Multiple Choice Questions

Transcription

1 Referral and Transfer of the Critically Ill Child 1. Appropriate statements regarding the transport of critically ill children include: (a). Most inter-hospital transfers are conducted by a specialist Transport Team (b). The number of children transferred between hospitals has decreased in the last 10 years (c). Children transferred by a specialist team have a lower risk-adjusted mortality rate in paediatric intensive care units (PICU) (d). A Transport Consultant may also cover PICU while on-call for Transport (e). Regional Transport Teams mean that referral hospitals are not required to transfer any paediatric patients 2. Regarding the stabilisation of children in a District General Hospital: (a). The specialist Transport Team should only be called once the decision to transfer a patient has been made (b). Children should not be admitted to the general Intensive Care Unit (ICU) (c). There should be a single person leading the care of the child at any one time (d). Stabilisation should usually be performed during the transfer to save time (e). Most stabilisation procedures will be carried out by the specialist Transport Team 3. The following statements are correct with regards to transporting critically ill children: a) The Anaesthetic Consultant should personally transfer the child if intubated b) Time-critical transfers should usually be transported by air c) Transport trolleys designed for adults can be safely used to transport children d) Vacuum mattresses are not appropriate for the transfer of children e) Lights and sirens should always be used during ground ambulance transport 4. Regarding the legal situation during the stabilisation of a critically ill child: (a). The Transport Consultant takes over the care of the patient once they have been referred by phone (b). The Transport Consultant will take overall control of the patient when the Transport Team have left the referring hospital (c). All Anaesthetists should have level 3 child protection training (d). The Bolam Test states that if a doctor reaches the standard of a body of medical opinion, they are not negligent (e). Anaesthetists are not required to maintain their skills in paediatric resuscitation and stabilisation if they solely undertake adult lists Spinal Cord Stimulation 1. A 50 year-old man presents with severe lumbosacral radicular pain secondary to multi-level degenerative spinal disease. He complains of shooting pain in the L5 dermatome bilaterally, and deep aching lumbar pain. He has had two prior discectomies with no symptom relief. With regard to Spinal Cord Stimulation (SCS), the following are true: (a). SCS is more effective than reoperation in Failed Back Surgery Syndrome (FBSS) patients with lumbosacral radicular pain (b). The active electrode poles should be place at the L5 level (c). This patient should have a trial period of stimulation for at least one week (d). Conventional SCS is more effective in FBSS patients with radicular leg pain versus those with mainly axial back pain (e). Clinical Depression is a contra-indication to implantation. 1 BJA Education Volume 16 Number Published by Oxford University Press on behalf of the British Journal of Anaesthesia 2016

2 2. With regard to the stimulation regimen employed in spinal cord stimulation (SCS): (a). Patients should have the SCS turned on most of the time. (b). High-frequency stimulation refers to SCS that discharges impulses at a frequency of over 100 Hz. (c). Pulse width in conventional SCS is generally between 100 to 500 microseconds (d). It is possible to perform a double-blind placebo-controlled trial with burst AND highfrequency stimulation (e). A sensory threshold amplitude of <0.2V suggests a lead fracture or disconnection. 3. Recognised complications of spinal cord stimulation are: (a) Electrode Migration (b) Postural headache (c) Paraesthesia (d) Device pocket seroma (e) Weight gain 4. A 34 year-old woman with Chronic Regional Pain Syndrome (CRPS) type-1 of her left hand attends the pain clinic. Her pain is well controlled with a spinal cord stimulator (SCS). Her GP referred her to the clinic because she is 8 weeks pregnant, and worried the spinal cord stimulator will affect the fetus. The following are appropriate statements: (a). The SCS should be switched off until the baby is delivered (b). Neuraxial anaesthesia is contraindicated in this woman (c). If this woman requires a caesarean section, bipolar diathermy is safe to use (d). A magnetic resonance image (MRI) to grade a possible placenta accreta is absolutely contraindicated in this woman (e). SCS should always be delivered with a physical therapy (PT) programme for CRPS. Pain in Patients with Spinal Cord Injury 1. Concerning classification of chronic pain following spinal cord injury: (a). This has been classified by the International Spinal Cord Injury Pain group (b). Tier 1 of the classification includes nociceptive, neuropathic pain, visceral pain, and other (c). There are 4 tiers in the classification (d). Tier 2 of the classification includes descriptions of type of nociceptive pain and anatomical location (e). Other and unknown types of pain have no tier 3 group. 2. Concerning chronic nociceptive pain in spinal cord injury: (a). It is common in the shoulders from chronic wheel chair use (b). Shoulder physiotherapy has minimal effect on shoulder pain (c). Treatment should follow the World House Organisation (WHO) analgesic ladder (d). Occupational therapy and social services have minimal effect (e). Back pain may be the result of misplaced screws. 3. The following are appropriate statements concerning chronic neuropathic pain in spinal cord injury: (a). The pain may be above, at or below the level of injury (b). Pain below the level of injury is centrally mediated (c). Gabapentin is the first line treatment (d). Pain must be present for 6-12 months before it is chronic (e). Syringomyelia can be a cause of pain and be misdiagnosed as chronic pain. 4. Concerning the role of surgery in chronic nociceptive or neuropathic pain: (a). This is somewhat limited and reserved for relieving pain caused by trapped nerves and dorsal root entry zone ablation (b). Neurostimulation may have a role for intractable chronic pain (c). Surgery is recommended for thoracic outlet syndrome (d). Cerebrospinal Fluid (CSF) bypass for syringomyelia is rarely done for pain alone 2 BJA Education Volume 16 Number

