Title: Anaesthetics

Q: Above what age should the FACES pain scale be used?
A: 4+

Q: Above what age can numerical pain rating scale be used?
A: 8+

Q: In what children should FLACC be used?
A: Pre-verbal children

Q: What are the components of FLACC?
A: Facial expression
Leg movement
Activity
Crying
Consolability

Q: Which non-pharmacological methods are helpful in paediatric procedures?
A: Explanation of procedure
Distraction
Relieving anxiety of caregivers
Having caregivers assist

Q: Does parenteral or rectal NSAID use have benefit?
A: No

Q: What is the dosing limit of paracetamol in liver disease?
A: 3g if compensated cirrhosis
CI if decompensated cirrhosis or acute hepatic disease

Q: How does ibuprofen work?
A: Non-selective COX inhibition
Reduces prostaglandin I2 and thromboxane A2 production

Q: What produces PGI2?
A: COX-2

Q: What are the functions of PGI2?
A: Inhibits platelet aggregation, causes vasodilation and prevents vascular smooth muscle cell proliferation (hence COX-2 specific inhibitors increase CVD risk)

Q: Which COX inhibitors increase CVD risk?
A: COX-2 inhibitors (through reduction in PGI2)

Q: What makes thromboxane A2?
A: COX-1

Q: What are the functions of thromboxane A1?
A: Platelet aggregation, vasoconstriction and vascular proliferation

Q: How do NSAID's cause renal impairment?
A: Inhibition of vasodilatory PGE2 (both COX-1 and COX-2 product)

Q: Dose of indomethacin?
A: 25-50mg q8h

Q: What is morphine metabolised to?
A: Morphine-6-glucuronide (active) by liver

Q: How long does IV fentanyl effect last?
A: 40-60min, peak at 4-6 min

Q: Why is pethidine no longer used?
A: Serotonin syndrome and norpethidine active metabolite is proconvulsant (esp. in renal impairment)

Q: How does codeine work?
A: Metabolised to codeine-6-glucuronide and morphine

Q: How common are codeine non-metabolisers?
A: 10% of all patients.
7% of Caucsians and 20% of Africans

Q: How common are codeine ultrametabolisers?
A: 10% of population
20% of Arabic

Q: How does tramadol work?
A: Mu agonist
SNaRI

Q: Side effects of tramadol?
A: Serotonin syndrome
Seizures
Agitation

Q: What should be done if a patient has a transdermal opioid patch on?
A: Remove and titrate acute opioid dosing to effect

Q: What oral dose of morphine equates to 10mg IV?
A: 60mg PO

Q: What oral dose of oxycodone equates to 10mg IV morphine?
A: 30mg

Q: How potent is IV fentanyl vs. morphine?
A: 1/100

Q: What is the ketamine analgesic dose?
A: 0.15-0.4mg/kg IV over 10 minutes
Infusion 0.1-0.2mg/kg/hr

Q: What dose of ketamine equates to 5mg morphine IV?
A: 15mg

Q: CI to nitrous oxide?
A: Altered mental status
Head injury
Suspected pneumothorax
Perforated abdominal viscous
Pregnancy

Q: Starting dose of gabapentin?
A: 300mg mane

Q: Starting dose of pregabalin?
A: 50mg TDS

Q: What can reduce the pain of capillary sampling?
A: Oral sucrose only

Q: Dose of sucrose for paediatrics?
A: 0.25mL of 24% sucrose up to 4x in up to 2 year olds

Q: What proportion of patients on chronic opioid therapy suffer dependence and addiction?
A: 1/3

Q: Preferred analgesic in renal failure?
A: Fentanyl or oxycodone

Q: Advice on discharge with opioid prescription?
A: Avoid making important decisions
Driving
Operating machinery
Working at heights
Advice around constipation
Securing the prescription and drugs from children/potential abusers

Q: Definition of chronic pain
A: >3 months
Pain persisting beyond reasonable time for injury to heal
Pain >1 month beyond usual course for acute illness

Q: What proportion of the population suffer chronic pain?
A: 30%

Q: Prevalence of neuropathic pain?
A: 7-10% of population

Q: Do opioids work for chronic pain management?
A: No studies beyond 1 year
Reasonable evidence that do not work for chronic back pain or joint pain

Q: What proportion of amputees suffer phantom limb pain?
A: ~50%

Q: Triggers of trigeminal neuralgia?
A: Brushing teeth, wind, chewing, speaking, touching face

