Multiple Choice Questions

Transcription

1 The future of general anaesthesia in obstetrics 1. The following statements are correct regarding accidental awareness during general anaesthesia (AAGA): (a). Difficult airway management is not a risk factor. (b). Increased cardiac output increases the intravenous inhalational interval. (c). Overpressure of volatile agents is not recommended. (d). The overall incidence of AAGA for caesarean section is 1:670. (e). The Fifth National Audit Project (NAP5) report recommended a dose of thiopental of 4 mg kg 1 2. The following statements are correct regarding the use of induction agents in obstetric patients: (a). Propofol has more adverse effects on the neonate compared with thiopental. (b). There was evidence of overdosing with thiopental in the Fifth National Audit Project (NAP5) report. (c). Thiopental antibiotic syringe swap has been reported in obstetric patients. (d). Thiopental causes less cardiovascular compromise than propofol. (e). Thiopental has a longer duration of action than propofol 3. The following statements are correct regarding obstetric airway management: (a). SAirway management and time to desaturation after induction of general anaesthesia are improved in the ramped position. (b). Failed intubation in obstetrics has an incidence of 1:1200. (c). For a 70-kg patient, a 1.2 mg kg 1 dose of rocuronium can be reversed using 280 mg of sugammadex. (d). Indirect laryngoscopes should not be used in obstetric patients. (e). Second-generation supraglottic devices should be used for first-line airway management in the obstetric patient 4. The following statements are correct regarding general anaesthesia in obstetrics: (a). Blood loss from reduced uterine tone may be minimized by using an end-tidal minimum alveolar concentration (MAC) of volatile agent of 0.5. (b). Human factors have been implicated in morbidity and mortality during general anaesthesia in obstetrics. (c). Most general anaesthetics administered for caesarean section are in elective patients. (d). Multidisciplinary simulation of emergency obstetric scenarios can reduce errors through human factors. (e). Physiological changes of pregnancy can mask the clinical signs of inadequate anaesthesia Ketamine: an old drug revitalized in pain medicine 1. The N-methyl-D-aspartate (NMDA) receptor is involved in the following neurological phenomena: (a). Colour vision. (b). Hallucination. (c). Opioid-induced hyperalgesia. (d). Consciousness. (e). Central sensitization. 2. It is appropriate to use ketamine for pain relief in the following scenarios: (a). Intravenous ketamine for post-mastectomy pain. (b). Oral ketamine for chronic sciatica. 1 BJA Education Volume 17 Number Published by Oxford University Press on behalf of the British Journal of Anaesthesia 2017

2 (c). Subcutaneous ketamine before elective gastrectomy. (d). Intrathecal ketamine for elderly hip fracture. (e). Intramuscular ketamine for dysuria with substance abuse. 3. The following might be related to ketamine use for postoperative analgesia: (a). Sedation. (b). Dysuria. (c). Airway obstruction. (d). Distress with unrelieved pain. (e). Hypotension. 4. Ketamine might augment the drug actions of (a). Fentanyl. (b). Epinephrine. (c). Atracurium. (d). Gabapentin. (e). Paracetamol Renal replacement therapy in critical care 1. Concerning the physical process of renal replacement therapy (RRT): (a). Haemofiltration achieves clearance of waste products by diffusion across a semipermeable membrane. (b). Smaller molecules are more reliably cleared by haemodialysis whilst haemofiltration improves clearance of middle-sized molecules. (c). The dose of RRT during continuous haemodiafiltration can be calculated without knowledge of the volume of fluid being removed. (d). Cellulose-based membranes are preferred. (e). During continuous venovenous haemodiafiltration (CVVHDF) two different fluids are required: one to act as a dialysate and another to replace fluid removed during haemofiltration. (b). Peritoneal dialysis is a commonly used mode of RRT for adults in the UK. (c). For continuous renal replacement therapy a dose of 35 ml kg 1 h 1 is associated with reduced mortality compared with 20 ml kg 1 h 1. (d). The femoral vein site should be avoided as a port of access. (e). The dose of β-lactam antibiotics should be reduced when providing RRT in the critically ill. 3. Continuous modes of renal replacement therapy (RRT) offer the following benefits: (a). More stable cerebral perfusion in acute brain injury. (b). Better preservation of renal function. (c). Shortened length of intensive care unit stay. (d). Improved outcomes in sepsis as a result of increased clearance of inflammatory mediators. (e). Superior fluid balance management 4. The following are indications for commencing renal replacement therapy (RRT) within critical care: (a). Hyperkalaemia. (b). Fluid overload. (c). Temperature control. (d). Control of inflammatory mediators. (e). Methanol poisoning 2. Concerning renal replacement therapy (RRT) within critical care: (a). Improvements in technology have led to a significant reduction in acute kidney injuryassociated mortality in recent years. 2 BJA Education Volume 17 Number

