurane. Hirakata H, et al.). However, it should be noted that some agents reportedly have different effects on different triggers - see, for example, Nozuchi S et al. Sevoflurane does not inhibit human platelet aggregation induced by thrombin. Anesthesiology. 2000 Jan;92(1):164-70. The platelet inhibitory effect of 0-40 ppm inhaled nitric oxide (NO) has been investigated in volunteers. ADP induced platelet aggregation is significantly inhibited at inspired concentrations of 5, 10, and 40 ppm. Moreover, the in vitro bleeding time is significantly prolonged during inhalation of 40 ppm (Thromb Haemost 2000 Feb;83(2):309-15. Randomized, placebo-controlled, blinded and cross-matched study on the antiplatelet effect of inhaled nitric oxide in healthy volunteers. Gries A et al.). The second aspect of platelet function which has been examined is the effect of volatile anaesthetics on the expression of the adhesion molecule P-selectin. This aspect is dealt with in another question. Number: 642 Overdosage of 'Ecstasy' (3,4-methylene dioxymethamphetamine) may be associated with:

291

1. Hyperthermia. 2. Coagulopathy. 3. Rhabdomyolysis. 4. Peripheral neuropathy. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: A Ingestion of 3,4-methylene dioxymethamphetamine (MDMA), commonly known as "Ecstasy", produces a pattern of toxicity that includes fulminant hyperthermia, convulsions, disseminated intravascular coagulation, rhabdomyolysis, and acute renal failure. Number: 669 A basic drug with a pKa of 5.0: 1. Can be expected to readily cross the blood-brain barrier. 2. Will be subject to increased excretion if the urine is alkalinised. 3. Will be 50% ionised at a pH of 5.0. 4. Will be almost totally ionised at normal blood pH (7.4). A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: B A basic drug with a pKa of 5.0 will be present largely in the unionised, lipid-soluble form at blood pH, and so can be expected to readily cross the blood-brain barrier. An alkaline urine retards the excretion of a basic drug - by increasing the proportion of drug in the unionised, lipid-soluble form which can be re-absorbed back into the blood. This is the definition of pKa. Only 0.5% of the drug will be in the ionised form at blood pH.

292

Number: 678 The term "opioid" can be correctly applied to a compound which: 1. Is an agonist at the mu receptor. 2. Is a naturally occurring compound. 3. Is a partial agonist at the mu receptor. 4. Is an antagonist at the mu receptor. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: E The term "opioid" can be applied to agonists, partial agonists, mixed agonist-antagonists, and competitive antagonists at the opioid receptors. Opioids can be either naturally occurring or synthetic agents, and includes the endogenous peptides that act on opioid receptors. Number: 679 With regard to morphine: 1. It is approximately 60% protein-bound in the plasma. 2. Its blood-brain barrier penetration is more rapid than most other opiates. 3. Its bioavailability is between 60 and 80%. 4. It has a large steady-state volume of distribution. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: D 1. After intravenous administration, about 1/3rd of the administered dose becomes proteinbound, primarily to albumin. The remainder is redistributed rapidly, with a mean redistribution half-time of between 1.5 and 5.0 minutes.

293

2. Morphine is more water soluble than most other opiates and as a result it crosses the blood brain barrier quite slowly. Its peak effects may be delayed for 10 minutes or longer after intravenous administration as a result of this hydrophilicity. 3. Morphine has a high hepatic extraction ratio of 0.7, and thus a bioavailability after oral administration of only 20-30%. 4. The steady-state volume of distribution of morphine is large, approximately 3-4 L/kg. Number: 727 Dopamine antagonists: 1. Cause extrapyramidal side-effects. 2. May be used as antiemetics. 3. May increase gastric emptying. 4. Cause tachycardia. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: A The therapeutic effects of the antipsychotics are most closely related to their receptor binding action on dopamine receptors. The desired reversal of hallucinations and delusions is directly related to the relative degree of blockade of central dopamine receptors that inhibit adenylate cyclase. Thus, blockade of dopaminergic receptors is responsible for many of the side effects of the compounds. Dopamine receptors are distributed in five main areas in the central nervous system: 1. The retina; 2. The tuberoinfundibular area; 3. The mesocortical area; 4. The mesolimbic area; 5. The nigrostriatal area. Blockade of dopamine receptors in the nigrostriatal area accounts for the extrapyramidal sideeffects of the dopamine antagonists. Dopamine antagonists have a powerful action on the Chemoreceptor Trigger Zone.

294

Domperidone and metoclopramide are dopamine antagonists which increase the rate of gastric emptying and the tone of the lower oesophageal sphincter. Dopamine antagonists do not cause tachycardia per se. However, some dopamine antagonists (e.g. chlorpromazine) also induce alpha-receptor blockade and this may lead to a tachycardia secondary to vasodilatation. Number: 738 Nitroglycerine (GTN) has been administered for 24 hours through the lumen of a central venous catheter (CVC). The infusion is now changed to one of normal saline administered through the same lumen. Clinically significant amounts of GTN will be eluted into the saline for approximately: A. 20 seconds. B. 2 minutes. C. 20 minutes. D. 2 hours. E. 20 hours. Select the single best answer ABCDE Correct Answer: C A surprisingly large amount of GTN can be absorbed into a CVC. Akiyama et al have reported that clinically significant amounts of GTN may be delivered by elution for 20-45 minutes after cessation of a GTN infusion. Number: 740 Plasma pseudocholinesterase is: 1. Predominately responsible for the inactivation of cis-atracurium. 2. Inhibited by aminoglycoside antibiotics. 3. Found at an increased level in pregnancy. 4. Inhibited by organophosphorous compounds. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: D

295

Plasma pseudocholinesterase is found in the plasma but not in the red cell. It is also present in many other tissues, including the liver, brain, kidney, intestine, and pancreas. The physiological function of this enzyme is unclear, but it hydrolyses a large number of choline and other esters and, thus, is less specific than true acetylcholinesterase. It is synthesized in the liver. A number of drugs of importance to the anaesthestist are metabolised by pseudocholinesterase. These include suxamethonium, mivacurium and some of the local anaesthetics, such as procaine, 2-chloroprocaine, and tetracaine, which are esters of benzoic acid derivatives. Cis-atracurium is predominately converted to laudanosine and the monoquaternary acrylate metabolite via Hofmann elimination. Aminoglycoside antibiotics have no effect on plasma pseudocholinesterase, but may prolong the action of non-depolarising neuromuscular blockers. The plasma level of pseudocholinesterase is reduced in pregnancy. Number: 746 The plasma concentration of a drug declines in a manner which is compatible with 'first-order' kinetics. Which of the following statements is correct? A. The drug is likely to be eliminated via a single metabolic pathway. B. The rate of elimination of the drug is independent of plasma concentration. C. The elimination half-life is constant whatever the plasma concentration of the drug. D. The plasma concentration of the drug plotted against time will yield a straight line. E. Aspirin is an example of such a drug. Select the single best answer ABCDE Correct Answer: C A. First-order kinetics do not imply the presence of a single metabolic pathway.- Provided that each elimination pathway follows first-order kinetics, the plasma level of the drug will also follow this kinetic model. B. The rate of elimination of the drug is directly proportional to the plasma concentration. C. The elimination half-life is constant whatever the plasma concentration of the drug. D. A logarithmic plot of the plasma concentration of the drug against time will yield a straight line. E. Aspirin is not an example of such a drug. The half-life of aspirin is determined by the plasma concentration of the drug.

296

Number: 756 Which of the following effects are NOT provoked by histamine? A. Tachycardia B. Enhancement of myocardial contractility. C. Coronary artery vasodilatation D. Prolongation of the PR interval E. Prolongation of the QT interval. Select the single best answer ABCDE Correct Answer: E Histamine is a positive chronotrope - both directly via H2 receptors and indirectly by stimulation of adrenal catecholamine release. Enhancement of myocardial contractility occurs via stimulation of H2 receptors. Both vasodilation (via H2 receptors) and vasoconstriction (via H1 receptors) can occur. Histamine markedly increases the PR interval. Blockade of H1 receptors causes prolongation of the QT interval. Number: 757 Dantrolene Sodium: 1. Depresses neuromuscular transmission. 2. Lowers the Ca++ level in the sarcoplasmic reticulum (SPR). 3. Is more soluble in an acid solution. 4. Is active at the ryanodine receptor. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct

ABCDE Correct Answer: D

297

Dantrolene is a skeletal muscle relaxant which acts by inhibiting intracellular Ca(2+) release from sarcoplasmic reticulum (SR). The skeletal muscle ryanodine receptor is the principal molecular target for the drug. It has no direct effects on neuromuscular transmission. Dantrolene is poorly soluble in water. It is supplied in ampoules containing 20 mg of lyophilised dantrolene sodium (powder) together with mannitol (3G, to improve solubility) and sodium hydroxide to yield a solution of pH 9.5, when the contents are dissolved in 60 mI of water. The final concentration of the parenteral preparation is 0.33 mg/ml. Number: 760 The risk of a severe reaction to protamine used for heparin reversal following cardiopulmonary bypass is considerably more likely in: 1. A diabetic treated with neutral protamine Hagedorn (NPH) insulin. 2. A man who has had a vasectomy. 3. A patient who gives a history of allergy to fish. 4. A non-insulin dependent diabetic A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: B In a recent study by Kimmel et al three risk factors which were independently associated with an adverse reaction to protamine were identified. These were neutral protamine Hagedorn insulin use, fish allergy and a history of non-protamine medication allergy. Surprisingly previous exposure to protamine (for heparin reversal) did not increase the risk of a severe reaction, but did increase the risk of development of transient pulmonary hypertension. The situation with regard to previous vasectomy is less clear. - The majority of vasectomised men develop antibodies against different sperm antigens, including protamine. Because salmon protamine is used for heparin reversal and a cross-reactivity has been observed between human and salmon protamine, vasectomised men are theorectically be at risk of adverse reactions. In practice this does not appear to be a major issue and (for example) Vezina et al have concluded that "Vasectomized men are not at increased risk of adverse reactions following the injection of protamine sulfate." Number: 775 Midazolam 1. Can be given intranasally.

298

2. May have a prolonged effect if given with erythromycin. 3. Has active metabolites. 4. Is soluble in water at a pH of 4.0 A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: E Midazolam can be given intranasally - it is particularly useful in children when used by this route. Both midazolam and erythromycin are substrates for the cytochrome P450 (CYP) 3A system. Midazolam is metabolised in the liver by hydroxylation to the major metabolite, 1-hydroxy midazolam, and a secondary metabolite, 4-hydroxy midazolam. Both 1- and 4-hydroxy midazolam metabolites are conjugated and then excreted in the urine as glucuronides. Although the metabolites have pharmacological activity, they are probably of little clinical importance. Midazolam is water soluble (pK, of midazolam is 6.5) and the parenteral formulation therefore does not contain organic solvents.

Number: 783 Esmolol: 1. Is metabolised by plasma pseudocholinesterase. 2. Has an elimination half-life of about 10 minutes. 3. Rarely causes hypotension. 4. Is a cardio-selective beta blocker. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: C

299

Esmolol is an ultra short-acting intravenous cardioselective beta-blocker. It has an extremely short elimination half-life (mean: 9 minutes; range: 4 to 16 minutes) and a total body clearance approaching 3 times cardiac output and 15 times hepatic blood flow. The elimination of esmolol is independent of renal or hepatic function as it is metabolised by red blood cell cytosol esterases to an acid metabolite and methanol. The acid metabolite, which is renally eliminated, has 1500-fold less activity than esmolol. The principal adverse effect of esmolol is hypotension. The incidence of hypotension appears to increase with doses exceeding 150 micrograms/kg/min and in patients with low baseline blood pressure. Hypotension infrequently requires any intervention other than decreasing the dose or discontinuing the infusion. The drug has been comprehensively reviewed by Wiest. See: Clin Pharmacokinet 1995 Mar;28(3):190-202: Esmolol. A review of its therapeutic efficacy and pharmacokinetic characteristics. Wiest D Number: 802 The use of sodium nitroprusside is relatively contraindicated in a patient with: 1. Tobacco Amblyopia. 2. Protein - Calorie Malnutrition (PCM). 3. Leber's Optic Atrophy. 4. Uncomplicated type I diabetes mellitus. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: A Tobacco amblyopia and Leber's optic atrophy have both been attributed to the effects of chronic cyanide intoxication. For this reason, the use of sodium nitroprusside is relatively contraindicated. Tobacco amblyopia is now so rare that some observers have questioned whether or not the condition exists!! - However, two cases were reported in the United States as recently as 1993. (See: Rizzo JF, Lessell S. Tobacco amblyopia. Am J Ophthalmol. 1993 Jul 15;116(1):84-7.)

300

Leber's Optic Atrophy is believed to be caused by a defect in cyanide metabolism. See: Berninger TA, von Meyer L, Siess E, Schon O, Goebel FD. Leber's hereditary optic atrophy: further evidence for a defect of cyanide metabolism? Br J Ophthalmol. 1989 Apr;73(4):314-6. The use of sodium nitroprusside is relatively contraindicated in a patient with protein - calorie malnutrition as thiosulfate stores are depleted in PCM. This is particularly true if the diet of the starving person includes cassava roots (as is the case in some parts of Africa) which are an important natural source of cyanide. See Osuntokun BO. Nutritional problems in the African region. Bull Schweiz Akad Med Wiss. 1976 Mar;31(4-6):353-76. The use of SNP does not appear to be contraindicated in a patient with uncomplicated diabetes mellitus. Number: 825 Clonidine: 1. Increases the minimal alveolar concentration of volatile agents. 2. Is an alpha 1 adrenoceptor agonist. 3. Is contraindicated via the epidural route. 4. Reduces plasma catecholamine levels. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: D Numerous studies have shown that the drug reduces the minimal alveolar concentration of volatile agents. Clonidine is a relatively selective alpha 2 agonist. By stimulating alpha 2 receptors in the central nervous system, sympathetic outflow from the central nervous system is reduced, catecholamine levels fall, and a reduction in blood pressure occurs. In addition, plasma renin activity falls, probably as a result of reduced sympathetic stimulation at the renal adrenergic receptors. Stimulation of the presynaptic receptors on the adrenergic neurons, which inhibit catecholamine release, may also contribute to the observed reduction in catecholamines following clonidine administration. Similarly, the drug has an important adjunctive role in the field of epidural analgesia. See, for example, Kizilarslan S, Kuvaki B, Onat U, Sagiroglu E. Epidural fentanyl-bupivacaine compared with clonidine-bupivacaine for analgesia in labour. Eur J Anaesthesiol. 2000 Nov;17(11):692-7.

301

Number: 838 Which of the following compounds is NOT a precursor of adrenaline? A. Tyrosine. B. Phenylalanine C. Dopamine. D. Phenylephrine. E. Noradrenaline. Select the single best answer ABCDE Correct Answer: D The biosynthetic pathway of adrenaline is: Phenylalanine - Tyrosine - DOPA - Dopamine - Noradrenaline - Adrenaline. Number: 838 Which of the following compounds is NOT a precursor of adrenaline? A. Tyrosine. B. Phenylalanine C. Dopamine. D. Phenylephrine. E. Noradrenaline. Select the single best answer ABCDE Correct Answer: D The biosynthetic pathway of adrenaline is: Phenylalanine - Tyrosine - DOPA - Dopamine - Noradrenaline - Adrenaline. Number: 839 Which statement is INCORRECT with regard to hydralazine? A. It is partly metabolised by acetylation. B. It is partly metabolised by plasma cholinesterase. C. It can cause a lupus-like syndrome. D. It stimulates the baroreceptor reflex. E. It is a direct-acting arteriolar vasodilator.

302

Select the single best answer ABCDE Correct Answer: B Hydralazine remains a useful and effective antihypertensive agent. It acts directly to produce arterial muscle relaxation with a consequent fall in peripheral resistance and blood pressure. Reflex tachycardia (due to stimulation of the baroreceptors) can be a troublesome side-effect - which is well treated by simultaneous beta blockade. A drug-induced lupus syndrome is produced by prolonged high-dose hydralazine therapy. This side effect occurs more commonly at high hydralazine concentrations, being seen in 10 to 20% of patients receiving 400 mg/day. The drug is partially metabolised by acetylation, the rate of which is bimodally distributed in the population. Slow acetylators, because they eliminate the drug more slowly, develop druginduced lupus at lower hydralazine doses than do fast acetylators. Number: 905 Which of the following drugs possess anti-platelet activity? 1. Sevoflurane. 2. Abciximab. 3. Hydroxy Ethyl Starch (Hetastarch). 4. Clopidogrel. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: E Sevoflurane (in common with many other volatile agents) alters platelet aggregation possibly by suppression of thromboxane A2 formation. Abciximab (human-murine chimeric monoclonal antibody Fab fragment) is a platelet GP IIb/IIIa receptor antagonist. Others in this class of drug are the peptide antagonist eptifibatide and the peptidomimetics tirofiban and lamifiban. Hetastarch inhibits platelet function by reducing the availability of the functional receptor for fibrinogen on the platelet surface. (It may also impair coagulation by prolonging the partial thromboplastin times and decreasing factor VIII activity and fibrinogen levels.)

303

Clopidogrel is an inhibitor of A.P. induced platelet aggregation acting by direct inhibition of adenosine diphosphate (ADP) binding to its receptor and of the subsequent A.P. mediated activation of the glycoprotein GPIIb/ IIIa complex. Chemically it is methyl (+)-( S)-a -(2chlorophenyl)-6,7-dihydrothieno[3,2-c] pyridine-5(4H)-acetate sulfate (1:1). Number: 938 The plasma half-life of protamine is approximately: A. 10 minutes. B. 30 minutes. C. 1 hour. D. 2 hours. E. 4 hours. Select the single best answer ABCDE Correct Answer: A This topic has been the subject of recent research by Buttwerworth et al. They found the halflife to be about 7.4 minutes. According to these authors: "Despite its long use in clinical medicine, protamine concentrations and pharmacokinetics in humans have not been reported. The occasional reoccurrence of anticoagulation after protamine reversal of heparin led us to hypothesize that protamine plasma concentrations decrease rapidly. We developed a method for the measurement of protamine in plasma. Eighteen fit volunteers gave their consent to receive 0.5 mg/kg protamine sulfate administered IV by an infusion pump over 10 min. Heart rate, mean arterial blood pressure, and cardiac output, all measured noninvasively, were recorded and blood samples obtained during and after protamine infusion. Blood plasma was subjected to solid-phase extraction and highperformance liquid chromatography. The administration of protamine was associated with no significant changes in heart rate, mean arterial blood pressure, or cardiac output. Plasma protamine concentrations decreased rapidly, becoming nondetectable within approximately 20 min. Protamine elimination differed significantly between men and women: men had significantly larger areas under the concentration versus time curve. Model-independent pharmacokinetic analysis revealed median (range) values as follows: volume of distribution at steady state, 12.3 (6.963.1) L; clearance, 2.2 (1.112.1) L/min; and t1/2, 7.4 (5.99.3) min. Concentration versus time plots revealed an atypical pattern inconsistent with usual exponential models. The Schwartz-Bayesian criterion identified a one-compartment Michaelis-Menten model and a two-compartment exponential model with irreversible binding as performing better than conventional one- or two-compartmental exponential models; however, performance errors were large with both Michaelis-Menten and exponential models. All models described rapid decreases in protamine blood concentrations. IMPLICATIONS: We developed a method for measurement of protamine in human blood. In volunteers, protamine concentrations decreased rapidly after administration. The rapid

304

disappearance of protamine from the circulation, as defined by a median half-life of 7.4 min, could contribute to cases of "heparin rebound" after initial adequate reversal of heparin. " See: Butterworth J, Lin YA, Prielipp R, Bennett J, James R. The pharmacokinetics and cardiovascular effects of a single intravenous dose of protamine in normal volunteers. Anesth Analg. 2002 Mar;94(3):514-22. Number: 939 The effects of cannabis include: 1. Anti-emesis. 2. A reduction in intra-ocular pressure. 3. Bronchodilatation. 4. Hypertension. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: A The pharmacological actions and therapeutic uses of cannabis and cannabinoids have recently been superbly reviewed by Kumar et al. According to these authors: 1. Cannabinoids have been used in the prevention of nausea and vomiting caused by anticancer drugs. Nabilone and dronabinol (THC in sesame oil) have been shown to be as effective or more effective than phenothiazines, metoclopramide and domperidone for this indication, although they have not been tested against the 5-HT3 antagonist ondansetron. Nabilone is usually given in a dose of 48 mg per day in divided doses for a few days during cancer chemotherapy. There is a high incidence of adverse effects and 50 100% of patients experience drowsiness, dizziness and lethargy. 2. Several studies have shown that smoked or orally administered cannabis and intravenous infusions of THC can decrease intraocular pressure (IOP) in normal subjects. Only two double-blind controlled trials of THC in patients with glaucoma have been reported. Merritt et al. studied 18 patients who inhaled THC 2%. They observed a significant decrease in IOP but also noted hypotension, palpitations and psychotropic effects. These effects occurred with such frequency as to militate against the routine use of cannabis in this way. Tolerance to the IOP-decreasing effect develops rapidly and the place of cannabinoids in the treatment of glaucoma remains to be established. 3. Acute administration of cannabis and THC exert a definite bronchodilator effect on the small airways of the lungs. Tashkin et al. studied 14 asthmatic volunteers and compared

305

smoked cannabis (THC 2%), oral THC (15 mg) and a standard bronchodilator (isoprenaline 0.5%). They found that smoked cannabis and oral THC produced significant bronchodilation for at least 2 h. However, smoking cannabis is not a therapeutic option because of the other smoke constituents. 4. The drug tends to cause hypotension - at least in part due to a peripheral vasodilatory effect. See: Kumar RN, Chambers WA, Pertwee RG. Pharmacological actions and therapeutic uses of cannabis and cannabinoids. Anaesthesia. 2001 Nov;56(11):1059-68. Number: 984 Clopidogrel: 1. May prolong the bleeding time for at least a week. 2. Is metabolised to a more active metabolite. 3. May cause thrombocytopenia. 4. Is a reversible platelet ADP receptor antagonist. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: A Kam and Nethery have recently published an excellent review on the thienopyridine platelet antagonists (Clopidogrel and Ticlopidine). According to these authors: "The ADP receptor antagonists produce irreversible inhibition of platelet aggregation, and therefore the effect is present for the life of the platelet. Bleeding time returns to normal 10 days after ceasing clopidogrel administration. A platelet count should be performed to exclude neutropenia or thrombocytopenia. Platelet aggregation tests may be useful in patients presenting for elective surgery. Further studies are required to evaluate the value of the pointof-care platelet function monitor (PFA-100) for assessing residual antiplatelet effects in patients receiving the thienopyridines and presenting for urgent or emergency surgery. For elective surgical procedures, these agents should be stopped 7-10 days before surgery, except if the benefit of the antiplatelet effect outweighs the risk of peri-operative bleeding. Clopidogrel treatment in addition to aspirin before percutaneous coronary intervention has been shown to decrease the incidence of coronary occlusive events. Pre-operative clopidogrel treatment may be useful in decreasing the incidence of thrombosis in patients with peripheral arterial disease undergoing vascular interventions, e.g. arterial bypass, endarterectomy or percutaneous transluminal angioplasty."

306

Clopidogrel undergoes extensive and rapid metabolism by the hepatic cytochrome P450-1A enzymes to produce active and inactive metabolites. The active metabolite has been identified only recently - being a thiol derivative of the parent molecule. The drug may cause thrombocytopenia, but far less commonly than ticlopidine. See: Kam PC, Nethery CM. The thienopyridine derivatives (platelet adenosine diphosphate receptor antagonists), pharmacology and clinical developments. Anaesthesia. 2003 Jan;58(1):28-35. Number: 989 Protamine administered after termination of cardio-pulmonary bypass may cause: 1. An anaphylactic reaction. 2. Intense pulmonary vasoconstriction. 3. Histamine release. 4. Profound myocardial depression. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: A The subject of protamine reactions is superbly addressed by Gravlee in his book on cardiopulmonary bypass. According to this author: "Horrow's classification sorts protamine reactions into type 1, type II, and type Ill. Type 1 reactions result in transient systemic hypotension secondary to rapid administration. Type II reactions consist of anaphylactic and anaphylactoid reactions, which are further divided into types Ha, Ilb, and Ilc. Type lla comprises true anaphylactic reactions. Immediate anaphylactoid reactions characterize type llb, and delayed anaphylactoid (e.g., noncardiogenic pulmonary edema) are considered type IIc reactions. Type Ill reactions consist of catastrophic pulmonary vasoconstriction. We propose an alternative classification as follows: (a) pharmacologic histamine release, (b) true anaphylaxis mediated by a specific antiprotamine immunoglobulin (Ig) IE antibody, and (c) thromboxane release leading to pulmonary vasoconstriction and bronchoconstriction. Thus, Horrow's type I reactions, which are characterized by systemic hypotension secondary to rapid administration, correspond in our classification to pharmacologic histamine release. Whereas Horrow includes true anaphylactic and anaphylactoid reaction in his type 11, we consider them as two different types because true anaphylaxis is mediated by a specific

307

antiprotamine lgE antibody that can be produced by protamine in the absence of heparin. The role of antiprotamine IgG antibodies is not clear. The anaphylactoid reaction is independent of a specific lgE antibody, is associated with the heparin-protamine complex, and does not occur in the absence of heparin. Catastrophic pulmonary vasoconstriction is the most common example of the anaphylactoid reaction in our categorization, whereas Horrow classifies it separately. The rare occurrence of delayed pulmonary edema and adult respiratory distress syndrome appear to represent different manifestations of anaphylactoid responses, thus we classify them that way." Ford et al have recently analysed the records of 23 patients who suffered anaphylaxis during cardiac surgery. In their study, 7 of 23 (30%) patients reacted to the antibiotics (6 to cephalosporins, 1 to vancomycin); 6 of 23 (26%), to gelatin solution (Hemaccel, Hoechst, Australia); 4 of 23 (17%), to nondepolarizing muscle relaxants; 3 of 23 (13%), to protamine; 2 of 23 (9%), to blood products; and 1 of 23 (4%), to morphine. The matter is slightly contentious, but the drug is almost certainly NOT a profound myocardial depressant. See: Cardiopulmonary Bypass: Principles and Practice 2/ed. Glenn P. Gravlee. Lippincott Williams & Wilkins ISBN: 0683304763 7 LCCN: 99057043 Ford SA, Kam PC, Baldo BA, Fisher MM. Anaphylactic or anaphylactoid reactions in patients undergoing cardiac surgery. J Cardiothorac Vasc Anesth. 2001 Dec;15(6):684-8. Number: 1021 Dexmedetomidine: 1. Is an alpha2-adrenoreceptor antagonist. 2. Has analgesic properties. 3. Has an elimination phase half-life of about 6 minutes. 4. Has a tendency to cause bradycardia. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: C

308

MEDICINE TESTS Number: 2 A 27 year old, otherwise fit man gives a history suggestive of recurrent tachyarrhythmias. During a previous anaesthetic he apparently arrested and required DC cardioversion. He now presents for an arthroscopy. His ECG is shown below. The most likely diagnosis is: A. Lown Ganong Levine syndrome. B. Prolonged QT syndrome. C. Wolff Parkinson White syndrome. D. Sick Sinus syndrome. E. Atrio-Ventricular (AV) nodal re-entrant tachycardia. Select the single best answer

ABCDE Correct Answer: C This is a classic picture of the Wolff Parkinson White syndrome. - Note the short PR interval (less than 120 ms), slurred upstroke to the QRS indicating pre-excitation ('delta' wave), broad QRS and secondary ST and T wave changes. The typical clinical presentation of prolonged QT syndrome is the occurrence of syncope or cardiac arrest, precipitated by emotional or physical stress, in a young individual with a prolonged Q-T interval on the ECG. The syncopal episodes are due to torsade de pointes (not tachycardia) - which often degenerates into ventricular fibrillation. Traditionally, a Q-T interval in excess of 440msec is considered prolonged. Lown Ganong Levine syndrome is a form of pre-excitation characterised by a short PR interval associated with a normal QRS complex.

309

The diagnosis of sick sinus syndrome is best made by Holter monitoring (at the time of symptoms). AV nodal re-entrant tachycardia is the most common type of re-entrant paroxysmal supraventricular tachycardia (SVT), occurring in about 60% of patients with SVT. Symptoms most commonly appear in the late teens or early twenties. Patients with AV nodal re-entrant tachycardia have no greater incidence of heart disease than the general population. The AV nodal re-entrant circuit involves the AV node and tissue in close proximity to it. Dual conduction pathways within the node allow electrical impulses to recycle within the AV nodal region at rate of 150-250 beats per minute after a premature beat encounters one of the pathways during its refractory period. The ECG is normal when the re-entry circuit is not active. For those with an interest in eponymous conditions: Louis Wolff qualified in medicine at Harvard in 1922. He spent his internship at the Massachusetts General Hospital and subsequently specialised in cardiology. He was a visiting physician and chief of the electrocardiographic laboratory at the Beth Israel Hospital. John Parkinson attended University College, London, and subsequently trained in medicine at the University of Freiburg and the London Hospital. He qualified 1907 and obtained a doctorate in 1910. He became the consultant in charge of the cardiology department at the London Hospital and was also appointed to the consulting staff of the National Heart hospital, London. From 1931 to 1956 he was a civilian cardiologist to the Royal Air Force. Paul Dudley White was the son of a family doctor in Roxbury, Massachusetts. He was educated at the Roxbury Latin Grammar School, proceeding to Harvard University and graduating in 1908. He studied medicine at Harvard, graduating in 1911 and interned at the newly established department of paediatrics at Massachusetts General Hospital. For the next two years he was on the medical service with Dr. R. I. Lee and together they developed a technique for measuring blood coagulation, which is still commonly used, called the Lee and White method. This was his first medical publication. Financed by a Sheldon travelling scholarship he then spent a year with Thomas Lewis (1881-1945) studying the electrocardiogram (ECG) at the University College Hospital in London. Number: 50 A fifty year old man suffers an acute myocardial infarction (MI). In which of the following conditions is temporary transvenous pacing most clearly indicated? A. First-degree heart block. B. Mobitz type I second-degree AV block with normal haemodynamics. C. Mobitz type II second-degree AV block. D. Accelerated idioventricular rhythm. E. Bundle branch block known to exist before the acute MI. Select the single best answer

310

ABCDE Correct Answer: C A Committee of the American College of Cardiology and the American Heart Association has published an authoritative series of recommendations for the management of patients suffering acute myocardial infarction. Their recommendations for the institution of temporary transvenous pacing (from 'Class 1' (most pursuasive) to 'Class 3' (least pursuasive)) are: Class 1: 1. Asystole. 2. Symptomatic bradycardia (includes sinus bradycardia with hypotension and type I seconddegree AV block with hypotension not responsive to atropine). 3. Bilateral BBB (alternating BBB or RBBB with alternating LAFB/LPFB) (any age). 4. New or indeterminate age bifascicular block (RBBB with LAFB or LPFB, or LBBB) with first-degree AV block. 5. Mobitz type II second-degree AV block. Class 2a: 1. RBBB and LAFB or LPFB (new or indeterminate). 2. RBBB with first-degree AV block. 3. LBBB, new or indeterminate. 4. Incessant VT, for atrial or ventricular overdrive pacing. 5. Recurrent sinus pauses (greater than 3 seconds) not responsive to atropine. Class 2b: 1. Bifascicular block of indeterminate age. 2. New or age-indeterminate isolated RBBB. Class 3: 1. First-degree heart block. 2. Type I second-degree AV block with normal hemodynamics. 3. Accelerated idioventricular rhythm. 4. Bundle branch block or fascicular block known to exist before acute MI. Number: 60 In the case of a fifty year old man with a phaeochromocytoma: 1. The administration of glucagon will elevate his plasma catecholamine levels. 2. The administration of clonidine will suppress his plasma catecholamine levels. 3. I-131 - metaiodobenzyl guanidine can be used to localise the site of his tumour. 4. There is a less than 1% chance that the tumour is malignant. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct

311

E: All Correct ABCDE Correct Answer: B The diagnosis of phaeochromocytoma requires the demonstration of excessive catecholamine secretion. The most widely used procedure includes measurement of urinary catecholamines or their metabolites, vanillomandelic acid and total metanephrines. Of these, the urinary metanephrines provide a more sensitive clue to the presence of phaeochromocytoma. Furthermore, plasma catecholamine measurements may be as reliable as the measurement of urinary metabolites. Determination of plasma catecholamines requires that the patient be in a fasting state and should rest comfortably in the supine position for at least 30 minutes before testing. The amounts of excreted free catecholamines and their metabolites vary depending on the levels of synthesising and metabolising enzymes within the tumour. Additional provocative testing may be done with a glucagon stimulation test. Glucagon is given as an IV bolus of 1.02.0mg. A positive glucagon test requires a clear increase of at least three fold or over 2,000 picogram/ml in plasma catecholamines one to three minutes after drug administration. A simultaneous increase in blood pressure of at least 20mmHg should be present. A suppression test uses the ability of clonidine, a centrally acting alpha- adrenergic agonist, to suppress the release of neurogenically mediated catecholamines. Plasma catecholamines in patients with essential hypertension are suppressed by clonidine, whereas they are unaltered in patients with phaeochromocytoma. A normal clonidine suppression tests consists of a fall of noradrenaline and adrenaline to a level below 500 picogram/ml 2- 3 hours after the administration of 0.3mg of clonidine. Bravo et al have devised the following approach to patients with possible pheochromocytoma. Concentrations of total plasma catecholamines are measured after the patient is rested in a supine position for at least 30 minutes. Values over 2,000 picogram/ml are considered pathognomonic of phaeochromocytoma. Patients with values between 1,000 and 2,000 picogram/ml receive a clonidine suppression test. An abdominal CT scan is then performed on patients with clinical and biochemical features suggestive of phaeochromocytoma. A recently developed technique for localisation of neoplastic chromaffin tissues uses I-131 metaiodobenzyl guanidine (MIBG), a radioactive compound selectively taken up by adrenergic cells. 8 - 10% of the tumours are malignant. See: Sjoberg RJ, Simcic KJ, Kidd GS. The clonidine suppression test for pheochromocytoma. A review of its utility and pitfalls. Arch Intern Med. 1992 Jun;152(6):1193-7. Grossman E, Goldstein DS, Hoffman A, Keiser HR. Glucagon and clonidine testing in the diagnosis of pheochromocytoma. Hypertension. 1991 Jun;17(6 Pt 1):733-41

312

Number: 222 With regard to the Dandy-Walker syndrome: 1. The cerebellar vermis is hypoplastic. 2. Obstructive hydrocephalus is the commonest mode of presentation. 3. Presentation usually occurs within the 1st two years of life. 4. A cyst is always present in the posterior fossa A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: E The syndrome comprises dilatation of the 4th ventricle, a posterior fossa cyst and cerebellar vermis agenesis. Presentation usually occurs in early childhood as obstructive hydrocephalus. Cone AM. Dandy-Walker syndrome. Anaesth. Intens. Care 1995; 23:613-615. Number: 251 In transfusion practice: 1. Fever is usually due to anti-leucocyte antibodies 2. Desmopressin (DDAVP) will raise levels of factor VIII in patients with mild haemophilia A 3. Haemolytic reactions may be delayed for up to 1 week 4. Severe anaphylaxis may be seen in IgA deficient individuals A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: E In IgA deficient individuals IgA is a foreign body. Number: 252

313

Recognised causes of macrocytosis in the peripheral blood with normoblastic erythropoiesis in the bone marrow include: 1. Hypothyroidism 2. Chronic alcohol abuse 3. Cryptogenic cirrhosis 4. The administration of phenytoin A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: A A number of drugs antagonize folate by mechanisms which are poorly understood but are thought to involve an effect on absorption of the vitamin by the intestine. In this category are the anticonvulsants phenytoin (Dilantin) and primidone (Mysoline) and phenobarbital (Luminal). Megaloblastic anemia induced by these agents is mild. Number: 253 Which are true of Hepatitis E virus? 1, It is a 34nm single stranded RNA virus. 2. It is more common in IV drug abusers 3. Can produce epidemic waterborne infections 4. Will cause 10% of patients to develop chronic hepatitis A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: B A distinct type of waterborne "non-A, non-B" hepatitis has been identified in India, Asia, Africa, and Central America (previously labeled epidemic or enterically transmitted non-A, non-B hepatitis). This agent, with epidemiologic features resembling those of hepatitis A, has been classified as hepatitis E virus (HEV). Hepatitis E virus is a 32- to 34-nm, nonenveloped, HAV-like virus with a 7600-nucleotide, single-stranded RNA genome.