Q: First line agent for trigeminal neuralgia?
A: Carbamezapine 100mg BD

Q: First line agent for spinal cord pain?
A: Pregabalin

Q: First line agent for diabetic neuropathic pain?
A: Duloxetine

Q: First line agent for acute phase of chronic regional pain syndrome?
A: Tapering prednisone

Q: What has greater risk of premature death and side effects in the elderly: Opioids or NSAIDs?
A: Opioids

Q: Consistent predictors of aberrant drug-related behaviour?
A: Previous illicit drug use
Alcohol abuse

Q: What is propofol infusion syndrome?
A: Severe heart failure with metabolic acidosis in context of high dose propofol use

Q: Side effects of dexmedetomidine?
A: Hypotension, bradycardia, hypoxaemia and AF

Q: ASA I
A: Healthy, no medical problems

Q: ASA II
A: Mild systemic disease

Q: ASA III
A: Severe systemic disease but not incapacitating

Q: ASA IV
A: Severe systemic disease, constant threat to life

Q: ASA V
A: Life expectancy <24 hours irrespective of operation

Q: ASA E
A: Emergency

Q: What is RSI?
A: Sequential administration of sedation and paralysis to facilitate endotracheal intubation

Q: When should paralysis not be given in RSI?
A: If BVM or rescue devices are likely to fail
If anatomical variations exist that will not improve with paralysis e.g. oedema/mass

Q: Which patients could have an NG prior to RSI?
A: Children
Bowel obstruction
Haematemesis
Suspected gastric aspiration
Already applied BVM

Q: How long does desaturation take without preoxygenation?
A: 45-60 sec

Q: How long to desaturation in well patient with pre-ox?
A: 8 minutes

Q: Average time to desaturation after pre-ox in obese patient?
A: 2.7min

Q: How long does nasal oxygen prolong desaturation?
A: 90 seconds

Q: When should pre-treatment fentanyl be given in RSI (if used)?
A: 3-5min prior to paralysis

Q: Pre-treatment dose of fentanyl?
A: 3mcg/kg IV

Q: Induction dose of propofol?
A: 1-2mg/kg

Q: Onset time of propofol
A: 20-40sec

Q: Duration of bolus propofol
A: 3-5min

Q: Unplanned intubation rate of propofol for procedural sedation
A: 1 in 5000

Q: Ketamine induction dose?
A: 1-2mg/kg

Q: Onset of ketamine induction?
A: 30-60sec

Q: Duration of bolus ketamine effect
A: 5-15min

Q: Induction dose of thiopentone
A: 5mg/kg IV (healthy adult)

Q: Induction dose of fentanyl
A: 3-10mcg/kg (200mcg in 70kg male)

Q: Onset time of IV midazolam
A: 2 minutes

Q: Induction dose of Sux
A: 1.5mg/kg (2mg/kg in infants + 3mg/kg in neonates)
ACTUAL BODY WEIGHT

Q: Is sux dosed on actual or ideal body weight?
A: Actual body weight

Q: How is sux metabolised?
A: Plasma cholinesterase

Q: Onset of sux
A: 45-60sec

Q: Duration of sux after dose
A: 5-9 min

Q: Which burns patients cannot receive sux?
A: 5-66 days and >20%

Q: Patient groups in whom sux is CI?
A: Burns >7 days, NM disease >7 days, crush injuries, renal impairment, spinal cord injury, malignant hyperthermia, known sux apnoea or FHx of sux apnoea

Q: Management of malignant hyperthermia post-sux?
A: Dantrolene 2mg/kg IV q5min up to total 10mg/kg

Q: Adverse reaction of rocuronium
A: Anaphylaxis

Q: Intubating dose of roc
A: 1.2mg/kg IDEAL BODY WEIGHT
**ROC IS IDEAL**

Q: Reversal of rocuronium
A: Suggamadex 16mg/kg

Q: Time to recovery from rocuronium
A: 75% muscle power back at 60 minutes

Q: Time to onset of vec for intubation?
A: 2-3min

Q: How much does video laryngoscopy improve first-pass success?
A: 5%

Q: What straight blade is used for average adult?
A: #2

Q: In which patients should NIV be considered for pre-oxygenation?
A: If SpO2 remains <95% at end of 3 minutes of 100% O2

Q: Causes of false-negative capnography?
A: Cardiac arrest, massive PE, morbid obesity, tube obstruction

Q: Causes of false-positive capnography/
A: Recent carbonated drink, endotracheal adrenaline, nebuliser (all transient)

