Anastethia EMQsTheme:Pre-Operative ManagementAAnabolic steroidsBAnti hypertensive drugsCAspirinDHeparinEOral anticoagulantsFOral contraceptives containing OestrogenGOral corticosteroids

For each of the statements below, select the most likely answer from the list above. Each option may be used once, more than once or not at all.

Inform anaesthetist and continue therapy up to and after surgery if appropriate

Incorrect - The correct answer is Anti hypertensive drugs

Anti hypertensive therapy can be continued up to surgery and re-introduced post-operatively. One will need to carefully monitor blood pressure post-operatively but generally these agents are once per day.

Discontinue and replace with intravenous equivalent 48-72 hours before surgery

Correct

Oral anticoagulants such as warfarin should be stopped at least 72hrs pre-op and replaced with IV heparin prior to the procedure – this being discontinued about 6 hours pre-operatively.

Discontinue oral administration but replace with intravenous equivalent at induction

Correct

Discontinue 1 week before surgery

Heparin

Oral anticoagulants

Oral corticosteroids

Correct

Aspirin is generally stopped one week before surgery. Hydrocortisone dose needs to escalated prior at surgery with a bolus IV of 50-100 mg given at induction.

Theme:Fluid and electrolyte disturbancesAFluid overloadBHypokalemiaCMetabolic acidosisDMetabolic alkalosisERespiratory acidosisFRespiratory alkalosis

Choose the most likely fluid/ electrolyte abnormality in the following case scenarios:

A 45-year-old male with pyloric stenosis presents with profuse vomiting and abdominal pain. What else besides a hypokalaemia may be expected.

Correct

A 65-year-old man has a two day history of anuria and back pain. He is tired, complains of hiccups and has a pruritus.

Correct

A 60-year-old man with villous adenoma presents with profuse diarrhoea.

Correct

A 68-year-old female presents 24 hours after hysterectomy with breathlessness. On examination, she has a raised jugular venous pressure and bi-basal chest crepitations.

Aspirin

Metabolic alkalosis

Metabolic acidosis

Hypokalemia

CorrectPatients with pyloric stenosis develop hypochloremic hypokalaemic alkalosis as the lose chloride ions with hydrogen ions when the vomit. The 65-year-old man has renal failure as suggested by the anuria, hiccups and pruritus and will have a metabolic acidosis (low pH, low bicarbonate and with compensation should have a high p02 and low pC02). Villous adenoma is associated with profuse watery diarrhoea which is typically associated with hypokalaemia. The post op female clearly has cardiac failure with fluid overload as indicated by the raised JVP and bibasal crepitations.

Theme:VentilationAPositive end-expiratory pressure (PEEP)BContinuous positive airway pressure (CPAP)CIntermittent positive pressure ventilation (IPPV)DHigh frequency jet insufflationEIntermittent mandatory ventilation (IMV)FHigh-frequency positive pressure ventilation (HEPPV)GSynchronized intermittent mandatory ventilation (SIMV)HExtracorporeal membrane oxygenation (ECMO)

The following patients require ventilation. Please choose the most appropriate answer from the list above

A 62-year-old male undergoing an elective right hemicolectomy following the induction of anaesthetic.

Incorrect - The correct answer is Intermittent positive pressure ventilation (IPPV)

This patient will require administration of muscle relaxants to perform the abdominal surgery. The muscle relaxant will produce narcotic-induced apnoea thus the patient will require tracheal intubation and IPPV. The IPPV allows good relaxation with control of the patient’s oxygenation and elimination of carbon dioxide.

A 75-year-old male has under gone an emergency repair of a leaking infra-renal abdominal aortic aneurysm. Following the procedure he was transferred to the intensive care unit ventilated. He has been stable since the procedure and it has therefore been decided to wean him from the ventilator.

Fluid overload

Continuous positive airw ay pressure (CPAP)

Correct

The transition from controlled mandatory ventilation to other modes allowing some patient input into ventilation is not an exact science. However, the most common initial step down modes is SIMV. CPAP and PEEP are usually introduced as the patient becomes more conscious.

A 19-year-old male presented to A&E unconscious following a collision between his motorcycle and an oncoming car. He required a right thoractomy and laparotomy to control bleeding. The patient was transfused 20 units of blood and developed Severe Inflammatory Response Syndrome (SIRS). Despite aggressive ventilation, his PaO2 began to drop.