314

Number: 254 Which of the following are correctly paired? 1. Conn's syndrome and metabolic alkalosis 2. Uretero-colic anastomosis and hyperchloraemic acidosis 3. Shock and metabolic acidosis 4. Pancreatic fistula and metabolic acidosis A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: E Conn's syndrome The majority of cases of Conn's syndrome involve a unilateral adenoma, usually small and occurring with equal frequency on either side. Rarely, primary aldosteronism occurs in association with adrenal carcinoma. It is twice as common in women as in men, occurs between the ages of 30 and 50, and is present in approximately 1 percent of unselected hypertensive patients. Many cases have clinical and biochemical features characteristic of primary aldosteronism, but a solitary adenoma is not found at surgery. Instead, these patients have bilateral cortical nodular hyperplasia. In the literature this disease has been alternatively termed "pseudo" primary aldosteronism, idiopathic hyperaldosteronism, or nodular hyperplasia. The cause is unknown. The continual hypersecretion of aldosterone increases the renal distal tubular exchange of intratubular sodium for secreted potassium and hydrogen ions, with progressive depletion of body potassium and development of hypokalemia. Most patients have diastolic hypertension, usually not of marked severity, and complain of headaches. The hypertension is probably due to the increased sodium reabsorption and extracellular volume expansion. Potassium depletion is responsible for the muscle weakness and fatigue and is related to the effect of potassium depletion on muscle membrane. The polyuria results from impairment of concentrating ability and is often associated with polydipsia. Number: 255 The following are recognised causes of pulmonary fibrosis: 1. External raditaion for carcinoma of the breast 2. Bleomycin 3. Sarcoidosis 4. Myelofibrosis A: 1,2,3 Correct B: 1,3 Correct

315

C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: A Idiopathic Pulmonary Fibrosis (IPF) is a chronic inflammatory fibrotic disorder localized to the lower respiratory tract and characterized by an alveolitis dominated by alveolar macrophages and neutrophils and, to a lesser extent, lymphocytes and eosinophils. The disease usually presents as dyspnea on exertion, The three classic x-ray patterns of pulmonary sarcoidosis are type I--bilateral hilar adenopathy with no parenchymal abnormalities; type II--bilateral hilar adenopathy with diffuse parenchymal changes; and type III--diffuse parenchymal changes without hilar adenopathy. The type III pattern is sometimes split into two categories, with films that show fibrosis and upper lobe retraction classified separately. Although patients with type I x-rays tend to have the acute or subacute, reversible form of the disease while those with types II and III often have the chronic, progressive disease, these patterns do not represent consecutive "stages" of sarcoidosis. Number: 256 Recognised causes of finger clubbing include: 1. Carcinoid tumour 2. Bronchial carcinoma 3. Iron deficiency anaemia 4. Coeliac disease A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: C The selective bullous enlargement of the distal segments of the fingers and toes due to proliferation of connective tissue, particularly on the dorsal surface, is termed clubbing; an increase occurs in the sponginess of the soft tissue at the base of the nail. Clubbing may be hereditary, idiopathic, or acquired and associated with a variety of disorders, including cyanotic congenital heart disease, infective endocarditis, and a variety of pulmonary conditions (among them primary and metastatic lung cancer, bronchiectasis, lung abscess, cystic fibrosis, and mesothelioma), as well as with some gastrointestinal diseases (including regional enteritis, chronic ulcerative colitis, and hepatic cirrhosis).

316

Clubbing in patients with primary and metastatic lung cancer, mesothelioma, bronchiectasis, and hepatic cirrhosis may be associated with hypertrophic osteoarthropathy. In this condition, the subperiosteal formation of new bone in the distal diaphyses of the long bones of the extremities causes pain and symmetric arthritis-like changes in the shoulders, knees, ankles, wrists, and elbows. The diagnosis of hypertrophic osteoarthropathy may be confirmed by bone radiographs and scans. Although the mechanism of clubbing is unclear, it appears to be secondary to a (presumably humoral) substance which causes dilation of the vessels of the fingertip. Number: 257 Dupuytren's contracture has a recognised association with: 1. Diabetes Mellitus 2. Peyronie's disease 3. Epilepsy 4. Alcoholic liver cirrhosis A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: E Palmar erythema, facial telangiectasia, and Dupuytren's contractures are associated with cirrhosis, particularly as a result of chronic ethanol ingestion. An interesting accompaniment of insulin-dependent diabetes is the presence of joint contractures (Dupuytren's contracture) coupled with tight, waxy skin over the dorsum of the hands. The hands resemble those in patients with scleroderma. The cause of the tendon contractures is unknown, although alterations of cross-linking in collagen has been proposed. Number: 259 In the treatment of chronic hepatitis B virus: 1. Corticosteroids are always beneficial 2. 40% of patients can be expected to respond to interferon 3. Combined treatment with acyclovir and interferon is more effective than interferon alone 4. Interferon can be associated with a rise in transaminases towards the end of therapy A: 1,2,3 Correct B: 1,3 Correct

317

C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: C Interferon a2b administered to patients with stable chronic hepatitis B infection resulted in loss of markers of HBV replication, such as HBeAg and HBV DNA, in 40 to 50 percent of patients who received daily doses of 5 million units for 16 weeks; 10 to 20 percent of patients also became HBsAg negative. More than 80 percent of patients who lose HBeAg and HBV DNA markers will have return of serum aminotransferases to normal levels, and both shortand long-term improvement in liver histopathology has been described. Predictors of a favorable response to therapy include low pretherapy HBV DNA levels, high pretherapy serum ALT levels, short duration of chronic hepatitis B infection, and active liver histopathology. Adverse effects of the preceding dose of interferon are common and include fever, chills, myalgia, and fatigue. Approximately 25 percent of patients receiving a daily dose of 5 million units will require dose reduction, but fewer than 5 percent will require discontinuation of therapy. Number: 260 Which of the following statements is / are true of streptococcus pyogenes infections: 1. They account for less than 5% of upper respiratory infections in children under the age of 2 years 2. Rheumatic chorea is a recognised sequela 3. It is a cause of erysipelas 4. The treatment of choice is ampicillin A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: A Lancefield's group A consists of a single species, S. pyogenes. As its species name implies, this organism is associated with a variety of suppurative infections. In addition, group A streptococci are unique among known bacterial pathogens in their capacity to trigger the postinfectious syndromes of acute rheumatic fever and poststreptococcal glomerulonephritis.

318

Erysipelas is due to S. pyogenes and is characterized by an abrupt onset of fiery, red swelling of the face or extremities. Distinctive features are its well-defined margins, particularly along the nasolabial fold, rapid progression, and intense pain. Flaccid bullae may develop during the second or third day of illness, but extension to deeper soft tissues is rare. Treatment with penicillin is effective; swelling may progress despite appropriate treatment, though fever, pain, and the intense red color diminish. Desquamation of the involved skin occurs 5 to 10 days into the illness. Infants and elderly adults are most commonly afflicted, and the severity of systemic toxicity may vary. Chorea is a disorder of the central nervous system characterized by sudden, aimless, irregular movements, often accompanied by muscle weakness and emotional instability. Chorea is a delayed manifestation of rheumatic fever, and other manifestations may or may not still be present at the time it appears. Polyarthritis, when part of the same attack, almost always subsides before chorea appears. Carditis is often discovered for the first time when the presenting feature of rheumatic fever is chorea. Chorea usually appears after a long latent period (up to several months) from the antecedent streptococcal infection and at a time when all other manifestations of rheumatic fever have abated. Number: 262 The following may occur in uncomplicated haemolytic jaundice: 1. Bilirubinuria 2. High conjugated serum bilirubin 3. High serum alkaline phosphatase 4. Reticulocytosis A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: D In many patients with haemolytic anemia, the diagnosis can be deduced from a careful history and physical examination. The patient often complains of fatigue and other symptoms of anemia. Less commonly, jaundice and even red-brown urine (haemoglobinuria) are reported. A complete drug history is often critical. The family history is especially helpful in the diagnosis of an inherited haemolytic anemia. Elevation of the reticulocyte count in the anemic patient is the single most useful indicator of haemolysis, reflecting erythroid hyperplasia of the bone marrow. Haemolysis produces unconjugated bilirubinaemia.

319

Number: 265 Nephrotoxicity is described with the following drugs: 1. Gentamicin 2. Acetazolamide 3. Ampicillin 4. Rifampicin A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: E Nephrotoxic ARF may complicate administration of diverse pharmacologic agents. The kidney is particularly susceptible to nephrotoxic injury by virtue of its rich blood supply (25 percent of cardiac output) and ability to concentrate toxins in the medullary interstitium (via the renal countercurrent mechanism) and renal epithelial cells (via specific transporters). ARF complicates 10 to 30 percent of courses of aminoglycoside antibiotics. Aminoglycosides are filtered across the glomerular filtration barrier and accumulated by proximal tubule cells after interaction with phospholipid residues on brush border membranes. Aminoglycosides appear to disrupt normal processing of membrane phospholipids by lysosomes. Patients with nephrotoxicity due to ampicillin or rifampicin have interstitial inflammation and a glomerular lesion almost identical to minimal change glomerulonephritis. Number: 266 1. Hyperacute rejection is mediated by T-cells 2. Chronic rejection is immunoglobulin mediated 3. Early acute rejection is mediated by B-lymphocytes 4. Steroids are effective in reversing acute rejection of a donor organ A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: C

320

Hyperacute rejection is mediated by preformed antibodies, Early acute rejection is mediated by T -lymphocytes. Number: 267 The following are recognised associations: 1. Ulcerative colitis and HLA B8 2. Primary sclerosing cholangitis and HLA B8 3. Haemochromatosis and HLA A3 4. Primary biliary cirrhosis and HLA DR3 A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: C Primary or idiopathic sclerosing cholangitis is a disorder characterized by a progressive, inflammatory, sclerosing, and obliterative process affecting the extrahepatic and, often, the intrahepatic bile ducts. The lesion may appear as an isolated entity or may occur in association with inflammatory bowel disease, especially ulcerative colitis, or with multifocal fibrosclerosis syndromes such as retroperitoneal, mediastinal, and/or periureteral fibrosis, The cause of primary biliary cirrhosis remains unknown. Several observations suggest that a disordered immune response may be involved. Primary biliary cirrhosis (PBC) is frequently associated with a variety of disorders presumed to be autoimmune in nature, such as the CRST syndrome (calcinosis, Raynaud's phenomenon, sclerodactyly, telangiectasia), the sicca syndrome (dry eyes and dry mouth), autoimmune thyroiditis, and renal tubular acidosis. Number: 268 Pleural calcification is a recognised result of: 1. Tuberculosis 2. Chronic empyema 3. Asbestosis 4. Bagassosis A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct

321

ABCDE Correct Answer: A Bagassosis is a hypersensitivity pneumonitis due to exposure to moldy sugar cane! Number: 269 The early manifestations of chronic inorganic lead poisoning include: 1. Absent knee reflexes 2, Punctate basophilia 3. Constipation 4. Abdominal colic A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: C The toxic effects of lead differ between children and adults. The adult form is generally characterized by abdominal pain, anemia, renal disease, headache, peripheral neuropathy with demyelination of long neurons, ataxia, and memory loss. Symptoms are usually associated with prolonged elevation of lead levels above 4 to 5 umol/L (80 to 100 ug/dL) of whole blood. A subclinical form in adults affects primarily the peripheral nervous system and the kidneys. A linear association between hypertension and elevated lead levels (i.e., greater than 1.5 umol/L (30 ug/dL)) has been reported. Encephalopathy is rare in adults. Childhood lead poisoning is manifested by abdominal pain and anaemia, but the central nervous system effects are most important. As an enzymatic poison, lead affects developing tissues more than tissues with slow turnover. Hence subclinical lead poisoning is most dangerous to children because its effects emerge without associated symptoms that bring the victim to medical attention. In the acute clinical form, signs and symptoms reflect both the direct effect of high concentrations of lead (i.e., blood lead greater than 4 umol/L (80 ug/dL)) and consequent severe alterations in porphyrin synthesis. Signs and symptoms include abdominal pain and irritability, followed by lethargy, anorexia, pallor (anaemia), ataxia, and slurred speech. In severe cases, convulsions, coma, and death are usually due to severe generalized cerebral oedema and renal failure. A history of "high-dose" exposure to lead (usually paint chips), pica (the ingestion of nonfood substances), and malnutrition (iron, calcium, and zinc deficiency) almost always is associated with this syndrome.

322

Number: 270 Temporal lobe epilepsy is particularly associated with: 1. Dreamy states 2. Euphoria 3. An olfactory aura 4. Repetitive conjugate movements of the eyes A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: B Temporal lobe epilepsy leads to changes in behavior in which an individual loses conscious contact with the environment. The onset of these seizures may consist of any of a variety of auras: an unusual smell (as of burning rubber), a feeling that the current experience has happened before (deja vu), a sudden intense emotional feeling, a sensory illusion such as that of objects growing smaller (micropsia) or larger (macropsia), or a specific formed sensory hallucination. Patients may come to recognize these as heralding their seizures, or the memory of the aura may be lost in the postictal amnesia that often occurs if the seizure becomes generalized. During complex partial seizures, there may be a cessation of activity with some minor motor activity, such as lip smacking, swallowing, walking aimlessly, or picking at one's clothes (automatisms). Complex partial seizures also may be accompanied by the unconscious performance of highly skilled activities such as driving a car or playing complicated musical pieces. When the seizure ends, the individual is amnesic for events which took place during the seizure and may take minutes or hours to recover full consciousness. Repetitive conjugate movements of the eyes are a feature of frontal lobe epilepsy. Number: 271 Cannon waves may be seen in the juglar veins in: 1. First degree AV heart block 2. Ventricular pacing 3. Tricuspid stenosis 4. Nodal tachycardia A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct

323

E: All Correct ABCDE Correct Answer: C In the case of tricuspid stenosis there are tall 'a' waves but they are not true cannon waves. Number: 274 Infective endocarditis rarely occurs with: A. Congenital bicuspid aortic valve B. Atrial septal defect C. Patent ductus arteriosus D. Coarctation of the aorta E. Mitral valve prolapse Select the single best answer ABCDE Correct Answer: B In native valve endocarditis, the proportion of males is higher than females, and most patients are over age 50. Endocarditis is uncommon in children. Between 60 and 80 percent of patients have an identifiable predisposing cardiac lesion. Rheumatic valvular disease accounts for about 30 percent of cases. The mitral valve is most commonly involved, followed by the aortic. Right-sided endocarditis usually affects the tricuspid valve but is rare on rheumatic valves. Congenital heart disease other than mitral valve prolapse is the underlying lesion in about 10 to 20 percent of patients with endocarditis. Predisposing lesions include patent ductus arteriosus, ventricular septal defect, tetralogy of Fallot, coarctation of the aorta, pulmonary stenosis, and bicuspid aortic valve but not uncomplicated atrial septal defect. Mitral valve prolapse is the underlying lesion in about 10 to 33 percent of cases. Number: 276 Cerebral abscess in the absence of endocarditis is a recognised complication of: 1. Tetralogy of Fallot 2. Eisenmenger's Syndrome 3. Tricuspid artresia 4. Transposition of the great arteries A: 1,2,3 Correct B: 1,3 Correct

324

C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: E Cerebral abscess can complicate any condition which is characterised by a right to left shunt. Number: 277 Nephrogenic diabetes insipidus: 1. Has an autosomal recessive inheritance 2. Can be associated with sickle cell anaemia 3. Is characterised by normal or low serum vasopressin levels 4. Can be caused by hypercalcaemia A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct

ABCDE Correct Answer: C Diabetes insipidus must be distinguished from other types of hypotonic polyuria (primary polydipsia and nephrogenic diabetes insipidus) and from states of osmotic diuresis. Several are recognizable by the history (e.g., following lithium or mannitol administration, surgery under methoxyflurane anesthesia, or renal transplantation). In others the physical examination or simple laboratory procedures will indicate the diagnosis (evidence of glycosuria, renal disease, sickle cell anemia, hypercalcemia, or potassium depletion, including primary aldosteronism). Congenital nephrogenic diabetes insipidus is usually inherited as an X-linked recessive trait. Affected males are totally resistant to vasopressin, while heterozygote females are asymptomatic or have mild polyuria. In several families the abnormal gene is localized to the Xq28 region of the long arm of the X chromosome. Almost all these patients have a V2 receptor abnormality. Nephrogenic diabetes insipidus also may be inherited as an autosomal recessive trait or may occur sporadically. Females with sporadic disease appear to have a defect in the pathway of AVP action distal the V2 receptor, and some of them respond to

325

large doses of desmopressin. V1 receptor-mediated functions are normal in patients with congenital nephrogenic diabetes insipidus. When patients with nephrogenic and central diabetes insipidus cannot be differentiated by simpler means, documentation of elevated plasma or urinary AVP concentration in relation to plasma osmolality or of a high AVP concentration in relation to urine osmolality will allow the diagnosis of nephrogenic diabetes insipidus. Number: 278 Extrinsic allergic alveolitis: 1. Occurs only in atopic individuals. 2. Is associated with precipitin production to relevant antigens. 3. Characteristically causes an eosinophilia. 4. Results in a restrictive pattern of ventilatory abnormality with marked reduction of transfer factor. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: C Hypersensitivity pneumonitis, or extrinsic allergic alveolitis, is an immunologically induced inflammation of the lung parenchyma, involving alveolar walls and terminal airways, secondary to repeated inhalation of a variety of organic dusts and other agents by a susceptible host. In contrast to many of the other interstitial lung diseases, the cause of this interstitial and alveolar filling disease is known. Number: 279 Which of the following are associated with dissecting aneurysm of the aorta? 1. Coarctation of the aorta 2. Hypertension 3. Marfan's syndrome 4. Syphilitic aortitis A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct

326

ABCDE Correct Answer: A The factors that predispose to aortic dissection include systemic hypertension, a coexisting condition in 70 percent of patients, and cystic medial necrosis. Aortic dissection is the major cause of morbidity and mortality in patients with the Marfan syndrome. The incidence is also increased in patients with congenital aortic valve anomalies (e.g., bicuspid valve), in those with coarctation of the aorta, and in otherwise normal women during the third trimester of pregnancy. Patients with syphilitic aortitis are prone to the development of aortic aneurysm, but not dissection. Number: 281 Lung complications may result from the ingestion of: 1. Paraquat 2. Busulphan 3. Bleomycin 4. Aspirin A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: E Paraquat causes pulmonary oedema, Busulphan - pulmonary fibrosis, Bleomycin pneumonitis and fibrosis, Aspirin - bronchospasm, Number: 283 In coarctation of the aorta: 1. Rupture of the aorta is a recognised complication 2. Congestive failure is usually due to hypertension 3. Cerebrovascular haemorrhage is a known hazard 4. Infective endocarditis of the bicuspid valves is a very rare occurrence A: 1,2,3 Correct

327

B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: B Most children and young adults with isolated, discrete coarctation are asymptomatic. Headache, epistaxis, cold extremities, and claudication with exercise may occur, and attention is usually directed to the cardiovascular system when a heart murmur or hypertension in the upper extremities and absence, marked diminution, or delayed pulsations in the femoral arteries are detected on physical examination. Enlarged and pulsatile collateral vessels may be palpated in the intercostal spaces anteriorly, in the axillae, or posteriorly in the interscapular area. The upper extremities and thorax may be more developed than the lower extremities. A midsystolic murmur over the anterior part of the chest, back, and spinous processes may become continuous if the lumen is narrowed sufficiently to result in a high-velocity jet across the lesion throughout the cardiac cycle. Additional systolic and continuous murmurs over the lateral thoracic wall may reflect increased flow through dilated and tortuous collateral vessels. The electrocardiogram reveals left ventricular hypertrophy of varying degree. Roentgenograms may show a dilated left subclavian artery high on the left mediastinal border and a dilated ascending aorta. Indentation of the aorta at the site of coarctation and pre- and poststenotic dilatation (the "3" sign) along the left paramediastinal shadow are almost pathognomonic. Notching of the ribs, an important radiographic sign, is due to erosion by dilated collateral vessels. Two-dimensional echocardiography from para- or suprasternal windows identifies the site and length of coarctation, while Doppler studies record and quantify the pressure gradient. Transesophageal echocardiography and magnetic resonance imaging or digital angiography allow visualization of the length and severity of the obstruction and the associated collateral arteries. In adults, cardiac catheterization is indicated primarily to evaluate the coronary arteries. The chief hazards result from severe hypertension and include the development of cerebral aneurysms and hemorrhage, rupture of the aorta, left ventricular failure, and infective endocarditis. Number: 285 Hypothyroidism: 1. Is more common than hyperthyroidism 2. Is a cause of pericardial effusion 3. Is associated with low serum carotene 4. May present with cerebellar ataxia A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct

328

D: 4 Correct E: All Correct ABCDE Correct Answer: C Hyperthyroidism is about 8 times more common than Hypothyroidism. Serum carotene levels are elevated in hypothyroidism. Hypothyroidism may be primary or secondary. Low thyroid hormone and elevated serum TSH concentrations are characteristic of primary hypothyroidism. Low thyroid hormone concentrations with a "normal" or "low" TSH concentration are found in secondary hypothyroidism. Number: 286 A patient suffering from dystrophia myotonica is likely to suffer from: A. Progressive external ophthalmoplegia. B. Cataracts. C. Symptoms that begin in childhood. D. Fasiculations presenting in childhood. E. Tendon reflexes that are retained despite muscle wasting. Select the single best answer ABCDE Correct Answer: B This condition was originally described by Steinert in 1909 and represents the most common adult muscular dystrophy. This disorder has an incidence of 13.5 per 100,000 live births and involves an equal proportion of males and females. Cardiac disturbances occur in the majority of patients with myotonic dystrophy. Electrocardiographic abnormalities are common, including first degree heart block or more extensive conduction system involvement. Complete heart block and sudden death can occur. Congestive heart failure occurs infrequently, but may result from cor pulmonale secondary to respiratory failure. Mitral valve prolapse also occurs commonly in myotonic dystrophy patients. Other features associated with myotonic dystrophy include intellectual impairment, hypersomnia, posterior subcapsular cataracts, gonadal atrophy, insulin resistance and decreased esophageal and colonic motility. Number: 286 A patient suffering from dystrophia myotonica is likely to suffer from: A. Progressive external ophthalmoplegia.

329

B. Cataracts. C. Symptoms that begin in childhood. D. Fasiculations presenting in childhood. E. Tendon reflexes that are retained despite muscle wasting. Select the single best answer ABCDE Correct Answer: B This condition was originally described by Steinert in 1909 and represents the most common adult muscular dystrophy. This disorder has an incidence of 13.5 per 100,000 live births and involves an equal proportion of males and females. Cardiac disturbances occur in the majority of patients with myotonic dystrophy. Electrocardiographic abnormalities are common, including first degree heart block or more extensive conduction system involvement. Complete heart block and sudden death can occur. Congestive heart failure occurs infrequently, but may result from cor pulmonale secondary to respiratory failure. Mitral valve prolapse also occurs commonly in myotonic dystrophy patients. Other features associated with myotonic dystrophy include intellectual impairment, hypersomnia, posterior subcapsular cataracts, gonadal atrophy, insulin resistance and decreased esophageal and colonic motility. Number: 290 Proliferative glomerulonephritis: 1. May present as a nephrotic syndrome 2. May present with haematuria + convulsions 3. Is the lesion which can occur in Henoch-Schnlein syndrome 4. In childhood can be expected to respond well to steroids A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: A Proliferative glomerulonephritis is a heterogeneous group of glomerular diseases. Some patients with this morphologic lesion may in fact represent resolving postinfectious glomerulonephritis, hereditary nephritis, or other multisystem diseases such as HenochSchonlein purpura, vasculitis, or systemic lupus erythematosus.

330

This lesion accounts for approximately 5 percent of idiopathic nephrotic syndrome in adults and 5 to 10 percent in children. It is more common in older children and young adults. Males are affected slightly more often than females. Hematuria, either gross or microscopic, is common. The childhood form of the disease tends to be unresponsive to steroids. Number: 291 Pneumococcal meningitis: 1. Has its peak age incidence in childhood 2. Is a recognised late sequel to splenectomy in children 3. Should be treated with 100 000 units benzyl penicillin intrathecally daily for seven days 4. Can be effectively treated with chloramphenicol in patients hypersensitive to penicillin A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: C Pneumococcal meningitis is the most frequently observed agent in adults over the age of 30 years and accounts for approximately 15 percent of the total cases of meningitis in the United States. Mortality rates remain high, in the 19 to 30 percent range. Pneumococcal infection of the meninges is often associated with distant foci such as pneumonia, otitis media, mastoiditis, sinusitis, or endocarditis. Serious pneumococcal infections may be observed in patients with predisposing conditions, including splenectomy or asplenic states, multiple myeloma, hypogammaglobulinemia, alcoholism, cirrhosis, and the Wiskott-Aldrich syndrome. S. pneumoniae is the most common meningeal isolate in head trauma patients who have suffered a basilar skull fracture with subsequent CSF leak. Number: 292 Legionnaire's disease: 1. May present with diarrhoea 2. Is associated with leucopenia 3. Should be treated with erythromycin 4. Causes microscopic haematuria in 10% patients A: 1,2,3 Correct B: 1,3 Correct

331

C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: B Legionnaires' disease refers to an epidemic of pneumonia that affected 221 people and caused 34 deaths during the American Legion Convention at the Bellevue-Stratford Hotel in Philadelphia during July and August 1976. Initially referred to as the Legionnaires' disease agent, the organism was shown to be a new species of bacterium and subsequently designated L. pneumophila. Pneumonic illness typically begins with an abrupt prodrome of malaise, headache, myalgia, and weakness. Fever and intermittent rigors appear 24 h later, with temperatures exceeding 40 degC in more than half of patients. Nonproductive cough is common. About half of patients eventually produce thin or minimally purulent sputum, and one-third may have scant hemoptysis. Pleuritic chest pain and dyspnea can raise the suspicion of pulmonary embolism. Gastrointestinal symptoms include diarrhea, nausea, vomiting, and abdominal pain. Altered mental status suggesting toxic encephalopathy may include confusion, disorientation, lethargy, hallucinations, depression, delirium, obtundation, or coma. Seizures are rare, but cranial or peripheral neuropathy and cerebellar dysfunction are not uncommon. Physical examination usually shows a toxic appearance and high fever. Relative bradycardia is common. Lung examination reveals rales and consolidation, but the physical findings are mild when compared to radiographic findings. Complications and systemic manifestations include lung abscess, empyema, respiratory failure, hypotension, shock, rhabdomyolysis, disseminated intravascular coagulation (DIC), thrombotic thrombocytopenic purpura (TTP), and renal failure. Pontiac fever is an acute, self-limited illness lasting 2 to 5 days. A prodrome of malaise, myalgia, and headache is followed rapidly by fever, chills, and, variably, cough, coryza, and sore throat. Diarrhea, nausea, and mild neurologic symptoms such as dizziness or photophobia may be present. Number: 293 Which of the following are true of Hepatitis C virus: 1. It accounts for >90% of post transfusional hepatitis 2. Less than 10% of patients will progress to chronic liver disease 3. 50% of patients treated with interferon will relapse on stopping treatment 4. It has an incubation period of less than 6 weeks A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct

332

ABCDE Correct Answer: B Routine screening of blood donors for HBsAg and the elimination of commercial blood sources in the early 1970s reduced the frequency of, but did not eliminate, transfusionassociated hepatitis. During the 1970s, the likelihood of acquiring hepatitis after transfusion of voluntarily donated, HBsAg-screened blood was approximately 10 percent per patient (up to 0.9 percent per unit transfused). Although hepatitis B accounted for up to 5 to 10 percent of these cases, the remaining 90 to 95 percent were classified, based on serologic exclusion, as "non-A, non-B" hepatitis. Although many of these patients have no symptoms and a nonprogressive course, ultimately, cirrhosis develops in as many as 20 percent of those with chronic posttransfusion hepatitis C within 10 years of acute illness. The likelihood of chronic hepatitis is also approximately 50 percent after sporadic hepatitis C occurring in the absence of identifiable percutaneous inoculation with blood products or contaminated needles. Number: 294 Pulsus paradoxus is found with: 1. Severe asthmatic attack 2. Severe left ventricular failure 3. Constrictive pericarditis 4. Cardiac amyloidosis A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: E Arterial 'paradox' is, in fact, an exaggeration of the normal blood pressure response to respiration - in contrast to venous paradox which is truly paradoxical. Number: 295 Renal papillary necrosis may be due to: 1. Obstructive uropathy

333

2. Blackwater fever 3. Phenacitin abuse 4. Polycystic kidneys A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: B When infection of the renal pyramids develops in association with vascular diseases of the kidney or with urinary tract obstruction, renal papillary necrosis is likely to result. Patients with diabetes, sickle cell disease, chronic alcoholism, and vascular disease seem peculiarly susceptible to this complication. Hematuria, pain in the flank or abdomen, and chills and fever are the most common presenting symptoms. Individuals who ingest large quantities of analgesic drugs are prone to develop tubulointerstitial damage and papillary necrosis. Indeed, in Australia, Switzerland, and Sweden, analgesic abuse is one of the most common causes of chronic renal failure, and it is an important cause in the United States as well. While aspirin, phenacetin, and acetaminophen (the metabolite of phenacetin) may alone or in combination induce chronic renal disease, epidemiologic studies incriminate phenacetin and acetaminophen as the more injurious combination. Chronic ingestion of aspirin without these other compounds seems to be an uncommon cause of serious renal damage. Number: 298 The following are features of ulnar nerve entrapment at the elbow: 1. It occurs more commonly in women 2. Weakness of grip 3. Symptoms and signs are more obvious when the elbow is flexed 4. Wasting of the thenar eminence A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: B

334

Complete ulnar paralysis results in a characteristic claw-hand deformity owing to wasting and weakness of many of the small hand muscles and hyperextension of the fingers at the metacarpophalangeal joints and flexion at the interphalangeal joints. The flexion deformity is most pronounced in the fourth and fifth fingers. Sensory loss occurs over the fifth finger, the ulnar aspect of the fourth finger, and the ulnar border of the palm. The superficial location of the nerve at the elbow makes it a common site of pressure palsy. The ulnar nerve may also become entrapped just distal to the elbow in the cubital tunnel formed by the aponeurotic arch linking the two heads of the flexor carpi ulnaris. Also, prolonged pressure on the base of the palm, as occurs with use of hand tools or bicycle riding, may result in damage to the deep palmar branch of the ulnar nerve, causing weakness of the small hand muscles but no sensory loss. The most common upper extremity injuries that result from malpositioning are ulnar damage, caused by direct pressure on the nerve at the elbow, and brachial plexus injury, caused by stretching of the plexus. Number: 306 The following disorders are recognised sequelae of long-continued abuse of alcohol: 1. Macrocytosis 2. Hypertriglyceridiaemia 3. Atrial fibrillation 4. Pancreatic carcinoma A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: A Macrocytosis may be encountered in patients with alcoholism. However, the red cell precursors in the bone marrow do not appear megaloblastic. In any individual, the daily consumption of large amounts of ethanol can produce a mild, asymptomatic elevation in the plasma triglyceride level due to an elevation of VLDL. However, in a subgroup ethanol ingestion regularly produces massive and clinically significant hyperlipidemia with elevations in both VLDL and chylomicrons (type 5 lipoprotein pattern). In most of this group, the VLDL level remains mildly elevated (type 4 lipoprotein pattern), even in the basal state after recovery from the severe alcoholic hyperlipidemia. This suggests that these individuals have a form of familial hypertriglyceridemia or multiple lipoprotein-type hyperlipidemia that is exacerbated and converted to a type 5 pattern by the ethanol ingestion.