3 Perioperative management of patients with dementia 1. A 71-year-old patient with mild Alzheimer s disease who is otherwise fit and well presents on the emergency list for laparotomy and probable Hartmann s procedure for a ruptured diverticulum. Having been judged to have capacity, she gave consent the day before surgery. However, in the anaesthetic room she is clearly disoriented, febrile and agitated. She is uncooperative and, when asked, clearly refuses surgery but does not appear to have the capacity to understand the consequences of her refusal. Appropriate courses of action could include: (a). Call for assistance to physically restrain her and continue with anaesthesia. (b). Administer a sedative agent to treat her delirium and wait for its effects before continuing with anaesthesia. (c). If the surgeon agrees, the patient should be returned to her room and treated with antibiotics and antipyretics and, once she regains mental capacity, a Ulysses pact should be negotiated, whereby she gives consent for the procedure even if she subsequently has a deterioration in mental capacity and refuses in future. (d). Call for a psychiatrist to review her and to determine her capacity to refuse potentially life-saving surgery. (e). Obtain an emergency court order to enable surgery to proceed in the absence of consent. 2. An 83-year-old gentleman with vascular dementia and severe gastro-oesophageal reflux disease (GORD) is listed for emergency bipolar hemiarthroplasty after a fracture to the neck of his femur. You note that he is taking donepezil. Suitable management techniques to anaesthetize this patient could include: (a). Stop his donepezil and manage him conservatively for 2 weeks while the anticholinesterase washes out of the body. (b). Avoid the potential for interactions with neuromuscular blocking drugs by performing a spinal anaesthetic. (c). Perform a modified rapid sequence induction with an increased dose of rocuronium and plan to reverse the induced neuromuscular block with sugammadex. (d). Perform a classical rapid sequence induction and tracheal intubation with thiopental and suxamethonium followed by boluses of atracurium as required. (e). Avoid tracheal intubation by using a secondgeneration laryngeal mask. 3. A 49-year-old with early-onset Alzheimer s disease of moderate severity and no other medical history has had a percutaneous endoscopic gastrostomy inserted under general anaesthetic. You are called to the recovery suite as the nurses report that she has become increasingly agitated and aggressive and is currently lashing out at staff. Appropriate treatments for acute delirium in this scenario include: (a). Risperidone 0.25 mg orally. (b). Olanzapine 5 mg orally. Lorazepam 1 mg im. (c). Lorazepam 1 mg im, repeated as necessary at 2-h intervals. (d). Haloperidol 1 mg im, repeated as necessary at 2-h intervals. (e). Diazepam emulsion 2 mg intravenously. 4. A 75-year-old man with Alzheimer s disease of moderate severity is scheduled to have a laparotomy for small bowel obstruction. His past medical history includes several episodes of delirium after urinary tract infections and a cystoscopy under general anaesthetic. You have requested the Bispectral Index (BIS) monitor to be used on this patient. With regard to BIS monitoring: (a). It prevents unnecessary depth of anaesthesia being administered to patients. (b). Low BIS scores are found in patients with Alzheimer s disease in the awake state. (c). Baseline BIS values can be used as guide to anaesthetic requirements patients with cognitive impairment. (d). The EEG pattern of an increase in slow-wave activity and a decrease in fast-wave activity is manifested as a reduction in the BIS values. (e). Use of BIS-guided anaesthesia has been shown to reduce the incidence of delirium in the immediate postoperative period. 3 BJA Education Volume 17 Number