3 (e). Dorsal root entry zone surgery is most effective at the level of injury. Paediatric Massive Transfusion 1. A nine year old pedestrian struck by moving car. The blood results demonstrate that he has an INR of 1.7 ( ), fibrinogen of 0.7g/L ( g/l), ph 7.1 ( ). His temperature is 35.2 C ( C) on arrival in the emergency department. The following statements appropriately describe his abnormal coagulation: (a). Tissue trauma results in increased release of cellular tissue factor and activation of the coagulation cascade. (b). Hypoperfusion results in increased expression of thrombomodulin and inactivation of protein C. (c). The haemostatic system is incompletely developed at this age and more likely to be deranged following severe trauma. (d). Acidosis and hypothermia from environmental exposure, hypotension and therapeutic interventions are likely to contribute to coagulopathy. (e). Haemodilution of coagulation factors from increased use of crystalloid solution can contribute to coagulopathy during massive blood transfusion. 2. A six year old child suffering blunt trauma and splenic injury is currently in theatre undergoing a laparotomy and splenectomy and receiving blood products as part of a massive transfusion protocol (MTP). The following statements are correct: (a). Blood loss in a paediatric patient can be difficult to assess owing to maintenance of blood pressure despite significant volume loss. (b). Damage control resuscitation includes minimising crystalloid resuscitation and obtaining definitive haemostasis, usually via surgical control. (c). Permissive hypotension is an effective method of minimising blood loss in a paediatric blunt trauma patient. (d). Following cessation of bleeding and restoration of blood volume the following are appropriate therapeutic end points Hb 80g/L ( g/L), fibrinogen >1.0g/L ( g/L), PT ratio < 1.5 ( ), platelet count > 75x109/L ( ). (e). Blood product ratio s in paediatric massive transfusion are well defined and should be followed in 1:1:1 packed red blood cells (PRBC): fresh frozen plasma (FFP): platelet ratio. 3. A four year old child is currently in the operating theatre undergoing a liver transplant, requiring a massive transfusion. Regarding the use of a massive transfusion protocol, are the following statements true or false? (a). Paediatric massive transfusion protocols have resulted in a reduction in mortality and morbidity. (b). Triggering a paediatric massive transfusion protocol is initiated by clinical identification of patients at risk, assessment of transfusion requirements and results of biochemical analysis. (c). Massive transfusion protocols are not blood product prescriptions but a logistical pathway ensuring the release and delivery of appropriate blood products to the patient in the shortest possible time. (d). Scoring systems identifying the likelihood of requiring massive transfusion in paediatric patients have clinical utility. (e). Massive transfusion protocols aim to assist resuscitation, communication and logistical support during massive blood loss. 4. Novel monitoring and therapeutic techniques are being investigated for use during paediatric massive transfusion. The following are appropriate statements describing their efficacy. (a). Point of care testing has successfully reduced morbidity and mortality in massively transfused adult and paediatric patients. (b). Fibrinogen replacement requires intact platelet activation and thrombin generation to be effective. (c). There is evidence that the use of factor VIIa improves mortality during massive transfusion with little in the way of adverse effects. (d). Tranexamic acid is best given as a loading dose followed by infusion for at least 8 hours or until bleeding stops. 3 BJA Education Volume 16 Number