335

Alcoholic cardiotoxicity may present in individuals without overt heart failure and consists of recurrent supraventricular or ventricular tachyarrhythmias. Termed the "holiday heart syndrome," it typically appears after a drinking binge; atrial fibrillation is seen most frequently, followed by atrial flutter and ventricular premature depolarizations. A large case control study has correlated chronic pancreatitis with an increased risk of pancreatic cancer, but there are no convincing data to link epidemiologic factors such as alcohol abuse. Number: 307 Carcinoma of the lung may present with: 1. Pain in the ulnar distribution of the arm. 2. Horner's Syndrome. 3. Hypercalcaemia. 4. Thrombophlebitis A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: E Pancoast's (or superior sulcus tumor) syndrome results from local extension of a tumor (usually epidermoid) growing in the apex of the lung with involvement of the eighth cervical and first and second thoracic nerves, with shoulder pain which characteristically radiates in the ulnar distribution of the arm, often with radiologic destruction of the first and second ribs. Sympathetic nerve paralysis with Horner's syndrome (enophthalmus, ptosis, miosis, and ipsilateral loss of sweat) occurs as a result of regional spread of tumor in the thorax. Endocrine syndromes are seen in 12 percent of patients with carcinoma of the lung and include hypercalcemia and hypophosphatemia resulting from ectopic parathyroid hormone or PTH-related peptide production by epidermoid cancer. Thrombotic manifestations occur in 1 to 8 percent of patients and include migratory venous thrombophlebitis (Trousseau's syndrome), Number: 314 Hypercalcaemia is associated with:

336

1. Sarcoidosis 2. Diabetes Insipidus 3. Zollinger-Ellison Syndrome. 4. Myxoedema A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: A In sarcoidosis hypercalcemia is directly related to an increased intestinal calcium absorption. This occurs because normal relations between 25(OH)D and the active metabolite 1,25(OH)2D, are not maintained. Hypercalcemia and hypokalemic nephropathy are reversible causes of nephrogenic diabetes insipidus. Thyrotoxicosis is associated with hypercalcaemia - The hypercalcemia seems due to increased bone turnover, with bone resorption exceeding bone formation. In 1955, Zollinger and Ellison described the syndrome that bears their names, which consists of ulcer disease of the upper gastrointestinal tract, marked increases in gastric acid secretion, and non-beta islet cell tumors of the pancreas. Between one-fourth and one-half of gastrinomas occur in association with the MEN 1 syndrome. Hyperparathyroidism is the most common component of MEN 1 and occurs in about 80 percent of patients with this form of Zollinger-Ellison syndrome. Number: 318 Antimicrobial agents effective against pseudomonas aeruginosa infections include 1. Metronidazole 2. Gentamicin 3. Cephalexin 4. Carbenicillin A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct

337

ABCDE Correct Answer: C Pseudomonas species are ubiquitous, free-living, opportunistic gram-negative pathogens. P. aeruginosa, is the most common human pathogen in this group. In general, the choice of antibiotics with antipseudomonal activity includes the aminoglycosides (e.g., gentamicin, tobramycin, netilmicin, amikacin), selected thirdgeneration cephalosporins (e.g., ceftazidime, cefoperazone), selected extended-spectrum penicillins (e.g., carbenicillin, ticarcillin, ticarcillin/clavulanate, piperacillin, mezlocillin, azlocillin), carbapenem (imipenem), monobactams (e.g., aztreonam), and fluoroquinolones (e.g., ciprofloxacin, ofloxacin). Number: 321 A broad complex tachycardia is more likely to be supraventricular tachycardia with aberrant conduction than ventricular tachycardia if: A. Cannon waves are seen in the neck waves. B. Fusion beats are seen on the ECG. C. The tachycardia is abolished by carotid massage. D. There is a concordant pattern across the precordial leads. E. The QRS duration is > 160 msec. Select the single best answer ABCDE Correct Answer: C Characteristics of the ECG during the tachycardia that suggest a ventricular origin for the arrhythmia are: (1) A QRS complex > 140 msec in the absence of antiarrhythmic therapy, (2) AV dissociation (with or without fusion or captured beats) or variable retrograde conduction, (3) A superior QRS axis in the presence of a right bundle branch block pattern, (4) Concordance of the QRS pattern in all precordial leads (i.e., all positive or all negative deflections), and (5) Other QRS patterns with prolonged duration that are inconsistent with typical right or left bundle branch block patterns. A wide, complex, bizarre tachycardia that is very irregular suggests AF with conduction over an AV bypass tract. Number: 327 Mycoplasma pneumoniae:

338

1. Infection is associated with the development of agglutinins to a non-haemolytic streptococcus 2. Predominantly causes infection in the elderly 3. Infection is associated with the Stevens-Johnson syndrome 4. Infection is associated with a polymorphonuclear leucocytosis A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: B Mycoplasmas are ubiquitous in nature and cause a wide variety of diseases among animals, birds, plants, and insects. In humans the most important pathogen is Mycoplasma pneumoniae, a common cause of respiratory tract infections. M. pneumoniae produces an influenza-like respiratory illness of gradual onset with headache, malaise, fever, and cough. When pneumonia is present, physical findings may be minimal despite extensive changes seen in chest x-rays. Synonyms include Eaton agent pneumonia, cold haemagglutinin-positive pneumonia, atypical or primary atypical pneumonia, and "walking" pneumonia. The organism has been implicated in up to 50 percent of pneumonia episodes in college students and in 20 to 30 percent of cases occurring in military recruits. Nondescript maculopapular skin rashes are frequent in children, and M. pneumoniae infections have been associated with erythema multiforme and the Stevens-Johnson syndrome. Number: 328 In Polycythaemia Rubra Vera (PRV): 1. Serum erythropoietin is low. 2. Serum iron is characteristically raised. 3. Hepatic vein thrombosis may occur. 4. The platelet count is typically low. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE

339

Correct Answer: B Typically, patients present with an elevated haemoglobin concentration and haematocrit associated with thrombocytosis, leukocytosis, and splenomegaly. Determination of the serum erythropoietin concentration is important in distinguishing primary from secondary causes of polycythaemia. An elevated erythropoietin concentration suggests secondary erythrocytosis, while a low level is compatible with PRV. Polycythaemia rubra vera is a cause of thrombosis of the hepatic veins (Budd-Chiari syndrome). In PRV, the neutrophil alkaline phosphatase score is frequently increased, as is the serum vitamin B12 level and serum vitamin B12-binding capacity. Number: 329 The Bain Circuit: 1. Requires a fresh gas flow of about 3 times the minute ventilation to prevent rebreathing during SV. 2. Requires a lower fresh gas flow than the Mapleson A circuit to prevent rebreathing during IPPV. 3. Will maintain a constant PCO2 in the presence of a changing MV during IPPV. 4. Is more effective than than the Mapleson A circuit at conserving moisture during SV. Where SV= Spontaneous Ventilation, IPPV = Intermittent Positive Pressure Ventilation and MV = Minute ventilation. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: A For the Bain circuit, the patient's PCO2 during controlled positive-pressure ventilation depends mainly on the fresh gas flow. During spontaneous breathing the Bain circuit requires higher fresh gas flow than the Mapleson A circuit to ensure no rebreathing; however, it is the most efficient circuit for CO2 clearance during positive-pressure ventilation. The Mapleson A circuit is the more efficient circuit for conserving moisture because the anatomical deadspace from the previous breath (fully saturated) is entirely rebreathed.

340

Bain JA, Spoerel WE: A streamlined anaesthetic system, Can Anaesth Soc J 19:426, 1972. Bain JA, Spoerel WE: Flow requirements for a modified Mapleson D system during controlled ventilation, Can Anaesth Soc J 20:629, 1973. Number: 331 A carotid bruit in an asymptomatic thirty year old is best managed by: A. Telling the patient to 'Forget about it' and recommending no further follow up. B. Carotid Angiography. C. Carotid Doppler studies. D. Annual review of the patient. E. Transthoracic Echocardiography. Select the single best answer ABCDE Correct Answer: A A cervical bruit is not necessarily indicative of carotid stenosis. Hammond and Eisenger examined 1000 normal patients for the presence of bruit. Patients under age 5 years had a bruit in 87% of cases, and patients aged 30 to 34 had bruit in 22% of cases. Jones reported that a cervical venous hum could be readily perceived in 27% of subjects with an average age of 32 years. The differential diagnosis also includes radiated cardiac murmurs. Hammond JH, Eisinger RP: Carotid bruits in 1,000 normal subjects, Arch Intern Med 109:109, 1962. Jones FL: Frequency characteristics and importance of the cervical venous hum in adults, N Engl J Med 267(13):658, 1962. Number: 333 Signs of posterior inferior cerebellar artery thrombosis include: 1. Ipsilateral 5th nerve sensory loss 2. Nystagmus to the side of the lesion 3. Contralateral loss of pain in limbs and trunk 4. Bulbar palsy A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct

341

E: All Correct ABCDE Correct Answer: E The posterior inferior cerebellar artery in its proximal segments supplies the lateral medulla and, in its distal branches, the inferior surface of the cerebellum. The 'lateral medullary syndrome' may include: On side of lesion: Pain, numbness, impaired sensation over half the face. Ataxia of limbs, falling to side of lesion. Nystagmus, diplopia, oscillopsia, vertigo, nausea, vomiting. Horner's syndrome Dysphagia, hoarseness, paralysis of palate, paralysis of vocal cord, diminished gag reflex. Loss of taste. Numbness of ipsilateral arm, trunk, or leg On side opposite lesion: Impaired pain and thermal sense over half the body, sometimes face Number: 340 Haemochromatosis is associated with: 1. Cirrhosis 2. Diabetes mellitus 3. Cardiomyopathy 4. Hypogonadotrophic hypogonadism A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: E This relatively common genetically determined disorder involves accumulation of abnormal amounts of iron due to inappropriate absorption in the intestine. The liver, as a primary site of iron storage, is affected most directly. There is diffuse deposition of excess iron in hepatocytes, in contrast to the characteristic accumulation of iron in the reticuloendothelial compartment typical of secondary iron overload and hemosiderosis. Cirrhosis, diabetes mellitus, arthritis, cardiomyopathy, and hypogonadotrophic hypogonadism are the usual manifestations of haemochromatosis.

342

Number: 344 Eaton-Lambert syndrome can be distinguished from Myasthesia Gravis by: 1. The response to exercise. 2. The response to succinyl choline. 3. The response to anticholinesterases. 4. The response to calcium channel blockers. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: E Eaton-Lambert syndrome (ELS) is a condition that results from an association between carcinomatous conditions, especially small cell carcinoma of the lungs, and motor neuropathy. Clinically, it resembles Myasthesia Gravis (MG). Patients complain of weakness of the proximal muscles that, unlike in patients with MG, improves with exercise. The sera of these patients contain IgG antibodies that are directed against voltage-dependent calcium channels. The cells of small cell carcinoma of the lung and other malignancies possess calcium channels that may serve as the antigenic stimulus for the production of these antibodies. The destruction of the presynaptic calcium channels at the nerve terminal by immune-mediated complement activation results in decreased release of acetylcholine. Patients with ELS have been reported to be excessively sensitive to calcium channel blockers. Patients with ELS symptoms do not respond well to anticholinesterases. The symptoms are improved by agents such as 4-aminopyridine, guanidine, and germine that increase repetitive nerve firing and therefore increase the synaptic release of acetylcholine. Patients with ELS are extremely sensitive to the effects of all muscle relaxants, both depolarisers and nondepolarisers. In this respect, they are different from patients with MG, who are usually resistant to the effect of succinylcholine. Number: 362 Which of the following is the LEAST likely cause of massive haemoptysis: A. Tuberculosis B. Bronchiectasis C. Emphysema D. Lung abscess E. Carcinoma

343

Select the single best answer ABCDE Correct Answer: C The common causes of massive haemoptysis include cavitary tuberculosis, anaerobic lung abscess, lung cancer and bronchiectasis. The risk of mortality is far greater than when the cause of the massive haemoptysis is bronchitis or bronchiectasis. Increasingly, the efficacy of bronchial arterial embolisation in the treatment of this condition is being recognised. See: Witt Ch, Schmidt B, Geisler A, Borges AC, John M, Fietze I, Romaniuk P. Value of bronchial artery embolisation with platinum coils in tumorous pulmonary bleeding. Eur J Cancer. 2000 Oct;36(15):1949-54. Number: 375 Recognised complications of chronic renal failure include: 1. Sensory-motor neuropathy 2. Pruritis 3. Metastatic calcification 4. Proximal myopathy A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: E Peripheral neuropathy is common in advanced CRF. Initially, sensory nerve involvement exceeds motor, lower extremities are involved more than the upper, and the distal portions of the extremities more than proximal. The "restless legs syndrome" is characterized by illdefined sensations of discomfort in the feet and lower legs and frequent leg movement. In CRF there is a tendency to extraosseous, or metastatic, calcification when the calciumphosphate product is very high.

344

The clinical picture of the myopathy of chronic renal failure is identical to that of primary hyperparathyroidism and osteomalacia. There is proximal limb weakness with bone pain. Number: 377 Complications of dialysis-dependent renal failure can include: 1. Arthropathy 2. Dementia 3. Accelerated artherosclerosis 4. Raised intracranial pressure A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: E 1 - If renal failure is due to amyloidosis, an arthropathy can complicate the clinical picture. Amyloid can directly involve articular structures by its presence in the synovial membrane and synovial fluid or in the articular cartilage. Amyloid arthritis can mimic a number of rheumatic diseases because it can present as a symmetric arthritis of small joints with nodules, morning stiffness, and fatigue. 2 - Characterised by speech dyspraxia, myoclonus, dementia and siezures. Thought to be due to aluminium overload. 3 - There are many reasons such as hypertension, hyperlipidaemia, glucose intolerance, chronic high cardiac output and metastatic calcification. 4. - Dialysis dysequilibrium - from lowering serum urea too quickly. Mannitol can be given during the first few haemodialysis sessions when the urea is particularly high. Number: 378 Circulating anticoagulants have been described in: 1. Systemic Lupus Erythematosus. 2. Factor VIII deficient patients who have received plasma transfusions. 3. Otherwise normal post-partum females. 4. Elderly individuals.

345

A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: E Circulating anticoagulants, or inhibitors, are usually IgG antibodies which interfere with coagulation reactions. Specific inhibitors inactivate individual coagulation proteins and may cause severe hemorrhage. As discussed above, they arise in 15 to 20 percent of patients with factor VIII or factor IX deficiency who have received plasma infusions. Specific inhibitors also occur in previously normal individuals. Although the most common target protein is factor VIII, inhibitors have been described with specificity for each of the coagulation proteins. In addition to hemophiliacs, anti-factor VIII antibodies are seen in postpartum females, in patients on various drugs, as part of the spectrum of autoantibodies in systemic lupus erythematosus patients, and in normal elderly individuals. Circulating anticoagulants also have been reported in patients with AIDS. Number: 380 The manifestations of lithium toxicity include: 1. Nephrogenic diabetes insipidus. 2. Seizures. 3. Hyperthermia. 4. Prolonged QT interval. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: E The manifestations of lithium toxicity include gastrointestinal effects such as nausea, vomiting, and diarrhoea; CNS effects including ataxia, tremor, myoclonus, seizures, confusion, and coma; and cardiovascular effects including hypotension, atrioventricular block, and prolonged QT interval. Hyperthermia and nephrogenic diabetes insipidus may also occur.

346

Number: 384 A 70 year old male is found to have a WBC count of 32,000/microliter with differential count of 8 segmented polymorphs, 1 band, 88 lymphocytes, and 4 monocytes. His haemoglobin is 122 g/l, hct 37.1%, and platelet count 178,000/microliter. His peripheral blood smear is shown here. The most likely diagnosis is: A. Infectious mononucleosis B. Chronic lymphocytic leukemia C. Acute myelogenous leukemia D. Hodgkin's disease E. Multiple myeloma Select the single best answer Number: 384 A 70 year old male is found to have a WBC count of 32,000/microliter with differential count of 8 segmented polymorphs, 1 band, 88 lymphocytes, and 4 monocytes. His haemoglobin is 122 g/l, hct 37.1%, and platelet count 178,000/microliter. His peripheral blood smear is shown here. The most likely diagnosis is: A. Infectious mononucleosis B. Chronic lymphocytic leukemia C. Acute myelogenous leukemia D. Hodgkin's disease E. Multiple myeloma Select the single best answer ABCDE Correct Answer: B Chronic lymphocytic leukemia (CLL) is a neoplasm of activated B lymphocytes. The CLL cells, which morphologically resemble mature, small lymphocytes of the peripheral blood, accumulate in the bone marrow, blood, lymph nodes, and spleen in large numbers. The disease is usually seen in patients over 50 years of age, but improved diagnosis has identified many younger patients. CLL is the most common form of leukemia in the Australia and is more frequent in males than females. The CLL cells commonly have trisomy 12 alone or with additional chromosomal abnormalities.

347

ABCDE Correct Answer: B Chronic lymphocytic leukemia (CLL) is a neoplasm of activated B lymphocytes. The CLL cells, which morphologically resemble mature, small lymphocytes of the peripheral blood, accumulate in the bone marrow, blood, lymph nodes, and spleen in large numbers. The disease is usually seen in patients over 50 years of age, but improved diagnosis has identified many younger patients. CLL is the most common form of leukemia in the Australia and is more frequent in males than females. The CLL cells commonly have trisomy 12 alone or with additional chromosomal abnormalities. Number: 385 A 17 year old male experiences easy fatiguability and cramping pain of muscles with exercise during physical education classes. This condition does not improve with additional exercise, or with anti-inflammatory medications. He does not have problems with activities of daily living. The best explanation is: A. Duchenne muscular dystrophy B. Myasthenia gravis C. McArdle's disease D. Amyotrophic lateral sclerosis E. Trichinosis Select the single best answer ABCDE Correct Answer: C

348

Myophosphorylase deficiency, or McArdle's disease, is an uncommon muscle energy disease. Symptoms of pain and cramps after exercise usually develop during the second or third decade. A history of myoglobinuria is present in most, and on occasion myoglobinuria can cause renal failure. Affected individuals are otherwise healthy, without evidence of hepatic, cardiac, or metabolic disturbance. Performance of an ischemic exercise test usually causes painful cramping, which is helpful diagnostically. In addition, blood lactate does not rise, whereas serum creatine phosphokinase usually is elevated at rest but rises substantially after strenuous exercise. Number: 386 A 42 year old female complains of recent onset of easy bruising. The PT and PTT are normal, but her platelet count is only 10,000/microliter. A bone marrow biopsy reveals a normocellular marrow with increased numbers of megakaryocytes. These findings most strongly suggest a diagnosis of: A. Myeloproliferative disorder B. Drug reaction to recent antibiotic therapy C. Wiskott-Aldrich syndrome D. Epstein-Barr virus infection E. Idiopathic thrombocytopenic purpura Select the single best answer ABCDE Correct Answer: E In contrast to children, Most adults present with an indolent form of idiopathic thrombocytopenic purpura which may persist for many years and is referred to as chronic ITP. Women aged 20 to 40 are afflicted most commonly and outnumber men by a ratio of 3:1. They may present with an abrupt fall in platelet count and bleeding similar to patients with acute ITP. More often they have a prior history of easy bruising or menoorrhagia. These patients have an autoimmune disorder with antibodies directed against target antigens on the glycoprotein IIb-IIIa or glycoprotein Ib-IX complex. Wiskott-Aldrich syndrome is is an X-linked genetic disease characterized by eczema, thrombocytopenia, and repeated infections. The platelets are small and have a shortened halflife. Affected male infants often present with bleeding and most do not survive childhood, dying of complications of bleeding, infection, or lymphoreticular malignancy.

349

Number: 401 A prolonged QT interval may: 1. Be caused by hypocalcaemia. 2. Predispose to 'Torsade de pointes'. 3. Be caused by amiodarone. 4. Be caused by cardiac glycosides. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: A Prolongation of the QT interval is seen with drugs that increase the duration of the ventricular action potential: - ie Vaughan-Williams type 1A antiarrhythmic agents and related drugs (e.g., quinidine, disopyramide, procainamide) and type III agents (amiodarone, sotalol). Marked QT prolongation, sometimes with deep, wide T-wave inversions, may occur with intracranial bleeds, particularly subarachnoid haemorrhage. Hypocalcaemia typically prolongs the QT interval (ST portion), while hypercalcaemia shortens it. Digitalis glycosides shorten the QT interval, often with a characteristic "scooping" of the STT-wave complex. Torsades de pointes ("twisting of the points") refers to VT characterised by polymorphic QRS complexes that change in amplitude and cycle length, giving the appearance of oscillations around the baseline. This rhythm is, by definition, associated with QT prolongation. Number: 401 A prolonged QT interval may: 1. Be caused by hypocalcaemia. 2. Predispose to 'Torsade de pointes'. 3. Be caused by amiodarone. 4. Be caused by cardiac glycosides.

350

A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: A Prolongation of the QT interval is seen with drugs that increase the duration of the ventricular action potential: - ie Vaughan-Williams type 1A antiarrhythmic agents and related drugs (e.g., quinidine, disopyramide, procainamide) and type III agents (amiodarone, sotalol). Marked QT prolongation, sometimes with deep, wide T-wave inversions, may occur with intracranial bleeds, particularly subarachnoid haemorrhage. Hypocalcaemia typically prolongs the QT interval (ST portion), while hypercalcaemia shortens it. Digitalis glycosides shorten the QT interval, often with a characteristic "scooping" of the STT-wave complex. Torsades de pointes ("twisting of the points") refers to VT characterised by polymorphic QRS complexes that change in amplitude and cycle length, giving the appearance of oscillations around the baseline. This rhythm is, by definition, associated with QT prolongation. Number: 405 Insulinoma: 1. Usually presents with symptoms of hypoglycaemia. 2. Has about a 1:10 chance of being malignant. 3. May be associated with peptic ulceration. 4. Is most common in the second and third decade of life. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: A The hallmark of pancreatic beta cell tumours is the development of symptomatic hypoglycemia from unregulated insulin hypersecretion. Symptoms related to the

351

hypoglycemia include headache, slurred speech, psychological alterations, visual disturbances and confusion. About 10% of tumours are malignant. As with gastrinomas, insulinomas are frequently associated with Multiple Endocrine Neoplasia type 1. Multiple endocrine neoplasia type 1, or Wermer's syndrome, is the association of neoplastic transformation of parathyroid, pituitary, and pancreatic islet cells. The syndrome is inherited as an autosomal dominant trait; each child born to an affected parent has a 50 percent chance of inheriting the predisposing gene. About 60% of patients with MEN 1 will develop a gastrinoma and about 35% an insulinoma. Insulinomas arise most frequently in the fifth to seventh decades, although cases have been reported at all ages. Number: 407 Hyposplenism: 1. Markedly increases the risk of overwhelming Neisseria meningitidis infection. 2. Is compatible with the blood film shown below. 3. Is an indication for vaccination against pneumococcal infection. 4. Is a cause of thrombocytopenia. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct

352

ABCDE Correct Answer: A The blood film shows Howell-Jolly Bodies. Thrombocytopenia is a feature of hypersplenism. The usual causes of hyposplenism are splenectomy, congenital asplenia, sickle cell anaemia in patients older than 5 years (with autosplenectomy due to repeated infarcts), and splenic irradiation Findings in the peripheral blood that indicate diminished splenic function include the presence of nucleated red cells, Howell-Jolly bodies, Heinz bodies, basophilic stippling and rarely, circulating nucleated red blood cells. Splenectomised patients or patients with functional asplenia (such as in sickle cell disease) are prone to bacterial infections, which are frequently overwhelming and life-threatening, particularly with encapsulated organisms such as Streptococcus pneumoniae, Neisseria meningitidis, Escherichia coli, and Haemophilus influenzae. The overall risk of bacterial sepsis in splenectomized patients has been estimated to be approximately 7 percent over a 10-year period. The role of pneumococcal vaccination has been the subject of a recent mata-analysis.

353

Number: 408 Hyperosmolar non-ketotic diabetic coma: 1. Is unusual in the elderly 2. Is rarely associated with a blood sugar level > 30 mmol/l 3. Typically causes hyperventilation. 4. May cause focal neurological signs A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: D Hyperosmolar, nonketotic diabetic coma is usually a complication of non-insulin-dependent diabetes. It is a syndrome of profound dehydration resulting from a sustained hyperglycemic diuresis under circumstances in which the patient is unable to drink sufficient water to keep up with urinary fluid losses. Commonly an elderly diabetic patient--often living alone or in a nursing home--develops a stroke or infection which worsens hyperglycemia and prevents adequate water intake. The absence of ketoacidosis is important in the pathophysiology. Clinically, patients present with extreme hyperglycemia, hyperosmolality, and volume depletion, coupled with central nervous system signs ranging from clouded sensorium to coma. Seizure activity--sometimes Jacksonian in type--is not unusual, and transient hemiplegia may be seen. Infections, particularly pneumonia and gram-negative sepsis, are common and indicate a grave prognosis. Pneumonia is often due to gram-negative organisms. Number: 410 Hypomagnesaemia: 1. Is likely to be found in a patient with alcoholic liver disease. 2. Is likely to be found in a poorly controlled diabetic. 3. Can cause ventricular arrhythmias. 4. Can occur as a complication of primary hyperaldosteronism. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct

354

ABCDE Correct Answer: E Ethanol causes a transient loss of magnesium into the urine. Alcoholics with a reasonably normal nutrient intake and normal intestinal function usually have normal or only slightly depressed magnesium levels in blood. The total-body deficit of magnesium in chronic alcoholics is modest, amounting to 100 to 150 mmol (2.4 to 3.6 g). Mild hypomagnesemia occurs in poorly controlled diabetes mellitus. Moderate hypomagnesemia may occur in hyperparathyroidism, hypoparathyroidism, hyperthyroidism, and primary hyperaldosteronism, as well as during recovery from diabetic ketoacidosis. In primary hyperaldosteronism, aldosterone enhances magnesium excretion directly and acts via volume expansion to cause net losses of magnesium. These effects can be reversed by spironolactone. Cardiac arrhythmias, disturbances of conduction, and even ventricular fibrillation and cardiac arrest can occur in patients with hypomagnesemia. Number: 412 A 56-year-old male with hypertension (blood pressure 155/95 mm Hg) smokes 2 packs of cigarettes per day and has an HDL cholesterol that is greater than normal. Which of the following factors in his case is NOT associated with an increased risk for his developing atherosclerosis: A Hypertension B Male sex C Age D Increased HDL cholesterol E Smoking Select the single best answer ABCDE Correct Answer: D High-density lipoproteins (HDL) The level of HDL, a complex family of particles that carry about 20 percent of the total plasma cholesterol, is inversely associated with the development of premature atherosclerosis and therefore can be considered an "antirisk factor." HDL levels can be assessed simply by measurement of cholesterol in the supernatant fluid after the other lipoproteins in plasma have been precipitated. Thus individuals whose HDL cholesterol is elevated may be less likely to

355

develop IHD; conversely, low HDL cholesterol is associated with increased risk of IHD. In the Framingham Study, low HDL cholesterol was a more potent lipid risk factor than was high total cholesterol or LDL. At least five diverse population studies have confirmed a close correlation between IHD and low HDL, independent of other factors. Consistent with differences in risk between the sexes, HDL cholesterol averages about 25 percent higher in women than in men. Estrogens tend to raise and androgens tend to lower HDL levels. In women, low HDL, particularly when associated with diabetes and obesity, markedly raises the risk of IHD. Octogenarians tend to have high HDL, which may be partly familial. Of interest for preventive measures, cigarette smoking decreases and regular strenuous exercise increases HDL cholesterol. Regular exercise increases HDL even in individuals after myocardial infarction. A small daily intake of alcohol has been associated with both reduced risk of IHD and high HDL levels. Mechanisms for these effects remain unknown. Number: 415 A 17 year old girl presents with breathlessness, ankle oedema and evidence of right heart failure. She is known to have had a heart murmur since birth and appears to be slightly cyanosed. Her ECG is shown below. This picture is compatible with: 1. Ebstein's anomaly. 2. Primary Pulmonary Hypertension. 3. Eisenmenger Syndrome. 4. Hypertrophic Obstructive Cardiomyopathy. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct

356

ABCDE Correct Answer: B The ECG shows: Sinus rhythm Markedly peaked P waves (best seen in leads 11, V,) Normal axis Right bundle branch block Right atrial hypertrophy is seen with pulmonary hypertension of any cause, tricuspid stenosis, and Ebstein's anomaly. Right bundle branch block is characteristic of atrial septal defects. These conditions can all be diagnosed by echocardiography. This patient had Ebstein's anomaly and an atrial septal defect. Ebstein's anomaly This malformation is characterized by a downward displacement of the tricuspid valve into the right ventricle, due to anomalous attachment of the tricuspid leaflets. Tricuspid valve tissue is dysplastic; a variable portion of the septal and inferior cusps adhere to the right ventricular wall some distance away from the atrioventricular junction. The abnormally situated tricuspid orifice produces a portion of the right ventricle lying between the atrioventricular ring and the origin of the valve, which is continuous with the right atrial chamber. This proximal segment is "atrialized," and the distal ventricular chamber is small. The degree of impairment of right ventricular function depends primarily on the extent to which the right ventricular inflow portion is atrialized and on the magnitude of tricuspid valve regurgitation. Most patients survive at least to the third decade. Although the clinical manifestations are variable, some patients come to initial attention because of progressive cyanosis from right-to-left atrial shunting, or symptoms due to tricuspid regurgitation and right ventricular dysfunction, or paroxysmal atrial tachyarrhythmias with or without bypass tracts (type B Wolff-Parkinson-White syndrome is common). Eisenmenger's syndrome In adults who were born with a large left-to-right shunt, pulmonary vascular obstruction with pulmonary hypertension, right-to-left shunting (shunt reversal), and cyanosis can develop. This is known as Eisenmenger's syndrome. Primary pulmonary hypertension Primary pulmonary hypertension is an uncommon disease characterized by increased pulmonary artery pressure and pulmonary vascular resistance without an obvious cause. The diagnosis can be made only after all causes of pulmonary hypertension have been excluded. There is a female-to-male preponderance (1.7:1), with patients most commonly presenting in the third and fourth decades, although the age range is from infancy to greater than 60 years. Because the predominant symptom of primary pulmonary hypertension is dyspnea, which can have an insidious onset in an otherwise healthy person, the disease is typically diagnosed late in its course. By that time, the clinical and laboratory findings of severe pulmonary hypertension are usually present.

