Childhood obesity and the anaesthetist

  • 1. Ideal body weight or lean body mass is most appropriately used when calculating the dose of:

    • Succinylcholine.

    • Propofol.

    • Morphine.

    • Paracetamol.

    • Neostigmine/glycopyrrolate.

  • 2. The most appropriate statements regarding body mass index (BMI) in children include:

    • Weight and height are the only measurements required to calculate BMI.

    • Centile charts of weight and height will permit the assessment of obesity.

    • A BMI of 22 kg m−2 is normal for a 5-yr-old.

    • A BMI of 22 kg m−2 represents obesity in a 12-yr-old.

    • Since obesity has become increasingly common, the definition for BMI obesity has changed.

  • 3. Co-morbidities in children are most likely to:

    • Occur in obese children and also overweight children.

    • Be as common as in obese adults.

    • Include asthma.

    • Include gastro-oesophageal reflux disease.

    • Include ischaemic heart disease.

  • 4. The following investigations are most likely to be required in the obese child presenting for surgery:

    • Arterial pressure.

    • Blood glucose measurement.

    • Arterial or capillary blood gases.

    • ECG.

    • Sleep studies.

Procedural sedation for adult patients: an overview

  • 5. You have been asked to administer conscious sedation to a healthy, 25-yr-old female patient in the hospital's outpatient department. She has dental phobia and requires a simple dental extraction. The most appropriate statements in this context include:

    • The patient must be able to understand and respond purposefully to verbal commands, throughout the period of sedation.

    • The end point is maintenance of a purposeful response after repeated or painful stimulation.

    • Sedation with either midazolam or nitrous oxide in oxygen is unlikely to be associated with over-sedation if titrated to effect.

    • Sedative drugs are administered as a single bolus.

    • Systemic opioid analgesia is likely to be administered with a benzodiazepine.

  • 6. A 75-yr-old man of ASA (American Society of Anesthesiologists) III status is scheduled for colonoscopy under conscious sedation. The most appropriate statements regarding this procedure include:

    • After an initial dose of midazolam, an additional dose is recommended if analgesia is inadequate.

    • Administration of a specific analgesic agent is likely to be needed for pain.

    • If midazolam and fentanyl are administered, then fentanyl should be given after the peak effect of midazolam is observed.

    • If a combination of midazolam and opioid is used, then the doses of each drug should be reduced.

    • Inhalational sedation using nitrous oxide in oxygen is used commonly.

  • 7. The most appropriate statements regarding propofol for procedural sedation include:

    • As a sole agent propofol appears to provide excellent sedation for the majority of patients, including those undergoing a painful procedure.

    • Propofol is used effectively for prolonged upper and lower gastrointestinal endoscopic procedures requiring deep sedation.

    • Propofol is suited to both short and long procedural sedation cases accompanied by the benefit of a rapid recovery profile.

    • The difference in dose required to produce conscious sedation and general anaesthesia is wide.

    • Synergistic effects occur when adjuvant drugs such as benzodiazepines and opioids are administered.

  • 8. You are asked to provide sedation for a 35-yr-old man requiring endoscopic retrograde cholangiopancreatography (ERCP) in the radiology department. The most appropriate statements regarding sedation for this patient include:

    • Systemic analgesia is not required normally.

    • Use of two or more drugs reduces the incidence of overdose and respiratory depression.

    • Loss of verbal communication necessitates the same level of care as general anaesthesia.

    • Supplemental oxygen may be administered to prevent hypoventilation.

    • Use of continuous waveform capnography to monitor adequacy of ventilation is recommended.

Post-herpetic neuralgia

  • 9. The most appropriate pathophysiological features of post-herpetic neuralgia (PHN) include:

    • Damage involving small but not large diameter nerve fibres.

    • Continuous and paroxysmal pain.

    • Allodynia, which is normally associated with normal thermal threshold.

    • Hyperalgesia.

    • Profound sensory loss corresponding to the area of greatest pain.

  • 10. The most appropriate statements concerning risk factors for PHN include:

    • Presence of prodrome increases the risk of developing PHN.

    • Severity of rash is unlikely to be an important risk factor.

    • PHN is associated with old age.

    • There is no gender preference for developing PHN.

    • Poor coping strategies are likely to increase the perception of pain.

  • 11. The most appropriate statements concerning prevention of PHN include:

    • Primary varicella vaccine decreases the incidence of chicken pox but increases the risk of reactivation of shingles.

    • Antiviral drugs reduce acute pain severity and duration.

    • Addition of steroids to antiviral treatment does not prevent PHN.

    • Anticonvulsants and antidepressants have no role in prevention.

    • Antiviral treatment should be given to all those who develop herpes zoster.

  • 12. The most appropriate statements regarding treatment of PHN include:

    • Pregabalin is similar to gabapentin in efficacy.

    • Useful topical therapies include 5% lidocaine plaster and 8% capsaicin patch.

    • Interventions such as sympathetic blocks and intrathecal steroids are first line treatments.

    • Antidepressants do not have proven efficacy.