Q: First attempt success rates in ED intubation?
A: 90%

Q: Risk of aspiration in RSI?
A: 1/7000

Q: Risk of morbidity in RSI?
A: 1/16 000

Q: Risk of death in RSI?
A: 1/100 000

Q: Treatment of laryngospasm
A: Deepen sedation
Bag through with sustained PPV
Larson's point pressure
Suxamethonium IV 1.5mg/kg (2mg/kg infants; 3mg/kg neonates) or IM 4mg/kg IM

Q: Likelihood of difficult intubation in Grade 1 Cormack and Lehane view?
A: <1%

Q: Grade 2a view and risk of difficult intubation
A: Cords partly visible. 4%

Q: Grade 2b view and risk of difficult intubation
A: Arytenoids only visible. 67%

Q: Grade 3 view and risk of difficult airway
A: Epiglottis only. 87%

Q: Grade 4 view and risk of difficult intubation
A: No epiglottis seen. 100%

Q: Average depth of insertion of ETT for males and females?
A: 23cm vs. 21cm

Q: What proportion of ED intubations are 'difficult intubations'?
A: 2%

Q: How sensitive is the 3-3-2 rule for airway assessment?
A: 75% sensitive

Q: PEEP to use in obese patients
A: 10cmH20

Q: Indications for intubation in poisoning?
A: GCS <8
GCS >7 but absent gag reflex**
Aspiration pneumonitis therapy
Haemodynamic instability
Arrest
Respiratory depression
Airway protection from aspiration
Deteriorating patient on sodium channel blocker

Q: Which paralysis agent is best for sodium channel blockade poisoning?
A: Roc (Sux promotes transition of sodium channels to desensitised state)

Q: Which sedation and paralysis drugs are dosed as per total body weight?
A: Lipophilic drugs
 - Maintenance Propofol, Thio, Fent
 - Midaz induction
 - Suxamethonium

Q: Which sedation and paralysis drugs are dosed by ideal body weight?
A: Hydrophilic
 - Propofol, Thio, Fent induction
 - Midaz maintenance
 - Roc/Vec

Q: Target totalPEEP in asthma?
A: <10cmH20

Q: Target Pplat in asthma?
A: <25cmH20

Q: How do volume and pressure control ventilation differ?
A: Volume control has rising pressures through inspiratory cycle
Pressure control has same pressures throughout inspiratory cycle
 - With gradual reduction in flow and no set volume

Q: Associated conditions with malignant hyperthermia?
A: Muscular dystrophy
Osteogenesis imperfecta
Phaeochromocytoma
SIDS

Q: Precipitants of malignant hyperthemia?
A: Caffeine
Sux
Volatile inhalational anaesthetics
Amide-type local anaesthetics (i before caine)
Cardiac glycosides
Ketamine

Q: Usual onset of malignant hyperthermia
A: 1-2 hours

Q: Presentation of malignant hyperthermia
A: Rising etCO2 2-3x normal
Tachycardia
Hypertension
Sweating
Ventricular dysrhythmias
Masseter spasm
Fever is late sign

Q: Management of malignant hyperthermia
A: Dantrolene 2mg/kg 15min up to 10mg/kg
100% O2
Change IV tubing
Active cooling
Replace insensible losses

Q: How long do surgical trache tracts take to mature?
A: 2-3 days minimum

Q: How long do perc trache tracts take to mature?
A: 5-7 days

Q: When do tracheo-innominate arterial fistulae present?
A: Weeks 1-2 post-trache

Q: Management of massive tracheostomy site bleeding
A: Hyperinflate cuff
If bleeding persists, slowly withdraw tube with cuff inflated to exert pressure on anterior trachea
Utley maneuver to digitally stop bleeding

Q: What are tracheo-oesophageal prostheses?
A: Long-term prosthetics used in laryngectomy patients to divert air when stoma is occluded into oesophagus where it vibrates to make speech

Q: Which LA are amides?
A: Lignocaine, Bupivacaine, Prilocaine, Ropivacaine

Q: Which LA are esters?
A: Procaine, tetracaine

Q: Duration of action of bupivacaine?
A: 200+ minutes

Q: Onset of bupivacaine?
A: 10-15min

Q: Concentration of bupivacaine?
A: 0.5%

Q: Duration of action lignocaine
A: 30-60min

Q: Onset of lignocaine
A: 5min

Q: Max dose lignocaine
A: 4mg/kg

Q: Max dose lignocaine with adrenaline
A: 7mg/kg

Q: Max dose prilocaine
A: 5mg/kg

Q: Concentration of prilocaine
A: 0.5% for biers

Q: Duration of action of ropivacaine
A: 200+ min

Q: Onset of ropivacaine
A: 5-15min

Q: mAx dose ropivacaine
A: 3mg/kg

Q: Concentration ropivacaine
A: 0.5%

Q: How long does lignocaine with adrenaline last?
A: 2-6 hours

Q: How long does lignocaine nerve block last?
A: 1-2 hrs

Q: Which LA has the most cardiotoxicity?
A: bupivacaine

Q: Which is the least cardiotoxic LA?
A: Prilocaine

Q: How does bicarbonate benefit LA administration?
A: Increases ambient pH higher than drug pKa, which means more drug is non-ionised and passes through tissues more easily
 - Less painful
 - More rapid onset

