Discharge following day surgery

Following a day case procedure under general anaesthesia, which one of the following

is NOT a criterion for approval of discharge from the day surgery unit?

a) Able to ambulate unassisted

b) No pain or mild pain controllable with oral analgesia

c) Agreed carer for 24 hours

d) No bleeding or minimal bleeding or wound drainage

e) Stable vital signs for one hour

Basic SI units

Which of the following is NOT a basic SI unit?

a) Candela

b) Kelvin

c) Mole

d) Newton

e) Ampere

Features of local anaesthetic toxicity

The following statements regarding the features of local anaesthetic toxicity are true

EXCEPT which one?

a) Prilocaine toxicity may cause the pulse oximeter to read 85%

b) At a plasma lidocaine concentration of 5 mg/mL, tinnitus may be present

c) As toxicity develops, inhibitory pathway inhibition at first causes excitation

d) Unconsciousness may precede convulsions

e) Cardiac resting membrane potential is made more negative

Severe sepsis

A 69-year-old, 80 kg male is admitted to the intensive care unit with respiratory failure

secondary to a lower respiratory tract infection. He has his trachea intubated and

mechanical ventilation of the lungs is commenced. He has a PiCCO cardiac output

monitor sited; an internal jugular central venous catheter and urinary catheter are

also inserted. He receives antibiotics, intravenous fluid resuscitation and an infusion

of noradrenaline. Three hours following admission to hospital, some of his clinical

measurands are as follows: heart rate 110 bpm; mean arterial blood pressure

66mmHg; central venous pressure 10 mmHg; arterial oxygen saturation 93%; central

venous oxygen saturation 68%; cardiac index 2.5 L/min per m2; urine output

30 mL/h; pH 7.23; PaCO2 6.0 kPa; PaO2 9.1 kPa; HCO3

– 19 mmol/L; base excess

−6.2 mmol/L; lactate 3.2 mmol/L; haematocrit 0.31; FiO2 0.7; MV 7.2 L/min; plateau

pressure 29cmH2O. Which one of the following should be prioritised for the patient

to receive NEXT?

a) Increased rate of noradrenaline infusion

b) Dobutamine infusion

c) Further intravenous fluid

d) Infusion of packed red cells

e) Increased minute ventilation

Teeth

At preoperative assessment it is noticed that a patient’s top teeth appear to be

abnormally anterior to their bottom teeth. When asked to close their mouth, the tip

of their top central incisors is 12mm anterior to the tip of their bottom central incisors.

Which one of the following terms BEST describes the patient’s condition?

a) Overbite

b) Malocclusion

c) Micrognathia

d) Overjet

e) Overclosure

Mental capacity

Which of the following scenarios would give you MOST CONCERN that the patient

lacked capacity to consent for the given procedure?

a) A 51-year-old understands the risks of delaying the surgery for her aggressive

bowel cancer but still maintains that she does not want an operation that may

cure her

b) For the fourth successive time a 63-year-old agrees to have surgery for a large

incarcerated inguinal hernia, but on arriving in the anaesthetic room panics at the

thought of the anaesthetic and refuses to have the operation

c) A 38-year-old woman who is 16 weeks pregnant with worsening signs and

symptoms of acute appendicitis has the risks and benefits of surgery including the

risks to the foetus explained. She refuses to have surgery as she believes any

medicines, including anaesthetics, may damage her baby

d) An 87-year-old with mild dementia who is conversational and orientated but prone

to being forgetful asks you twice to repeat the risks you have explained to him about

the anaesthetic for his dynamic hip screw surgery

e) A 24-year-old with depression thought to be at high risk of suicide who has

benefited from electroconvulsive therapy (ECT) in the past, refuses ECT against the

recommendations of two senior psychiatrists. Six months earlier, the patient, during

a period when considered by her mental health team to be of sound mind, had

legally signed an advanced directive stating that she did not wish to ever have ECT

again

Invasive arterial blood-pressure monitoring

Regarding invasive arterial blood pressure monitoring, which one of the following

statements is TRUE?

a) An overdamped waveform underestimates diastolic pressure

b) An anacrotic notch is a sign of severe aortic stenosis

c) A rapid systolic upstroke is associated with a high systemic vascular resistance

d) The dicrotic notch appears later in the waveform complex if measured at the radial

artery compared to the dorsalis pedis

e) Critical damping refers to the perfect level of damping and is the desired set-up for

the system

Sodium nitroprusside

Regarding the drug sodium nitroprusside (SNP), the following statements are correct

