1.Concerning renal blood flow.

A. efferent glomerular arteriolar pressure affects systemic arterial pressure

B. renal vasoconstriction is stimulated by a decreased baroreceptor discharge
C. arterial hypoxaemia produces an increase in renal blood flow D. renal vasodilation is a
dopaminergic response
E. glomerular perfusion pressure is controlled by local autoregulatory mechanisms
TTFTF
2. Side effects of ganglion blocking drugs include
A. intestinal ileus
B. atony of the bladder
C. postural hypotension
D. miosis
E. bradycardia
TTTFF
3. EKG changes associated with hyperkalaemia include
A. a prolonged PR interval
B. high peaked T waves
C. U waves
D. ST segment depression
E. ventricular extrasystoles
FTFFT
4. Bilateral section of the recurrent laryngeal nerves
A. causes aphonia
B. causes respiratory embarrassment
C. causes tetany
D. allows adduction of the vocal cords on inspiration
E. puts the vocal cords into the cadaveric position
TTFT
5. Concerning body fluid compartments:

a) Water constitutes 70% of the total body weight

b) Plasma constitutes a quarter of the ECF volume
c) Sucrose can be used to measure the ECF volume
d) Interstitial fluid volume for a 70 kg man is approximately 9 litres
e) The ECF/ICF volume ratio is smaller in infants and children than it is in adults
FTTTF
6. Hyponatraemia:
a) may increase intracellular fluid volume
b) may be seen in SIADH
c) may incease the secretion of atrial natriuretic peptide
d) may increase the plasma osmolality
e) of acute onset may be associated with cerebral oedema
FTTFT
7. Hyponatraemia:
a) should be corrected with hypertonic saline
b) always implies a disturbance of total body water
c) is associated with abnormal aldosterone secretion
d) cannot be interpreted without clinical data
e) is associated with advanced carcinoma of the bronchus
FFFTT
8. Human plasma albumin:
(a) is the greatest contributor to plasma oncotic pressure
(b) is produced in the liver
(c) carries carbon dioxide in the blood
(d) is an anion at pH 7.5
(e) is actively filtered by the glomerulus
TTFTF
9. The following statements pertain to asthma (true or false):
a) the presence of wheezing is diagnostic
b) one distinctive feature is airway hyper-responsiveness
c) inhaled adrenaline is an effective therapy

d) it can be triggered by exercise alone

e) no confirmatory diagnostic test exists .
Concerning asthma:
a) FALSE. The presence of wheezing is NOT diagnostic. Wheezing is present in numerous
disease processes including bronchiolitis, cystic fibrosis, recurrent pulmonary aspiration,
mediastinal masses, tracheomalacia, brochomalacia, tracheal web, tracheal stenosis, and
bronchial stenosis to name a few.
b) TRUE. Asthma has three distinct features: 1) airway obstruction, 2) airway inflammation,
and 3) airway hyper-responsiveness.
c) TRUE. Inhaled epinephrine is an effective, although not first line, therapy.
d) TRUE. Asthma can be triggered by exercise alone.
e) TRUE. No confirmatory diagnostic test exists for asthma.
10. Mild intermittent asthma is characterised by the following (true or false):
a) daytime symptoms twice per week
b) nighttime symptoms twice per month
c) PEFR/FEV1% 80% predicted
d) PEFR variability 50% predicted
Concerning mild intermittent asthma:
a) TRUE. Daytime symptoms occur twice per week.
b) TRUE. Nighttime symptoms occur twice per month.
c) TRUE. PEFR/FEV1% is 80% of the predicted value.
d) FALSE. PEFR variability must be 20% (rather than
11. During general endotracheal anaesthesia of a patient with asthma, signs of
intraoperative bronchoconstriction include the following (true or false):
a) upsloping of the end-tidal CO2 waveform
b) hypoxaemia
c) decreased peak airway pressure
d) wheezing
During general endotracheal anesthesia of a patient with asthma, signs of intraoperative
brochoconstriction include the following:
a) TRUE. An upsloping of the end-tidal CO2 waveform may occur.
b) TRUE. Hypoxemia may occur.