    • Opioids are as effective as antidepressants for PHN.

Pre-hospital trauma care and aero-medical transfer: a military perspective

  • 13. There are six casualties after an army Land Rover has been struck by a roadside bomb. The most appropriate statements concerning priorities for treatment and evacuation include:

    • Application of triage is confined to military operations.

    • An individual patient will have their triage category re-assessed on several occasions.

    • It is unethical to annotate the torso of these patients.

    • Patients on a stretcher are classified as T1 (Triage category 1, requiring immediate treatment and evacuation).

    • Apnoeic patients will receive Basic Life Support in this situation.

  • 14. An army vehicle has been struck by a roadside bomb. In a soldier with high amputations of both legs, the most appropriate statements concerning damage control resuscitation include:

    • Damage control resuscitation describes a sequential package of care.

    • Damage control resuscitation is commenced at the point of wounding.

    • Once i.v. access is secured, 2 litre of Hartmann's solution are administered during transfer to hospital.

    • Damage control resuscitation aims to correct the coagulopathy of trauma.

    • Damage control resuscitation is completed before the commencement of surgery.

  • 15. Intra-osseous access is:

    • Used safely in young children, but is unsuitable for resuscitation in adults.

    • The route of last resort.

    • Confined to the long bones.

    • Suitable for administration of crystalloids but not blood products, which should be given intravenously.

    • Associated with a high incidence of long term morbidity.

  • 16. A soldier has multiple injuries including bilateral above knee amputations, open book pelvic fractures, orbital fractures with air in both globes and pneumocephalus. Following damage control surgery, he remains anaesthetized and requires repatriation by air for specialist tertiary treatment. The most appropriate statements regarding this transfer include:

    • The patient is likely to be repatriated immediately after surgery.

    • According to Charles' law, intra-cranial gas will expand with increasing altitude.

    • Compared with other remote settings, intensive care during level flight is unlikely to be different.

    • The physiological condition of the patient is likely to be maintained in equilibrium by the transfer team.

    • Prophylaxis of duodenal ulceration is unlikely to be required.

Ultrasound in critical care

  • 17. Typical echocardiographic features of massive pulmonary embolism include:

    • Dilated right ventricle.

    • Dilated right pulmonary artery.

    • Paradoxical septal wall motion.

    • Dilated right atrium.

    • Collapsed inferior vena cava.

  • 18. In the critical care setting, ultrasound is a useful imaging modality to:

    • Differentiate post-renal failure from other causes of renal failure.

    • Identify free intraperitoneal gas.

    • Assess a patient with a low Glasgow Coma Scale.

    • Facilitate peripheral arterial or venous access.

    • Reduce the need for seeking a specialist opinion.

  • 19. In critical care setting, thoracic ultrasound:

    • Has limited use in differentiating lung pathologies because an aerated lung causes multiple artefacts.

    • Is insensitive for the detection of small pleural effusions.

    • Is highly recommended before aspirating a pleural effusion.

    • Is known to detect alveolar-interstitial syndrome.

    • Can only visualize a pneumothorax with the patient sitting upright.

  • 20. Level 1 training in ultrasound imaging is most likely to:

    • Include theoretical training.

    • Follow a curriculum.

    • Be supervised by other Level 1 practitioners when they have gained experience of 6 months in ultrasound.

    • Include performing 100 echo scans before being deemed competent.

    • Include multiple forms of assessments.

Cations: potassium, calcium, and magnesium

  • 21. The most appropriate statements regarding calcium metabolism include:

    • It is the ionized calcium concentration rather than total calcium concentration which influences physiological effects.

    • The normal value of ionized calcium is 2.12–2.65 mmol litre−1.

    • Calcitonin plays a major role in calcium homeostasis.

    • Parathyroid hormone (PTH) regulates calcium absorption from the gastrointestinal tract.

    • The kidneys reabsorb 98–99% of filtered calcium.

  • 22. The most appropriate statements concerning magnesium therapy include:

    • Magnesium reverses cerebral vasospasm.

    • Magnesium decreases bleeding time.

    • Respiratory muscle weakness is associated with hypermagnesaemia.

    • Magnesium increases uterine tone.

    • Hypermagnesaemia is associated with hyporeflexia.

  • 23. The most appropriate statements regarding potassium include:

    • Common cardiac arrhythmias associated with hypokalaemia include ventricular extrasystoles and atrial fibrillation.

    • 2% of potassium is in the extracellular fluid.

    • Cellular uptake is stimulated by insulin.

    • Acidosis potentiates hypokalaemia.

    • The main reservoir of potassium is skeletal muscle.

  • 24. Hypercalcaemia causes:

    • Prolonged QT-interval.

    • Anaemia.

    • Shortened PR-interval.

    • Lethargy.

    • Peptic ulceration.

Care bundles in intensive care

  • 25. A care bundle:

    • Comprises 8–10 evidence based interventions.

    • Assesses how well individual interventions are performed.

    • Does not permit any variation from the schedule.

    • Is a powerful audit tool.

    • Is comprised only of interventions with a high level of supporting evidence.