EXCEPT which one?

a) SNP ultimately causes vasodilation via increased concentration of intracellular

cyclic guanylate monophosphate (cGMP)

b) Dicobalt edetate has a place in the management of toxicity induced by SNP

c) Vitamin B12 deficiency may predispose to SNP toxicity

d) SNP causes increased right-to-left intrapulmonary shunt

e) Thiocyanate, produced during one pathway of SNP metabolism, is non-toxic

Hepatitis B

A British anaesthetist working in the United Kingdom suffering a needle stick injury

with a bloody, hollow sharp from a patient known to have hepatitis B, has serum tests

at ten weeks post-inoculation. Which of the following is LEAST LIKELY to be found?

a) Positive for antibody to hepatitis B surface antigen

b) Positive for IgM for anti-hepatitis D virus

c) Positive for anti-hepatitis B surface antigen

d) Positive for hepatitis B virus DNA

e) Positive for hepatitis B e antigen

Measurement of biopotentials

Regarding the measurement of biopotentials, which one of the following statements

is TRUE?

a) Signal-to-noise ratio must be minimised to optimise fidelity of displayed

biopotential

b) Electrocardiogram electrodes generate potential as well as conduct current

c) Input impedance at the amplifier must be minimised in order to maximise the

potential measured

d) The bandwidth of frequencies over which an electromyogram must consistently

amplify is 0.5 to 100 Hz

e) Gain and common-mode rejection ratio are measured in Sone units

Ankle block

The following nerves must be anaesthetised when performing regional anaesthesia of

the foot. Which nerve is readily amenable to location using the peripheral nerve

stimulator?

a) Superficial peroneal (fibular) nerve

b) Deep peroneal (fibular) nerve

c) Tibial nerve

d) Sural nerve

e) Saphenous nerve

Temperature measurement

Regarding temperature measurement, the following statements are true EXCEPT

which one?

a) Rectal temperature tends to be higher than oesophageal temperature

b) Oesophageal probes most commonly incorporate a thermistor to transduce

temperature to electrical changes

c) A thermopile is a collection of thermocouples connected in parallel

d) Tympanic membrane thermometers often employ the Seebeck effect

e) Miniaturised temperature measurement probes typically have response times of

around one second

Anaesthesia in a patient with porphyria

A patient with known variegate porphyria presents with suspected acute appendicitis

and requires a laparoscopy. The patient is fasted, in pain and extremely anxious. Which

one of the following options describes the BEST peri-operative management?

a) Fluid: Hartmanns + 10% glucose; Premedication: Midazolam; Induction agent:

Propofol; Maintenance anaesthetic agent: Isoflurane

b) Fluid: Hartmanns; Premedication: none; Induction agent: Thiopentone;

Maintenance anaesthetic agent: Propofol

c) Fluid: Hartmanns + 10% glucose; Premedication: none; Induction agent: Propofol;

Maintenance anaesthetic agent: Sevoflurane

d) Fluid: 5% dextrose; Premedication: none; Induction agent: Propofol; Maintenance

anaesthetic agent: Isoflurane

e) Fluid: Hartmanns + 10% glucose; Premedication: none; Induction agent:

Thiopentone; Maintenance anaesthetic agent: Isoflurane

Jehovah’s Witness

A 30-year-old Jehovah’s Witness presents for emergency surgery. Which of the following

options is likely to be LEAST ACCEPTABLE to this patient during the perioperative

period?

a) Transfusion of pre-operatively donated autologous blood

b) Transfusion of human albumin solution

c) Epidural blood patch

d) Intraoperative cell salvage

e) Cardiac bypass

Anaphylaxis triggers

The MOST COMMON cause for an anaphylactic reaction under anaesthesia is which

one of the following?

a) Antibiotics

b) Latex

c) Neuromuscular blocking drugs

d) Colloid solutions

e) Radiocontrast media

Lumbar plexus

Regarding the anatomy and regional anaesthesia of the lumbar plexus, the following

statements are true EXCEPT which one?

a) The lumbar plexus is described as being derived from spinal nerve roots T12–L4

b) The genitofemoral nerve is of L1–2 spinal root origin

c) The lumbar plexus is embedded in the psoas major muscle

d) A lumbar plexus block combined with a proximal sciatic nerve block can provide

complete anaesthesia for all leg and foot surgery

e) As the skin on the back is less sensitive, a lumbar plexus block is one which is better

tolerated by patients without the need for sedation/analgesia

Surgical risk-assessment tools

A 55-year-old man is awaiting a transjugular intrahepatic portosystemic shunt procedure.