c) FALSE. Increased (rather than decreased) peak airway pressure may occur.
d) TRUE. Intraoperative wheezing may occur.
12. A 5 year old boy is brought to your hospital at midnight from a housefire. He had been
rescued from his upstairs bedroom by a neighbour who had subsequently jumped to the
ground with him. His rescuer, who suffered a fractured ankle, tells you that when he found
him in his smoke-filled room, he was deeply asleep and his sheets were smouldering. On
examination he is sleepy but rouseable and cries when disturbed. His pyjamas are charred
across the chest and left arm. His respiratory rate is 25/min, pulse 130/min, BP 75/40 and
capillary refill time 4 seconds. A pulse oximeter reads 99%. You notice soot around his
nostrils.
Which of the following statements are true?
1) His vital signs are normal
2) His conscious level is of no concern
3) The story is suggestive of smoke inhalation
4) Dehydration is the likely cause of the observed vital signs
5) Based on the story, he is unlikely to need early intubation
6) The priority of treatment is to dress any burns
7) Burns which encircle the chest are generally harmless
8) Fluid loss from the burn in the early stages would account for the vital signs
9) The extent of the burn can be estimated from the rule of 9
10) Appropriate early fluid therapy for this child is warmed saline 0.9% 20ml/kg 11) Pulse
oximeters can be relied upon in this scenario
12) Other injuries must be excluded by thorough examination
Answers to MCQ & Discussion 1)F 2)F 3)T 4)F 5)F 6)F 7)F 8)F 9)F 10)T 11)F 12)T
The history has several clues as to the likely type and extent of the injuries. He was found
deeply asleep, probably unconscious, in an enclosed burning room (his sheets were
smouldering). The fact that the rescuer sustained a broken ankle suggests he may also
have traumatic injury. The pattern of charring to his pyjamas raises the possibility of
circumferential chest burn. His initial vital signs indicate that he is shocked. The reduced
level of consciousness in the context of soot around the nostrils strongly suggests an
inhalational injury, despite the normal pulse oximeter reading. He will require early definitive
airway management. After giving high inspired oxygen and applying an immobilising hard
cervical collar resuscitation proceeds according to the familiar ABCDE approach. Upon

removing his pyjamas, he is seen to have an extensive area of pink blistered skin across his
chest and left arm. Unfortunately, no burns chart is available so the extent of the burnt area
is estimated using the childs palm + adducted fingers = 1% rule. Using this method the
burn, which has partial thickness characteristics, is estimated at 20%. Using the Parkland
formula (and assuming a weight of [age+4] x2 i.e. [5+4] x2=18kg), the fluid bolus required
over the ensuing 24 hours is: 20x18x4=1440ml. 720ml should be given over the first 8 hours
since the burn and the rest over the next 16 hours. This is in addition to the normal daily
maintenance requirements. Estimated weight enables calculation of drug doses e.g.
morphine bolus 0.1mg/kg = 1.8mg. Endotracheal tube size is estimated in the usual way:
age/4+4 i.e. 5/4+4=5. It is prudent to have smaller tube sizes available than the estimated
size in case of airway oedema.
13.
.Name the 4 main classes of analgesic drugs.
2. How does paracetamol work?
3. By what routes may paracetamol be given?
4. What is the oral loading dose of paracetamol?
5. Paracetamol may be used to treat:
a. mild pain?
b. moderate pain?
c. severe pain?
6. How do NSAIDs work
7. In what situations should you be cautious about using NSAIDs?
8. By what routes may NSAIDs be given?
9. Is morphine more or less efficacious in neonates compared with older children? Does that
mean you need more or less of it?
10. What are the 2 main potentially serious side effects of opioids?
11. What are the main routes of giving opioids? Discuss the advantages and disadvantages
of each route. 1. Paracetamol, NSAIDs, opioids, local anaesthetics
2. See text
3. Oral, rectal, intravenous
4. 20 mg/kg
5. a, b,and c are all correct, but other analgesics will probably need to be given in moderate
and severe pain when paracetamol is synergistic with NSAID drugs and will reduce the
amount of opioids needed, but not enough on its own.
6. See text
7. See text
8. Oral, rectal, intravenous, topical