4 Current recommendations on adult resuscitation 1. As part of basic life support (BLS): (a). An automated external defibrillator (AED) should be requested when calling for help. (b). Rescue breaths should be given over 2 s. (c). Resuscitation must be interrupted regularly to check for pulse and breathing. (d). The absence of a carotid pulse must be determined before starting cardiopulmonary resuscitation (CPR). (e). The depth of chest compressions is 5 6 cm, with a rate of min After return of spontaneous circulation (ROSC): (a). Blood glucose levels should be kept below 8 mmol litre 1. (b). Oxygenation should be titrated to achieve SaO 2 of 94 98%. (c). Percutaneous coronary intervention (PCI) should be considered in comatose patients. (d). Therapeutic hypothermia (TH) with cooling to C must be commenced in comatose patients initially presenting with both shockable and non-shockable rhythms. (e). There are reliable clinical indicators and tests to prognosticate at <24 h after cardiac arrest. 2. When treating cardiac arrest with ventricular fibrillation (VF)/pulseless ventricular tachycardia (pvt) as the first monitored rhythm: (a). Epinephrine 1 mg is given when chest compressions have restarted after the third shock. (b). Amiodarone is no longer recommended. (c). Chest compressions should continue while the defibrillator is charged. (d). Precordial thump is an important intervention. (e). Three successive (stacked) shocks can be used in special circumstances. 3. During CPR: (a). A ratio of 30 chest compressions to two breaths must continue throughout CPR. (b). Central venous access is advised if peripheral venous access cannot be achieved. (c). Supraglottic airway (SGA) devices have superseded tracheal intubation. (d). The use of ultrasound is not recommended. (e). Waveform capnography is only useful in confirming tracheal tube placement. 4 BJA Education Volume 17 Number

5 Antinociceptive and immunosuppressive effect of opioids in an acute postoperative setting: an evidence-based review 1. In a patient receiving opioid therapy: (a). An increased opioid dose requirement to achieve the same level of analgesia may imply tolerance. (b). Worsening of the underlying pain while on an increasing opioid dose may imply opioidinduced hyperalgesia. (c). Activation of the N-methyl-D-aspartate (NMDA) receptor will prevent tolerance and hyperalgesia. (d). Tolerance or opioid-induced hyperalgesia, but rarely both, can develop in an acute setting. (e). Glial cells are passive cells supporting the neurones and have no influence on analgesia. 2. Appropriate statements regarding perioperative immune function include: (a). It can be improved by analgesics. (b). 2. It may be adversely affected by pain. (c). 3. It is known to be improved by neuraxial anaesthesia and hence, where appropriate, patients undergoing major cancer surgery should receive neuraxial block. (d). 4. It has not been shown to be affected by opioids in humans. (e). 5. It may be affected by some opioids as a result of a direct effect on µ receptors. (c). Some opioids are more clinically advantageous than others because they cause less immunosuppression. (d). Tramadol suppresses NK cell activity and hence has an immunoprotective effect. (e). Cyclooxygenase-2 (COX-2) inhibitors have a favourable effect on the immune system. 4. A 30-year-old patient is undergoing a laparotomy for ulcerative colitis under general anaesthesia. He is otherwise fit and well. He usually takes morphine sulphate 60 mg twice daily. Intraoperatively, he is initially stable, with his analgesia maintained using remifentanil 0.2 µg kg 1 min 1, but then develops tachycardia and high blood pressure. After ruling out other causes, including inadequate depth of anaesthesia, the anaesthetist increases the remifentanil infusion dose to 0.4 and then to 0.6 µg kg 1 min 1. The following are appropriate statements: (a). This increase in remifentanil will improve perioperative analgesia in all patients. (b). It is appropriate to consider administering ketamine to this patient. (c). Clonidine is a reasonable adjuvant analgesic to give. (d). His haemodynamics are best controlled with an inhalational anaesthetic such as sevoflurane. (e). Propofol has a favorable modulatory effect in opioid-induced hyperalgesia. 3. During a pre-assessment for a 65-year-old lady due to undergo an anterior resection for colon cancer, the patient tells you that she has learnt from her internet search that anaesthetic may result in the spread of her cancer. She asks you about the options available to minimize her risk of cancer spread. The following are appropriate statements: (a). Morphine is contraindicated in this patient as it can worsen cancer spread. (b). Local anaesthetic-based regional techniques result in immunosuppression and hence facilitate cancer spread. 5 BJA Education Volume 17 Number