Q: Which LA is most benefited by lipid emulsion therapy in toxicity?
A: Bupivacaine (most lipid soluble)

Q: Dose of intralipid in LA toxicity?
A: 1.5mL/kg bolus then 0.25mL/kg/min infusion

Q: Which LA can cause methaemoglobinaemia?
A: Prilocaine

Q: What is methaemoglobinaemia?
A: Oxidation of Ferric to ferrous form Hb

Q: How long does EMLA take to work?
A: 60 minutes

Q: How long does ALA take to work?
A: 20-30min

Q: What is the dose of ALA?
A: 0.1mL/kg = 4mg/kg

Q: How long does Angel cream take to work?
A: 30 min

Q: Above what age can Angel cream be used?
A: >1 month

Q: Where does a median nerve block get performed?
A: Between palmaris longus and flexor carpi radialis tendon at carpal tunnel

Q: Where does radial nerve block get performed?
A: Proximal to anatomical snuff box then across dorsum of wrist in ulnar direction

Q: Where is ulnar nerve block performed?
A: Underneath flexor carpi ulnaris 1-2cm proximal to wrist crease

Q: Where is deep fibular nerve block performed?
A: Medial malleolus between tendons of extensor hallucis longus and tibialis anterior tendons

Q: Where is superficial fibular nerve block performed?
A: Between lateral malleolus and tibialis anterior tendon

Q: Where is sural nerve block performed?
A: between achilles tendon and lateral malleolus

Q: Where is saphenous nerve block performed?
A: Between medial malleolus and tibialis anterior

Q: What nerve innervates the bridge of the nose?
A: Supratrochlear nerve

Q: Where does the supratrochlear nerve exit the skull?
A: 5-10mm medial to the supraorbital foramen

Q: How is an ear nerve block performed?
A: Inject anterior and posterior from inferior aspect of ear
Then inject anterior and posterior from superior aspect of ear

Q: Drugs for femoral nerve block?
A: 3mg/kg of ropivacaine 0.5%
= 20mL (150mg) diluted up to 40mL with N/saline

Q: How much anaesthetic to inject in haematoma block?
A: 5-15mL

Q: steps for Bier's block
A: Consent
Exanguinate limb
Double cuff up to 100mmHg above systolic
Check for absence of pulse
Prilocaine 0.5% 3mg/kg (0.6mL/kg)
or 4mg/kg (0.8mL/kg) in lower limb
Wait for loss of sensation
Perform procedure
Deflate at least 30 minutes after inflation and ideally <60 min
 - Lower 10 seconds, reinflate 1 min, deflate 3-5x
Monitor for 30 minutes

Q: Onset time of prilocaine Bier's block?
A: 5min

Q: Predictors of difficult BVM
A: MOANS
 - Mask seal: Beard, trauma
 - Obese
 - Age >55
 - No teeth
 - Stiff lungs

Q: Predictors of difficult LMA
A: RODS
 - Restricted mouth opening
 - Obese
 - Disrupted anatomy
 - Stiff lungs

Q: Hudson mask FiO2
A: 0.4-0.6

Q: What is procedural sedation?
A: Administration of sedatives or dissociative anaesthetics to induce depressed LOC while maintaining cardiorespiratory function in order to perform a medical procedure without patient reaction or memory

Q: Incidence of hypoxia/hypotension in moderate sedation?
A: 10-30%

Q: Risk of significant complications in ASA I or II with procedural sedation?
A: <5%

Q: Focused history prior to procedural sedation
A: Fasting
PMHx
Meds
Allergies
Previous anaesthetics

Q: Focused examination prior to procedural sedation
A: Airway
Volume status
Active cardiorespiratory disease or URTI
Intoxication

Q: ANZCA fasting guidelines
A: 2hrs clear flluids, 4hrs breastmilk, 6 hrs solids

Q: Fasting recommended for N2O in children?
A: 2 hours

Q: When are the highest risk times in procedural sedation?
A: After each bolus and after completion of procedure when stimulus is gone

Q: When should analgesia be given prior to procedural sedation?
A: Sedation should not be given until last dose of analgesia has reached peak effect (3-5 min)