Incorrect - The correct answer is Extracorporeal membrane oxygenation (ECMO)

Extracorporeal membrane oxygenation / extracorporeal life support which involves veno-venous cardiopulmonary bypass may be considered if the patient is deteriorating despite aggressive ventilation. However, no prospective randomised controlled trials in adults have shown an improved survival.

Theme:Complications of anaesthesia and analgesiaAEpidural anaestheticBGeneral anaestheticCIntramuscular pethidineDNitrous OxideEPudendal blockFSpinal anaesthetic

For each complication below select the SINGLE most likely anaesthetic or analgesic from the list of options above.

Malignant hyperpyrexia syndrome

Correct

Synchronized intermittent mandatory ventilation (SIMV)

Positive end-expiratory pressure (PEEP)

General anaesthetic

Reduced variability cardiotocograph

Incorrect - The correct answer is Intramuscular pethidine

Sudden maternal hypotension

Incorrect - The correct answer is Spinal anaesthetic

Severe headache

Correct

Aspiration syndrome

CorrectPethidine, other opiates and some anti-hypertensives (alpha methyldopa and labetalol) reduce CTG variability. Maternal hypotension is more likely to be secondary to spinal, rather than epidural anaesthetic. In a spinal anaesthetic, a very fine needle is used to puncture the dura and this is not often associated with a headache.Postdural puncture headache appears to be highr in association with spinal (3%) than epidural (1%). Malignant hyperpyrexia is most likely to be secondary to the use of volatile anaesthetic agents

Theme:ECG abnormalitiesADelta wavesBLeft axis deviationCJ wavesDProlonged PR intervalEProlonged QT intervalFRight axis deviationGShortened PR intervalHShortened QT intervalIST elevationJU waves

Pudendal block

Epidural anaesthetic

Spinal anaesthetic

General anaesthetic

Which of the above ECG abnormalities are characteristically associated with the following?

Hypothermia

Correct

Hypocalcaemia

Correct

Pulmonary embolism

Correct

Although prolonged PR and QT elongation are associated, J waves are pathognomonic of hypothermia.Other causes of prolonged QT include congenital prolonged QT (Romano ward syndrome, Jervell and Lange-Nielsen syndrome), hypocalcaemia and drug therapy such as Amiodarone and sotalol.With pulmonary embolism, there is right heart strain with the typical SI QIII TIII pattern and right axis deviation.

Theme:Cardiac abnormalitiesAAortic regurgitationBAortic stenosisCAtrial septal defectDCoarctation of the aortaEFlow murmurFMitral valve prolapseGMitral regurgitationHMitral stenosisIPatent ductus arteriosusJVentricular septal defect

Select one of the above diagnoses that is most likely to be responsible for the presentation of the following patients who attend for routine surgical procedures:

J w aves

Prolonged QT interval

Right axis deviation

A 73-year-old male is admitted for inguinal herniorrhaphy. On examination, his blood pressure is 110/90 mmHg and auscultation reveals a harsh systolic murmur at the second right intercostals space.

Correct

The first case has a harsh systolic murmur at the right second intercostals space and a narrow pulse pressure suggesting aortic stenosis. This is most likely to be due to calcific aortic sclerosis and echo would be required to assess the severity of this prior to surgery.

A 21-year-old female with Turner’s syndrome is reviewed prior to dental surgery. On examination her blood pressure is 118/80 mmHg and she has a soft systolic murmur at the second right intercostals space.

Incorrect - The correct answer is Aortic stenosis

The second case of a woman with Turner's, a systolic murmur at the second right intercostals space would suggest aortic stenosis due to a bicuspid aortic valve rather than co-arctation where hypertension would be expected.. Both Coarctation and bicuspid aortic valves are found in Turner's syndrome, with the latter commoner.

A 25-year-old male attends for eye surgery for anterior dislocation of the lens. On examination, he is tall, has a blood pressure of 134/84 mmHg and has a mid-systolic click with murmur at the apex.