Considering the Child–Pugh classification of liver disease, of the following

clinical features, which one does NOT score two points?

a) Ascites controlled with diuretics

b) Encephalopathy grade II

c) Bilirubin 42 micromol/L

d) Albumin 27 g/L

e) INR 2.4

Ventilators in the operating theatre

You are ventilating a patient in theatre using a simple bag-in-bottle ventilator connected

to the common gas outlet. You are using a fresh gas flow of 1 L/min, a circle

breathing system and volume control ventilation mode. Using spirometry connected to

your anaesthetic machine you note a tidal volume of 500 mL, a respiratory rate of

12 breaths per minute and an I:E ratio of 1:2. You need to rapidly affect a change in

circuit concentration of volatile anaesthetic agent. You increase your fresh gas flow to

4 L/min. You leave all the ventilator settings unchanged. One minute later, what

delivered minute volume would you expect the spirometry to be registering?

a) 5 L/min

b) 6 L/min

c) 7 L/min

d) 8 L/min

e) 9 L/min

Altitude anaesthesia

While working abroad, at an altitude of 5000m, it becomes necessary to administer a

general anaesthetic with an FiO2 of 0.9, to a healthy patient who lives locally. The

operating theatre is heated and equipped with an anaesthetic machine that uses variable

orifice flowmeters and a Tec5 isoflurane vaporiser, out of circuit. Regarding your anaesthetic

management, the following statements are true EXCEPT for which one?

a) The delivered concentration of isoflurane will be more than that shown on the dial

of the vaporiser

b) The oxygen rotameter will accurately read the delivered flow of oxygen

c) The alveolar concentration of isoflurane will need to be higher than at sea level to

achieve the same degree of anaesthesia

d) The partial pressure of isoflurane in the vaporiser is the same as it would be if you

returned with the same vaporiser to sea level

e) The patient’s oxygen saturation is more likely to be 90% than 96%

Gas analysis

Which one of the following gases is paramagnetic?

a) Nitrogen

b) Nitrous oxide

c) Nitric oxide

d) Nitrogen dioxide

e) Dinitrogen tetroxide

Approaches to regional anaesthetic blockade of the brachial plexus

Which one of the following statements regarding approaches to the blocking of the

brachial plexus is TRUE?

a) The axillary approach alone is sufficient for all aspects of awake hand surgery

b) The interscalene approach blocks the plexus at the level of the trunks

c) The vertical infraclavicular approach has the highest rate of pneumothorax

d) An advantage of the supraclavicular approach is, being more distal, phrenic nerve

block is not a complication

e) The subclavian perivascular approach relies on the plexus being immediately

posterior to the subclavian artery as it crosses the first rib in between the scalenus

anterior and medius

Beta-adrenoreceptor antagonists

Which one of the following statements regarding β-blockers is TRUE?

a) When using esmolol, a loading dose of 0.1 mg/kg intravenously over one minute is

reasonable

b) Propranolol has high oral bioavailability

c) Atenolol has high β1 receptor selectivity

d) Metoprolol has low lipid solubility thus its absorption and bioavailability are

limited

e) Labetalol antagonises α1:β adrenoreceptorswith a ratio of 1:7 when administered orally

Herbal remedies

Which of the following DECREASES the anticoagulant effect of warfarin?

a) Garlic

b) Glucosamine

c) Echinacea

d) Evening primrose oil

e) St John’s wort

Prostaglandins in pregnancy

A 23-year-old severely asthmatic primigravida suffers a major post-partum haemorrhage

due to uterine atony following a vaginal delivery. As well as appropriate therapy

of major haemorrhage she receives syntometrine intramuscularly, syntocinon intravenously

as a bolus and then by infusion. Which one of the following would be the

MOST SUITABLE agent for further pharmacological management of her condition?

a) Carboprost

b) Mifepristone

c) Misoprostol

d) Alprostadil

e) Dinoprostone