Q: Onset of N2O
A: 1-2 min

Q: Recovery time from N20
A: 3-5 min with O2 flush

Q: Why is N2O contraindicated in pregnancy?
A: Inhibits folate metabolism

Q: Why might N2O have a prolonged effect in COAD?
A: Reduced ventilation and washout

Q: Procedural sedation dose of midazolam?
A: 0.15mg/kg

Q: What proportion of patients suffer paradoxical agitation with midazolam?
A: 10%

Q: Flumazenil dose?
A: 20mcg/kg every minute until reversal

Q: Is rigid chest syndrome reversible?
A: No

Q: Fent/Midaz dosing for procedural sedation
A: 2mcg/kg + 0.1mg/kg

Q: Rate of laryngospasm with paediatric ketamine procedural sedation?
A: 2%

Q: Vomiting in ketamine procedural sedation?
A: 8%

Q: CI to ketamine procedural sedation
A: Glaucoma
Globe injury
Psychosis
Oropharyngeal stimulation during procedure
Significant URTI symptoms - risk of laryngospasm

Q: Why do repeat boluses of propofol have a greater effect than the initial one?
A: Saturation of tissues with distribution occurs, resulting in higher serum concentrations with each bolus

Q: Ketamine + Propofol PS?
A: Ketamine 1mg/kg IV + 0.5mg/kg propofol

Q: Benefits of ketamine and propofol vs. propofol
A: Not proven to be any safer
Less erratic depth of sedation
No need for opioids and their inherent risks when used with propofol
Lower total doses than either agent alone

Q: Complication rate for ED procedural sedation?
A: 2.3-11%

Q: Discharge criteria post-procedural sedation
A: 1 hr since procedure
Appropriate support person
Must not drive or be alone
Appropriate follow-up
Written instructions

Q: Under what age is Seldinger tracheostomy preferred?
A: <12yo (mandatory <8yo)

Q: What proportion of attempted surgical airways have acute complications?
A: 15%

Q: When should intubation be performed if ongoing traumatic haemorrhage?
A: As close as possible to definitive haemorrhage control

Q: Post-intubation hypoxia algorithm
A: DOPES
 - Displacement
 - Obstruction
 - Patient: Pneumothorax, Bronchospasm, PE, arrest, APO
 - Equipment: Ventilator issues
 - Stacked breaths

Q: Maximum dose of lignocaine without adrenaline?
A: 4mg/kg (300mg in adult)

Q: Maximum dose of lignocaine with adrenaline?
A: 7mg/kg

Q: Maximum dose of bupivacaine without adrenaline?
A: 2mg/kg

Q: Maximum dose of bupivacaine with adrenaline?
A: 2.5mg/kg

Q: Max dose of bupivacaine in 24 hours?
A: 400mg

Q: Which NMBA has highest risk of anaphylaxis?
A: Suxamethonium 1/9000

Q: What is the risk of anaphylaxis with rocuronium?
A: 1/17 000

Q: What is the most common cause of anaphylaxis in the perioperative environment?
A: Antibiotics (50%)

Q: Which antibiotic has the highest risk of anaphylaxis in the perioperative environment?
A: Teicoplanin

Q: What proportion of penicillin allergies are true?
A: 10%

Q: How long after major burn is sux a risk?
A: 66 days

Q: Components of MACOCHA score?
A: Mallampati III or IV (5)
Apnoeic (OSA) (2)
Cervical spine immobility (1)
Opening mouth <3cm (1)
Coma (1)
Hypoxaemia (1)
Non-anaesthetist (1)

Q: How is a MACOCHA score useful?
A: If score <3 = 2% risk of difficult airway (in ICU population)
vs. 36% risk if score 3 or more

Q: Max dose of bupivacaine + adrenaline?
A: 2.5mg/kg vs. 2mg/kg

Q: Predictors of difficult intubation
A: LEMON
 - Look externally
 - Evaluate 3-3-2 (inter-incisor, thyromental, thyro-hyoid)
 - Mallampati score III or IV
 - Obstruction
 - Neck immobillity

Q: What proportion of Mallampati III or IV are actually difficult?
A: 5%

Q: Mallampati score
A: I - Soft palate, uvula, fauces and pillars
II - Soft palate, uvula and fauces. No pillars
III - Soft palate and uvula base only
IV - Hard palate only

Q: Is there any evidence that egg/soy allergy is a contraindication to propofol?
A: No

Q: What did the cochrane review article of sux vs. roc find?
A: Roc is slightly less effective and producing excellent intubating conditions (however, minimum roc dose was 0.6mg/kg)