9. More efficacious, so less is needed. See text

10. Over-sedation and respiratory depression, so patients given opioids should always be
carefully monitored poet-operatively.
11. See text.
14.concerning pediatric fluid management
1 How long should children be fasted preoperatively?
2. For what reasons may you need to give fluids intraoperatively?
3. How do you calculate fluid requirements?
4. What is the maintenance requirement for:
i. a 3-day-old 3 kg neonate
ii. a 16 kg child
iii. a 44 kg child
5. Define isotonic and hypotonic
6. List the intravenous fluids you know. Which are isotonic, which are hypotonic?
7. What factors may cause hyponatraemia perioperatively?
8. What are the signs and symptoms of hyponatraemia?
9. Which children are at risk of hypoglycaemia?
10. What fluids can you use for:
i. maintenance infusion?
ii. correction of hypovolaemia?
iii. replacement of intraoperative losses
1. How long should children be fasted for preoperatively?
A: See text
2. For what reasons may you need to give fluids intraoperatively?
A: Resuscitation, maintenance and replacement. See text
3. How do you calculate fluid requirements?
A: The 4-2-1 rule is a quick method for calculating fluids except
in neonates who have different requirements. See text.
4. What is the maintenance requirement for:
i. a 3-day-old 3 kg neonate
A: 80-100 ml/kg/24 hours. See table.
ii. a 16 kg child
A: 52 ml/hour. [40 ml + (2 x 6 ml)]. See text.
iii. a 44 kg child

A: 84 ml/hour. [60 ml + (24 x 1 ml)]. See text.

5. Define isotonic and hypotonic
A: an isotonic fluid exerts the same osmotic force as plasma.
A hypotonic fluid exerts a lower osmotic force than plasma. This is
either because the concentration of solutes is lower than in
plasma, or because the solute is metabolised, diluting the plasma
and leaving free water to move into cells. This may result in
hyponatraemia (a low plasma sodium).
6. List all the fluids you know. Which are isotonic, which are
hypotonic?

Fluid
0.9%
saline

Solutes:
Tonicit
mmol
Notes
y
/litre
Na+ 150
Cl- 150

Isotoni
c

Na+ 131
K+ 4
Although almost isotonic, this fluid
2+
Hartmann' Ca 2
still has a lower sodium than
Isotoni
2+
s (Ringers Mg 2
plasma and may result in
c
lactate)
Cl 111
hyponatraemia if given over a
Bicarbona
prolonged period of time.
te 29
0.45%
saline

Na+ 75
Cl- 75

Hypoto
nic

Na 75
0.45%
Cl- 75
Hypoto
saline / 5%
Dextrose nic
dextrose
50 mg/ml
0.18%
saline
10%

Na+ 30
Cl- 30
Dextrose

Hypot
onic
Hypoto

dextrose

100
mg/ml

5%
dextrose

Dextrose Hypoto
50 mg/ml nic

nic

7. What factors may cause hyponatraemia perioperatively?

A: Stress causing a rise in ADH levels and water retention. Rapid
infusion of hypotonic fluids (at greater than maintenance rates).
Prolonged infusion of hypotonic fluids.
N.B. Prolonged infusion of isotonic fluids may also result in
hypernatraemia. Any patient on intravenous fluids should have
their plasma electrolytes checked on a regular basis (at least
every 24 hours).
8. What are the signs and symptoms of hyponatraemia?
A: Oedema, including cerebral oedema. The signs of raised
intracranial pressure may be mistaken for the side effects of
anaesthesia. See text.
9. Which children are at risk of hypoglycaemia?
A: See text
10. What fluids can you use for:
i. maintenance infusion?
ii. correction of hypovolaemia?
iii. replacement of intraoperative losses
A: See text.
15: Regarding the pre-operative psychological preparation of a five year old, the following
statements are true:
a: Five-year-olds readily accept surrogates instead of parents.
b: It is the age when stormy inductions are most likely.
c: They tend to take the things that are said to them literally.
d: They generally respond best to a full explanation of what is to happen.
e: They are the age group most likely to suffer separation anxiety.
FFTTF