357

Number: 416 Platelet activation: 1. Is caused by Von Willebrand factor 2. Is inhibited by prostacyclin (PGI2) 3. Is inhibited by endothelium derived nitric oxide 4. Is inhibited by thromboxane A2 A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: A 1 - binding to glycoprotein Ib receptors and exposed subendothelial components 2 - by increasing intraplatelet cAMP 3 - by increasing intraplatelet cGMP 4 - ADP and thromboxane A2 are released by platelet degranulation and lead to further platelet activation (Am J Med 1996;101:199-209) Number: 417 Which are true? 1. Wilcoxon's rank test needs equal sample sizes 2. 'r' is the symbol denoting coefficent of correlation 3. Student's t-test is a non-parametric test 4. y=a+bx is a regression equation A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: C Student's t-test is a parametric test. y=a+bx is a regression equation and is the equation of a straight line.

358

Number: 418 In acute tubular necrosis: A The urinary sodium concentration is classically less than 30 mmol/l B The urine plasma osmolality ratio is more than 1:1 C Red cell casts are usually present in the urine D Proteinuria is an expected finding E The creatinine clearance is uaually normal after 1 year Select the single best answer ABCDE Correct Answer: D A > 30. B < 1:1. C Suggests nephritis. E Only 40% of cases. Number: 423 Hypomagnesemia: 1. Is commonly present in patients on admission to surgical Intensive Care Units. 2. Can occur as a result of treatment with aminoglycoside antibiotics. 3. Will potentiate the effect of non-depolarising muscle relaxants. 4. Can prolong the QT interval. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: E Abnormalities of serum magnesium (Mg++) concentrations may rank as the most common electrolyte disturbance among hospitalised patients. Disorders of Mg++ balance appear to be especially common among patients in intensive care. The clinical signs of hypomagnesemia are similar to those seen in patients with hypocalcemia and are characterized by neuronal excitability and tetany. Trousseau's sign, Chvostek's sign, muscle fasciculations, muscle spasticity, hyporeflexia, and seizures occur with progressive hypomagnesemia. Hypomagnesemia can cause subclinical respiratory muscle weakness in patients that improves after Mg++ supplementation. Both hypomagnesemia and hypocalcemia prolong the QT interval on the ECG.

359

Laboratory evidence of hypomagnesemia has been found in over 60% of surgical patients being admitted for postoperative intensive care in at least two studies. Chernow B, Bamberger S, Stoiko M, et al: Hypomagnesemia in postoperative intensive care, Chest 95:391-397, 1989. Ryzen E, Wagers PW, Singer FR, and Rude RK: Magnesium deficiency in a medical ICU population, Crit Care Med 13:19-21, 1985. Number: 424 Low T waves on an ECG are seen in: 1. Hypokalaemia. 2. Hypercalcaemia. 3. Pericardial effusion. 4. Athletes. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: B 1. In association with prominent U waves. 2. Hypercalcaemia causes a shortened ST segment and steeper distal limb of the T wave. 3. In association with generally small P waves and QRS complexes. 4. Athletic or vagotonic hearts tend to have tall T waves. Number: 425 Ostium secundum ASD is associated with 1. Left bundle branch block. 2. Fixed splitting of the second heart sound. 3. Onset of atrial fibrillation in the second decade. 4. Mitral stenosis. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct

360

ABCDE Correct Answer: C 1. Right bundle branch block. 2. A feature of all ASDs 3. Usually AF occurs later in life 4. This is Lutembacher's syndrome. Secundum ASD is also associated with mitral valve prolapse. Number: 427 Which of the following are features of Fallot's tetralogy? 1. A prominent systolic murmur from the ventricular septal defect. 2. Squatting. 3. Pulmonary plethora. 4. Paradoxical embolism. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: C 1. The systolic murmur comes from the pulmonary infundibular stenosis. 2. Squatting relieves the dyspnoea by increasing SVR. 3. There is usually pulmonary oligaemia as there is a right to left shunt. 4. Because of the right to left shunt at ventricular level. Tetralogy accounts for about 10 percent of all forms of congenital heart disease and is the most common cause of cyanotic forms. The four components of the tetralogy of Fallot are ventricular septal defect, obstruction to right ventricular outflow, aortic override of the ventricular septal defect, and right ventricular hypertrophy. The basic anomaly results from an anterior and superior deviation of the infundibular ventricular septum away from its usual location in the heart between the limbs of the trabecular septum. This displacement causes subpulmonary obstruction, aortic "override," and a large, nonrestrictive, malalignment-type ventricular septal defect.

361

Number: 430 Autosomal dominant inheritance: 1. Has surviving affected individuals, in a heterozygous state. 2. Is the mode of inheritance in multiple neurofibromatosis. 3. Affects both sexes equally. 4. Shows a pattern of vertical inheritance in a pedigree. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: E Dominant diseases are those manifest in the heterozygous state, i.e., when only one abnormal gene (mutant allele) is present and the corresponding partner allele on the homologous chromosome is normal. The gene responsible for an autosomal dominant disorder is located on one of the 22 autosomes, and both males and females can be equally affected. Since alleles segregate independently at meiosis, there is a 1 in 2 chance that the offspring of an affected heterozygote will inherit the mutant allele and, similarly, a 1 in 2 chance of the offspring inheriting the normal allele. The characteristic features of an autosomal dominant trait are that: (1) Each affected individual has an affected parent (unless the condition arose by a new mutation or is mildly expressed in the affected parent); (2) an affected individual will bear, on average, both normal and affected offspring in equal proportions; (3) normal children of an affected individual will have only normal offspring; (4) males and females are affected in equal proportions; (5) each sex is equally likely to transmit the condition to male and female offspring, with male-to-male transmission occurring; and (6) vertical transmission of the condition through successive generations occurs, especially when the trait does not impair reproductive capacity. Number: 447 Which statement is true with regard to Campylobacter jejuni: A. It most commonly attack the elderly B. It usually responds to treatment with ciprofloxacin C. Is a recognised pathogen in domestic animals D. It is readily isolated in stool culture E It is a rare cause of enteritis. Select the single best answer

362

ABCDE Correct Answer: C Campylobacter infections are not rare. Several studies indicate that in the United States diarrhoeal disease due to campylobacters is more common than that due to Salmonella and Shigella combined. Infections occur throughout the year, but their incidence peaks during summer and early autumn. Persons of all ages are affected; however, attack rates are highest among young children and young adults. If antibiotic therapy is indicated, erythromycin is the drug of choice. Campylobacters are found within the gastrointestinal tract of many animals used for food production (including poultry, cattle, sheep, and swine) and of household pets (including birds, dogs, and cats). However, these microorganisms usually do not cause illness in their animal hosts. In most cases, campylobacters are transmitted to humans in raw or undercooked food products or through direct contact with infected animals. In the United States and other developed countries, ingestion of contaminated poultry that has not been sufficiently cooked is the most common means of acquiring infection (50 to 70 percent of cases). The organism is difficult to culture. Number: 448 Which of the following is NOT a recognised complication of chronic renal failure? A. Sensory-motor neuropathy B. Pruritis C. Metastatic calcification D. Menorrhagia E. Proximal myopathy Select the single best answer ABCDE Correct Answer: D A. Common, sensory preceeds motor and dialysis helps prevent progression. B. Often resistant to treatment. C. Particularly when the serum phosphate and calcium levels are high. D. Amenorrhoea is a common and early symptom of uraemia - Infertility in men also occurs. E. The myopathy of chronic renal failure is distinct from the better known uraemic polyneuropathy.

363

Number: 449 Which of the following is NOT a well-recognised complication of long-term haemodialysis? A. Arthropathy B. Dementia C. Accelerated artherosclerosis D. Raised intracranial pressure E. Leucocytosis Select the single best answer ABCDE Correct Answer: E A. Amyloid can directly involve articular structures by its presence in the synovial membrane and synovial fluid or in the articular cartilage. Amyloid arthritis can mimic a number of rheumatic diseases because it can present as a symmetric arthritis of small joints with nodules, morning stiffness, and fatigue. B. Characterised by speech dyspraxia, myoclonus, dementia and siezures. Though to be due to aluminium overload. C. Caused by hypertension, hyperlipidaemia, glucose intolerance, chronic high cardiac output and metastatic calcification. D. Dialysis dysequilibrium - from lowering serum urea too quickly. Mannitol is often given during the first few haemodialysis sessions when the urea is particularly high. E. Leucopenia is common and transient in those exposed to cellophane-derived filters Number: 450 Which of the following is/are found in a patient with jaundice due to uncomplicated haemolytic anaemia? 1. Bilirubinuria 2. High conjugated serum bilirubin 3. High serum alkaline phosphatase 4. Reticulocytosis A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE

364

Correct Answer: D In the haemolytic anaemias, the rate of bilirubin production is increased and may exceed the amount that can be removed by a normal liver. The resulting jaundice is primarily an unconjugated hyperbilirubinaemia. There may also be a small increase in the serum conjugated bilirubin. Bilirubin appears in the urine only after it is converted to a water-soluble form; generally this involves conjugation with polar glucuronide groups which enhance water solubility. In the absence of bone disease or pregnancy, elevated levels of alkaline phosphatase activity usually reflect impaired biliary tract function. The increased levels reflect increased synthesis of the enzyme by hepatocytes and biliary tract epithelium rather than regurgitation of enzyme due to obstruction. Number: 460 Which of the following statements are true with regard to hereditary haemorrhagic telangiectasia (Osler-Weber-Rendu disease)? 1. Cerebral abscess is associated with the condition. 2. Cyanosis is associated with the condition. 3. Nose bleeding is associated with condition. 4. It is inherited as an autosomal dominant disorder. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: E Hereditary haemorrhagic telangiectasia is an important risk factor for brain abscess, especially in affected patients with clubbing, cyanosis, and/or polycythaemia. The condition is inherited as an autosomal dominant disorder and patients have frequent episodes of nasal and gastrointestinal bleeding from abnormal telangiectatic capillaries. A significant degree of right-to-left shunting (through pulmonary telangiectases) can occur.

365

Number: 476 Which of the following statements are true regarding Ankylosing Spondylitis? 1. It is associated with aortic incompetence. 2. It is associated with upper lobe fibrosis. 3. The earliest radiologically apparent changes are in the sacro-iliac joints. 4. About 10% of sufferers have the HLA B27 gene. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: A Aortic insufficiency develops in a small percentage of cases. There is thickening of the aortic valve cusps and the aorta near the sinuses of Valsalva, with dense adventitial scar tissue and intimal fibrous proliferation, the scar tissue often extending into the ventricular septum with resultant heart block. Pulmonary involvement, characterized by slowly progressive upper lobe fibrosis, is a rare complication of long-standing AS. Radiological abnormalities generally appear in the sacroiliac joints before appearing elsewhere in the spine. In most ethnic groups, the HLA-B27 gene is present in approximately 90 percent of patients with AS. Number: 479 The signs of hypertrophic cardiomyopathy with ventricular outflow obstruction can include: 1. A pansystolic murmur 2. The murmur becoming louder with Valsalva manoeuvre 3. A presystolic lift at the apex. 4. A slow rising pulse A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct

366

ABCDE Correct Answer: A 1. A pansystolic murmur of associated mitral regurgitation is common. 2. It is also diminished by the Mueller manoeuvre (creating a negative intrathoracic pressure). 3. This is characteristic. Most patients with gradients demonstrate a double or triple apical impulse, a rapidly rising carotid arterial pulse, and a fourth heart sound. 4. A jerky pulse due to shortened systolic ejection is seen in HOCM - a slow rising pulse is seen in aortic stenosis. Number: 480 Giant 'a' waves in the JVP occur in: 1. Pulmonary hypertension 2. Aortic regurgitation 3. Tricuspid stenosis 4. Constrictive pericarditis A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: B Giant 'a' waves occur when there is a poorly compliant right ventricle (or tricuspid stenosis) increasing the impedence against which the right atrium has to eject blood. A giant a wave in the jugular venous pulse without palpatory evidence of pulmonary hypertension or right ventricular enlargement is particularly suggestive of tricuspid stenosis. In constrictive pericarditis the JVP is high with an abrupt fall in systole (x descent) and may rise with inspiration (Kussmaul's sign).

367

Number: 482 Contraindications to streptokinase include: 1. Age over 75 years 2. Recent stroke. 3. Atrial fibrillation 4. Pregnancy. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: C The role of thrombolysis in pregnancy has been reviewed by Turrentine et al. Obstet Gynecol Surv 1995 Jul;50(7):534-41 Turrentine MA, Braems G, Ramirez MM Use of thrombolytics for the treatment of thromboembolic disease during pregnancy. Number: 496 Diabetic nephropathy: 1. Occurs more commonly in type II (as opposed to type I) diabetes mellitus. 2. Is usually associated with retinopathy. 3. Is more likely in hypertensive diabetics. 4. Can be reversed by meticulous diabetic control. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: A 1. It occurs in about 30% of those who have had diabetes for 20 years and is therefore more likely in IDDM.

368

2. It is almost always associated with diabetic retinopathy. If it is not then another cause of renal failure in a diabetic should be considered. 3. Hypertension must be treated agressively in diabetics to help prevent diabetic nephropathy. 4. Slowed but not reversed. Number: 501 Score: 14 Attempted: 84 Category: Medicine Hyponatraemia is a recognised feature of: 1. Primary hyperaldosteronism. 2. Acute renal failure. 3. Hyperthyroidism. 4. Prolonged oxytocin infusion. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: C 1. Primary hyperaldosteronism is characterised by hypokalaemia (less than 3 mmol/L) and hypernatraemia (due to both sodium retention and a concomitant water loss from polyuria). 2. Due to volume overload. 3. Hyponatraemia is a feature of severe hypothyroidism. Decreased delivery of tubular fluid to diluting segments and persistent release of ADH both limit water excretion in this condition. 4. Oxytocin has mild ADH activity. Water intoxication and hyponatraemia are particularly likely if the drug has been administered in 5% dextrose for a prolonged period. See: Eur J Obstet Gynecol Reprod Biol 1996 Sep;68(1-2):47-8 Higgins J, Gleeson R, Holohan M, Cooney C, Darling M Maternal and neonatal hyponatraemia: a comparison of Hartmanns solution with 5% dextrose for the delivery of oxytocin in labour. Number: 515 Legionella pneumophila: 1. Causes Pontiac fever. 2. Infection is characterised by encephalopathy and renal failure. 3. Pneumonia is associated with hyponatraemia and hypophosphataemia.

369

4. Is best treated with carbenicillin. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: A Pontiac fever is a self-limiting tracheobronchitis caused by legionella pneumophila. Clinical features include high fever, gastrointestinal upset, headache and encephalopathy. Serious infections are characterised by the development of hyponatraemia, hypophosphataemia and renal failure. Treatment options include erythromycin +/- rifampicin or the newer macrolide antibiotics such as azithromycin or clarithromycin. Number: 517 The cough associated with angiotensin-converting enzyme (ACE) inhibitors is: A. Dose dependent B. More common in women than men C. More common in patients who smoke cigarettes D. More likely to occur when treating hypertension E. Likely to improve on changing to a different ACE inhibitor Select the single best answer ABCDE Correct Answer: B A dry, tickly and often bothersome cough is the most common adverse effect of ACE inhibitors. Recent studies indicate that cough may develop in around 10% of the patients treated with ACE inhibitors. In half of these patients, the ACE inhibitor has to be discontinued. Cough has emerged as a class effect occurring with all ACE inhibitors with no clear difference between the single substances. While ACE inhibition is safe in the vast majority of patients with obstructive airways disease, asthmatic symptoms or exacerbation of asthma as well as a rise in bronchial reactivity have been occasionally reported. ACE inhibition increases the cough reflex.

370

The mechanisms underlying ACE inhibitor-induced cough are probably linked to suppression of kininase II activity, which may be followed by an accumulation of kinins, substance P and prostaglandins. Physicians should be aware that a dry cough is the most common adverse effect of ACE inhibitors and that this symptom may occur not necessarily shortly after institution of therapy but months or even a year later. Replacement by another ACE inhibitor should not be tried, since the cough will almost always recur on rechallenge with the same or another ACE inhibitor. After withdrawal of the ACE inhibitor, which is the treatment of choice, cough will resolve usually within a few days. Cough occurs more commonly in women than men. Number: 518 Guillain-Barre syndrome: 1. Is usually associated with a raised CSF protein. 2. Is commonly preceded by a viral-like illness. 3. Can involve the cranial nerves. 4. Can involve sensory nerves. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: E Guillain-Barre syndrome (GBS) is an acute, frequently severe and fulminant polyneuropathy. In over two-thirds of cases, an infection, usually viral, either clinically overt or evidenced by serum titre rise, precedes the onset of neuropathy by 1 to 3 weeks. GBS also occurs against a background of lymphoma, including Hodgkin's disease, and in lupus erythematosus. The clinical features of GBS typically include areflexic motor paralysis with mild sensory disturbance coupled with an acellular rise of total protein in the cerebrospinal fluid by the end of the first week of symptoms. The paralysis is typically symmetrical and can include bulbar cranial nerves. Most patients with GBS require hospitalisation, and about 30 percent will need ventilatory assistance at some point during the illness. The prognosis is good; approximately 85 percent of patients will make a complete or nearly complete recovery. The mortality rate is 3 to 4 percent. Management is generally supportive care, but plasmapheresis also has a role. Large, multicentre, controlled trials in North America and Europe have demonstrated a beneficial effect of plasmapheresis, if initiated in the first 2 weeks of illness. Intravenous administration of high-dose immunoglobulin (2 g/kg body weight given over 5 days) is probably as effective as plasmapheresis. In contrast, glucocorticoid treatment has not been shown to be effective.

371

Number: 532 Pneumocystis carinii pneumonia: 1. Occurs almost exclusively in the immunocompromised patient. 2. May respond to treatment with co-trimoxazole. 3. Is frequently accompanied by cytomegalovirus infection. 4. Can usually be isolated from the sputum. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: A Pneumocystis carinii causes severe pneumonia in immunocompromised hosts. Although this most commonly occurs in patients with the acquired immunodeficiency syndrome (AIDS), other groups of immunocompromised patients without AIDS are also at risk for P. carinii pneumonia. These patients have solid or haematologic malignancies, organ transplantation, or inflammatory conditions requiring chronic immunosuppressive drugs, particularly corticosteroids. There are important differences in the clinical presentation of P. carinii pneumonia in patients with and without AIDS. P. carinii causes an acute fulminate pneumonia in patients without AIDS while patients with AIDS have more insidious involvement. The two major drugs used in the treatment of Pneumocystis carinii pneumonia have been trimethoprim-sulfamethoxazole and pentamidine isethionate. These agents are equally effective, with an overall success rate of 70 to 80 percent. Trimethoprim-sulfamethoxazole acts by inhibiting folic acid synthesis, but the mode of action of pentamidine against Pneumocystis is unclear. The organism is not usually isolated in the sputum. Fibreoptic bronchoscopy with bronchoalveolar lavage (BAL), is the mainstay of P. carinii diagnosis. This procedure provides information about the organism burden, host inflammatory response, and the presence of other opportunistic infections. Transbronchial biopsy and open lung biopsy, which are the most invasive procedures, are reserved for situations when a diagnosis cannot be made by lavage. CMV and pneumocystis are frequently found together in immunosuppressed patients with severe interstitial pneumonia. CMV may function as a cofactor to activate latent HIV infection.

372

Number: 547 Clopidogrel: A. Is a platelet glycoprotein IIb / IIIa receptor blocker. B. Is a platelet cyclooxygenase inhibitor. C. Is a platelet ADP receptor inhibitor. D. Is a factor Xa inhibitor. E. Is an anti-thrombin III activator. Select the single best answer ABCDE Correct Answer: C Clopidogrel inhibits ADP-induced platelet activation. It is generally believed that clopidogrel is biotransformed and activated in the liver. However, the precise active metabolite(s) of ticlopidine and clopidogrel have not been precisely identified. It has been proposed that this metabolite is highly reactive and labile, and binds quickly and irreversibly to platelets, altering certain receptors, interfering with the binding of ADP, and blocking further ADPinduced signaling. Recent data have also suggested that both ticlopidine and clopidogrel can interfere with invitro ADP-induced aggregation of washed human platelets; thus biotransformation may not be a necessary step. This effect was not noted when either plasma or albumin was present. Regardless of the exact mechanism, thienopyridines produce a permanent inhibition of the low-affinity ADP receptor, and platelets exposed to clopidogrel are irreversibly inhibited for their lifetime. Clopidogrel has superceded ticlopidine because of its better safety profile. Number: 548 Platelet activators include: 1. Thrombin. 2. Calcium. 3. Thomboxane A2 4. Prostacyclin. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct

373

ABCDE Correct Answer: A The important platelet activators include: Collagen, ADP, Thrombin, TXA2 and Calcium. Prostacyclin is the 'natural' platelet inhibitor which acts by elevating the level of intraplatelet cyclic AMP. Elevation of cAMP facilitates entry of calcium into the sarcoplasmic reticulum, lowers cytoplasmic calcium and thus inhibits TXA2 production.

Number: 549 Type II Heparin-Induced Thrombocytopenia: 1. Is usually associated with the presence of Heparin:Platelet Factor 4 complex antibodies. 2. Typically occurs within 2-3 days of iniotiation of heparin therapy. 3. Can complicate therapy with low molecular weight heparin. 4. Can occur as a result of the use of hirudin. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: B Type I Heparin-Induced Thrombocytopenia occurs early in the course of treatment, is not immunologically mediated and does not usually depress the platelet count severely. Heparin-induced thrombocytopenia (HIT) type II is an immune-mediated reaction that generally occurs 5 to 14 days after initiation of heparin therapy. It is characterized by a severe decline in platelet count (by >50%) in association with a new thromboembolic complication. Type II HIT is mediated by antibodies, usually of the IgG class. The antibodies cause platelet activation in the presence of heparin or other polysulfated saccharides. The antigen in type II HIT frequently is a complex of platelet factor 4 (PF4) and heparin. Hirudin is structurally unrelated to heparin and does not cause Heparin-Induced Thrombocytopenia. LMWH may rarely cause the syndrome.

374

Nuttall et al have recently reviewed the management of 12 patients with a history of HIT type II who required cardiac surgery on cardiopulmonary bypass. See: Nuttall GA, Oliver WC Jr, Santrach PJ, McBane RD, Erpelding DB, Marver CL, Zehr KJ. Patients with a History of Type II Heparin-Induced Thrombocytopenia with Thrombosis Requiring Cardiac Surgery with Cardiopulmonary Bypass: A Prospective Observational Case Series. Anesth Analg. 2003 Feb;96(2):344-50. Number: 552 Which of the following forms of sickle cell disease represent a significant risk to a patient undergoing general anaesthesia? 1. S - S disease. 2. Sickle - Beta thalassaemia. 3. S - C disease. 4. Sickle cell trait. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: A Different genotypes can give rise to sickle cell disease. The classic form of the disease may be considered to be the homozygous state for haemoglobin S, i.e., SS disease or sickle cell anaemia. However, the manifestations of SC disease, and sickle cell - Beta thalassemia are very similar. Typically, sickle cell anaemia has the most severe clinical course whereas extreme splenomegaly may be more likely to occur in haemoglobin SC disease and S - Beta thalassaemia. However, there is a great deal of overlap between the severity and clinical manifestations of these disorders. The principal importance of the distinctions between different sickle disease genotypes is in their diagnosis and in genetic counseling. A number of factors influence the course of sickle cell disease and may be important in precipitating crises. These include infection and fever, dehydration, and exposure to low oxygen tension. Even apart from these factors, the severity of the clinical manifestations of sickle cell disease varies greatly from patient to patient, not only in the degree to which they are affected but also with respect to which of the morbid manifestations predominate. Thus, some may suffer chiefly from anaemia with few, if any, painful episodes, while others experience many painful crises but have haemoglobin levels that are nearly normal.

375

The trait does not constitute a significant risk to the patient who is to undergo otherwise uncomplicated general anaesthesia and more recently it has been confirmed that patients with sickle cell trait can be safely anaesthetised for coronary artery grafting. Djaiani GN, Cheng DC, Carroll JA, Yudin M, Karski JM Anesth Analg 1999 Sep;89(3):598603 Fast-track cardiac anesthesia in patients with sickle cell abnormalities. Number: 561 With regard to an X-linked recessive disease: 1. Mothers are always carriers 2. Fathers never transmit to their sons 3. Variable expression in females is due to random inactivation 4. 50% of daughters of carrier females will be carriers A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: E The genes responsible for X-linked disorders are located on the X chromosome, and the clinical risks are different for the two sexes. Since a female has two X chromosomes, she may be either heterozygous or homozygous for a mutant gene, and the mutant allele may demonstrate either recessive or dominant expression. Expression in females is often variable and influenced by random X-chromosome inactivation. Males, on the other hand, have only one X chromosome, so they are more likely to display the full phenotype, regardless of whether the mutation produces a recessive or dominant allele in the female. Thus, the terms X-linked dominant or X-linked recessiverefer only to the expression of the mutation in women. An important feature of all X-linked inheritance is the absence of male-to-male (i.e., father-toson) transmission of the trait. This follows because a male contributes his Y chromosome to his son and does not contribute an X chromosome. On the other hand, since a male contributes his sole X chromosome to each daughter, all daughters of a male with an X-linked disorder will inherit the mutant allele. Examples of X-linked recessive disorders in humans include the Lesch-Nyhan syndrome, glucose-6-phosphate dehydrogenase deficiency, testicular feminization, and Hunter's mucopolysaccharidosis

376

Number: 571 Which of the following cytotoxic agents is / are quite likely to cause pericarditis? 1. Doxorubicin 2. Busulfan 3. Bleomycin 4. Cyclophosphamide A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: D Busulphan and bleomycin rarely cause pericarditis. Subacute doxorubicin toxicity occurs uncommonly. It develops early in the course of therapy and is characterised by myocarditis and pericarditis. Chronic toxicity is the most common form of doxorubicin-induced cardiac toxicity. It is manifest by chronic dilated cardiomyopathy, which develops late in the course of therapy or shortly after its termination. The incidence of pericarditis in association with the use of cyclophosphamide may be as high as 33%. Number: 572 The risk of acquiring hepatitis C (HCV) from a needle stick injury where the needle has been contaminated with the blood of an HCV +ve patient is approximately: A. 0.003% B. 0.1% C. 3% D. 10% E. 30% Select the single best answer ABCDE Correct Answer: C The risk of hepatitis C from a HCV-infected needle stick is approximately 3%. Number: 573 Which of the following forms of hepatitis is / are primarily transmitted by blood?

377

1. B 2. D 3. C 4. A A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: A Hepatitis B, D, and C are most commonly transmitted by parenteral inoculation with the blood of an infected person. Hepatitis A is primarily transmitted by the faeco-oral route Number: 575 A patient with osteogenesis imperfecta is at increased risk of: 1. Kyphoscoliosis. 2. Mitral valve prolapse. 3. Hyperthermia. 4. Joint laxity. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: E 1. In types III and IV osteogenesis imperfecta, multiple fractures from minor physical stress can produce severe deformities. Kyphoscoliosis can result. 2. Mitral valve prolapse is a frequent finding in patients with heritable disorders of connective tissue, including Marfan's syndrome, osteogenesis imperfecta, and Ehler-Danlos syndrome. 3. For unknown reasons, some patients are at risk of a hypermetabolic state with elevated serum thyroxine levels, hyperthermia, and excessive sweating. They are also at increased of classical malignant hyperthermia.

378

4. About 50% of patients have a molecular defect in type I procollagen that produces lax joints similar to those in type VII Ehler-Danlos syndrome. Number: 580 Which of the following is an example of discrete interval data? A. ASA physical status B. Mallampati score C. Nasopharyngeal temperature D. Pain score E. None of the above. Select the single best answer ABCDE Correct Answer: E ASA physical status, Mallampati score and Pain score are examples of ordinal data. (Data which can be ranked or measured without a constant scale interval.) Nasopharyngeal temperature is an example of continuous data. (Data which are measured on a continuum with a consistent scale interval.) Number: 581 In the case of a sample population which is normally distributed, the proportion who are within +/- 1 standard deviation of the mean is approximately: A. 33% B. 50% C. 68% D. 95% E. 99% Select the single best answer ABCDE Correct Answer: C One standard deviation encompasses roughly 68% of the sample; two standard deviations roughly 95% and three standard deviations roughly 99%.

379

Number: 583 Which of the following factors increase the risk of bleomycin-induced pulmonary toxicity? 1. Age. 2. Concurrent radiotherapy. 3. Concurrent cytotoxic therapy. 4. Cumulative dose. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: E Risk factors predisposing to the development of pulmonary toxicity by bleomycin include: total dose administered, age, concurrent radiotherapy, exposure to a high inspired oxygen and concomitant use of other cytotoxic drugs. Of most significance to anaesthetists is the association between the development of pulmonary toxicity and transient exposure to a high FiO2. The risk of toxicity is strongly dose-related, and above a cumulative dose of ~ 500 mg, the incidence increases exponentially. Fatal pulmonary toxicity has been reported with doses as low as 100 mg. Number: 584 The most important complcation of cisplatin therapy is: A. Cardiotoxicity. B. Nephrotoxicity. C. Pulmonary toxicity. D. Hepatotoxicity. E. Neurotoxicity. Select the single best answer ABCDE Correct Answer: B Cisplatin is a common component of combination chemotherapy for ovarian, testicular and bladder tumours. Nephrotoxicity is by far the most important complication of cisplatin therapy.

380

As early as 35 days after administration, there may be a progressive decrease in glomerular filtration rate followed by evidence of acute tubular necrosis. In addition to the usual biochemical pattern of a tubular injury, a magnesium-wasting defect may be evident in up to 50% of patients with renal impairment. Number: 588 With regard to renal transplantation: 1. The one year graft survival rate for cadaveric grafts is > 85%. 2. The maximum acceptable pre-implantation ischaemic time is 24 hours. 3. A cadaveric graft is likely to function for more than 10 years. 4. The one year graft survival rate for living donor grafts is > 98%. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: B The one year graft survival rate for cadaveric grafts is about 87% and that for living donors 93.9%. The maximum acceptable pre-implantation ischaemic time is about 48 hours. The half-life graft survival for cadaveric grafts is 19.5 years. N Engl J Med 2000 Mar 2;342(9):605-12. Hariharan S et al Improved graft survival after renal transplantation in the United States, 1988 to 1996. Hariharan S et al. have recently reported the results of ~94000 renal transplants in the US (See abstract). Number: 593 Chronic alcohol abuse is associated with: 1. Korsakoff's syndrome. 2. Peipheral neuropathy. 3. Wernicke's syndrome. 4. Cerebellar atrophy.

381

A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: E Wernicke's and Korsakoff's syndromes are the result of thiamine deficiency in vulnerable individuals (possibly in association with a genetic transketolase deficiency). Korsakoff's syndrome presents with profound anterograde amnesia and a milder retrograde amnesia, in the presence of a normal intelligence quotient. Chronic intake of high doses of ethanol causes peripheral neuropathy in 5 to 15 percent of alcoholics - probably related to thiamine deficiency. Thiamine (vitamin B1) deficiency causes Wernicke's encephalopathy. The clinical presentation is of a malnourished individual with confusion, ataxia, and diplopia (Charcot's triad). About 1 percent of malnourished alcoholics develop cerebellar degeneration. Number: 599 Nephrogenic diabetes insipidus may be caused by: 1. Lithium. 2. Hypokalaemia. 3. Hypercalcaemia. 4. Cerebral death. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: A 20-70% of patients receiving long term lithium therapy have some degree of nephrogenic diabetes insipidus. The condition can also be caused by other drug or electrolyte disturbances - particularly hypercalcaemia and hypokalaemia.

