Multiple Choice Questions

Transcription

1 Analgesia in intensive care: part 2 1. Appropriate statements regarding the use of regional anaesthesia in intensive care unit (ICU) patients include: (a). There is a higher incidence of complications compared with the perioperative setting. (b). Nerve stimulation as a method of nerve location may be unreliable. (c). The intensive care environment is a challenging setting in which to perform regional anaesthesia. (d). There is rarely a need for dosage adjustment of local anaesthetics in organ dysfunction. (e). Meningitis, as a complication after neuraxial anaesthesia, often presents with typical clinical features in ICU patients. 2. Appropriate statements regarding compartment syndrome (CS) include: (a). CS occurs invariably in fractures of the lower limb. (b). Pain is a consistent symptom of CS. (c). In sedated patients, an increasing requirement for sedatives or analgesics may be attributable to CS. (d). Patients could have a delayed diagnosis of CS on patient-controlled analgesia (PCA). (e). Epidural analgesia is contraindicated. 3. Regarding regional anaesthesia in ICU patients, the following statements are true: a) The risk of bleeding from fascial plane blocks is higher when compared with superficial perivascular blocks. b) An international normalized ratio (INR) of >1.4 is considered a contraindication for neuraxial block. c) A review of the prescription chart must precede the decision to perform regional anaesthetic block. d) Regional anaesthesia should not be performed in sedated patients. e) A diagnosis of epidural haematoma may be difficult or delayed. 4. Appropriate statements regarding the management of pain in ICU patients who have undergone laparotomy include: (a). Rectus sheath blocks offer adequate analgesia for lower abdominal transverse incisions (Pfannenstiel incision). (b). Transversus abdominis plane (TAP) blocks offer adequate analgesia for lower abdominal transverse incisions. (c). Epidural analgesia improves respiratory function by increasing the functional residual capacity (FRC). (d). Subcostal oblique TAP block covers operations involving the T10 T12 dermatomes (e). A rectus sheath haematoma may mimic sepsis. 1 BJA Education Volume 16 Number Published by Oxford University Press on behalf of the British Journal of Anaesthesia 2016

2 Anaesthesia for transjugular intrahepatic portosystemic shunt insertion 1. In patients with cirrhosis: (a). A significant risk of variceal bleeding is present when the hepatic venous pressure gradient (HVPG) is between 5 and 10 mm Hg. (b). Ascites is initially treated with sodium restriction and diuretics. (c). Portal hypertension may have a dynamic component that is exacerbated by sepsis. (d). The Model for End-Stage Liver Disease (MELD) score is use to grade the degree of portal hypertension. (e). Hepatic hydrothorax occurs most often within the right hemithorax. 2. The insertion of a transjugular intrahepatic portosystemic shunt (TIPS): (a). Is indicated for primary prevention of variceal haemorrhage. (b). Confers a survival benefit in patients with diuretic resistant ascites. (c). Is contraindicated in the presence of severe pulmonary hypertension. (d). Is a proven treatment for hepatorenal syndrome. (e). Can be complicated by liver capsule rupture during the insertion procedure 3. Anaesthesia for transjugular intrahepatic portosystemic shunt (TIPS) insertion: (a) Should involve the use of invasive arterial blood pressure monitoring. (b) Can normally be safely undertaken using a laryngeal mask airway and spontaneous breathing technique. (c) In the elective situation should be preceded by drainage of tense ascites or significant hepatic hydrothorax. (d) Should utilize patient and fluid warming systems. (e) Has better outcomes using a total intravenous anaesthesia technique compared with volatilebased anaesthesia. 4. Well recognized complications of successful transjugular intrahepatic portosystemic shunt (TIPS) include: (a). Persistent pain. (b). Encephalopathy. (c). Renal dysfunction. (d). Hepatic dysfunction. (e). Heart failure Anaesthetic management for craniosynostosis repair in children 1. With regard to syndromes associated with craniosynostosis in children: (a). Most cases are syndromic. (b). Syndromes most frequently show autosomal recessive inheritance. (c). Children with Crouzon syndrome frequently have associated limb abnormalities. (d). Up to 50% of children with Carpenter syndrome have congenital heart disease. (e). Children with Muenke syndrome often have the most severe forms of craniosynostosis of all syndromic cases 2. With respect to surgery for craniosynostosis: (a). Total cranial vault reshaping involves helmet therapy immediately after operation and relies on early rapid brain growth to drive remodeling. (b). Minimally invasive surgery, such as springassisted craniectomy, involves two procedures performed 6 months apart. (c). The risk of venous air embolism (VAE) is highest in the modified prone position. (d). Minimally invasive endoscopic surgery is most often performed in children over 10 months of age (e). The risk of VAE is increased in endoscopic suture release compared with other operations. 2 BJA Education Volume 16 Number