4 (e). Individual factor concentrates offer an alternative to the use of conventional blood products with the advantage of reduced volume and higher concentration of procoagulants. This has been shown to be useful and has led to their inclusion in many MTPs. TIVA 1. Specific indications for total intravenous anaesthesia (TIVA) include: (a). Long QT Syndrome (QTc 500 msec) (b). A history of severe postoperative nausea and vomiting (PONV) (c). Romano-Ward syndrome (d). Porphyria (e). Anaesthesia in a non-theatre environment. 2. With regards to awareness in patients undergoing TIVA: (a). Clinical studies have consistently shown a higher incidence of awareness in optimal TIVA technique (b). Studies using the isolated forearm show that Bispectral Index (BIS) guided TIVA allows more patients to respond to command compared to patients receiving a volatile based anaesthetic (c). A significant percentage of awareness in TIVA is attributed to technical errors or poor application of pharmacokinetic (Target controlled infusion) TCI knowledge (d). National Institute for Health and Care Excellence (NICE) recommends the use of processed electroencephalography (EEG) monitoring only in patients requiring neuromuscular blocking drugs (e). Use of BIS monitoring helps limit excess hypnosis in patients undergoing a TIVA technique 3. Concerning TIVA in the morbidly obese: (a). This is not a safe practice (b). TCI models have been formally validated in this cohort of patients (c). Above a critical of BMI, the Minto model increases the bolus dose and infusion rate to achieve a therapeutic analgesic effect (d). Lean body mass (LBM) may be calculated using the James equation (e). TCI pump manufacturers limit the weight to 170Kg in the Marsh model 4. When considering various TCI pharmacokinetic algorithms used in common TIVA techniques: (a). Schnider effect-model administers a higher dose of propofol compared to the Marsh kinetics (b). Schnider kinetics incorporates age as a modulating factor on bolus dose and infusion rates (c). Minto model in plasma-targeting mode utilises a bolus dose three to four times greater than with effect site-targeting (d). Minto effect-targeting is best reserved for robust patients (e). In the Schnider model, the rate constant (K10) for drug elimination from the central compartment is corrected for LBM Does NIRS Play A Role In Paediatric Intensive Care? 1. Near infrared spectroscopy (NIRS): (a). uses infrared light in the nm range (b). measures the mixed venous oxygen saturation (SvO2) (c). uses the Beer-Lambert Law of tissue absorption (d). uses only sensors and not detectors (e). should reflect a value similar to tissue oxygen saturation (rso2) 2. A Low Cardiac Output state: (a). Has a mortality of 10% associated with it (b). Is easy to measure using the thermodilution technique and the Fick principle in everyday medicine (c). can be associated with a decrease in urine output, hypotension and increase capillary refill time (d). can be objectively assessed with measures of serial lactate and low mixed venous oxygen saturations (e). cannot be monitored using NIRS as a reliable trend for any changes in SvO2 4 BJA Education Volume 16 Number

5 3. Considering NIRS and long term outcomes: (a). There is no evidence that NIRS helps with improved long term outcomes: (b). A NIRS value of <40% intra-operatively is normal (c). The trends are as important as the absolute readings on the NIRS monitor (d). Low NIRS readings in the renal perfusion somatic region have been associated with increases serial creatinine levels post op (e). Two site NIRS has no advantage over one site NIRS. 4. With regard to limitations to NIRS: (a). Equipment in intensive care and the operating room has been validated prior to its use (b). Regional measurements are generally the same as global measurements (c). Melanin and hyperpigmentation can interfere with the NIRS reading (d). There is no gold standard to compare to NIRS (e). Caution must be exercised when extrapolating data from adult studies and applying it to the paediatric population. 5 BJA Education Volume 16 Number