382

Central diabetes insipidus may complicate head injury or brain death. When patients with nephrogenic or central diabetes insipidus cannot be differentiated by simpler means, documentation of elevated plasma or urinary vasopressin (AVP) concentration in relation to plasma osmolality or of a high AVP concentration in relation to urine osmolality will allow the diagnosis of nephrogenic diabetes insipidus. The causes of acquired nephrogenic diabetes insipidus include: (1) Various forms of chronic renal disease. (2) The recovery phases of obstructive uropathy and acute tubular necrosis. (3) Potassium deficiencies, including primary aldosteronism. (4) Acute and chronic hypercalcaemia, including hyperparathyroidism. (5) Drug-induced: lithium, methoxyflurane, Amphotericin B. (6) Systemic disorders including: multiple myeloma, amyloidosis, sickle cell anaemia, Sjogren's syndrome. Number: 606 With regard to systemic hypertension: A. 1% is caused by primary renal disease. B. Benign nephrosclerosis is the usual cause of renal impairment in patients with essential hypertension. C. Medial hypertrophy is a common reno-vascular abnormality . D. Cerebrovascular disease is loosely correlated with it. E. All of the above. Select the single best answer ABCDE Correct Answer: B 95% of hypertension is considered idiopathic or "essential"; 5% is considered secondary to identifiable causes. Renal disease represents the majority of these. Renal dysfunction resulting from chronic essential hypertension is generally due to benign nephrosclerosis which is associated with intimal degeneration. Accelerated renal dysfunction associated with malignant hypertension involves the classic "onion skinning" hypertrophy of the media. There is a strong correlation between hypertension and cerebrovascular disease and similarly, control of blood pressure is associated with delayed progression of cerebrovascular disease. The Joint National Committee on the Detection , Evaluation and Treatment of Hypertension defines it as a systolic BP > 140 or diastolic BP > 90. This is obtained from an average of three readings reproducible on three different days. A pathophysiological classification describes primary or essential hypertension which accounts for 95% and secondary, accounting for 5%. Of the latter, renal disease accounts for the majority. This includes renovascular disease (RAS), disorders in Na/H2O excretion, and disorders of the renin-angiotensin system. Endocrine disorders constitute less than 1% of causes, and include hyperaldosteronism, Cushings syndrome, and phaeochromocytoma.

383

Globally, the common histopathological changes are intimal proliferation but further changes may be seen as end organ disease develops. End organ sequelae may affect any circulatory bed but heart, brain and kidneys are of greatest significance. Renal dysfunction associated with hypertension may manifest in a number of ways. Long standing hypertension may cause chronic renal injury characterized by intimal hyperplasia, sclerosis of afferent arterioles and parenchymal fibrosis causing gradual deterioration in function: this process is called benign nephrosclerosis. Conversely, a more fulminant decline culminating rapidly in irreversible renal failure may occur less commonly in a process called malignant nephrosclerosis: it is commonly associated with hypertensive crisis. Histologically, fibrinoid necrosis of the medial layer of the vessel walls is the most prominent feature. The course of malignant nephrosclerosis is such that renal failure will ensue within days to weeks unless blood pressure is controlled. There is an established role of hypertension in the genesis of cerebrovascular disease and lowering blood pressure has been shown to offer protection from cerebrovascular accidents. The pathogenesis of these may be thrombotic, embolic, hypotensive (haemorrhagic, dysrhythmic). References The Washington Manual- Manual of Medical Therapeutics, Little Brown & Co.,27th Ed., 1992, pp 62-64. ROGERS, M.C ET AL (EDS); Principles and Practice of Anesthesiology, Mosby, 1993, pp 155-65. Number: 623 A patient newly diagnosed with pulmonary tuberculosis (TB): 1. Should be nursed by personnel wearing masks capable of filtering particles in the submicrometre range. 2. Can undergo elective surgery provided that appropriate therapy has been initiated. 3. Is not a risk to others once 2 negative acid-fast bacillus sputum examinations have been performed. 4. Should be screened for Human Immuno-deficiency Virus (HIV) infection. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: D TB is transmitted by aerolisation of sputum and all those involved in the care of such patients should wear masks designed to filter particles 1-5 microns in diameter.

384

Elective surgery should be postponed until an infected individual has had an adequate course of therapy. In a recent study, it was found that of a total of 166 acid-fast bacilli positive suspects who had three sputum smears examined sequentially, 128 (77.1%) were found on the first smear, a further 25 (15%) on the second smear and 13 (7.9%) additional cases were identified on the third smear. Alcoholics, drug users, individuals who have been in close contact with people with tuberculosis, and patients with AIDS are all at increased risk of the disease. Number: 625 The proportion of patients infected with hepatitis C (HCV) who will develop chronic hepatitis is about: A. 10% B. 30% C. 50% D. 80% E. 100% Select the single best answer ABCDE Correct Answer: D Infection with HCV proceeds to chronicity in more than 80% of cases, and even recovery does not protect against subsequent re-exposure to the virus. Number: 626 The risk of acquiring hepatitis B from a needle stick injury where the needle has been contaminated with the blood of an hepatitis B +ve patient is approximately: A. 0.3% B. 0.1% C. 3% D. 10% E. 30% Select the single best answer ABCDE Correct Answer: E

385

The risk of acquiring hepatitis B is about 30%. For comparison, the risk of hepatitis C from an HCV-infected needle stick is approximately 3% and the risk of acquiring HIV from an HIVinfected needle stick is about 0.3%. Number: 644 A 20 year old asthmatic is admitted to the Emergency Department with acute asthma. He is breathing 100% oxygen via a non-rebreathing system. He has used his salbutamol puffer 'several times' since the attack began. His blood pressure is 140/55 mm Hg and his pulse rate is 110 bpm. A blood gas analysis is performed which shows: PaO2: 55 mm Hg. PaCO2: 86 mm Hg. pH: 7.08. BXS: -3 Given the scenario above, what should the next step in management be? A. Immediate intubation. B. Reduction of FiO2 from 1.0 to 0.28. C. Administration of more aerosolised salbutamol. D. Administration of intravenous adrenaline. E. Administration of intravenous aminophylline. Select the single best answer ABCDE Correct Answer: D The PaCO2 of 86 mm Hg is very worrying, but is not an indication for immediate intubation in the present context. Neither is it an indication for a reduction in FiO2! - Young asthmatics do not rely on hypoxic drive (and if more evidence is needed, the lack of a base XS attests to this) and any reduction in FiO2 will only worsen the hypoxaemia. The patient needs adrenaline -although it is debatable whether it needs to be given intravenously or not. It should be remembered that adrenaline is probably more effective than salbutamol in acute asthma - possibly because it has vasoconstrictive effects on the bronchial mucosa which further enhances its bronchodilator activity and / or the fact that it is less likely to cause inappropriate release of hypoxic pulmonary vasoconstriction (See for example: Coupe MO, Guly U, Brown E, Barnes PJ. Nebulised adrenaline in acute severe asthma: comparison with salbutamol. Eur J Respir Dis. 1987). Aminophylline has practically no role in the therapy of acute asthma (See: Littenberg B. Aminophylline treatment in severe, acute asthma. A meta-analysis. JAMA. 1988 Mar 18;259(11):1678-84.). Number: 650 Hirschprung's Disease: 1. Is usually not diagnosed until several weeks after birth.

386

2. Is more common in females. 3. Is incurable. 4. Can be diagnosed by biopsy of the anorectal wall. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: D 90% of cases are diagnosed within 3 days of life. It is much more common in males than females. It is curable through surgical intervention. This often involves an initial colostomy to relieve intestinal obstruction. The definitive operation is designed to bypass the aganglionic segment and bring normal bowel down to the anus. Prognosis is associated with the amount of viable bowel left after resection.The diagnosis may be made by barium enema, rectal biopsy or ano-rectal manometry.The presence of Auerbach's and Meissner's plexuses are diagnostic; excluding Hirschsprung's. Hirschsprung's Disease is results from the failure of migration of ganglion cells to the submucosal (Meissner's) and myenteric (Auerbach's) nerve plexuses of the large gut. The aganglionic segment, which remains tonically contracted and aperistaltic, invariably involves the internal sphincter. Sometimes it involves a very short segment, but 80% involve the rectosigmoid colon and 15% extend to the more proximal colon. The incidence is 1/4500 births. It accounts for 10% of neonatal intestinal obstruction, and must be considered if constipation presents in infancy. It may also present in the older child. The typical infant fails to pass meconium within the first 24 hours of life, develops abdominal distension, refuses to feed and finally, develops bilious vomiting. A severe form of enterocolitis with perforation and septicaemia may complicate this and carries a high mortality rate. The older child suffers intermittent bouts of intestinal obstruction from faecal impaction, failure to thrive, hypochromic anaemia and hypoproteinaemia. Soiling is extremely unusual, but not unknown. George Meissner was the Professor of Physiology at Gottingen University and described the plexus in 1853. Auerbach described his plexus in 1862. References HULL, D. JOHNSTON, D.I; Essential Paediatrics, 2nd Ed., pp 162. Number: 653 Which of the following pituitary hormones are well known to be secreted by a malignant lung tumour? 1. ACTH.

387

2. MSH. 3. Prolactin (in men). 4. Gonadotrophin. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: A Although other hormones are secreted, these are the most likely. By far the most common are ACTH and MSH. This phenomena is part of a constellation of complications of malignancy not directly caused by the tumour mass effect, or paraneoplastic syndrome. The effects are presumed to be mediated by either secreted tumour products or the development of autoantibodies and include hypercalcemia, SIADH, polymyositis, dermatomyositis, Eaton-Lambert myasthenic syndrome, clubbing and Hypertrophic Pulmonary Osteoarthropathy (HPOA). A useful classification of paraneoplastic syndromes is: (1) Metabolic/endocrine (2) Neuromuscular (3) Haematologic/vascular (4) Dermatologic (5) Skeletal/connective tissue The Washington Manual- Manual of Medical Therapeutics, Little Brown & Co., 27th Ed., 1992, pp 363-5. Number: 654 Which of the following are signs of Subacute Bacterial Endocarditis? A. Osler's Nodes. B. Splenomegaly. C. Microscopic haematuria. D. Splinter haemorrhages. E. All of the above. Select the single best answer ABCDE Correct Answer: E The clinical features of infective endocarditis depend upon the causative organism. Streptococcus viridans causes the classical picture of subacute bacterial endocarditis (SBE).

388

Parenteral drug abusers and patients with catheter associated sepsis have an increased risk of staphylococcal disease which typically causes acute bacterial endocarditis (ABE). Either organism may cause either syndrome, however. Gram negative and fungal endocarditis occur infrequently and are usually seen in patients with prosthetic valves and parenteral drug users. Patients with SBE are chronically ill, with symptoms of fatigue, weight loss, low grade fever, immune complex disease (nephritis, arthralgia, petechiae, Osler's nodes on fingertips, Janeway lesions on ophthalmoscopic examination) and embolic phenomena (renal, splenic and cerebral infarcts). The Washington Manual- Manual of Medical Therapeutics, Little Brown & Co, 27th Ed., 1992, pp 259-60. Number: 655 A 38 year old male presents with increasing dyspnoea and peripheral oedema. A chest X-Ray reveals a grossly enlarged heart. A CT scan demonstrates a 15 cm mass involving the right ventricle that appears to contain areas of haemorrhage and necrosis. Which of the following neoplasms is most probable, given these findings: A. B. C. D. E. Rhabdomyosarcoma Mesothelioma Myxoma Angiosarcoma Papillary fibroelastoma

Select the single best answer ABCDE Correct Answer: D The clinical picture is suggestive of a high grade malignancy - thus a myxoma is not likely. Primary cardiac malignancies are very rare, but by far the most common are the angiosarcomas. Papillary fibroelastomas are benign, usually valvular tumours, which are being increasingly noted as echocardiographic imaging of the heart becomes more widespread. Number: 656 A 17 year old previously healthy female dies suddenly and unexpectedly. She had complained only of a slight headache in the days before her demise. At autopsy, the heart is noted to be slightly dilated and there is a small pericardial effusion. The coronary arteries and heart valves are normal. Microscopically, the myocardium is infiltrated by lymphocytes and there are areas of focal necrosis. Which of the following infectious agents is most likely to have caused these findings? A Coxsackie B virus.

389

B Cytomegalovirus. C Hepatitis C virus. D Streptococcus viridans. E Corynebacterium Diphtheriae. Select the single best answer ABCDE Correct Answer: A Coxsackie infection is by far the most common cause of primary myocarditis in young people. Cytomegalovirus also has a predilection for cardiac muscle but is usually more problematic when reactivated in patients under immunosuppression. Hepatitis C is associated with dilated cardiomyopathy, but not with a picture of fulminant, acute myocarditis. Diphtheric myocarditis is becoming more common, but is associated with more marked symptomatology. Number: 662 A patient presents with ventricular tachycardia associated with a BP of 100/60. A diagnosis of digoxin toxicity is made. Appropriate management might include the use of: 1. Lignocaine. 2. Digoxin Fab fragments (Digibind). 3. Phenytoin. 4. Immediate cardioversion. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: B The management of VT associated with digoxin toxicity depends upon the clinical condition of the patient. If the patient is not markedly haemodynamically compromised, then treatment includes lignocaine and or phenytoin. If the patient is hypotensive such that they will not tolerate these agents, immediate cardioversion is indicated. Caution is required as this may precipitate asystole and 0.25 joules/ Kg is the recommended current. Digibind is indicated when absolute ingested dose exceeds 10 mg in adults or 4 mg in children; plasma levels of

390

digoxin are > 10ng/ml; serum potassium is > 5 mmol/L or when life threatening rhythm disturbances occur which do not respond to conventional therapy. Digoxin toxicity occurs in 5-15% of patients at some time during therapy. The therapeutic range is narrow and toxicity may develop despite serum levels within the normal range. Factors which commonly contribute to toxicity include hypokalemia, hypoxaemia, hypomagnesaemia, hypothyroidism, renal insufficiency and hypovolemia. Manifestations include cardiac arrhythmias of virtually all types including VEBs, bigeminy, and junctional tachycardia with varying degrees of block. More specifically, bidirectional VT, PAT with AV block and regularization of atrial fibrillation occur almost exclusively as a result of digoxin toxicity. Non-cardiac manifestations include anorexia, nausea, diarrhoea, agitation, lethargy and visual disturbances (xanthopsia). On the basis of this, management involves discontinuation of the drug, correction of precipitating factors and monitoring of cardiac rhythm and blood pressure. K+ should be maintained in the high normal range hence, it is often indicated, however if haemodynamic comprise is marked a metabolic acidosis may cause hyperkalemia. Symptomatic bradycardias should be treated with atropine or temporary pacing. Sympathomimetic agents should be avoided as they may precipitate a malignant ventricular arrhythmia. Ventricular arrhythmias or accelerated supraventricular arrhythmias should be treated with lignocaine. Phenytoin has a proven role in the management of VT unresponsive to lignocaine. Quinidine should not be used as it may elevate digoxin levels further. Cardioversion in the presence of digoxin toxicity is generally contraindicated as it may precipate malignant arrhythmias, specifically asystole. However, it may be necessary when all other measures have been exhausted or in haemodynamic compromise. In this situation the current required is generally smaller than for other arrhythmias; ie 0.25 J/kg. Digibind is digoxin specific Fab Antibody Fragments. It works by reversibly binding with digoxin whereupon the complexes are cleared from the circulation via renal excretion. It is useful in acute intoxication. Literature to date suggests its use be reserved for specific clinical situations. These include a serum K+ > 5.0 ,ingested dose > 10 mgs , serum level > 10 ng/ml , or when death appears imminent. The suggested dose is determined by the estimated amount of drug in the circulation: Dose = ingested dose (mg) x 0.8 / 0.6 Dose = serum level (ng/ml) x wt(kg) /100 One vial (40mg) inactivates 0.6mg digoxin. In acute intoxication this may require many vials making it a very expensive therapy. References The Washington Manual- Manual of Medical Therapeutics, Little Brown & Co., 27th Ed., 1992, pp 109-10.

391

Number: 667 Which of the following is true of the second heart sound: A. Normal splitting is present throughout life. B. Normal splitting is heard maximally at end expiration. C. Fixed splitting can occur in aortic stenosis. D. Reversed splitting can be a normal variant. E. None of the above. Select the single best answer ABCDE Correct Answer: E Normal splitting of the second heart sound can generally be heard up until the fourth decade of life, and is heard maximally at end inspiration. Fixed splitting may occur when the pulmonary valve closure is delayed as in pulmonary stenosis, hence accentuation on inspiration (normal splitting) is lost. Reversed splitting may occur when closure of the aortic valve is so delayed that it occurs even after the pulmonary valve. It is never a normal variant and occurs with, for example, severe aortic stenosis. The second heart sound is caused by closure of the aortic and pulmonary valves. Normally, the aortic component (A2) precedes the pulmonary (P2). This can be heard as " normal splitting " which is heard maximally in the pulmonary area at end inspiration and minimally at end expiration. During inspiration, negative intrathoracic pressure enhances filling of the right ventricle and hence right ventricular filling pressure. Closure of the valve is delayed. The converse is true during expiration. Normal splitting is invariably present in healthy individuals < 30 years old. After this age , splitting has an increasing chance of being abnormal. Fixed splitting occurs when there is failure of splitting to close during expiration and appears split throughout the respiratory cycle. It is caused by either delayed closure of the pulmonary valve (acute right heart strain, pulmonary embolus, right bundle branch block, atrial septal defect, or pulmonary stenosis) or early closure of the aortic valve. Reversed or Paradoxical splitting is when splitting increases on expiration and decreases during inspiration. It may be caused by delayed closure of the aortic valve and never occurs in the absence of cardiac disease. Aortic stenosis and left bundle branch block constitute 25% of the conditions; Coronary artery disease and hypertension are others. References ALPERT,J.S &RIPPE,J.M; Manual of Cardiovascular Diagnosis and Therapy, Little Brown & Co., 3rd Ed., 1988, pp 5-8.

392

Number: 671 Which of the following is/are indicative of SEVERE Aortic Stenosis (AS)? 1. A long ejection systolic murmur. 2. A peak gradient of 100 mm Hg. 3. A history of Stokes Adams attacks. 4. Cardiomegaly on CXR. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: A Cardiomegaly is not necessarily present unless there is also volume overload of the LV. A gradient at rest of 100 mmHg would be considered as severe, although it should be remembered that this measurement is CO dependent. An absolute valve area of 0.75 cm2 is usually taken as severe AS. Stokes Adams attacks, angina, and pulmonary oedema are always taken seriously. Aortic stenosis is classified as valvular, subvalvular, or supravalvular based on the anatomic location of the stenotic lesion. Pure valvular aortic stenosis is the most common, accounting for more than 75% of cases. In the past, rheumatic valvular degeneration was the primary cause. More recently, calcific degeneration of a congenitally bicuspid aortic valve has emerged as the most common aetiology. This anomaly is present in 1-2% of the population. Senile degeneration of a normal valve also occurs. 30% of patients >85 years are found to have significant degeneration of the aortic valve at autopsy. Patients with rheumatic aortic valve disease may be asymptomatic for 40 years or more. Patients with congenitally bicuspid valves may develop symptomatic stenosis anywhere between the ages of 15-65, but calcification of the valve more often occurs after 30 and usually in the 7th and 8th decades. The onset of the triad of symptoms of angina, syncope and exertional dyspnoea is ominous and indicates a life expectancy of < 5 years. (1) Angina pectoris is the initial symptom in 50-70% of patients with severe aortic stenosis. It develops due to a progressive imbalance between myocardial oxygen supply and demand in a hypertrophied ventricle. Concurrent coronary disease may also exist. Angina secondary to the stenotic valve is commonly exertional. Angina occurring at rest commonly indicates coronary disease. These patients are at high risk of subendocardial ischaemia, ventricular dysrhythmias, and sudden death. (2)Syncope is the first symptom in 15-30 %, and is associated with a life expectancy of 3-4 years.

393

(3)Exertional dyspnoea and other stigmata of congestive cardiac failure carry a life expectancy of 2 years. Quantitative criteria for severity include peak systolic pressure gradient and effective aortic valve orifice size: values greater than 50 mm Hg and less than 0.7 cm2 respectively are associated with a 72% 5 year mortality. References: The Washington Manual - Manual of Medical Therapeutics, Little Brown & Co., 27th Ed., 1992, p 117. HENSLEY,F.A; The Practice Of Cardiac Anaesthesia, Little Brown & Co.,1990, pp 351-3. Number: 673 A 40 year old man with a long history of alcohol abuse presents to an emergency department. He is emaciated and difficult to rouse. On closer examination you note that he has an impairment of his lateral gaze. Given this scenario, which vitamin deficiency is the most likely cause of his signs? A. Folic Acid. B. Thiamine. C. Pyridoxine. D. Cyanocobalamin. E. Niacin. Select the single best answer ABCDE Correct Answer: B In developed nations, thiamine deficiency occurs principally in alcoholics or food faddists. In chronic alcoholics it is mainly due to low thiamine intake and impaired thiamine absorption. The two major manifestations of thiamine deficiency are 'wet' and 'dry' beriberi - involving the cardiovascular and nervous systems respectively. 'Dry' beriberi is manifest as either Wernicke's encephalopathy or Korsakoff's syndrome. Wernicke's encephalopathy is a syndrome of vomiting, nystagmus (horizontal more commonly than vertical), rectus muscle palsy progressing to ophthalmoplegia, fever, ataxia and a global confusional state. It may progress to coma and death. Korsakoff's syndrome consists of retrograde amnesia, impaired ability to learn, and confabulation.

394

Number: 674 A patient presents with a pulse of 150 / min. Carotid sinus massage causes it to slow initially, then return to its original rate. The underlying rhythm may be: 1. Sinus tachycardia. 2. Paroxysmal atrial tachycardia. 3. Atrial fibrillation. 4. Orthodromic SVT associated with Wolff-Parkinson-White syndrome. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: B The role of manoeuvres which stimulate vagal tone is to differentiate dysrhythmias which are generated from sites above the AV node as opposed to those from the AV node, and to terminate the latter. Dysrhythmias generated from the AV node often involve a re-entrant pathway. Increased vagal tone may delay conduction through this site and terminate the reentrant behaviour. A return to sinus rhythm may occur. In contrast, when vagal tone is increased during other tachyarrhythmias, ventricular rate will be slowed transiently. The effect of carotid sinus massage and other vagal manoeuvres (ocular pressure, valsalva manoeuvres) is to accentuate vagal tone in the heart. The effect of this is: -Rate-spontaneous discharge of the sinus node is markedly slowed. -Conduction-is delayed throughout the entire conducting system. -Contractility is mildly reduced. In the presence of tachyarrhythmias this effect may intervene transiently, or until the manoeuvre is completed. The exception is rhythms caused by re-entrant or circus rhythms in the atrioventricular node, where transient slowing of conduction by increased vagal tone may arrest the re-entrant cycle, restoring the normal rhythm or underlying rhythm. Hence, sinus tachycardia may transiently slow then speed up again as will AF. PAT may be arrested completely causing a return to SR. In orthodromic SVT in WPW the anterograde path of the re-entrant pathway is the AVN so it will behave like PAT. Antidromic SVT is again similar . In AF or Flutter the degree of block may be increased transiently causing slowing which reveals the underlying flutter waves. References The Washington Manual- Manual of Medical Therapeutics, Little Brown & Co., 27th Ed., 1992, pp 128-44.

395

ECHO TESTS Number: 4 The structure labelled 'A' in this 2D, mid-oesophageal echo image is: A. The left main coronary artery. B. The right main coronary artery. C. The left anterior descending artery. D. The circumflex artery. E. The first diagonal artery Select the single best answer

ABCDE Correct Answer: D

396

The division of the left main coronary artery into the left anterior descending artery and the circumflex artery is not usually visualised. However, in this patient, the left main trunk was very short, and the division into the anterior LAD and more posterior Cx is well seen. New techniques for transoesophageal imaging of coronary arteries are becoming available. See: Wild PS, Zotz RJ. Fragment reconstruction of coronary arteries by transesophageal echocardiography: a method for visualizing coronary arteries with ultrasound. Circulation. 2002 Apr 2;105(13):1579-84. Number: 6 This pulsed wave Doppler image of the mitral inflow of a 50 year old man is most compatible with a pattern of: A. Impaired relaxation. B. Restrictive inflow. C. Normality. D. Moderate mitral stenosis (MS). E. Severe mitral incompetence. Select the single best answer

397

ABCDE Correct Answer: A This is a fairly typical picture of impaired ventricular relaxation. The deceleration time is prolonged at 290 msecs (Normal 160 - 240 msecs) and the 'E' veolocity is less than the 'A'. In a fifty year old, the peak 'E' velocity should still exceed the peak 'A' velocity. The normal pattern is one where the 'E' wave velocity is greater than the 'A' wave velocity and the deceleration time is in the range 160-240 msecs. The restrictive pattern is one where the 'E' wave velocity is considerably greater than the 'A' wave velocity and the deceleration time is less than 160 msecs. The pressure half-time is incompatible with mitral stenosis (as it corresponds to a mitral valve area of about 2.5 sq cms). (Note also the virtual absence of acoustic broadening and the presence of an 'A' wave - both of which are against the diagnosis of MS) 398

The maximum 'E' velocity of 50 cm/sec is incompatible with mitral incompetence - where values of more than 1.5 m/sec are often observed. See: Rakowski H, Appleton C, Chan KL et al. Canadian consensus recommendations for the measurement and reporting of diastolic dysfunction by echocardiography: from the Investigators of Consensus on Diastolic Dysfunction by Echocardiography. J Am Soc Echocardiogr. 1996 Sep-Oct;9(5):736-60. Number: 79 This descending thoracic aortic pulsed wave doppler trace is consistent with: 1. A patient with severe aortic incompetence. 2. A patient on full cardio-pulmonary bypass. 3. A patient with a patent ductus arteriosus. 4. A normal patient undergoing general anaesthesia. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct

399

ABCDE Correct Answer: D The trace is consistent with a normal patient undergoing general anaesthesia. Note the absence of diastolic flow reversal (which would suggest either a patient with severe aortic incompetence or a patient with a patent ductus arteriosus) and the fact that pulsatile rather than continuous flow is occurring - which would suggest that the patient is on full cardio-pulmonary bypass.

400

Number: 85 The structure labeled 'A' in this 2D mid-oesophageal view is: A. The main pulmonary artery. B. The coronary sinus. C. The left atrial appendage. D. The left pulmonary artery. E. The right pulmonary artery. Select the single best answer

ABCDE Correct Answer: E In this typical long-axis view through the aortic valve, the aorta is seen arching over the right pulmonary artery.

401

OBSTETRICS TESTS Number: 20 The plasma volume of a normal primiparous patient in the 32nd week of pregnancy exceeds plasma volume in the non-pregnant state by: A. 0 - 10%. B. 10 -20%. C. 20 -30%. D. 30 - 40%. E. 40 - 50%. Select the single best answer ABCDE Correct Answer: E Cilberto and Marx have written a comprehensive, on-line review of the physiological changes associated with pregnancy. According to these authors, "Blood volume increases progressively from 6-8 weeks gestation (pregnancy) and reaches a maximum at approximately 32-34 weeks with little change thereafter. Most of the added volume of blood is accounted for by an increased capacity of the uterine, breast, renal, striated muscle and cutaneous vascular systems, with no evidence of circulatory overload in the healthy pregnant woman. The increase in plasma volume (40-50%) is relatively greater than that of red cell mass (20-30%) resulting in hemodilution and a decrease in haemoglobin concentration. Intake of supplemental iron and folic acid is necessary to restore hemoglobin levels to normal (12 g/dl). The increased blood volume serves two purposes. First, it facilitates maternal and fetal exchanges of respiratory gases, nutrients and metabolites. Second, it reduces the impact of maternal blood loss at delivery. Typical losses of 300-500 ml for vaginal births and 750-1000 ml for Caesarean sections are thus compensated with the so-called "autotransfusion" of blood from the contracting uterus." Number: 26 An otherwise fit, primiparous patient is undergoing emergency caesarean section under general anaesthesia. The extraction of the infant is proving difficult and the obstetrician requests that the patient be given glyceryl trinitrate (GTN) intravenously in order to facilitate uterine relaxation. The most appropriate initial dose of GTN is:

402

A. 25 micrograms. B. 50 micrograms. C. 250 micrograms. D. 1 mg. E. 2.5 mg. Select the single best answer ABCDE Correct Answer: C Caponas has recently written a comprehensive review on the role of glyceryl trinitrate as a uterine relaxant. He noted that "The dosage of GTN used in published reports varies from 50 micrograms to 1850 micrograms. Generally intravenous GTN 100 micrograms to 500 micrograms and sublingual GTN 400 micrograms to 800 micrograms (1-2 metered sprays) was administered." However, it should also be noted that the author also concluded that "The evidence supporting the acute administration of GTN in producing uterine relaxation to assist in the resolution of obstetric emergencies is inconsistent. The traditionally held view that GTN releases NO, with subsequent effects of NO on uterine smooth muscle acting via a cGMP mediated process in effecting uterine relaxation, is not borne out by all laboratory work." and that "A randomized controlled trial conducted in the nonemergency setting would require sufficient numbers of labouring women with intrauterine pressure transducers to monitor the potential effects of GTN and placebo. Until such trials are performed, clinicians seeking potentially life-saving management options are faced with reliance on clinical reports, in the presence of conflicting clinical and experimental data." Thus, although the dosage of the drug seems to have been established, the efficacy of this form of treatment remains uncertain. See: Caponas G. Glyceryl trinitrate and acute uterine relaxation: a literature review. Anaesth Intensive Care. 2001 Apr;29(2):163-77. Number: 33 The 'D' antigen can be found on the erythrocytes of Rh-positive foetuses by the: A. 6th week of gestation. B. 10th week of gestation. C. 14th week of gestation. D. 18th week of gestation. E. 20th week of gestation. Select the single best answer ABCDE

403

Correct Answer: A The 'D' antigen can be found on the erythrocytes of Rh-positive foetuses by the 6th week of gestation. As foeto-maternal transfusions occur in the majority of pregnancies, from the 6th week of pregnancy, blood containing Rhesus antigens may be infused into the maternal circulation and cause sensitisation in Rh negative women. In case of miscarriage, abortion, ectopic pregnancy and cystic mole the chance of foetomaternal transfusion followed by sensitisation of the mother is significantly increased. Therefore, in such cases, immunoprophylaxis with anti-D-immunoglobins should be performed in all Rhesus negative women.. Rh haemolytic disease is the prototype of maternal alloimmunization and fetal haemolytic disease although there are other antigens capable of causing alloimmunisation and haemolytic disease such as 'C', Kell, and Fya. Rh immunisation is usually caused by a prior Rh positive foetal maternal transplacental haemorrhage, which occurs in at least 75% of pregnancies. See: Maas DH. Anti-D prophylaxis after abortions and interruptions. Fortschr Med. 1979 Jan 25;97(4):148-52. Bowman J. The management of hemolytic disease in the fetus and newborn. Semin Perinatol. 1997 Feb;21(1):39-44. Chalmers I, Enkin M, Keirse MJNC. Effective care in pregnancy and childbirth. Oxford: Oxford University Press, 1989 pp. 569-571, 605 Number: 39 The typical arterial PCO2 (PaCO2) of a normal, non-labouring woman at term is: A. 44 mm Hg. B. 40 mm Hg. C. 36 mm Hg. D. 32 mm Hg. E. 28 mm Hg. Select the single best answer ABCDE Correct Answer: D Minute ventilation at term is increased by about 50% - primarily due to an increased tidal volume with little change, or at most a slight increase, in respiratory rate. As a result of this increased alveolar ventilation at term, maternal PaCO2 is usually decreased to about 32 mm

404

Hg, but little maternal alkalosis occurs because of a compensatory decrease in serum bicarbonate of about 4 mmol/L(from 26 to 22 mmol/L). See: Templeton A, Kelman GR. Maternal blood-gases, (PAo2--Pao2), physiological shunt and VD/VT in normal pregnancy. Br J Anaesth. 1976 Oct;48(10):1001-4. Number: 39 The typical arterial PCO2 (PaCO2) of a normal, non-labouring woman at term is: A. 44 mm Hg. B. 40 mm Hg. C. 36 mm Hg. D. 32 mm Hg. E. 28 mm Hg. Select the single best answer ABCDE Correct Answer: D Minute ventilation at term is increased by about 50% - primarily due to an increased tidal volume with little change, or at most a slight increase, in respiratory rate. As a result of this increased alveolar ventilation at term, maternal PaCO2 is usually decreased to about 32 mm Hg, but little maternal alkalosis occurs because of a compensatory decrease in serum bicarbonate of about 4 mmol/L(from 26 to 22 mmol/L). See: Templeton A, Kelman GR. Maternal blood-gases, (PAo2--Pao2), physiological shunt and VD/VT in normal pregnancy. Br J Anaesth. 1976 Oct;48(10):1001-4. Number: 41 Which of the following parameters support improved neonatal outcome from epidural/spinal anaesthesia as compared with general anaesthesia for caesarean section ? A. Apgar score. B. Acid-base status. C. Neurobehavioural score (ENNS or ABS). D. All of the above. E. None of the above. Select the single best answer ABCDE Correct Answer: E

405

Historically, it has been believed that regional anaesthetic techniques were associated with less neonatal depression than general anaesthesia for delivery by LSCS. Those parameters studied have included: (1) Apgar scores (2) Acid-base status (3) Time to sustained respiration (4) Neurobehavioural scores More recently, these parameters have been challenged and no significant correlation has been found to favour any one technique. The literature of the 60's and 70's suggested that the 1 minute Apgar scores were higher with regional than with general anaesthetic techniques, whereas 5 minute scores tended not to be statistically significant. Studies done in the late 70's and early 80's looked at Apgar scores with halothane, methoxyflurane, trilene, and N2O compared with epidural anaesthesia. There were no statistically significant differences in the 1-minute and 5-minute scores when any general and regional anaesthetic technique was compared in elective caesarian section. Similarly, improved acid-base status has been a proposed advantage of regional anaesthesia. Recent studies have shown differences between maternal artery and uterine vein pH to be essentially negligible. The neonate should have a sustained respiratory pattern in less than 60 seconds. All studies in the 70's showed that although time to sustained respirations may be a few seconds faster with regional than general anaesthesia, all occurred within 60 seconds. A recently developed index of neonatal depression is the neurobehavioural scoring scale. The early neonatal neurobehavioural score (ENNS) was adapted for use in the operating theatre by a paediatrician called Scanlon from the Brazelton paediatric scoring scale. This has recently been modified by Amiel-Tielsen, Barrier and Schnider (ABS) to a less invasive but still complete scoring scale. As with the other parameters, no differences in foetal outcome could be ascribed to either technique using neonatal neurobehavioural scores. See: Joyce,T.H; " Regional versus General Anaesthesia- Any Advantage? ", Seminars in Anesthesia, vol 1, no 2, June 1982. Anesth Analg 1995 Jul;81(1):90-5 Gambling DR, Sharma SK, White PF, Van Beveren T et al Use of sevoflurane during elective cesarean birth: a comparison with isoflurane and spinal anesthesia. Number: 43 The administration of 0.5% halothane as a supplement to nitrous oxide during Lower Segment Caesarean Section is associated with: A. Increased post-partum blood loss. B. Depressed neonatal neurobehavioural scores for several hours. C. Decreased sensitivity to oxytocin.

