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 ‘child’s 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 NSAID’s work 7. In what situations should you be cautious about using NSAID’s? 8. By what routes may NSAID’s 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, NSAID’s, 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 it’s 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 child’s induction stressful b: After attending their child’s 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 parent’s 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: Apert’s 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 Apert’s 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: Down’s 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 Down’s 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 24˚C 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