3 3. Concerning the intraoperative management of children undergoing craniosynostosis correction, the following are true statements: (a). There is an increased risk of difficult facemask ventilation. (b). An arterial line is considered essential monitoring in all cases. (c). Tranexamic acid has been shown to reduce blood loss and the need for transfusion in craniosynostosis surgery. (d). Blood loss may be greater than 100% of the child s circulating volume. (e). Preoperative autologous blood donation is a commonly used strategy to reduce allogeneic transfusion in paediatrics 4. The following are appropriate statements regarding the postoperative management of patients after craniosynostosis surgery: (a). Patients commonly require postoperative ventilation in the intensive care unit. (b). Factors that may delay tracheal extubation include large-volume blood transfusions and the presence of obstructive sleep apnoea before operation. (c). Most patients are cared for on a specialist craniofacial ward after operation. (d). Hyponatraemia can develop in the postoperative period. (e). Non steroidal anti-inflammatory drugs (NSAIDs) are commonly used for postoperative analgesia. Cerebral Oximetry 1. The following are appropriate statements concerning cerebral oximetry values: (a). Hyperbilirubinaemia lowers measured cerebral oximetry values. (b). Alterations in the cerebral artery: venous blood volume ratio will affect cerebral oximetry values. (c). Unilateral cerebral oximetry value is reliable. (d). Hyperthermia causes a reduction in cerebral oximetry values. (e). Administration of methylene blue causes an increase in measured cerebral oximetry values 2. Regarding the physics of cerebral oximeters: (a). Cerebral oximetry probes can only be applied over the frontal lobe. (b). Light of all wavelengths is able to penetrate the skull. (c). Increasing the distance between the light emitter and light receiver reduces the depth of the tissue sampled by oximeter probes. (d). Cerebral oximeters utilize similar physical principles to pulse oximeters. (e). Cerebral oximeters are dependent upon pulsatile blood flow 3. Concerning cerebral oximeters in cardiac surgery: (a). Cerebral oximeters can detect misplacement of arterial/venous cardiopulmonary bypass cannulae. (b). Lower preoperative cerebral oximetry values compared with the general population are considered abnormal in cardiac surgical patients. (c). Cerebral desaturation has been associated with increased incidence of postoperative neurocognitive dysfunction. (d). Cerebral oximetry enables a longer period of deep hypothermic circulatory arrest. (e). Patient positioning affects cerebral oximetry values 4. Concerning the use of cerebral oximetry in noncardiac surgery: (a). A reduction in observed values indicates the need for immediate shunt placement during carotid endarterectomy. (b). The concept can be used to measure perfusion of organs other than the brain. (c). It may assist in the diagnosis of cerebral hyperperfusion syndromes. (d). It may prevent the development of periventricular leucomalacia in neonates. (e). The observed values are unaffected by anaesthetic depth 3 BJA Education Volume 16 Number