406

D. Awareness. E. None of the above. Select the single best answer ABCDE Correct Answer: E The use of halogenated agents-low dose halothane (0.5%); isoflurane (0.75%); or enflurane (1%) as supplements to N2O is very common. The N2O concentration is usually reduced to 50%. The halogenated agents decrease the incidence of maternal awareness, permit higher maternal inspired oxygen tension; may improve uterine blood flow; and do not depress the neonate. Whilst they decrease uterine muscle tone, the uterus remains immediately responsive to oxytocin and postpartum blood loss does not increase. Concern has been raised that the halogenated agents may decrease uterine muscle tone resulting in increased postpartum blood loss. They produce a dose dependent decrease in uterine contractility and tone, however several studies have failed to reveal any increased blood loss with low dose halothane (0.1-0.8%); enflurane (0.5-1.5%),or isoflurane (0.75%), during caesarian section. At these low concentrations, the uterus is immediately responsive to oxytocin. When higher concentrations are used, blood loss is still not clinically significantly raised , and this may be utilized when higher concentrations of oxygen are desired. Moreover, clinical experience indicates that the slight increase in maternal depth is not reflected in the neonate at birth. Several surveys have reported a high incidence of maternal awareness and postoperative recall of intraoperative events with subsequent unpleasant experiences, such as nightmares, associated with the use of N2O/O2 and muscle relaxant techniques. The incidence of awareness appears to vary inversely with the concentration of N2O. In one study, approximately 9% of parturients who received 67% of N2O in O2 were aware compared with 26% in the 50% N2O group. No awareness has ben reported if halothane 0.1-0.65%, enflurane 0.5-1.5%, methoxyflurane 0.1%, or isoflurane 0.75% is added to 50% N2O before delivery. References Schnider, S.M & Levinson, G; Anesthesia for Obstetrics, 3rd Ed., 1993, pp 231-235. Number: 44 A pulmonary embolus is suspected in a 36 week gestation woman: 1. Hypoxaemia is predominantly caused by an increase in dead space ventilation. 2. Pulmonary angiography is considered safer for the foetus than V/Q scanning. 3. Warfarin is contraindicated because it is teratogenic. 4. Thrombolytic agents are contraindicated. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct

407

E: All Correct ABCDE Correct Answer: D The initial pathophysiological effect of a pulmonary thromboembolus is an increase in dead space ventilation. Regional microatelectasis and pulmonary oedema supervene resulting in intrapulmonary shunting which is exacerbated in the presence of a low cardiac output state. This is reflected by hypoxaemia which is poorly responsive to oxygen supplementation. Ventilation/perfusion scans using technetium as the marker, are considered safer than pulmonary angiography and its associated radiation exposure. Warfarin is highly teratogenic in the first trimester. It is contraindicated in the second and third trimesters because of the risk of foetal bleeding. Thrombolytic agents are contraindicated in the treatment of thromboembolism during pregnancy. Epidemiological studies indicate that thromboembolic disease is 5 times more common during pregnancy or in the postpartum period than in non-pregnant women. The most recent large review of maternal death in the USA (1985) identify it as the leading cause of death followed by, in decreasing order, hypertensive disease, ectopic pregnancy, hemorrhage, cerebrovascular accidents and anaesthetic complications. The last Report on Confidential Enquiries into Maternal Deaths in England and Wales for the period 1982-4 also shows that it remains the leading cause of maternal death in the U.K. The aetiology is best described in terms of Virchow's triad: vessel wall trauma, venous stasis, and alterations in the coagulation mechanism. Vessel wall trauma may contribute to some forms of thrombosis, ie. pelvic thrombosis following caesarian section. Venous stasis is a risk factor during pregnancy. Venous distensibility increases during the first trimester of pregnancy. Varicose veins, hormonal changes, anaemia, toxaemia and the hypercoaguable state have also been implicated. Mechanical compression by the gravid uterus on the inferior vena cava causes venous stasis and is uniformly considered to be a major factor contributing to deep venous thrombosis. This begins in the early part of the second trimester. Leg vein obstruction is found to be almost universal in the standing position in the third trimester. Pregnancy causes a number of alterations in the coagulation mechanism. Factors VII, VIII, IX, X, and fibrinogen are increased. Antithrombin III activity falls in patients with hereditary antithrombin III deficiency. Fibrinolytic activity is decreased. Neither the platelet count or adhesiveness is increased. The decreased number of platelets observed after delivery is probably due to normal thrombus formation at the placental site. Pathophysiological events depend upon the size and nature of the embolus, the site of impaction and preexisting cardiovascular disease. A single large embolus may cause sudden fatal obstruction of the pulmonary circulation, or may break up showering the lungs (predominantly the lower lobes) resulting in emboli, infarction, secondary infection, and or adult respiratory distress syndrome (ARDS). Very small emboli may pass to the microcirculation, undergo lysis and cause no respiratory dysfunction. Recurrent emboli may result in pulmonary hypertension and cor pulmonale. Respiratory changes may include hypoxaemia secondary to an increased A-a gradient; and a decreased ETCO2 secondary to an increased dead space gradient. The latter may be the first sign of the event during anaesthesia. Hypoxaemia may initially be caused by an increase in

408

dead space ventilation. Release of humoral factors including histamine and serotonin, and decreased CO2 tensions have been attributed to regional bronchial alveolar constriction and loss of surfactant. This may then cause foci of atelectasis and pulmonary oedema resulting in intrapulmonary shunting. This explains why hypoxaemia may not improve despite oxygen supplementation. Falls in cardiac output consequent to right heart strain will exacerbate intrapulmonary shunting. If the patient is awake this may manifest as dyspnoea, tachycardia, anxiety, confusion, , syncope, fever, or sweating. During anaesthesia, changes in monitored parameters may occur; decreased ETCO2, desaturation, elevation of CVP or PAP/PCWP. The ECG may show signs of right ventricular strain; right bundle branch block, right axis deviation, or S1 Q3 T3 configurations, however the most common changes are sinus tachycardia or other supraventricular tachyarrhythmias consequent to increased right atrial pressures, ie: atrial fibrillation or supraventricular tachycardia. The CXR may show diminished vascular markings, enlargement of the proximal pulmonary vessels, elevation of the hemidiaphragm, pleural effusion, patchy opacities, or wedged shaped opacities. It may alternatively be normal. More accurate is a combined ventilation/perfusion scan. If highly suggestive, therapy may be commenced on the basis of this without a pulmonary angiogram. Nuclear medicine scans can be performed safely however, technetium should be used rather than iodine and uterine shielding is necessary. Pulmonary angiography is usually avoided because of the risk of radiation exposure to the foetus. With respect to abnormalities of skeletal growth, this risk is maximal in the first trimester. Latent bony malignancy can occur in latter life subsequent to significant exposure to radiation in utero or early childhood. It should in principle be minimized. The cornerstone of treatment after supportive measures is anticoagulation. It is now recommended that warfarin not be used at any point during the pregnancy, however, it has been used for long term therapy during the middle stages of the pregnancy. Warfarin is a small molecule that readily crosses the placenta. Exposure during the first trimester has significant teratogenic potential. Used in the third trimester, it can cause pre or intrapartum foetal bleeding. Because of immature liver enzymes, it appears to affect the foetus more profoundly than the mother. An overall foetal mortality of 10-15% has been reported in women taking oral anticoagulants. If warfarin has been used, it is recommended that it is converted to heparin several weeks before delivery is expected. In this group, 3-14 days will be required before the effects of the warfarin subside. No benefit will be gained from administration on maternal IV or intraamniotic vitamin K, or FFP, however, parenteral vitamin K administered to the foetus will normalize clotting factors within 30-48 hours. Heparin is the agent of choice. It does not cross the placenta hence, does not affect the foetus. It has a short half life and can be discontinued within 4-6 hours of the expected delivery. Its specific antagonist protamine may be used in more urgent cases. Thrombolytic agents are contraindicated during pregnancy. References SKERMAN, J.H. & BLASS, N.H;" Management of the Obstetric Patient with Thromboembolic Disease ", Chapter 30, Clinics in Anaesthesiology, vol 4, no 2, April 1986.

409

Number: 45 Which of the following are seen with therapeutic maternal plasma concentrations of MgSO4 during the treatment of pre-eclampsia? 1. Decreased neonatal muscle tone. 2. Widening of QRS complexes on ECG. 3. Loss of maternal deep tendon reflexes. 4. Delayed recovery from non-depolarizing muscle relaxants. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: C In many countries, magnesium is the first line treatment of pre-eclampsia/eclampsia. It is usually initiated by IVI administration of 4-6 g over 15 minutes. 2-4 g given more rapidly during eclamptic convulsions frequently terminate them. Therapeutic blood levels of 4-8 mmol/l are then maintained by continuous infusion at a rate of 1-3 g/hour. Magnesium therapy is associated with maternal and neonatal side effects. Serious toxicity may be the result of absolute overdosage or , more frequently, elevation of blood levels, following repeated doses or continuous infusions in the presence of decreased renal function. Most of these develop at plasma levels greater than 10 mmol/l at which loss of deep tendon reflexes occurs. This should be monitored clinically and used as a marker at which the infusion is decreased or ceased. In therapeutic dosages it is associated with abnormal neuromuscular transmissions which correlates with increased serum magnesium levels and decreased serum calcium levels. It increases the sensitivity of the mother to both depolarizing and non-depolarizing muscle relaxants by decreasing release of acetyl choline from the nerve terminal, decreasing the depolarizing action of acetyl choline at the motor endplate, and decreasing the excitability of the muscle fibre membrane. It does not affect the pseudocholinesterase activity. Magnesium readily crosses the placenta, however significant detrimental effects are not seen in the neonate at therapeutic maternal levels. When high maternal levels are reached, the neonate may develop decreased muscle tone, respiratory depression, and apnoea. Below is a guide to the clinical monitoring of serum magnesium levels (their similarity to bupivacaine toxicity may make the numbers easier to remember !). Values are quoted in mEq/L. 1.5 - 2.0 -- normal plasma level 4.0 - 8.0 -- therapeutic plasma level 5.0 - 10.0 -- electrocardiographic changes (P-R interval prolonged, QRS complexes widened) 10 -- loss of deep tendon reflexes

410

15 -- sino-atrial and atrio-ventricular block 15 -- respiratory paralysis 25 -- cardiac arrest References SCHNIDER, S.M. & LEVINSON, G; Anesthesia for Obstetrics, 3rd Ed., 1993, pp 315-6. Number: 99 Which of the following changes to the coagulation system are considered normal with pregnancy? 1. Increased factor VII. 2. Decreased factor XI. 3. Decreased fibrinolysis. 4. Thrombocytopenia. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: A Pregnancy has various effects on the coagulation system and has been described as a state of chronic compensated disseminated intravascular coagulopathy. Clotting factors which increase include fibrinogen, factor VII, VIII, VIII antigen, VIII von-Willebrand, X, and XII. Fibrinogen is elevated approximately twice normal levels at 20 weeks and remains elevated throughout pregnancy. Factor VII appears to increase 200% in the second trimester and also remains elevated. All components of VII peak and plateau in the third trimester. X increases 200% in the third trimester, and XII may increase modestly. Factors that decrease include XI, and XIII. These decrease to approximately 70% of normal by the third trimester. There is a slight increase in FDPs that reflects increased fibrin formation. Although controversial, it appears that the platelet count and functional capacity are unchanged, however, small falls have been observed. It has been suggested that the normal range is lower in pregnancy. Regardless, thrombocytopenia is a term used to describe an abnormally low platelet count. Antithrombin III is unchanged in normal pregnancy. John Bonnar has written extensively on the subject of haemostasis in pregnancy. JANES, S.L;" Thrombocytopenia in Pregnancy ", Postgrad Med J, 68, 1992, pp 321-6.

411

PERRY,G.P & MARTIN,J.N;" Abnormal hemostasis and coagulopathy in pre-eclampsia and eclampsia ", Clinics of Obstetrics and Gynaecology, vol 35, no 2, June 1992. Number: 111 A woman presents at 28 weeks gestation for emergency appendicectomy. Which of the following agents should be avoided? 1. Halothane. 2. Neostigmine. 3. Atropine. 4. Ketorolac (Toradol). A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: D The basic objectives of anaesthetic management of pregnant women undergoing general surgery are: (1) Maternal safety. (2)Avoidance of teratogenic drugs. (3)Avoidance of intrauterine foetal asphyxia. (4)Prevention of preterm labour. No anaesthetic agent- premedicant, induction, inhalation, or local anaesthetic has been proven to be teratogenic in humans, however recommendations are to minimize foetal exposure in first trimester. In no study has any anaesthetic agent or technique been found to be associated with a higher or lower risk of preterm labour. Some agents carry a theoretical risk and should be avoided when possible. These include ketamine > 1.1 mg/Kg, some vasopressors, and rapid injections of neostigmine and edrophonium (increase uterine tone). With regard to pretrerm labour, the incidence rises from 5.13% without surgery to 7.4% with surgery. It is largely related to the type of surgery performed. For instance, the incidence is very high following insertion of a Shirodker suture (30%). Apart from this, intra-abdominal procedures involving retraction of the uterus carry the greatest risk, whilst neurosurgical, orthopedic, and plastic procedures carry a smaller risk. Prostaglandin inhibitors may cause early closure of the ductus arteriosus and should be avoided.

412

SCHNIDER, S.M. & LEVINSON, G; Anesthesis for Obstetrics, 3rd Ed., Williams and Wilkins, 1993, pp 275-6. Number: 411 Placenta praevia: 1. Is more common in multiparous patients. 2. Can be an indication for classical Caesarean section. 3. Increases the risk of postpartum haemorrhage. 4. Is graded I - V. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: A Placental implantation in the lower uterine segment occurs in 1 of every 200 pregnancies. The multiparous patient is at greater risk than is the primigravida. The incidence of recurrence in a subsequent pregnancy is approximately 5%. Placenta praevia varies in degree and may be complete (37%), partial (27%), or marginal (low implantation; 46%) - defined by the degree of encroachment onto the internal os. The main symptom is painless vaginal bleeding in the third trimester of pregnancy. Placenta praevia can be an indication for classical caesarean section and significantly increases the risk of postpartum haemorrhage. Anticipate placenta accreta which often accompanies placenta praevia (Clin. Obs. Gyn 33:414, 1990) Number: 616 A nulliparous woman in early labour with no other risk factors asks your advice on the possible impact of epidural analgesia on maternal outcome. Your advice is that the technique: A. Has no adverse effect. B. May prolong labour, but otherwise has no adverse effect. C. May prolong labour and increase the instrumental delivery rate. D. May prolong labour and increase the Caesarean section rate. E. None of the above. Select the single best answer

413

ABCDE Correct Answer: C (WMD=Weighted Mean Difference, OR=Odds Ratio, CI=Confidence Interval). An important meta-analysis by Halpern has concluded that: The risk of caesarean delivery does not differ between patients receiving epidural (8.2%) vs parenteral opioid (5.6%) analgesia (OR, 1.5; 95% CI, 0.81-2.76). Epidural patients have longer first (WMD, 42 minutes; 95% CI, 17-68 minutes) and second (WMD, 14 minutes; 95% CI, 5-23 minutes) labour stages. Epidural patients are more likely to have instrumented delivery (OR, 2.19; 95% CI, 1.327.78), but they are not more likely to have instrumented delivery for dystocia (OR, 0.68; 95% CI, 0.31-1.49). Thus it seems likely that epidural analgesia prolongs labour and increases the instrumental delivery rate. Number: 666 Hyperemesis in the first trimester of pregnancy may be associated with: 1. Multiple pregnancy. 2. Helicobacter pylori infection. 3. Hydatiform mole. 4. Diabetes mellitus. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: A Hyperemesis gravidarum, is usually associated with a marked increase Human Chorionic Gonadotrophin (HCG) level - such as occurs in cases of multiple pregnancy or hydatiform mole. More recently, an association between helicobacter pylori infection and hyperemesis has been recognised. (See, for example: Jacoby EB, Porter KB. Helicobacter pylori infection and persistent hyperemesis gravidarum. Am J Perinatol. 1999;16(2):85-8.)

414

Number: 680 The properties of a drug that would tend to favour trans-placental diffusion from the mother to the foetus include: 1. A high degree of ionisation 2. A molecular weight < 50 daltons 3. Extensive maternal protein binding 4. High lipid solubility A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: C Drugs cross the placenta by simple diffusion, with the rate of transfer being principally determined by: the concentration gradient, lipid solubility, degree of ionisation, and molecular size. Lipophilic compounds cross much more easily than hydrophilic compounds and, because unionised drugs are considerably more lipophilic than those that exist in the ionised form, they also cross much more readily. Smaller compounds also cross the placenta with greater ease, and drugs with a molecular weight of less than 50 daltons cross the placenta virtually unimpeded. A high degree of maternal protein binding tends to impede the placental transfer of a substance. Number: 713 With regard to placental abruption ('Abruptio Placentae'): 1. The perinatal mortality rate is more than 50%. 2. Abruption is typically accompanied by bright vaginal bleeding. 3. The incidence is increased in patients with hypertensive disease. 4. Augmentation of labour (in order to expedite vaginal delivery) is usually indicated. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct

415

ABCDE Correct Answer: B Abruptio placenta carries a maternal mortality of 2 to 3% and a perinatal mortality of over 50%. It usually occurs in the final 10 weeks of pregnancy in association with hypertensive disease of pregnancy. The diagnosis is suggested by uterine tenderness and hypertonus in the presence of dark vaginal bleeding. Haemorrhage may be severe, and is quite often concealed. Artificial rupture of the membranes and augmentation of labour may be acceptable in mild cases, but emergency caesarean section is indicated in the presence of foetal distress or severe haemorrhage. A coagulopathic state due to disseminated intravascular coagulation and / or fibrinolysis frequently complicates severe cases of abruption. Number: 798 The most common early sign of amniotic fluid embolism (AFE) following a normal vaginal delivery is: A. Skin rash. B. Hypertension. C. Fitting. D. Abnormal bleeding. E. Cyanosis. Select the single best answer ABCDE Correct Answer: E The overall incidence of amniotic fluid embolus ranges from 1 in 8,000 to 1 in 80, 000 pregnancies, with a maternal mortality of up to 86%. Cyanosis and respiratory distress are the commonest early presenting signs of AFE. These are shortly followed by cardiovascular collapse +/- coma. In addition, prodromal chills, sweating, coughing, hyperreflexia, and convulsions occasionally occur. Although the classic opinion holds that a haemorrhagic tendency is likely only if the patient survives beyond the first hour, abnormal bleeding was the presenting feature in 12% of cases reviewed by Morgan in 1979. For a more recent review, see: Am J Obstet Gynecol 1995 Apr;172(4 Pt 1):1158-67; discussion 1167-9 Amniotic fluid embolism: analysis of the national registry. Clark SL, Hankins GD, Dudley DA, Dildy GA, Porter TF

416

Number: 863 Intrapulmonary shunt(Qs/Qt) in a pregnant, normotensive woman in the lateral position at term is approximately: A. 3% B. 5% C. 10% D. 15% E. 20% Select the single best answer ABCDE Correct Answer: D Hankins et al measured Qs/Qt in a group of pregnant volunteers at term. They found that directly measured Qs/Qt averaged 15.3% in the left lateral, 15.2% in the right lateral, 13.9% in the supine, 12.8% in the knee-chest, 13.8% in the sitting, and 13.0% in the standing position. This represented a marked increase in venous admixture in comparison with the non-pregnant state. See: Hankins GD, Clark SL, Uckan E, Van Hook JW. Maternal oxygen transport variables during the third trimester of normal pregnancy. Am J Obstet Gynecol. 1999 Feb;180(2 Pt 1):406-9. Number: 871 Ritodrine infusion (for tocolysis) may be associated with: 1. Hypokalaemia. 2. ECG changes. 3. Hyperglycemia. 4. Hypomagnesaemia A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: A

417

Maternal side effects associated with the USE of ritodrine include: hyperglycemia, hypokalaemia and various ECG changes (ST segment depression and 'peaking' of the 'T' wave). Importantly, there are also some 'rebound' effects associated with the CESSATION of ritodrine - of these, extreme hyperkalaemia is probably the most significant, but hypoglycemia has also been reported. In a series of cases reported by Kotani et al, these authors remarked that "Ritodrine administration frequently causes hypokalemia because of a marked increase in plasma insulin, which results in stimulation of cellular uptake of potassium. The decrease in insulin after cessation of ritodrine leads to a considerable change in the equilibration between intracellular and extracellular potassium, and might produce a rebound release of intracellular potassium to the extracellular space. Similarly, an intraoperative glucose-insulin-potassium infusion for inotropic support can cause a life-threatening hyperkalemia postoperatively. We found that hyperkalemia was maximal 90150 minutes after cessation of ritodrine, which is compatible with the 60120 minutes of plasma half-life of ritodrine. According to Braden et al., intraoperative factors including changes in acid-base balance and plasma aldosterone do not modulate plasma potassium levels. " See: Anesth Analg 2001 Sep;93(3):709-711 Rebound perioperative hyperkalemia in six patients after cessation of ritodrine for premature labor. Kotani N, Kushikata T, Hashimoto H, Muraoka M, Tonosaki M, Matsuki A. Number: 878 The most appropriate anticonvulsant for the treatment of an eclamptic fit is: A. Thiopentone. B. Phenytoin. C. Diazepam. D. Magnesium sulphate. E. Lorazepam. Select the single best answer ABCDE Correct Answer: D Refer to the important conclusions of the Collaborative Eclampsia Trial and the Cochrane Review by Duley and Gulmezoglu. See: Which anticonvulsant for women with eclampsia? Evidence from the Collaborative Eclampsia Trial. Lancet. 1995 Jun 10;345(8963):1455-63. Duley L, Gulmezoglu AM. Magnesium sulphate versus lytic cocktail for eclampsia (Cochrane Review).

418

Cochrane Database Syst Rev. 2001;1:CD002960. The authors of the collaborative review noted that: "Eclampsia, the occurrence of a seizure in association with pre-eclampsia, remains an important cause of maternal mortality. Although it is standard practice to use an anticonvulsant for management of eclampsia, the choice of agent is controversial and there has been little properly controlled evidence to support any of the options. 1687 women with eclampsia were recruited into an international multicentre randomised trial comparing standard anticonvulsant regimens. Primary measures of outcome were recurrence of convulsions and maternal death. Data are available for 1680 (99.6%) women: 453 allocated magnesium sulphate versus 452 allocated diazepam, and 388 allocated magnesium sulphate versus 387 allocated phenytoin. Most women (99%) received the anticonvulsant that they had been allocated. Women allocated magnesium sulphate had a 52% lower risk of recurrent convulsions (95% CI 64% to 37% reduction) than those allocated diazepam (60 [13.2%] vs 126 [27.9%]; ie, 14.7 [SD 2.6] fewer women with recurrent convulsions per 100 women; 2p < 0.00001). Maternal mortality was non-significantly lower among women allocated magnesium sulphate. There were no significant differences in other measures of serious maternal morbidity, or in perinatal morbidity or mortality. Women allocated magnesium sulphate had a 67% lower risk of recurrent convulsions (95% CI 79% to 47% reduction) than those allocated phenytoin (22 [5.7%] vs 66 [17.1%] ie, 11.4 [SD 2.2] fewer women with recurrent convulsions per 100 women; 2p < 0.00001). Maternal mortality was nonsignificantly lower among women allocated magnesium sulphate. Women allocated magnesium sulphate were also less likely to be ventilated, to develop pneumonia, and to be admitted to intensive care facilities than those allocated phenytoin. The babies of women who had been allocated magnesium sulphate before delivery were significantly less likely to be intubated at the place of delivery, and to be admitted to a special care nursery, than the babies of mothers who had been allocated phenytoin. There is now compelling evidence in favour of magnesium sulphate, rather than diazepam or phenytoin, for the treatment of eclampsia."

Number: 902 The glomerular filtration rate (GFR) of a normal primiparous patient at term exceeds GFR in the non-pregnant state by: A. 10 -20%. B. 20 -30%. C. 30 - 40%. D. 40 - 50%. E. 50 - 60%. Select the single best answer ABCDE Correct Answer: E Cilberto and Marx have written a comprehensive, on-line review of the physiological changes associated with pregnancy.

419

According to these authors, "Renal plasma flow and glomerular filtration rate begin to increase progressively during the first trimester. At term, both are 50-60% higher than in the non-pregnant state. This parallels the increases in blood volume and cardiac output. The elevations in plasma flow and glomerular filtration result in an elevation in creatinine clearance. Blood urea and serum creatinine are reduced by 40%. The increase in glomerular filtration may overwhelm the ability of the renal tubules to reabsorb leading to glucose and protein losses in the urine. Thus, mild glycosuria (1-10 gm/day) and/or proteinuria (to 300 mg/day) can occur in normal pregnancy. There is also an increase in filtered sodium, but tubular absorption is increased by an increase in aldosterone secretion, via the reninangiotensin mechanism (see Physiology of the Kidney). There is also a decrease in plasma osmolality. This is a measure of the osmotic activity of a substance in solution and is defined as the number of osmoles in a kilogram of solvent. In practice it indicates that the plasma concentrations of electrolytes, glucose and urea, fall if more water than sodium, for example, is retained. Over the whole period of gestation there is retention of 7.5L of water and 900 mmol of sodium." Number: 904 The Functional Residual Capacity (FRC) of a normal primiparous patient at term is reduced (in comparison with the non-pregnant state) by: A. 10%. B. 20%. C. 30%. D. 40%. E. 50%. Select the single best answer ABCDE Correct Answer: B Cilberto and Marx have written a comprehensive, on-line review of the physiological changes associated with pregnancy. According to these authors, "Upward displacement by the gravid uterus causes a 4 cm elevation of the diaphragm, but total lung capacity decreases only slightly because of compensatory increases in the transverse and antero-posterior diameters of the chest, as well as flaring of the ribs. These changes are brought about by hormonal effects that loosen ligaments. Despite the upward displacement, the diaphragm moves with greater excursions during breathing in the pregnant than in the non-pregnant state. In fact, breathing is more diaphragmatic than thoracic during gestation, an advantage during supine positioning and high regional blockade. From the middle of the second trimester, expiratory reserve volume, residual volume and functional residual capacity are progressively decreased, by approximately 20% at term. Lung compliance is relatively unaffected, but chest wall compliance is reduced, especially in the lithotomy position"

420

Number: 904 The Functional Residual Capacity (FRC) of a normal primiparous patient at term is reduced (in comparison with the non-pregnant state) by: A. 10%. B. 20%. C. 30%. D. 40%. E. 50%. Select the single best answer ABCDE Correct Answer: B Cilberto and Marx have written a comprehensive, on-line review of the physiological changes associated with pregnancy. According to these authors, "Upward displacement by the gravid uterus causes a 4 cm elevation of the diaphragm, but total lung capacity decreases only slightly because of compensatory increases in the transverse and antero-posterior diameters of the chest, as well as flaring of the ribs. These changes are brought about by hormonal effects that loosen ligaments. Despite the upward displacement, the diaphragm moves with greater excursions during breathing in the pregnant than in the non-pregnant state. In fact, breathing is more diaphragmatic than thoracic during gestation, an advantage during supine positioning and high regional blockade. From the middle of the second trimester, expiratory reserve volume, residual volume and functional residual capacity are progressively decreased, by approximately 20% at term. Lung compliance is relatively unaffected, but chest wall compliance is reduced, especially in the lithotomy position" Number: 945 In relation to foetal outcome following Caesarean section, which is the most important? A. Uterine incision-delivery time. B. Displacement of the uterus. C. Minimal thiopentone on induction. D. The use of 100% oxygen. E. Minimal use of inhalational agent. Select the single best answer

421

ABCDE Correct Answer: A Much literature exists examining this issue. Many of the controversies in results have arisen secondary to criticisms of the selection of parameters which have been correlated with neonatal morbidity. It has perhaps been better clarified more recently as a result of a strengthening correlation between neonatal depression and acid-base status The relationship between induction-to-delivery and uterine incision-to-delivery times to neonatal outcome in 105 parturients undergoing caesarian section was studied by Datta. During general anaesthesia, induction-to-delivery times >8 minutes, and uterine incision-todelivery times > 3 minutes were associated with significantly more instances of neonatal acidosis (umbilical artery pH 7.31 vs 7.22), and a greater incidence of low 1-minute Apgars (4% vs 73%). In groups receiving regional anaesthesia, prolongation of the latter > 3 minutes was the only important factor influencing foetal outcome, as determined by increased acidosis (7.3 vs 7.18), and by depressed 1-minute Apgars (0% vs 62%). In another study, no neonatal morbidity was associated with an induction-delivery time of up to 30 minutes. Crawford and Datta showed that a time in excess of 90-100 sec from the beginning of the surgical incision into the uterus to complete expulsion of the neonate will tend to produce a higher incidence of depressed 1-minute Apgar scores, but normal acid-base scores. In those neonates where uterine incision to delivery time exceeds 300 seconds both 1-minute and 5minute scores tend to be depressed. There is also an increased possibility of lower acid-base scores. The uterine incision-delivery time does appear to be significant. In 1972, Crawford in England reported on the effects of lateral tilt. This paper demonstrated clearly the significant impact of aortic caval compression upon the foetus. Since this time left uterine displacement have been universally employed. Failure to apply this to earlier caesarian sections has been one of the criticisms directed at early studies on induction time. Thiopentone crosses the placenta and it is not possible to deliver the baby before the drug is transferred to the foetus. After a single maternal intravenous dose, the drug can be detected in the umbilical venous blood within 30 seconds.Peak concentrations are found in umbilical venous blood in 1 minute and umbilical arterial blood in 2-3 minutes. All the pharmacokinetic studies have shown that mother and foetus are in equilibrium in 2 minutes. An early report from the MAYO Clinic suggested that the neonate should not be delivered within 10 minutes of induction to allow redistribution. .There is no advantage to delaying delivery until the thiopentone has redistributed in the mother or foetus. There is an observed resistance of the foetal brain to maternally administered barbiturate following a single intravenous injection . Reasons for lack of neonatal depression after a sleep dose of thiopentone are the rapid falls in maternal plasma concentration due to redistribution, dilution within the central compartment, non-homogeneity of blood in the intervillous spaces, and progressive dilution in the circulation due to shunting. Moreover,because of the foetal circulatory pattern, the foetal liver will extract a large percentage of the drug on its first pass before it reaches the brain The foetal brain will not be exposed to high concentrations if the induction dose is < 4mg/Kg. With this dose, umbilical arterial levels are much lower than

422

umbilical vein. It should be stressed however, that after large doses of thiopentone (8 mg/Kg), babies are depressed. Maternal hyperoxia has been shown to improve foetal oxygenation and neonatal clinical condition at birth. A summary of literature follows: (1)A study of 75 women undergoing elective LSCS under general anaesthesia demonstrated that foetal oxygen tension, saturation and content improved significantly with increase in maternal FIO2 until maternal PaO2 reached 300 torr. The clinical condition of the newborn was also better in the higher oxygen groups. It was noted that no additional benefit was gained from maternal PaO2 > 300 torr. (2)Another study compared general anaesthesia between 50% oxygen/N2O/halogenated agent and 100% oxygen/halogenated agent. The use of 100% oxygen significantly improved foetal oxygenation with particular benefit in emergency cases. Babies born to the 100% group required less resuscitation. This issue has been contested on the grounds that foetal acid-base status is the best indicator of neonatal depression, and it was not measured in this study. Proponents of 30%-50% O2 during caesarian section, argue that the parameters that have been shown to be depressed as a result of lower FIO2 do not constitute clinically significant neonatal depression, and that as long as maternal arterial oxygen saturation is well maintained, neonatal outcome will not be influenced by FIO2. This group also argues that the use of a high FIO2 is associated with an increased incidence of maternal awareness. The use of halogenated agents-low dose halothane (0.5%); isoflurane (0.75%); or enflurane (1%) as supplements to N2O is very common. The N2O concentration is usually reduced to 50%. The use of these concentrations do not result in neonatal depression. References Schnider, S.M. and Levinson, G; Anesthesia For Obstetrics, 3rd Ed., 1993, p 231-2. Datta, S;" Neonatal effects of prolonged anaesthetic induction for caesarian section ", Obstetrics and Gynaecology, vol 58, no 3, Sept 1981. Crawford, J;" Time and Lateral Tilt at Caesarian Section ", BJA, 48, 1976, p 661. Joyce, T.H; " Regional versus General Anaesthesia- Any Advantage? ", Seminars In Anaesthesia, Vol 1,no 2, June 1982. Number: 951 Which of the following cardiovascular abnormalities could be consistent with normal changes of pregnancy? 1. 2. 3. 4. A grade II systolic ejection murmur at the left sternal edge. A grade I diastolic murmur at the left sternal edge. Left axis deviation on ECG. Right axis deviation on ECG.