16: With respect to ex-premature babies scheduled for surgery, are the following statements
true or false?
a: They should all receive daycase surgery where possible to minimise disruption to their
routine.
b: They are at risk of central apnoea following surgery
c: It is important to confirm gestational age at birth in all neonates presenting for surgery
d: They are at risk of perioperative bradycardia
e: Daycase surgery is contra-indicated until after the first year of life
FTTTF
17: Considering fasting prior to surgery, the following statements are true:
a: Cows milk generally empties from the stomach faster than human milk.
b: Clear fluids should be allowed up to 30 minutes prior to surgery.
c: Starvation of over 12 hours reduces the incidence of post-operative nausea and vomiting.
d: Prolonged starvation has been shown to increase the volume of gastric contents.
e: Child behaviour can be improved by minimising starvation times.
FFFTT
18: A 2yr old child presents for an emergency laparotomy for an incarcerated hernia.
Capillary refill is 6s, cool peripheries, normal blood pressure, sinus tachycardia and
tachypnoea. The following statements are true:
a: Blood pressure is a sensitive marker for shock.
b: Surgery should be delayed for fluid resuscitation.
c: Hypovolaemia should be corrected over 24 hours.
d: They are shocked.
e: Blood sugar should be measured.
FTFTT
19: Concerning parental presence at induction, the following statements are true.
a: Most parents find attending their childs induction stressful
b: After attending their childs induction, most parents would choose to do it again.
c: It is of particular benefit for the induction of neonates.
d: Parental presence at induction should always be determined by the parents wishes
e: There may be advantages of parental presence during child resuscitation.
TTFFT
20: Considering premedicating a child, the following are true

a: Local anaesthetic cream is helpful if an intravenous induction is planned

b: Oral analgesics should be avoided because the child is nil-by-mouth.
c: The dose of oral midazolam for a 20kg child is 10mg.
d: Anxiolytic premedication has become more frequently used in recent years.
e: Anxiolytics should never be used in children with obstructive sleep apnoea
TFTFF
21. The following are contraindications to sedation
a. Abnormal airway
b. Raised intracranial pressure
c. Respiratory failure
d. History of sleep apnoea
e. Infants less than 1 year of age.
TTTTF
22. The following subgroup requires special caution for sedation
a. Neonates, especially if premature or ex-premature
b. Children with cardiovascular instability or impaired cardiac function
c. Renal and hepatic impairment
d. Children who have been fasted as for a general anaesthetic
e. Gastro-oesophageal reflux disease
TTTFT
23. Regarding sedation in children, the following statements are correct
a. To prevent hypoxic incidents sedation by non-anaesthetists should be limited to minimal
sedation
b. Non-anaesthetists should use drugs and techniques with a narrow margin of safety
c. Sedation calms but does not gain assent for a procedure
d. Sleep is less easily achieved in children for painless procedures e. Recovery is more
predictable in children compared to adults
TFTFF
24. Airway obstruction or apnoea is rare with the following sedation techniques
a. Calming an infant with intra nasal midazolam
b. Nitrous oxide used for dentistry
c. Rectal thiopental used for painless imagery

d. Low dose propofol used for painless imaging

e. Intra muscular ketamine for wound care
TTFFT
25. Regarding drugs used in sedation, the following statements are correct
a. Triclofos is more palatable but is slower and less potent compared to chloral hydrate
b. Laryngospasm, nausea and vomiting are potential complications with ketamine
c. Rectal thiopental induces sleep in children immediately after administration
d. Apnoea and desaturation are common when propofol is used for sedation
e. Opioid induced respiratory depression can be reversed with naloxone at a dose of
1mcg/kg IV
TTFTF
25.Pierre Robin syndrome is associated with the following conditions:
a. Cardiac anomalies
b. Macroglossia
c. Cleft palate
d. Micrognathia
e. Severe obstructive sleep apnoea occasionally requiring tracheostomy
TFTTT Pierre Robin Sequence is characterised by micrognathia, glossoptosis and
cleft palate. It is sometimes associated with cardiac anomalies.
26: The following are useful in predicting the difficult airway in the paediatric patient:
a. Mallampati
b. Thyromental distance
c. Mouth opening
d. Neck mobility
e. Size of tongue
FFTTT Mallampati score does not accurately predict a poor view of the glottis
during direct laryngoscopy in paediatric patients. Standard values for thyromental
and horizontal mandibular lengths do not exist for the paediatric population.
27: Aperts syndrome is associated with the following conditions:
a. Cardiac anomalies