4 Paediatric mechanical ventilation in the intensive care unit 1. When considering equipment selection for mechanical ventilation in children: (a). Cuffed endotracheal tube (ETT) use increases the incidence of post-extubation stridor and re-intubation. (b). Uncuffed ETT use results in better long-term outcomes compared with cuffed ETTs in paediatrics. (c). When compared with nasal intubation, orotracheal intubation leads to a higher rate of unplanned tracheal extubation in infants (d). ETT size is most accurately predicted using the width of the patient s fifth finger (e). Equipment dead space may significantly interfere with the ventilation of young children. 2. With regard to the oxygenation of a paediatric patient with an intubated trachea: (a). The major determinant of arterial oxygenation saturation is the peak inspiratory pressure delivered. (b). Patients with unrestrictive single-ventricle physiology are vulnerable to excessive amounts of inspired oxygen. (c). Excessive amounts of inspired oxygen in all patients may lead to atelectasis and/or toxicity. (d). High-frequency oscillation should not be used in paediatrics for refractory oxygenation failure. (e). The main advantage of high-frequency oscillation is the ability to deliver a lower tidal volume. 3. With regard to the carbon dioxide clearance of a paediatric patient: (a). The major determinant of carbon dioxide clearance is alveolar ventilation. (b). Children are routinely ventilated with larger weight-adjusted tidal volumes (ml kg 1) compared with adults. (c). Paediatric patients may invariably be ventilated using a permissive hypercapnia strategy. (d). Patients with severe asthma exacerbations should be ventilated with high respiratory rates. (e). Non-invasive positive pressure ventilation (NIPPV) is not indicated for an infant with bronchiolitis and hypercapnia. 4. With regard to novel paediatric ventilation techniques: (a). High-frequency jet ventilation (HFJV) is performed by the use of a single ventilator. (b). HFJV is thought to improve secretion clearance. (c). Neurally adjusted ventilatory assist (NAVA) measures diaphragmatic electrical activity by a transcutaneous monitor. (d). NAVA may improve patient ventilator synchrony. (e). The use of NAVA has been shown to have superior patient outcomes compared with flow-triggered respiratory sensors. Rheumatological conditions in critical care 1. Regarding macrophage activation syndrome (MAS): (a). There is unregulated hyperinflammation and increased natural killer cell activity. (b). It is most often associated in those patients with rheumatoid arthritis. (c). Diagnostic criteria include splenomegaly, fever, hyperferritinaemia and hypofibrinogenaemia. (d). Treatment involves high-dose antibiotics and intravenous heparin. (e). Serum ferritin levels can be used as a marker of the response to treatment. 4 BJA Education Volume 16 Number

5 2. Regarding scleroderma renal crisis (SRC): (a). There is a gradual rise in blood pressure associated with proteinuria. (b). Patients typically present with neurological symptoms. (c). Blood tests may show raised creatinine levels, thrombocytosis and polycythaemia (d). Angiotensin-converting enzyme (ACE) inhibitors are the mainstay of treatment. (e). Most patients recover full renal function within a year 3. With regard to antiphospholipid syndrome (APS) and catastrophic antiphospholipid syndrome (CAPS): (a). APS is thought to account for up to 20% of recurrent arterial and venous thrombosis in young people. (b). There is a reduction in the production of thromboxane-a2, leading to a pro-coagulative state in APS. (c). In CAPS there is small-vessel thrombosis. (d). In CAPS there is often an obvious preceding trigger. (e). Treatment of CAPS is with subcutaneous low molecular weight heparin injections. 4. With regard to methotrexate: (a). It is an example of a first-line diseasemodifying antirheumatic drug (DMARD). (b). It is safe in pregnancy. (c). The risk of developing methotrexate pneumonitis increases the longer the duration of therapy. (d). Methotrexate pneumonitis (MX-P) is diagnosed clinically. (e). If MX-P is suspected, methotrexate therapy should be discontinued immediately. 5 BJA Education Volume 16 Number