423

A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: B The diaphragm rises and shifts the position of the heart leftward. This may cause equivocal cardiomegaly on CXR. Echocardiography at 38 weeks indicate an increased end-diastolic chamber size and an increase in total left ventricular wall thickness. Asymptomatic pericardial effusion has been demonstrated in some women. An innocent grade I-II systolic murmur caused by increased blood flow may occur. The ECG may show an increase in benign dysrhythmia, reversible ST, T, and Q wave changes, and left axis deviation. These normal findings must be differentiated from those indicating heart disease. These include a systolic murmur > grade III, any diastolic murmur, severe arrhythmias, and unequivocal cardiomegaly on CXR. SCHNIDER,S.M. & LEVINSON, G; Anesthesia for Obstetrics, 3rd Ed., 1993, pp 6-7. Number: 961 In comparison with a normal patient at the same stage of pregnancy, a patient with severe pregnancy-induced hypertension (PIH) will have: 1. An increased plasma volume. 2. A higher blood viscosity. 3. A similar serum albumin concentration. 4. A lower cardiac output. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: C Pregnancy-induced hypertension (PIH) is estimated to affect 7% to 10% of all pregnancies in the United States. Despite being the leading cause of maternal death and a major contributor of maternal and perinatal morbidity, the mechanisms responsible for the pathogenesis of PIH have not yet been fully elucidated.

424

The initiating event in PIH appears to be reduced uteroplacental perfusion as a result of abnormal cytotrophoblast invasion of spiral arterioles. Placental ischemia is thought to lead to widespread activation / dysfunction of the maternal vascular endothelium that results in enhanced formation of endothelin and thromboxane, increased vascular sensitivity to angiotensin II, and decreased formation of vasodilators such as nitric oxide and prostacyclin. The quantitative importance of the various endothelial and humoral factors in mediating the reduction in renal haemodynamic and excretory function and elevation in arterial pressure during PIH is still unclear. In established severe disease there is volume contraction, reduced cardiac output, enhanced vascular reactivity, increased vascular permeability and platelet consumption. Serum albumin falls, both due to loss from the intravascular space because of the increased vascular permeability and renal loss in the form of proteinuria. Blood viscosity increases, thereby aggravating the problem of decreased perfusion. Despite a frequently increased haemoglobin value and hematocrit, these patients have relative anaemia and tolerate blood loss poorly. Number: 1012 The drug of choice for the treatment of Chlamydia trachomatis infection during pregnancy is: A. Metronidazole. B. Cephazolin. C. Amoxycillin. D. Tetracycline. E. Clindamycin. Select the single best answer ABCDE Correct Answer: C Chlamydia infection in the non-pregnant state is usually treated with a tetracycline, or with erythromycin - although more recently, amoxycillin has been found to be as effective as the latter. During pregnancy, tetracycline therapy is contraindicated because of incorporation into fetal bones and teeth. Thus, for the options listed, amoxycillin is the drug of choice. See the systematic review by Brocklehurst and Rooney who concluded that: "Amoxycillin appears to be an acceptable alternative therapy for the treatment of genital chlamydial infections in pregnancy when compared with erythromycin. Clindamycin and azithromycin may be considered if erythromycin and amoxycillin are contra-indicated or not tolerated."

425

Brocklehurst P, Rooney G. Interventions for treating genital chlamydia trachomatis infection in pregnancy (Cochrane Review). In: The Cochrane Library, Issue 4 2002. Oxford: Update Software. Number: 1013 Which of the following conditions found in pregnancy is NOT associated with an increased risk of pre-eclampsia? A. Diabetes mellitus. B. Systemic lupus erythematosus. C. Multiple pregnancy. D. Hydatidiform mole. E. Placenta praevia. Select the single best answer ABCDE Correct Answer: E Diabetes mellitus, systemic lupus erythematosus, multiple pregnancy and hydatidiform mole all place the patient at a significantly increased risk of pre-eclampsia. Placenta praevia is not associated with any such increase in risk.

PEDIATRIC

ANESTHESIA

1, A child with dystrophic epidermolysis bullosa is also likely to suffer from: 1. Iron deficiency anaemia. 2. Malnutrition. 3. Oesophageal reflux. 4. Cardiomyopathy A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct Correct Answer: A Epidermolysis bullosa is the name given to a group of rare, genetically determined disorders characterised by mucocutaneous blistering and subsequent scarring. Several variants have

426

been established, which can be grouped into three broad categories: epidermolysis bullosa simplex, junctional epidermolysis bullosa and dystrophic epidermolysis bullosa. Iohom and Lyons have recently published an excellent, comprehensive review of the subject. According to these authors: "Anaemia is present in most patients with severe dystrophic epidermolysis bullosa. Investigations demonstrate haematological features both of iron deficiency and of decreased red cell iron utilization (anaemia of chronic disease)." "The malnutrition, which occurs in severe dystrophic epidermolysis bullosa, is a consequence of a combination of decreased nutritional intake and increased requirements as a result of blood and plasma loss from denuded epithelium, skin infection and continuous wound healing." "Gastro-oesophageal reflux is extremely common in this population group." There is no association between any variants of the syndrome and cardiomyopathy. See: Iohom G, Lyons B. Anaesthesia for children with epidermolysis bullosa: a review of 20 years' experience. Eur J Anaesthesiol. 2001 Nov;18(11):745-54.

2, A woman is treated for imminent eclampsia with therapy which includes large doses of magnesium sulphate. A live infant is subsequently delivered by Caesarean section A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Signs in the neonate which are suggestive of hypermagnesaemia include: 1. Hypereflexia. 2. Lethargy. 3. Convulsions. 4. Paralytic ileus Correct Answer: C The classic signs of neonatal hypermagnesaemia include hyporeflexia, hypotonia, lethargy and respiratory depression. Paralytic ileus and 'meconium plug' syndrome have also been reported.

427

See: Sullivan JE, Berman BW. Hypermagnesemia with lethargy and hypotonia due to administration of magnesium hydroxide to a 4-week old infant. Arch Pediatr Adolesc Med. 2000;154:1272-1274.

3, With regard to an infant with a tracheo-oesophageal fistula: 1. The diagnosis is suggested by the inability to pass a feeding tube into the stomach. 2. Other congenital abnormalities commonly occur. 3. Polyhydramnios may well have been a feature of the antenatal period. 4. The child should be intubated soon after birth to reduce aspiration risk. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct Correct Answer: A Tracheo-oesophageal fistula is generally diagnosed by the triad of reflux of secretions, failure to pass a feeding tube, and CXR confirmation of this. These infants experience problems relating to aspiration/dehydration; prematurity/pulmonary insufficiency, and congenital anomalies. The severity of their illness is highly variable and management should be guided by this. Oesophageal atresia and TOF represent one of the commonest congenital malformations, occurring in 1/4000 births. The prenatal history often features polyhydramnios. The infants are often premature and the condition clusters with other congenital problems (50%), including oesophageal atresia, imperforate anus and cardiovascular disease.30-50% have the associated anomalies of the VATER syndrome. 90% of these infants have a blind oesophageal pouch and a fistula connecting the distal oesophagus and the distal trachea, usually within 1-2 cm of the carina. It may be suspected in the delivery room if the neonate produces excessive secretions which require frequent suctioning. Failed attempts to pass a catheter through the nose or mouth are highly suggestive. A CXR appearance of the feeding tube coiled in the distal oesophagus is diagnostic. Early intervention is mandatory to prevent pulmonary aspiration. A large sump catheter is inserted into the pouch, and suction is maintained to clear secretions. If significant aspiration occurs, corrective surgery is deferred and a decompressing gastrostomy is placed under local or caudal anaesthesia. This condition rarely presents as life threatening although associated conditions may be problematic. Prematurity may be associated with pulmonary immaturity requiring ventilatory assistance. These infants may present an enormous challenge for the management team. The

428

stomach may have a much higher compliance than the lungs, with the result that positive pressure ventilation may be quite ineffective in ventilating the lungs, however, insufflates the stomach with gas. This is further aided by the air leak through the fistula, which increases regurgitation and aspiration, and elevates the diaphragm, further reducing pulmonary compliance. Gastric perforation is also possible. For these reasons, these infants are often managed with an emergency ligation of the fistula, or passage of a Fogarty catheter down the trachea and into the fistula, with ventilation until pulmonary function is optimized whereupon definitive surgical repair can be carried out. Improved survival from 68% to 94% has been described in Seattle as a result of delayed repair. Prior to 1939, all children with TOF died. The procedure of oesophageal anastomosis was introduced in 1941. In 1962, a large review was conducted by Waterston et al who devised a classification of factors influencing survival: Class A - Birth weight >2.5 Kg; healthy- survival 1962, 100%. Class B1 - 1.8 - 2.5 Kg; healthy. Class B2 - >2.5 Kg; moderate pneumonia; moderate congenital anomaly (limb, cleft lip/palate, ASD, or small PDA)- survival all group B 1962, 68%. Class C1 - <1.8 Kg; severe pneumonia; severe congenital anomaly (additional intestinal atresia, cyanotic congenital cardiac disease, severe renal abnormalities, multiple moderate anomalies)- survival 1962, 6%. Survival in groups B and C has been improving due to earlier diagnosis, improved ventilatory management, improved anaesthetic and surgical management, and improved multidisciplinary management of multiple congenital anomalies. Pneumonia has been replaced by congenital anomalies as the main cause of death. Anaesthetic issues relating to improved outcome include management of the problems of persistent air leak through the fistula, and gastric distension. Both of these result in hypoventilation, particularly of the left lung. Studies existing describe guidelines to placement of the ETT in the trachea below the fistula, occlusion of the fistula, and decompressive gastrostomy as measures to deal with these problems. More recently the classification proposed by Spitz has been adopted. References ROGERS, M.C. ET AL (EDS); Principles and Practice of Anesthesiology, Mosby, 1993 pp 2149-50. BENUMOF, J.L & SAIDMAN, L.J; Anesthesia and Perioperative Complications, Mosby, 1992, pp 553-4. BROWN, D.L; Risk and Outcome in Anesthesia, Lippincott, 2nd Ed., 1992, pp 434-5.

4, With regard to fluid resuscitation in an infant awaiting pyloromyotomy for pyloric stenosis, which of the following are considered reliable indicators of volume status? 1. Serial body weight.

429

2. Urinary sodium. 3. Serum sodium. 4. Urinary chloride A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct Correct Answer: D Patients with pyloric stenosis may show a wide range of metabolic disturbances. Typically, it is characterised by a chloride (or saline) responsive, hypochloraemic, hypokalaemic, hypovolaemic, and sometimes hyponatraemic metabolic alkalosis. The pathophysiology of these is as follows: Hypochloraemia- results from Cl- losses in the vomitus. Conservation of Cl- at a renal level is maximal and relatively efficient. This is manifest as a falling urinary Cl concentration. Urinary Cl is felt to flux in a manner which reliably indicates volume status. < 20mmol/l is indicative of volume depletion. > 20mmol/l suggests volume status has been corrected. Note that this parameter will remain low if adequate volumes (manifest as return to baseline weight) of inappropriately hypotonic solutions are used for resuscitation. Urine Cl results are more relevant than serum electrolytes when assessing volume status in these infants. Hypokalaemia - whilst some K is lost in the vomitus, its concentration here is < 15mmol/l. Of greater importance are renal losses followed by intracellular uptake. To recall normal events, H+ secreted into gastric juice is accompanied by equimolar amounts of HCO3- which are secreted across the basal membrane of the parietal cell to enter the blood stream. Eventually, this is secreted with pancreatic juices into the duodenum to neutralize acidic chyme as it arrives. As HCL is lost in the vomitus, an excess of HCO3- develops causing a metabolic alkalosis. At a renal level, the capacity of the proximal convoluted tubule (PCT) to reabsorb HCO3- is rapidly saturated. Normally, 80% of HCO3- is secreted here with subsequent reabsorption of most as NaHCO3 to maintain electroneutrality. The concentration of Na HCO3 in the ultrafiltrate entering the distal convoluted tubule (DCT) rises. NaHCO3 cannot be reabsorbed in the DCT. An attempt to conserve sodium is made via aldosterone with the subsequent loss of large amounts of K as the cation. K is also lost in the urine as it is exchanged for H+ in an attempt to maintain serum electroneutrality. K+ also moves intracellularly in exchange for H+. Hypovolaemia results both from vomiting and a relatively inefficient renal concentrating mechanism. Hyponatraemia - Despite attempts to conserve sodium, excess may be lost in the urine as a cation to HCO3-. In contrast to Cl-, urinary sodium may not move in a predictable fashion. In hypovolemic states not caused by vomiting, the urinary Cl- and sodium are usually reduced the same degree as they are conserved by reabsorption together. Similarly, they will rise together as resuscitation proceeds. Here, the finding of a reduced or absent urinary sodium is virtually pathognomonic of reduced tissue perfusion and is diagnostic of hypovolemia. In

430

vomiting however, urinary sodium may remain normal as described in (2) and is not a useful indirect marker of volume status See the excellent review by: Bissonnette B, Sullivan PJ. Pyloric stenosis. Can J Anaesth. 1991 Jul;38(5):668-76.

5, Which of the following conditions typically complicate the syndrome of tetralogy of Fallot? 1. Congestive cardiac failure. 2. Polycythaemia. 3. Eisenmenger's Syndrome. 4. Neonatal hypoxaemia. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct Correct Answer: C Typically, this condition presents with cyanosis developing progressively after the neonatal period. The sequelae are related the right to left shunt and include cyanosis, secondary polycythaemia and embolic phenomena - septic, thrombotic, gaseous, etc. As Eisenmenger's Syndrome complicates left to right shunts, it is not seen. CCF is not typical. Tetralogy of Fallot and Transposition of the Great Vessels comprise the most common causes of cyanotic congenital heart disease. It comprises stenosis or atresia of the pulmonary valve or infundibulum; right ventricular hypertrophy consequent to this; a VSD high up in the membranous part of the septum beneath the aortic valve and, secondary to this, an overriding aorta (the septal defect lies just inferior to the valve and blood is shunted directly from the right ventricle to the aorta which appears to override it.) The right to left shunt is responsible for a number of associated problems. The child is typically pink in the newborn period and cyanosis develops over a period of weeks to months as influenced by the magnitude of stenosis and shunt. The baby may be pink at rest with cyanosis developing during feeding or crying. Alternatively, the baby may be well most of the time with cyanotic spells occurring periodically which are thought to be due to spasm of the infundibular septum, increasing the right to left shunt As the child ages the severity of the disease progresses. The child may learn to modify symptoms. For example, during episodes of cyanosis the child may assume a squatting position. This acts to decrease venous return and hence mitigate the degree of right to left shunt temporarily. Congestive cardiac failure is not a feature of the disease

431

Polycythaemia may develop secondary to hypoxaemia and may be complicated by thromboembolic phenomena including cerebral abscesses. The Eisenmenger syndrome does not occur because the direction of the shunt is essentially always right to left. The Eisenmenger complex is a term applied to those cases of atrial septal defect (ASD), ventricular septal defect (VSD), or patent ductus arteriosus (PDA), in which there is pulmonary hypertension . It occurs in a fair proportion of VSDs and PDAs but rarely in ASDs (ostium primum defects). The changes in the pulmonary vessels in many cases are present at birth and possibly result from a persistence of foetal circulation, the pulmonary arteries preserving their thick walls and narrow lumen after birth. Pulmonary hypertension results and in its turn causes more severe changes in the vessels. In other cases the changes in the pulmonary vessels are acquired; this is possibly more often the case in VSD. The pressure in the pulmonary artery is either equal to , or more commonly, greater than that in the aorta so that there is a reversal of the shunt through the defect.The prognosis is poor and surgery is contraindicated References HULL, D. & JOHNSTON, D.I; Essentials of Paediatrics, 2nd Ed., pp 138-9. JOLLY, H. & LEVENE, M; Diseases of Children, 5th Ed., 1985, p 171.

6, The most likely cause of persistent hypertension in a six year old child with a normal body mass index is: A. Reno-vascular disease. B. Coarctation of the aorta. C. Phaeochromocytoma. D. Renal disease. E. 'Essential' hypertension. Select the single best answer Correct Answer: D

7, A woman is treated for imminent eclampsia with therapy which includes large doses of magnesium sulphate. A live infant is subsequently delivered by Caesarean section. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct

432

Correct Answer: C The classic signs of neonatal hypermagnesaemia include hyporeflexia, hypotonia, lethargy and respiratory depression. Paralytic ileus and 'meconium plug' syndrome have also been reported. See: Sullivan JE, Berman BW. Hypermagnesemia with lethargy and hypotonia due to administration of magnesium hydroxide to a 4-week old infant. Arch Pediatr Adolesc Med. 2000;154:1272-1274. and: Narchi H. The pediatric forum: neonatal hypermagnesemia: more causes and more symptoms. Arch Pediatr Adolesc Med. 2001 Sep;155(9):1074. 8, The smallest 'Univent' tube available for paediatric use has an internal diameter of: A. 3.5 mm. B. 4.0 mm. C. 4.5 mm. D. 5.0 mm. E. 5.5 mm Select the single best answer Correct Answer: A

9, A neonate awaiting repair of a congenital diaphragmatic hernia will typically have which of the following associated problems: 1. Pulmonary hypertension. 2. Aspiration. 3. Other congenital abnormalities. 4. Prematurity. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct Correct Answer: E

433

The condition typically clusters with other congenital abnormalities (16%).These may include cardiac abnormalities. All are associated with a degree of gut malrotation. 75% have polyhydramnios. The high incidence of polyhydramnios carries with it a risk of premature labour. As a result neonates with a diaphragmatic hernia, like those with trache-ooesophageal fistula and related conditions, may be premature. In this event, problems related to prematurity may also exist. Gut malformations may be associated with gastric insufflation and aspiration, particularly if the stomach occupies an intrathoracic site and resuscitation is attempted without tracheal intubation. The pathogenesis is unresolved; one theory maintains that the presence of the gut in the pleural cavity restricts development of the lungs. Conversely, the other proposes that primary pulmonary hypoplasia occurs, and that the gut migrates into the thoracic cavity by default. The net result in Severe CDH is respiratory insufficiency secondary to pulmonary hypoplasia. Hypoxaemia ensues and this results in increased pulmonary vascular resistance, pulmonary hypertension and a persistence of the right to left shunt present in utero. This is called persistent foetal circulation. Left untreated, this will result in a self sustaining cycle of progressive hypoxaemia and acidosis, pulmonary hypertension, right heart failure, systemic hypotension and death. Management consists of early intubation, ventilation with 100% oxygen, neuromuscular paralysis, nasogastric suctioning, pulmonary vasodilators, and emergency surgical decompression of intrathoracic intestinal contents. Typically, neonates with diaphragmatic hernia may be divided into two groups based on the age at presentation. They are considered to have CDH if they develop respiratory symptoms at less than 24 hours of age. Most often this group will develop symptoms at birth or within the first 6 hours of life. The mortality rate remains between 40%-80% despite initial expectations that in-utero diagnosis and transfer to obstetric centres with neonatal intensive care facilities would lead to improved outcome. Neonates presenting after 24 hours generally have limited defects and a reduced incidence of pulmonary complications. They have a survival of 100% (excluding other congenital abnormalities). It should be noted that the severity of the defect often correlates with early detection on ultrasound, and that if it is missed such that diagnosis occurs in the delivery room, then the neonate is likely to fall into this group (ie severe pulmonary hypoplasia is unlikely). References BROWN, D.L.; Risk and Outcome in Anesthesia, 2nd Ed., Lippincott, 1993, pp 428-34.

10, Which of the following are true when comparing general anesthesia with halothane in a three year old compared with an adult? 1. Induction is faster. 2. Higher concentrations will be required for maintenance of anaesthesia. 3. Myocardial depression is greater. 4. The risk of aspiration is higher.

434

A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct Correct Answer: E Several differences in the response to anaesthetic agents in the paediatric population exist. Induction of anaesthesia proceeds more rapidly. Studies demonstrate a steady decline in MAC with age; ie: 1.2% at 0-6 months, 1.16% at 6-24 months, and 1.07% at 24-48 months. The younger the child is, the more halothane is required achieve adequate anaesthesia. At the same time, increasing doses are more likely to cause myocardial depression. The therapeutic index is low, and it may be difficult to achieve anaesthesia and normotension simultaneously. In one study, a dose dependent decrease in blood pressure, pulse rate and cardiac output occured which was generally responsive to atropine. This was felt to be of particular relevance in infants whose cardiac output is largely rate dependant due to low myocardial compliance. Depression of baroreceptor function is also more pronounced. Children under the age of 12 years are at greater risk of aspiration. One study showed 74% to be at risk. This is associated with a lower gastric acid pH and higher residual gastric volume compared with adults. References BROWN, D.L.; Risk and Outcome in Anesthesia, 2nd Ed., Lippincott, 1993, pp 419-22.

11, Which of the following statements are true of bronchiolitis: 1. Up to 50% of patients continue to wheeze after recovery 2. Tachypnoea is invariable 3. Air-trapping is normally present 4. The typical pathogen is para influenza virus A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct Correct Answer: A

435

Bronchiolitis is usually caused by Respiratory Syncitial Virus (RSV). RSV infection leads to a wide spectrum of respiratory illnesses. In infants, 25 to 40 percent of infections result in lower respiratory tract involvement, including pneumonia, bronchiolitis, and tracheobronchitis. In infants, illness begins most frequently with rhinorrhea, low-grade fever, and mild systemic symptoms, often accompanied by cough and wheezing. Most patients gradually recover in 1 to 2 weeks. In more severe illness, tachypnea and dyspnea develop, and eventually frank hypoxia, cyanosis, and apnea can ensue. Physical examination may reveal diffuse wheezing, rhonchi, and rales. Chest x-ray shows hyperexpansion, peribronchial thickening, and variable infiltrates ranging from diffuse interstitial infiltrates to segmental or lobar consolidation.

12, A ventricular septal defect in children: 1. Is the commonest congenital heart lesion 2. If of Maladie de Roger type is the most severe form 3. Closes spontaneously in up to 50% of cases 4. Is associated with pulmonary oligaemia A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct Correct Answer: B Defects of the ventricular septum are common as isolated defects and as one component of a combination of anomalies. The opening is usually single and situated in the membranous portion of the septum. The functional disturbance is dependent primarily on its size and on the status of the pulmonary vascular bed, rather than on the location of the defect. The 'Maladie de Roger' is a small VSD.

13, The distance from the incisors to the mid-tracheal point in a five year old child is most likely to be: A. 10 cms. B. 12 cms. C. 15 cms. D. 17 cms. E. 19 cms. Select the single best answer

436

Correct Answer: C Premature 8-9 cms. 0 - 6 mo 10 -11cms. 6 - 12 mo 12 cms. 1 - 2 yr 13 cms. 2 - 4 yr 14 cms. 4 - 6 yr 15 cms. 6 - 8 yr 16 cms. 8 - 10 yr 17 cms. 10 - 12 yr 18 cms. 14, A 3400g neonate is examined at 5 minutes of life with the following findings: temperature: 37.2C ; heart rate: 120 bpm; respiration rate: 25 bpm (regular); blood pressure: 80/60 mm Hg. His eyes are closed and his pupils are constricted. All four extremities are actively moving with good muscle tone. When you suction the nares there is no response. Skin colour is pink on both the body and the extremities. What is the correct 5 minute Apgar score for this neonate? A. 5. B. 7. C. 8. D. 9. E. 10. Select the single best answer Correct Answer: C The Apgar scoring system is: Colour: 0: Pale or cyanosed. 1: Pink trunk / blue limbs. 2: Pink. Pulse rate (normally 120-160 bpm): 0: Absent. 1: < 100 bpm. 2. > 100 bpm. Reflex response to airway suction: 0: Absent. 1. Grimace. 2. Cough / sneeze.

437

Muscle tone: 0: Flaccid. 1. Present. 2: Actively moving. Respiration (Normal: 30 - 60 bpm): 0: Absent. 1: Irregular. 2. Regular. 15, A 5-month-old female infant presents with persistent tachypnoea of a few weeks duration following an upper respiratory tract infection. The chest X-Ray is shown below. This scenario is compatible with: 1. Congenital lobar emphysema. 2. Aspiration of a foreign body. 3. Congenital cystic adenomatoid malformation. 4. Lobar pneumonia A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct Correct Answer: B Aspiration of a foreign body - typically occurs in children aged 1-2 years and is therefore unlikely although the Xray is compatible with the diagnosis. Tracheobronchial foreign body aspiration in children. Burton EM; Brick WG; Hall JD; Riggs W Jr; Houston CS South Med J, 89(2):195-8 1996 Feb. In this retrospective study, we reviewed the demographic and radiographic findings of 155 children with bronchoscopy-proven tracheobronchial foreign body aspiration (FBA). Two thirds of the patients were male, and most were children between 1 and 2 years of age. An aspirated peanut accounted for one third of all cases. Foreign body location was distributed nearly evenly to the right and left primary bronchi; tracheal foreign body was noted in 16 patients. The most frequent symptoms of FBA were cough (85 patients) and wheezing (60 patients). Although most patients were seen within 1 day of aspiration, 30 patients had symptoms that lasted at least 1 week before diagnosis. The most common radiographic findings were unilateral or segmental hyperlucency (59) or atelectasis (38). The trachea was the site of the foreign body in one half of children with a normal chest radiograph and FBA. The Xray is compatible with both congenital lobar emphysema and congenital cystic adenomatoid malformation. - It is, in fact, a case of the latter.

438

Congenital cystic adenomatoid malformation is a relatively uncommon developmental abnormality of the lung thought to be caused by an arrest of bronchial maturation and, at the same time, overgrowth of mesenchymal elements. It occurs sporadically as a defect in the embryogenesis of the lung without identifiable causes and can be identified in utero as early as 20 weeks of gestation, either incidentally or because it often causes hydramnios. The usual mode of presentation is respiratory distress in the neonatal period, the degree being proportional to the degree of emphysema and mediastinal shift. Histologically, congenital cystic adenomatoid malformation has been subdivided into three types. Type I consists of relatively large cysts of uneven size, and has a better prognosis compared to types II and III, which are often associated with other congenital malformations. Type II congenital cystic adenomatoid malformation consists of uniform small cysts throughout. It often coexists with chromosomal abnormalities and other defects. Type III is predominantly solid. Surgery is therapeutic, the ultimate prognosis dependent on associated anomalies. 16, In a 3 year old child with congenital heart disease, which of the following murmurs are best heard at the apex? 1. 2. 3. 4. Hypertrophic Obstructive Cardiomyopathy Tetralogy of Fallot Mitral Regurgitation Patent Ductus Arteriosus

A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct

Correct Answer: B 1. In hypertrophic obstructive cardiomyopathy, the abnormal interventricular septum is often associated with mitral regurgitation. 2. The murmur in Tetralogy of Fallot is usually pulmonary and best heard at the upper left sternal margin. 3. The apex is the best place to hear a mitral valvular murmur. 4. The murmur of a PDA is best heard at the upper left sternal margin.

439

17, Which of the following may predispose to the development of respiratory distress syndrome (RDS) in the neonate? 1. Low gestational age. 2. Low weight for gestational age. 3. Maternal diabetes. 4. Congenital heart disease in the foetus. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct Correct Answer: B The incidence of RDS is higher in infants of low gestational age. However, there is no significant difference in the incidence between infants whose birth weight is above or below the mean for their gestational age. Maternal diabetes is a powerful determinant of the incidence of RDS - the risk being increased about twentyfold if no specific prophylactic therapy is used. Congenital heart disease in the foetus has no effect on the incidence of RDS. 18, One minute after birth, a 2.2 kg term infant has a pink trunk but cyanotic fingers and toes and an irregular respiratory pattern. The child grimaces with nasal suctioning, is immobile, but has flexion of the elbows and knees and a heart rate of 85 bpm. Which of the following statements are true? 1. The Apgar score is consistent with mild intrauterine asphyxia. 2. Atropine 40 mcg via the umbilical vein is indicated. 3. Bag-mask ventilation with pure oxygen should be initiated. 4. Intubation is indicated. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct Answer: B The child has an Apgar score of 5.

440

At 1 minute, the appropriate guidelines for the management infants with various Apgar scores are: 7-10: Warm the baby, nasal / oral suction only. 4-6: Stimulate baby, suction airway. If respiration remains irregular or heart rate (HR) persists at < 100 bag-mask ventilation with FiO2 1.0. 0-3: Bag-mask ventilate with FiO2 1.0; if HR stays < 60, intubate and begin chest compressions; commence a formal resuscitation protocol. Bradycardia in this context is a symptom of hypoxia and will not be helped by atropine. The Apgar scoring system is: Colour: 0: Pale or cyanosed. 1: Pink trunk / blue limbs. 2: Pink. Pulse rate (normally 120-160 bpm): 0: Absent. 1: < 100 bpm. 2. > 100 bpm. Reflex response to airway suction: 0: Absent. 1. Grimace. 2. Cough / sneeze. Muscle tone: 0: Flaccid. 1. Present. 2: Actively moving. Respiration (Normal: 30 - 60 bpm): 0: Absent. 1: Irregular. 2. Regular.

19, The parents of a 10 year old boy are worried that his school performance has decreased over the past 2 months. The boy complains of increasing headache and double vision and on examination you note that he has gait ataxia. Which of the following is the most appropriate immediate investigation?