b. Midface hypoplasia
c. Micrognathia
d. Increased incidence of difficult bag mask ventilation
e. Syndactyly
TTFTT Children with Aperts syndrome have midface hypoplasia/hypertelorism, syndactyly
and a 10% incidence of cardiac defects/genitourinary anomalies. Bag mask ventilation may
be difficult but intubation is not usually difficult. A smaller size endotracheal tube may be
required
28: Downs syndrome (trisomy 21) is commonly associated with the following conditions:
a. Atlanto-axial subluxation
b. Atrioventricular septal defects
c. Difficult bag mask ventilation
d. Difficult intubation e. Micrognathia
TTTFF Children with Downs syndrome have macroglossia, atlanto-axial
subluxation and cardiac anomalies. They can often be difficult to bag mask
ventilate due to the macroglossia but are not usually difficult to intubate.
29.The Airtraq:
a. Is an indirect laryngoscope
b. Is not suited to children with limited mouth opening
c. Is useful where neck movement is limited
d. Is a single use device
TTTT The Airtraq is an example of a single use indirect laryngoscope. It is useful in
situations where neck movement is limited. However good mouth opening is required for it
to be used successfully
30.How is an apnoea in a pre-term infant defined?
An apnoea is a pause in breathing of greater than 20 seconds or loss of effective breathing
associated with bradycardia
31.Which of the following will increase pulmonary vascular resistance in a
neonate?
a. Hypoxia
b. Hypercarbia
c. Isoflurane
d. Nitrous oxide
2. a) and b)

32. Foetal haemoglobin will shift the oxyhaemoglobin dissociation curve in which
direction?
a. Left
b. Right What clinical effect will this have?
a) left oxygen is bound more avidly but has a reduced ability to release it to the
tissues
33. Which of the following statements are true?
a. Babies born prior to surfactant development are prone to developing respiratory
distress syndrome
b. Pain pathways do not develop until 36 weeks gestational age
c. Theatres should be pre-warmed to 24C for a pre-term
d. A neonate of <1200g will require a size 2.5mm endotracheal tube
e. Pressure controlled ventilation is preferred to volume controlled ventilation
f. Pre-term babies can be have day case operations at 45 weeks post gestational age
g. Intravenous caffeine can be given at 100mcg/kg to try and reduce the incidence
of postoperative apnoeas
4. a), d) and e)
34. Regarding conduction of pain in labour:
A. Pain during the first stage of labour is caused by uterine contractions and
dilatation of the cervix
B. Afferent nerves from the body of the uterus and cervix travel with sympathetic
nerves
C. Sensation from the vagina, vulva and perineum is conveyed by the pudendal
nerve
D. Sympathetic and parasympathetic fibres carry efferent impulses to the uterus
and affect its motor function
(a) T, (b) T, (c) T, (d) T
Second stage pain is caused by stretching, distension and tearing of fascia, skin and
subcutaneous tissues. Although afferent nerves from the uterus are somatic sensory
fibres, they travel with sympathetic nerves and enter the sympathetic chain in the
lumbar and lower thoracic regions.
35.The following are true regarding Trans Cutaneous Electrical Nerve Stimulation
(TENS):
A. Electrodes place over the S2-S4 dermatomes aim to provide analgesia for the
1st stage of labour