Incorrect - The correct answer is Mitral valve prolapse

The final case of a young man with tall stature, anterior lens dislocation and a harsh midsystolic murmur at the apex suggests a diagnosis of Marfan's syndrome which is of course associated with mitral valve prolapse. In particular the harsh mid systolic murmur with click is typical.

Theme:Cardiac abnormalitiesAAortic stenosisBAortic regurgitation

Aortic stenosis

Atrial septal defect

Mitral regurgitation

CAtrial spetal defectDCoarctation of the aortaEFlow murmurFMitral valve prolapseGMitral regurgitationHMitral stenosisIPatent ductus arteriosusJVentricular septal defect

Which one of the above diagnoses is typically associated with the following conditions:

Eisenmenger’s syndrome

Correct

Eisenmenger’s syndrome is the right to left shift associated with deteriorating pulmonary hypertension and RV overload in conditions such as large ventricular septal defects.

Ankylosing spondylitis

Incorrect - The correct answer is Aortic regurgitation

Ankylosing spondylitis like other sero-negative arthropathies is associated with aortic regurgitation more so than mitral regurgitation.

Syphilitic aortitis

Incorrect - The correct answer is Aortic regurgitation

Syphilitic aortitis is asscoaited with aortic aneurysmal formation and dilatation of the aortic ring with associated aortic regurgitation.

Theme:Cardiac abnormalitiesAAortic regurgitationBAortic stenosisCAtrial septal defect

Ventricular septal defect

Coarctation of the aorta

Coarctation of the aorta

DCoarctation of the aortaEFlow murmurFMitral valve prolapseGMitral regurgitationHMitral stenosisIPatent ductus arteriosusJVentricular septal defect

Select one of the above diagnoses that is most likely to be responsible for the presentation of the following patients who attend for routine surgical procedures:

A 14-year-old girl attends for removal of a facial naevus. On examination she has a blood pressure of 110/72 mmHg and a soft murmur at the second left intercostal space without any radiation.

Correct

The 14-year-old provides a good description of a flow murmur where there is no radiation of the murmur, it appears to be over the pulmonary area and she is otherwise quite well.

A 13-year-old girl with Down’s syndrome is admitted for umbilical hernia surgery. On examination, she has typical features of Down’s syndrome, a blood pressure of 108/74 mmHg and a loud harsh systolic murmur best heard over the fourth left intercostal space.

Incorrect - The correct answer is Ventricular septal defect

Downs syndrome is associated with both atrial septal defects (AV canal defects) andventricular septal defects. In this patients case, with her otherwise well condition, the normal blood pressure and the loud systolic murmur at the fourth left intercostal space suggests a small VSD so called Maladie de Roger.

A 73-year-old woman is admitted for left hip replacement. On examination, both cheeks appear rather ruddy, she has a blood pressure of 122/82 mmHg, a faint mid diastolic murmur with no other sounds.

Incorrect - The correct answer is Mitral stenosis

Flow murmur

Mitral regurgitation

Aortic regurgitation

The elderly woman with a mid diastolic murmur associated with a malar flush suggests mitral stenosis. The absence of a pre-systolic click or loud first heart sound would suggest that the valve maybe calcified.

Theme:ECG abnormalitiesADelta WavesBLeft axis deviationCJ wavesDProlonged PR intervalEProlonged QT intervalFRight axis deviationGShortened PR intervalHShortened QT intervalIST elevationJInverted U waves

Which of the above ECG abnormalities would you typically expect to be found in association with the following:

Hypomagnesaemia

Correct

The changes in Hypomagnesaemia may be indistinguishable from hypokalaemia. They include flattened T waves, widened QRS complexes, prolonged QT interval prolonged PR interval, small T waves and U waves.

Pericarditis

Correct

Pericarditis is associated with concave upwards, ST segment elevation on the ECG versus convex upward ST segment elevation in MI.

Wolff Parkinson White disease

Incorrect - The correct answer is Delta Waves

WPW is associated with an accessory bundle, which causes a delta wave (notch) preceding the QRS complex, giving the impression of a

Prolonged QT interval

ST elevation

Shortened PR interval

shorter PR interval. However, the delta wave is characteristic. Other causes of prolonged QT include congenital prolonged QT (Lown-Ganong Levine syndrome), hypocalcaemia and drug therapy such as Amiodarone, sotalol.