441

A. B. C. D. E.

Computed tomography (CT) scan of the brain. Electroencephalogram. Auditory evoked potentials. Single Photon Emission Computed Tomography (SPECT) scan of the brain. Magnetic resonance imaging (MRI) scan of the brain

Select the single best answer Correct Answer: E An MRI scan is the most appropriate initial investigation for a suspected posterior fossa lesion - CT resolution in this region being less good. See, for example: Kent DL, Haynor DR, Longstreth WT Jr, Larson EB. The clinical efficacy of magnetic resonance imaging in neuroimaging. Ann Intern Med. 1994 May 15;120(10):856-71. SPECT scanning is used in the assesment of regional cerebral blood flow and for the diagnosis of functional brain abnormalities - in particular epilepsy. Number: 723 Shortly after birth, a full-term infant weighing 3.1 kgs, is noted to be cyanosed during feeding. The cyanosis is relieved by crying. The infant was delivered normally following an uncomplicated pregnancy. Which of the following diagnoses is most likely? A. Tracheo-oesophageal fistula. B. Tetralogy of Fallot. C. Respiratory distress syndrome. D. Patent ductus arteriosus (PDA). E. Choanal atresia. Select the single best answer Correct Answer: E Neonates are obligate nose-breathers. For this reason, choanal atresia classically presents with cyanosis during feeding or at rest which is relieved by crying. The diagnosis is confirmed by the inability to pass a suction catheter through either nostril. Some cases of choanal atresia are associated with the CHARGE syndrome or other congenital abnormalities. In contrast, an infant with a right-to-left shunt will become more cyanosed during crying because crying increases pulmonary vascular resistance. Tracheo-oesophageal fistula is characterised by episodes of choking and / or cyanosis during feeding - but it will not improve if the infant cries. A PDA constitutes a left-to-right shunt and does not cause cyanosis.

442

Respiratory Distress Syndrome is unlikely given the scenario and does not present in this manner anyway.

20, The retinopathy of prematurity (ROP): 1. Is a cause of myopia in later life. 2. Is more likely to occur in an infant exposed to supplemental oxygen. 3. Is associated with the development of strabismus in later life. 4. Is unlikely to occur in an infant born at a gestational age of more than 32 weeks. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct Correct Answer: E ROP is associated with the development of both myopia and strabismus in later life. The development of the condition is most clearly related to the use of supplemental oxygen in low birth weight infants (<1200G) of low gestational age (<28 weeks). The condition is very unusual in infants born at a gestational age of more than 32 weeks. Avoidance of arterial hyperoxia is almost certainly important in reducing the incidence of the disease. See: Pediatrics 1999 Sep;104(3): Current incidence of retinopathy of prematurity, 1989-1997. Hussain N, Clive J, Bhandari V. Curr Opin Ophthalmol 1999 Jun;10(3):155-63: Results of screening low-birth-weight infants for retinopathy of prematurity. Clemett R, Darlow B. 21, The typical biochemical profile of a neonate with severe, newly diagnosed, pyloric stenosis includes: 1. Hypochloraemia. 2. Alkalosis. 3. Hypokalaemia. 4. Unconjugated hyperbilirubinaemia

443

A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct Correct Answer: A 22, The smallest size of double lumen tube (DLT) which is commercially available for paediatric use is: A. 24 F B. 26 F C. 28 F D. 30 F E. 32 F Correct Answer: B Conventional plastic DLTs, once available only in adult sizes (35F, 37F, 39F, and 41F), are now available in smaller sizes. The smallest cuffed DLT is a 26F (Rusch, Duluth, GA), which may be used in children as young as 8 yr old. DLTs are also available in sizes 28F and 32F (Mallinckrodt Medical, Inc., St. Louis, MO), suitable for children 10 yr and older. See the comprehensive review by Hammer entitled "Pediatric thoracic anesthesia." (Hammer GB. Pediatric thoracic anesthesia. Anesth Analg. 2001 Jun;92(6):1449-64.)

23, A 4-day-old, 1500-gram, premature infant recovering from a hyaline membrane disease is noted to have bounding peripheral pulsations and a hyperactive precordium. A continuous machinery murmur is most audible in the left infraclavicular area. Left ventricle hypertrophy is present on the electrocardiogram. The chest x-ray shows slight enlargement of the heart and increased pulmonary venous markings. Which of the following is the most likely diagnosis? A. Ventricular septal defect. B. Atrial septal defect. C. Patent ductus arteriosus. D. Pulmonary stenosis. E. Tetralogy of Fallot. Select the single best answer

444

Correct Answer: C A patient with patent ductus arteriosus has a continuous machinery murmur and bounding pulses with a hyperactive precordium. Although the electrocardiogram is usually not helpful, it may show left ventricular hypertrophy. Patients with atrial septal defect have a widely split and fixed second heart sound. Patients with ventricular septal defect have a pan-systolic murmur. The tetralogy of Fallot is constituted by the presence of a VSD, right ventricular hypertrophy, pulmonary stenosis, and an overriding aorta. The murmur of tetralogy of Fallot is a long, systolic ejection murmur most audible at the mid-left sternal border. In patients with pulmonary stenosis, there is a high-pitched systolic ejection murmur, most audible at the upper left sternal border, that transmits fairly well to the back. A systolic thrill may be present at the upper left sternal border and, rarely, in the suprasternal notch.

24, The American Society of Anesthesiologists recommends that a breast fed infant scheduled for elective surgery be fasted for: A. 30 minutes. B. 1 hour. C. 2 hours. D. 4 hours. E. 6 hours. Select the single best answer Correct Answer: D The Consultants and Task Force support a fasting period for breast milk of 4 hours for both neonates and infants. 25, The most appropriate drug for the treatment of an autonomic crisis in a patient with Riley-Day syndrome is: A. Midazolam. B. Droperidol. C. Metoprolol. D. Sodium Nitroprusside. E. Morphine.

445

Select the single best answer Correct Answer: A Familial dysautonomia (Riley-Day syndrome) is a rare genetic disorder that is transmitted via an autosomal recessive gene. The disease, typically involving Jewish children, affects the central nervous system and can be characterised by pathological deficits in peripheral autonomic and sensory neurones. The signs, which begin in early childhood, include poor perception of pain and temperature, poor co-ordination of muscles, emotional crises with hypertension and profound sweating, postural hypotension, and excessive vagal reflexes. Benzodiazepines are extremely effective in the treatment of crises. 26, Electrocardiographic evidence of left ventricular hypertrophy (LVH) is found in children with: 1. Coarctation of the aorta. 2. Tetralogy of Fallot. 3. Ventricular septal defect. 4. Atrial septal defect. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct Correct Answer: B LVH occurs when the left ventricle is either pressure or volume overloaded. This is the case in the presence of coarctation of the aorta and ventricular septal defect (with a left-to-right shunt). In tetralogy of Fallot and atrial septal defect there is right ventricular overload, and consequently there may be electrocardiographic evidence of right ventricular hypertrophy. 27, Which of the following childhood conditions may present with acute stridor? 1. Viral croup. 2. Acute bacterial tracheitis. 3. Epiglottis. 4. Tetany. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct

446

Correct Answer: E 28, Cleft lip and Palate: A. Are usually associated with other congenital anomalies. B. Need to be repaired urgently because the infant will be unable to feed. C. Are usually a midline defect. D. Constitute a major intubation problem. E. Are usually repaired separately. Select the single best answer Correct Answer: E There is not an association with other anomalies. There is no urgency regarding the repairs which are usually undertaken as separate procedures (lip first then palate). It is rarely a midline defect. The defects are generally repaired as elective procedures and the greatest anaesthetic concerns relate to the nutrition of the child A cleft lip rarely occurs in the midline. The cleft generally occurs to one side of the midline, may be single or bilateral and may exist by itself or in association with a cleft palate. A midline cleft lip and palate is very rare and if present is often associated with a cerebral malformation, particularly abscence of the corpus callosum with a single ventricle; these features may occur in trisomy 13-15. The disorder of cleft lip may be familial. In its mildest form there is only a lip scar (submucous cleft), indicating delayed intrauterine fusion of the maxillary process, but when severe the cleft extends to the nose. No major intubation difficulties are encountered. It is usually repaired at 3 months and surgeons commonly insist that the baby's weight has reached 5 kg. In its mildest form this condition exists as a fish-tail notching of the uvula. In increasing order of severity it includes bifid uvula, cleft soft palate, cleft soft and hard palate. Cleft palate may be lateral or midline.A lateral cleft is usually associated with a cleft lip; a midline is rarely associated with a cleft lip.The maxilla on the side of the cleft is underdeveloped. Surgical repair is usually left until 12 months , treatment being complete by the time speech is developed. The orthodontic fitting of an oral appliance early is used to stimulate development of the underdeveloped maxilla, making primary surgical repair more successful. Cleft lip and palate do not present a problem in intubation. The immediate problem is difficulty feeding and a variety of modified feeding teats of tubes can be used if breast feeding is unsuccessful. Attention to this is crucial; surgical repair may be postponed in babies that have become poorly nourished and anaemic whilst on the waiting list. Children with cleft palate are particularly prone to otitis media from reflux up the eustachian tube. Recurrent infections and deafness may result. References JOLLY, H. & LEVENE, M.I; Diseases of Children, 5th Ed., 1985, pp 136-9. HULL, D. & JOHNSTON, D; Essential Paediatrics, Churchill Livingstone, 2nd Ed, p 162.

447

29, Congenital Diaphragmatic Hernia (CDH): 1. Complicates about 1 in 5000 live births. 2. Most often occurs on the left side. 3. Is associated with other congenital abnormalities in at least 50% of cases. 4. May be associated with severe pulmonary hypertension. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct Correct Answer: C See the comprehensive review by Hammer. According to this author: "CDH is a life-threatening condition occurring in approximately 1 in 2000 live births. Failure of a portion of the fetal diaphragm to develop allows abdominal contents to enter the thorax, interfering with normal lung growth. Most often (70%80% of diaphragmatic defects), a portion of the left posterior diaphragm fails to close, forming a triangular defect known as the foramen of Bochdalek. Hernias through the foramen of Bochdalek occurring early in fetal life usually cause respiratory failure immediately after birth because of pulmonary hypoplasia. Distension of the gut postnatally, as with bag-and-mask ventilation, exacerbates the ventilatory compromise by further compressing the lungs. The diagnosis is often made before birth, and fetal surgical repair has been described. Neonates present with tachypnea, a scaphoid abdomen, and absent breath sounds over the affected side. Chest radiography (CXR) typically shows bowel in the left hemithorax, with deviation of the heart and mediastinum to the right and compression of the right lung. Right-sided hernias may occur late and present with milder signs. In the presence of significant respiratory distress, bag-and-mask ventilation should be avoided and immediate tracheal intubation performed. Because pulmonary hypertension with right-to-left shunting contributes to severe hypoxemia in neonates with CDH, a variety of vasodilators have been used. These include tolazoline, prostacyclin, dipyridamole, and nitric oxide. High-frequency oscillatory ventilation has been used in conjunction with pulmonary vasodilator therapy to improve oxygenation before surgery. In cases of severe lung hypoplasia and pulmonary hypertension refractory to these therapies (e.g., PaO2 <50 mm Hg with a fraction of inspired oxygen of 1.0), extracorporeal membrane oxygenation (ECMO) should be initiated early to avoid progressive lung injury. Improved outcomes have been associated with early use of ECMO followed by delayed surgical repair." About 15% of neonates with CDH have other congenital abnormalities. See: Hammer GB. Pediatric thoracic anesthesia. Anesth Analg. 2001 Jun;92(6):1449-64.

448

30, A 5 year old child diagnosed with a patent ductus arteriosus: 1. Is inoperable if there is a loud 2nd sound and right ventricular hypertrophy on ECG. 2. Should have surgical closure delayed until adult life if asymptomatic. 3. Should have a trial of closure with Indomethacin. 4. Will have pulmonary plethora on CXR. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct Correct Answer: D A patent duct may present as failure to thrive. Pulmonary hypertension is usually reversible at this stage and is not a contraindication to surgery. Duct closure is recommended at this age because the risk of subacute bacterial endocarditis is high if left untreated. A simple duct will show pulmonary plethora on X-ray because of the large left to right shunt. Indomethacin is only of use in neonates. This condition is after VSD one of the commonest types of non-cyanotic congenital cardiac disease. Others include coarctation of the aorta, aortic stenosis and hypoplastic left heart; all of these tend to present as CCF in infancy. PDA is twice as common in girls. It is usually detected by hearing a typical machinery murmur on routine examination. The murmur, which is accompanied by a thrill, is best heard in the pulmonary area and is continuous throught systole and diastole, though louder in systole. A venous hum may sound similar (continuous murmur heard in normal individuals just below the clavicles, especially on the right). It is caused by flow of blood in the great veins. It is a softer murmur and can be abolished by occlusion of the jugular vein in the neck and varies with extension and flexion of the head) ; apart from this it is distinct. Diagnosis is more difficult in infancy as at this age the ductus produces only a systolic murmur. Absence of the diastolic murmur is due to the pulmonary artery pressure in infancy being nearly equal to that in the aorta, thereby preventing flow through the ductus during diastole. The diastolic component is usually present by the end of the first year when the aortic pressure has become higher than the pulmonary. If a PDA causes CCF, it will manifest in infancy, hence diagnosis is essential in this age group. Diagnostic signs include a high pulse pressure and collapsing pulse indicative of a high cardiac output state. CXR shows some degree of cardiac enlargement and dilatation of the pulmonary artery; and plethora of the lung fields. The ECG is normal or shows either left ventricular hypertrophy or a combination of right and left ventricular hypertrophy. A PDA should be ligated in all cases to prevent later complications. If this is not carried out adult life will almost certainly be shortened by the onset of CCF and/or bacterial endocarditis. The best time for surgical repair is 3-7 years. Surgery is contraindicated in some situations. If pulmonary hypertension has progressed to an Eisenmenger Complex closure of the ductus is likely to be fatal because of the need for a right to left shunt through the open duct. It should

449

not be undertaken if the patient is cyanosed or if right axis deviation is present on the ECG. Pulmonary hypertension is generally reversible in a 5 year old and is not a contraindication to surgery. Medical manipulation is possible in the neonate with an inhibitor of prostaglandin synthesis; ie: indomethacin. This may be necessary as a PDA may precipitate intractable heart failure in infancy especially in preterms. Conversely, if a coexisting anomaly is present such as transposition, in which the only communication between the left and right sides of the heart is the patent ductus, spontaneous closure will cause death. As a protective measure, until surgical repair is performed, a continuous infusion of prostaglandin should be given to delay closure.

PERFUSION ( CARDIAC ANESTHESIA) TESTS Number: 38 An adult is undergoing cardio-pulmonary bypass at 26 degrees celsius. The perfusionist is attempting to follow an 'Alpha Stat' management strategy. The target PaCO2 (measured at 26 degrees celsius) which the perfusionist should aim for is approximately: A. 15 mm Hg. B. 25 mm Hg. C. 40 mm Hg. D. 50 mm Hg. E. 65 mm Hg. Select the single best answer ABCDE Correct Answer: B The aim of 'alpha-stat' management is to maintain normocarbia (and a pH of 7.40) in the arterial blood when the blood gas tensions are measured at 37 degrees celsius. Blood with a PCO2 of 25 mm Hg at 26 degrees celsius will have a PCO2 of about 40 mm Hg when warmed to 37 celsius (depending on the temperature correction algorithm used). The 'alpha-stat' technique is based on the proposition that the constancy of the 'internal milieu' is accomplished predominantly by the buffering capacity of the imidazole group of histidine. As temperature changes, this imidazole protein buffer changes its pK, in parallel with the pN of water. The fraction of unprotonated histidine imidazole groups, known as alpha, remains constant; total CO2 remains constant; and pH changes as temperature changes. The term "alpha-stat" refers to maintenance of this constant net charge on proteins with temperature changes by keeping total CO2 stores constant. The alternative method of acid-base strategy is termed 'pH-stat'. Under these circumstances, the strategy is to maintain a pH of 7.40 and normocarbia at the actual patient temperature.

450

Several formulae are available for adjusting a blood gas pCO2 determined at 37 C for a patient's body temperature. For elevated body temperatures the pCO2 is increased; for reduced body temperatures the pCO2 is decreased. corrected pCO2 = (measured pCO2) * (10^ ( X * ((patient temperature in C) - 37))) where X = 0.021 for the Radiometer ABL-3 X = 0.019 for the Corning and Instrumentation Laboratory (IL) instruments References: Ashwood ER, Kost G, Kenny M. Temperature correction of blood-gas and pH measurements. Clin Chem. 1983;29:1877-1885. Ciba-Corning 288 Blood Gas System Operator's Manual. 1988, page 2-15 Kelman GR, Nunn JF. Nomograms for correction of blood pO2, pCO2, pH and base excess for time and temperature. J Appl Physio. 1966; 21: 1484-1490. Pruden EL, Siggaard-Andersen O, Tietz NW. Chapter 30: Blood gases and pH. pages 13751410 (1406-1409). IN: Burtis C, Ashwood E. Tietz Textbook of Clinical Chemistry, Second edition. W.B. Saunders Company. 1994. Number: 48 A 50 year old man presents for urgent on-pump, coronary artery grafting after suffering an acute coronary syndrome. He has been treated with intravenous heparin for one week. During this time his platelet count has fallen from 250,000 / microlitre to 100,000 / microlitre, but Heparin-PF4 antibodies are not present. Given this scenario, the most appropriate anticoagulant management for cardiopulmonary bypass is: A. The use of systemic heparin in conventional dosages. B. Systemic anticoagulation with ancrod. C. Systemic anticoagulation with danaparoid (Orgaran). D. Systemic anticoagulation with hirudin. E. The use of a Carmeda coated circuit without systemic heparinisation Select the single best answer ABCDE Correct Answer: A From the description that has been given, there is little doubt that the patient is either suffering from HIT type I or has some other cause for thrombocytopaenia. This being so, it is entirely reasonable to use systemic heparinisation in a routine manner. Thrombocytopaenia associated with the use of heparin occurs in two general forms. The first (HIT Type I) is a benign type seen in many patients 1-3 days after starting standard heparin

451

and felt to be caused by the non-immune enhancement of platelet aggregation followed by sequestration and removal by the spleen. The platelet count usually remains above 100,000, resolves spontaneously, and requires neither cessation of heparin nor other treatment. It is not associated with the development of thrombosis. Unlike HIT Type I, HIT Type II is a more severe, delayed-onset thrombocytopaenia that is immunologically mediated. Consistent with the generation of an immune response, HIT Type II typically occurs approximately 5 to 14 days following initiation of heparin therapy but may occur earlier if the patient has been previously exposed to heparin. The thrombocytopaenia is usually more severe than in HIT Type I, with platelet counts often dropping to 60,000/ microlitre or below and remaining low until heparin is withdrawn. After cessation of heparin therapy, platelet counts usually take several days to rebound, but in rare cases may take up to 1 month to normalise. HIT Type II is much more dangerous than Type I because a proportion of those affected will go on to develop intravascular thrombosis. The diagnosis of HIT Type II is based on immunological testing and platelet function analysis. The immunological test consists of an enzyme-linked immunosorbent assays (ELISA) which measures the presence of antibodies capable of binding the heparin-PF4 complex. Although this test may be more sensitive than the functional tests, it is also less. Sensitivities and specificities also vary depending on the specific ELISA used. Various functional analyses have been used for establishing the diagnosis, but the most sensitive and specific appears to be the serotonin release assay (SRA). Donor platelets are isolated from platelet-rich plasma and incubated with radiolabeled (14C) serotonin. The platelets are then washed to remove free serotonin and incubated with heat-inactivated patient serum in the presence of therapeutic (0.1 U/mL) and high (100 U/mL) concentrations of heparin. A positive result is defined as more than 20% release at low heparin concentrations and less than 20% release at high concentrations of heparin. The test is generally thought to be the most sensitive test for confirmation of HIT Type II. Nuttall et al have recently reviewed the management of 12 patients with a history of HIT type II who required cardiac surgery on cardiopulmonary bypass. See: Nuttall GA, Oliver WC Jr, Santrach PJ, McBane RD, Erpelding DB, Marver CL, Zehr KJ. Patients with a History of Type II Heparin-Induced Thrombocytopenia with Thrombosis Requiring Cardiac Surgery with Cardiopulmonary Bypass: A Prospective Observational Case Series. Anesth Analg. 2003 Feb;96(2):344-50. Number: 70 A patient is undergoing hypothermic cardio-pulmonary bypass at 25 degrees Celsius. 'Alphastat' (as opposed to 'pH-stat') management is being used. Which of the following statements is / are true? 1. pH will be higher if an alpha stat technique is being used. 2. Cerebral blood flow is greater if pH stat management is used. 3. Alpha stat management is associated with a better neurological outcome.

452

4. Cerebral autoregulation is better maintained under pH stat conditions. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: A Alpha stat management is now commonly used throughout Australia. It is characterised by lower cerebral blood flows with maintenance of autoregulation and no uncoupling of oxygen demand and supply. At this temperature the PCO2 difference between alpha stat and pH stat management would be about 12-15 mm Hg. Studies contrasting alpha stat and pH stat indicate that myocardial function during hypothermic CPB is better preserved when the alpha stat method is used. When pH is held constant at 7.4 by the addition of CO2, myocardial lactate extraction decreases, indicating the presence of either myocardial ischaemia or, more likely, depression of cellular function due to relatively acidotic conditions. Also, during pH stat perfusions, contractility, myocardial oxygen consumption, and coronary blood flow have been shown to decrease. These observations are believed to indicate depressed cellular function in the acidotic environment produced by maintaining the actual body temperature pH at 7.4 during hypothermia. Similar depression of cellular function may occur in other organs as well. Maintenance of cerebral blood flow autoregulation appears to remain intact with alpha stat management, whereas flow becomes pressure dependent with pH stat. Alpha stat management is probably associated with better neurological outcomes. See: Patel et al. References Murkin JM, Farrar JK, Tweed WA, McKenzie FN, Guiraudon G. Cerebral autoregulation and flow / metabolism coupling during cardiopulmonary bypass: the influence of PaCO2. Anesth Analg. 1987 Sep;66(9):825-32. Rogers AT, Stump DA, Gravlee GP, Prough DS, Angert KC, Wallenhaupt SL, Roy RC, Phipps J. Response of cerebral blood flow to phenylephrine infusion during hypothermic cardiopulmonary bypass: influence of PaCO2 management. Anesthesiology. 1988 Oct;69(4):547-51. Patel RL, Turtle MR, Chambers DJ, James DN, Newman S, Venn GE. Alpha-stat acid-base regulation during cardiopulmonary bypass improves neuropsychologic outcome in patients undergoing coronary artery bypass grafting. J Thorac Cardiovasc Surg. 1996 Jun;111(6):1267-79.

453

Number: 204 Which of the following may be a cause of micro-embolism during Cardio-pulmonary bypass (CPB)? 1. Rapid re-warming. 2. Rapid cooling. 3. PVC from the roller pump insert of the circuit. 4. pH stat management A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: A There are numerous causes of microembolism during CPB. Gaseous microembolism can occur during both heating and cooling of the patient. At the initiation of CPB (when rapid cooling may be occuring) microemboli may be created in the patient as the cold blood reaches the tissues and is rapidly re-warmed. Conversely, during rewarming, if blood reaches the oxygenator relatively well saturated then raising the blood temperature in the heat exchanger will produce showers of microemboli in the extra-corporeal circuit. In both cases, the mechanism of embolisation is the same. - As the temperature of the blood is raised, so the solubility of oxygen in the blood is reduced and the gas comes out of solution. In addition, as temperature rises, so does PCO2. This has the secondary effect of decreasing the affinity of haemoglobin for oxygen and as a result, further raising the PO2. Roller pumps tend to microfracture the interior surface of the PVC (or Silicone Rubber) 'boot'. This phenomenon is known as 'spallation'. The result is particulate micro-embolism of either PVC or Silicon into the circulation. This effect is particularly marked with Silicone Rubber. In addition, silicate particles from the defoamer used in reservoirs has also been found to embolise. pH stat management is not a cause of microembolism, but may make the sequelae of embolism worse. - As cerebral blood flows during pH stat are often inappropriately high, the brain is exposed to a larger number of emboli when compared to alpha stat management. References: Analysis of' Microembolic Particles Originating in Extracorporeal Circuits. Perfusion, Vol. 2, No. 1, 1987 Gideon Uretzky Particulate microembolism resulting from extracorporeal circuits (ECC) are regarded as the cause of many complications and organ dysfunction after cardiopulmonary bypass (CPB). This investigation demonstrated that large numbers of particles are released from that part of the tubing which is in contact with the roller pumphead during pumping. The present study identifies and quantitates by number, size and time the nonbiological microembolic particles

454

spalled off polyvinyl chloride (PVC) and silicon tubing during recirculation without an oxygenator in the circuit. These nonbiological particles carry a great hazard since they are liable to be retained in the patients organs following CPB. The mock circulation set-up in this study managed to show substantial production of these nonbiological microemboli by a roller pump in conjunction with the use of silicone rubber and PVC tubing. The fact that even during a short period of pumping, silicone rubber spalls off particles precludes its use in CPB. The Silicone tubing continuously generated a marked quantity of particulate matter at a steadily increasing rate. Electron microscopic examination of the silicone tubing revealed multiple particles emanating from the inner surface of the tubing. When using PVC tubing, the amount of particles of all sizes rose above acceptable standards shortly after activating the roller pump. Following the early upsurge, the number of particles continued to increase for the remainder of the pump run, albeit at a more moderate rate. The authors advocate replacing roller pump heads with a recently developed, less traumatic, vortex pump, for routine usage during cardiopulmonary bypass. Number: 233 In a patient on bypass with a hollow-fibre membrane lung, an abnormally high inlet (premembrane) pressure is more likely to be observed if: 1. The pre-operative platelet count is high. 2. The circuit prime contains albumen. 3. The patient has demonstrated relative heparin resistance. 4. The patient is normothermic. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: B Abnormally high inlet pressures are occasionally observed with modern, hollow-fibre membranes. The aetiology is uncertain, but probably relates to cryoprecipitation of fibrinogen. The incidence can be eliminated or greatly reduced by including in the circuit prime a small amount (~2 grams) of albumen. Number: 241 Which of the following manoeuvres may improve outcome in a patient who is to be subjected to a deep hypothermic arrest at 17 degrees centigrade? 1. Haemodilution to a haematocrit of 18 - 20%. 2. Maintenance of a blood sugar level of at least 15 mmol/L.

455

3. Administration of thiopentone prior to the arrest. 4. Induction of hypocarbia prior to arrest. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: B Hypothermia is associated with marked increases in blood viscosity. As a result, microcirculatory flow is far better maintained under hypothermic conditions if haemodilution is used. The presence of hyperglycaemia at the time of a neurological insult is associated with poorer outcomes. The administration of barbiturates prior to an ischaemic insult probably improves neurological outcome. Hypocarbia prior to arrest is almost certainly of no benefit to the patient Number: 242 With regard to the following balloon pump trace: 1. Inflation is too early. 2. The assistance ratio is 1:1. 3. Deflation is too early 4. Deflation is too late. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct

456

ABCDE Correct Answer: D Inflation is correctly timed to a point just before the dicrotic notch and the assistance ratio is 1:2. Deflation is set too late, as evidenced by a 'Pump End-Diastolic Pressure' which exceeds the patient's own diastolic pressure. Of all the 'mistimings' which are possible with an IABP, the two most harmful are early inflation and late deflation. Number: 316 With reference to hypothermic blood cardioplegia: 1. Bicarbonate will potentially reduce the availability of the delivered oxygen in the solution. 2. Hypothermia will potentially reduce the availability of the delivered oxygen in the solution. 3. Myocardial acidosis during cross-clamping will facilitate the extraction of oxygen from the solution. 4. The partial pressure of oxygen in the delivered solution has little effect on myocardial preservation. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: A Vinten-Johansen J, Julian JS, Yokoyama H, et al. Efficacy of myocardial protection with hypothermic blood cardioplegia depends on oxygen. Ann Thorac Surg 1991;52:939-948.

457

Vinten-Johansen et al. studied whether oxygen was an important factor in the myoprotection afforded by hypothermic blood cardioplegia. The oxygen content was adjusted by controlled gas mixture in the cardioplegia delivery line to fully saturated (10.2 +/- 0.6 ml O2 per deciliter), intermediate (4.3 +/- 0.5 ml O2 per deciliter) and low (1.1 +/- 0.2 ml O2 per deciliter) levels, while other compositional attributes were held constant. The heart was subjected to 30 minutes of normothermic ischemia, and hypothermic (4C) blood cardioplegia was delivered every 20 minutes for 1 hour of cardioplegia arrest. Postischaemic left ventricular function, evaluated by pressure-volume relations, generally reflected the level of oxygen content in the cardioplegia. Postischaemic left ventricular performance was wellpreserved in the saturated blood cardioplegia group, moderately depressed in the intermediate oxygenated group, and severely depressed in the relatively desaturated group (Fig. 7.11). It was concluded that oxygen is extracted in significant quantities from hypothermic blood cardioplegia, and that oxygen is important to the myocardial protection provided by hypothermic blood cardioplegia. Therefore, despite the unfavorable shift in the oxyhaemoglobin dissociation curve with profound hypothermia, the ischemic myocardium apparently creates an environment that counteracts these effects of hypothermia and facilitates extraction of oxygen. These enviromental forces include: * the increased tissue PCO2 * tissue acidosis (Bohr effect) * the facilitated extraction due to low tissue PO2 and * the greater affinity of hypothermic tissue for oxygen. Number: 317 Which of the following will reduce the likelihood of myocardial reperfusion injury: 1. The use of a leucocyte depletion filter in the cardioplegia system . 2. The addition of mannitol to the cardioplegia solution. 3. The addition of a calcium channel blocker to the cardioplegia solution. 4. The addition of glucose to the cardioplegia solution. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: B The majority of damage resulting from suboptimal myocardial protection is realised during reperfusion. Experimental evidence gained from research on long-term myocardial preservation for cardiac transplantation supports the concept that reperfusate modification can lead to subsequent improvements in myocardial function. In particular, leucocyte depletion

458

with blood filters has been demonstrated to significantly enhance the functional recovery of donor hearts preserved for 12 hours with Stanford solution. Calcium plays a central role in the establishment of a reperfusion injury. For this and other reasons calcium channel blockers have been added to cardioplegia solutions. Mannitol will reduce the likelihood of myocardial oedema and improve the distribution of blood flow once perfusion is re-established. It will not modify the reperfusion injury process itself. Glucose will provide a substrate source, but may, in fact, worsen the reperfusion injury: Number: 322 Which statements are true of the 'Delphin' centrifugal pump? 1. Its output will change in response to a change in the vascular resistance of the patient. 2. It works on the principle of 'viscous drag'. 3. It can be used to kinetically assist venous drainage. 4. It can be interfaced to the 'Biomedicus' pump console. A: 1,2,3 Correct B: 1,3 Correct C: 2,4 Correct D: 4 Correct E: All Correct ABCDE Correct Answer: B Like all centrifugal pumps, output is afterload dependent. Unlike the 'Biomedicus' pumphead, it is an impeller device. As with all centrifugal pumps, it can be used in the venous line to kinetically assist venous drainage through a small venous cannula. It can only be interfaced to the Sarns pump console. Number: 451 A 'Biomedicus' centrifugal pump is hand-cranked in the wrong direction. In comparison to a pump being hand-cranked in the right direction at the same rpm, this will result in: A. Blood flow at the same rate in an antegrade direction. B. Blood flow at the same rate in a retrograde direction. C. Blood flow at a reduced rate in an antegrade direction. D. Blood flow at a reduced rate in a retrograde direction. E. None of the above. Select the single best answer

459

ABCDE Correct Answer: C Perhaps surprisingly, the 'Biomedicus' centrifugal pump is almost as efficient going 'backwards' as compared to going 'forwards. Note that the direction of blood flow is NOT reversed when the direction of rotation of the pump head is reversed (unlike the case of a roller pump). Number: 452 A capnograph applied to the effluent port of a co-current hollow fibre membrane oxygenator wll provide: A. An accurate measure of arterial PCO2 at the current nasopharyngeal temperature. B. An accurate measure of arterial PCO2 at the current arterial temperature. C. An accurate measure of venous PCO2 at the current nasopharyngeal temperature. D. An accurate measure of venous PCO2 at the current arterial temperature. E. None of the above. Select the single best answer ABCDE Correct Answer: B The relationship between effluent PCO2 and arterial CO2 is not well-recognised by perfusionists. A capnograph applied to the effluent port of a co-current hollow fibre membrane gives a very accurate indication of the arterial PCO2 corrected to the current arterial temperature. This is in contrast to a bubble oxygenator which has a relatively high deadspace - and, as a result, there is no close relationship between gas and blood phase PCO2. Number: 459 Blood at 27 centigrade with a haematocrit of 24% is equilibrated with oxygen at a partial pressure of 100 mm Hg. It is then warmed under hermetic (sealed) conditions to 3