B. Theories behind TENS analgesia include the increased local release of

endorphins
C. TENS causes significant interference with fetal heart monitoring
D. TENS provides better analgesia than placebo
(a) F, (b) T, (c) F, (d) F
In TENS, most commonly the electrodes are placed over the T10 T11
dermatomes for first stage labour analgesia and over the S2-S4 dermatomes for
second stage labour. Some machines have a dual channel function allowing
stimulation of all 4 electrodes simultaneously. TENS does not seem to cause
significant interference to fetal heart rate monitoring and current studies do not
support the notion that TENS provides significantly better analgesia than placebo.
36. The following statements regarding regional analgesia in labour are true:
A. Epidurals in labour cause an increase in the caesarean section rate
B. Provision of written information increases the chance that women recall
complications associated with epidural analgesia
C. Ropivacaine is equipotent to bupivacaine at concentrations used in labour
analgesia
D. Intrathecal opioids may cause fetal bradycardia
(a) F, (b) T, (c) F, (d) T
Epidurals are associated with prolongation of labour and may increase the
operative vaginal delivery rate but there is no evidence that they increase the
caesarean section rate. Several studies have compared ropivacaine and bupivacaine
for labour analgesia and studies consistently show that ropivacaine is less potent
than bupivacaine. Several studies suggest intrathecal opioids may increase the
incidence of fetal bradycardia; however the magnitude of this increase is difficult
to determine and may be small.
37. Nitrous oxide inhaled in labour;
A. Provides no significant analgesia when compared with inhaled oxygen or air
B. Alters the force of uterine contractions and progress in labour
C. Is associated with adverse neonatal outcome
D. When administered with other inhalational agents may improve analgesic
efficacy
(a) F, (b) F, (c) F, (d) T
Adverse neonatal outcomes associated with the use of inhaled nitrous oxide have
not been demonstrated. The addition of other inhalational agents and use of higher
than 50% concentrations of nitrous oxide in air improves efficacy but is associated

with increased side effects and technical difficulties in administration and

scavenging.
38.In pre-eclamptic parturients, magnesium sulphate is likely to
a. decrease maternal heart rate
b. prolong the effects of non depolarising muscle relaxants
c. decrease succinyl choline induced fasciculations
d. prevent hypokalaemia
e. produce fetal bradycardia
(a) False (b) True (c) True (d) False (e) False
(a,e) Magnesium does slow the rate in an isolated heart. However, this effect does not occur
physiologically due to decreased acetyl choline release by the vagus in the presence of a
raised serum magnesium. (b,c) Magnesium will decrease the release of acetyl choline at the
neuromuscular junction and thereby prolong both non-depolarizing and depolarising block.
(d) Magnesium has diuretic actions but may be useful in arrythmias associated with
hypokalaemia.
39. Regarding features of Eclampsia/ Pre-Eclampsia;
a. General oedema is a useful diagnostic feature
b. Pre-eclampsia always precedes eclampsia
c. A blood pressure of 160/110 gives a diagnosis of severe pre-eclampsia
d. Thrombocytopenia is a common finding in pre-eclampsia
e. The use of spinal anaesthesia is absolutely contra-indicated
(a) False (b) False (c) True (d) False (e) False
(a) Oedema occurs in up to 80% of normotensive parturients whereas pre-eclampsia
complicates less than 10% of pregnancies. (b) An eclamptic fit may occur without preceding
symptoms and signs of pre-eclampsia. (c) By definition. (d) Thrombocytopenia is one part of
HELLP syndrome together with haemolysis and elevated liver enzymes. (e) Opinions differ
40. A 25 year old woman is receiving magnesium for eclampsia at 36 weeks gestation.
Each of the following is a potential maternal effect of this treatment
a. sedation
b. sensitisation to depolarising muscle relaxants
c. sensitisation to non depolarising muscle relaxants
d. decre ased uterine blood flow
e. loss of deep tendon reflexes prior to significant cardiac dysrhythmia
(a) True (b) True (c) True (d) False (e) True
(a,b,c,e) All known effects of increasing magnesium levels. (d) Magnesium is a vasodilator.
41. Two hours after delivery a healthy multiparous woman has a grand mal seizure that is

initially controlled with intravenous diazepam. Subsequent management may include

a. magnesium sulphate
b. lithium
c. anti-hypertensives
d. diuretics
e. intravenous twice normal saline
(a) True (b) False (c) True (d) True (e) False
(a,c,d) Magnesium, anti-hypertensives and diuretics may all be utilized in management of
eclampsia and pre-eclampsia.
42. HELLP syndrome is characterised by the following features
a. Fatty liver
b. Thombocytopenia
c. Pelvic pain
d. Haemolysis
e. Abnormal renal function
(a) False (b) True (c) False (d) True (e) False
(a e) HELLP syndrome is Haemolysis, Elevated Liver enzymes and Low Platelets