  • 26. Care bundle use:

    • Is uniform across the UK.

    • Is uniform internationally.

    • Is subject to European Union (EU) directive.

    • Is licensed by the Food and Drug Administration (FDA).

    • Is subject to biennial review.

  • 27. Care bundles are constructed:

    • From well-validated individual elements.

    • From elements whose combined effect is known to be additive.

    • To apply primarily to nursing interventions.

    • To include both compulsory and optional elements.

    • By government-appointed experts and opinion-leaders.

  • 28. The sepsis care bundle:

    • Includes guidance on appropriate antibiotics for Gram negative sepsis.

    • Includes guidance on the use of vasopressors.

    • Includes guidance on management of acute kidney injury.

    • Specifies interventions to be completed in the first 72 h post admission to hospital.

    • Allows clinical discretion regarding the use of activated protein C.

Anaesthesia for non-obstetric procedures during pregnancy

  • 29. The most appropriate statements regarding fetal safety include:

    • Maternal hypercapnia results in uterine vasodilation.

    • Maternal hypocapnia causes a shift of the oxyhaemoglobin dissociation curve to the left.

    • Tocolytic therapy is indicated if premature labour occurs.

    • There is an overall miscarriage rate of 20% for all surgery during pregnancy.

    • Surgery that cannot be postponed until after delivery should be carried out in the second trimester if possible.

  • 30. The most appropriate statements regarding maternal physiology include:

    • The normal range for PaCO2 during pregnancy is 3.7–4.2 kPa.

    • Epidural space volume is increased in pregnancy.

    • Aortocaval compression occurs from 24 weeks.

    • Lower oesophageal sphincter tone is reduced.

    • Increased minute ventilation leads to slower inhalational induction.

  • 31. The most appropriate statements concerning anaesthetic agents include:

    • Nitrous oxide exacerbates respiratory complications after extubating a patient with an oedematous airway.

    • Volatile anaesthetic agents increase uterine blood flow.

    • Compared with the non-pregnant state, a lower dose of thiopentone may be required in pregnancy.

    • Anaesthetic agents are potentially teratogenic.

    • Neostigmine does not cross the placenta.

  • 32. The most appropriate statements regarding regional anaesthesia in pregnancy compared with regional anaesthesia in the non-pregnant state include:

    • Higher doses of intrathecal local anaesthetic are required.

    • Epidural loss of resistance is easier to detect.

    • The risk of local anaesthetic toxicity is reduced.

    • Protein binding of local anaesthetics is increased.

    • Sympathetic activity is reduced in pregnancy.

Cellular oxygen utilization in health and sepsis

  • 33. Mitochondria are most likely to be involved in:

    • Apoptosis.

    • Oxidative phosphorylation.

    • Glycolysis.

    • Lipid metabolism.

    • Steroid biosynthesis from cholesterol.

  • 34. The proton motive force is most likely to be utilized in:

    • Heat production.

    • Carnitine shuttle.

    • Mitochondrial membrane transport.

    • ATP (Adenosine triphosphate) synthesis.

    • Diffusion of oxygen.

  • 35. The most appropriate cellular processes in sepsis include:

    • Cytochrome C release from the inner mitochondrial membrane.

    • Increased mitochondrial permeability.

    • Nitric oxide synthase production.

    • Increased oxygen utilization.

    • Increased reactive oxygen species.

  • 36. Antibiotics that have the potential to inhibit mitochondrial function are most likely to include:

    • Ciprofloxacin.

    • Amoxycillin.

    • Tetracycline.

    • Chloramphenicol.

    • Cefuroxime.

Bone cement and the implications for anaesthesia

  • 37. The most appropriate statements regarding bone cements include:

    • Intense heat is generated during the formation of bone cement.

    • Chemical binding occurs between the components of bone cement.

    • Bone cements are radiolucent.

    • Polymethyl methacrylate (PMMA) is the major constituent of bone cement.

    • Use of antibiotic laden bone cement affects the mechanical properties of the cement.

  • 38. The most appropriate statements concerning bone cement implantation syndrome (BCIS) include:

    • BCIS is a well understood phenomenon.

    • BCIS is associated with pulmonary hypertension and right ventricular failure.

    • General anaesthesia reduces the severity of BCIS.

    • Cardiac output monitoring has no advantage over standard haemodynamic monitoring in detection of haemodynamic changes during the pericementation period.

    • BCIS is an irreversible phenomenon.

  • 39. Interventions which are likely to reduce the severity of bone cement implantation syndrome (BCIS) include:

    • Thorough lavage of the intramedullary canal of the femoral shaft.

    • Performing uncemented hip arthroplasty in high risk patients.

    • Maintenance of normothermia.

    • Avoidance of hypovolaemia.

    • Drilling of a venting hole during cemented hip arthroplasties.

  • 40. The use of antibiotics in the bone cement is associated with:

    • Systemic toxicity.

    • Bone cement implantation syndrome.

    • Allergic reactions.

    • Hypotension.

    • Antibiotic resistance.

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