Medication Flashcards

Question

21.1 The main advantage of using norepinephrine (noradrenaline) over phenylephrine for the prevention of hypotension as a result of spinal anaesthesia for elective caesarean section is A. Better APGAR B. Better foetal acid/base C. Less nausea/vomiting D. Less maternal bradycardia

Answer 1

less maternal bradycardia

Answer 2

c. Pharyngeal muscles Millers Anaesthesia: Reference artyicle from Millers: https://pubs.asahq.org/anesthesiology/article/92/4/977/710/The-Incidence-and-Mechanisms-of-Pharyngeal-and An adductor pollicis TOF ratio of 0.90 or less was associated with impaired pharyngeal function and airway protection, resulting in a four- to fivefold increase in the incidence of pharyngeal dysfunction causing misdirected swallowing. Moreover, pharyngeal function and airway protection may be impaired, even if the adductor pollicis muscle has recovered to a TOF ratio of more than 0.90.

Answer 3

a) Flecanide WPW ECG = short PR, wide QRS, delta wave at start of QRS If WPW, need to prolong refractor period of accessory pathway with agents such as procainamide/flecainide/amiodarone/sotalol. Avoid verapamil (increases ventricular rate). Avoid beta blockers (don’t affect accessory pathway). https://litfl.com/wolff-parkinson-white-syndrome-ccc/

Answer 4

Bolus 1 IU oxytocin; start oxytocin infusion at 2.5–7.5IU.h (0.04–0.125 IU.min) EmLSCS; 3 IU oxytocinover≥30 s; start oxytocininfusion at 7.5–15 IU.h (0.125–0.25 IU.min). https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/10.1111/anae.14757

Answer 5

hydroxycobalamin

Answer 6

decompress the bladder Autonomic Dysreflexia: - medical emergency characterised by severe hypertension, - brought on by stimulation below the level of the lesion Factors affecting the development of ADR: 1. Level of spinal injury 2. Duration of injury 3. Whether injury is complete or incomplete Pathology: Stimuli arise from caudal roots below the level of the lesion leading to uncontrolled sympathetic activation below the level of the lesion ○ 80% being due to bladder distension ○ Other triggers include § bowel distension § acute abdo pathology § activation of pain fibres § sexual activity § uterine contractions

Answer 7

a. Drugs that absolutely must not be used for pregnancy. (absolute contraindication) https://www.tga.gov.au/australian-categorisation-system-prescribing-medicines-pregnancy

Answer 8

b. hypotension The use of dexmedetomidine did not increase the duration of PACU LOS but was associated with reduced emergence agitation, cough, pain, postoperative nausea and vomiting, and shivering in PACU. There was an increased incidence of hypotension but not residual sedation or bradycardia in PACU. https://pubmed.ncbi.nlm.nih.gov/35085107/#:~:text=Conclusions%3A%20The%20use%20of%20dexmedetomidine,sedation%20or%20bradycardia%20in%20PACU

Answer 9

E - SSRIs ANZCA PG12 Background Paper

Answer 10

100 years Desflurane: 10yrs Sevoflurane 1yr

Answer 11

A. Inhalational anesthesia or b. Clonidine Prospect: two studies focused on tonsillectomy, and those did not show any additional analgesic effect of clonidine when used on top of adequate baseline medication after tonsillectomy. PROSPECT https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/10.1111/anae.15299#:~:text=The%20basic%20analgesic%20regimen%20should,analgesic%20and%20anti%2Demetic%20effects.

Answer 12

a) methylene blue Drugs to avoid: Antibiotics Sulphonamides (check with your doctor) Co-trimoxazole (Bactrim, Septrin) Dapsone Chloramphenicol Nitrofurantoin Nalidixic acid Antimalarials Chloroquine Hydroxychloroquine Primaquine Quinine Mepacrine Chemicals Moth balls (naphthalene) Methylene blue Foods Fava beans (also called broad beans) Other drugs Sulphasalazine Methyldopa Large doses of vitamin C Hydralazine Procainamide Quinidine Some anti-cancer drugs

Answer 13

midazolam - Opioids, benzodiazepines and pregabalin may also be used to alleviate symptoms. Perioperative treatment of symptoms If RLS symptoms occur perioperatively, patients should be allowed to walk or move their legs in bed as soon as possible. If prolonged bed rest is required, the frequency of RLS medications may be increased to three times a day. If oral intake is feasible, a patient’s usual oral medication may be given. Levodopa (a dopamine agonist) may be administered by nasogastric tube. Alternatively, parenteral apomorphine or a rotigotine patch may be used. Apomorphine (1 milligram) may be injected subcutaneously on an hourly basis. Nausea is a common side effect so it may need to be given with an antiemetic. Rotigotine patches may be used every 24 hours. Opioids, benzodiazepines and pregabalin may also be used to alleviate symptoms. Patients should be proactively investigated and treated for iron deficiency, targeting ferritin level greater than 300 micrograms/ litre in adults, and 50 micrograms/litre in children.

Answer 14

D) Cefaclor 1. Cephalexin? More so than Cephazolin (no B-lactam) 2. Cefaclor Source: UpToDate

Answer 15

Increased latency, decreased conduction speed, decreased amplitude

Answer 16

d) G6PD deficiency (contraindicated) Methylene blue PI: PROVEBLUE® is indicated: * for the treatment of drug-induced methaemoglobinaemia (e.g. prilocaine) * for the treatment of idiopathic methaemoglobinaemia (in which structural abnormality of haemoglobin is not present) * as a bacteriological stain * as a dye in diagnostic procedures such as fistula detection * for the delineation of certain body tissues during surgery. Contraindications: PROVEBLUE® is contraindicated in the following circumstances: * known hypersensitivity to the drug or any other thiazide dyes * patients with severe renal impairment * patients with glucose-6-phosphate dehydrogenase deficiency * methaemoglobinaemia due to chlorate poisoning * methaemoglobinaemia during treatment of cyanide poisoning Intrathecal and subcutaneous injection of methylene blue are also contraindicated as they can result in neural damage (intrathecal administration) and necrotic abscess (subcutaneous administration). Precautions: Methylene blue is a potent monoamine oxidase inhibitor. Serotonin syndrome. Dose: Adults and children: In the treatment of methaemoglobinaemia, methylene blue is administered intravenously as the 0.5 % solution in doses of 1 to 2 mg per kg bodyweight injected over a period of 5 minutes. A repeat dose may be given after one hour if required. A maximum dose of 7mg/kg bodyweight is recommended. The use of methylene blue is not recommended in infants under 4 months of age. STAT PEARLS :Methylene blue https://www.ncbi.nlm.nih.gov/books/NBK557593/ "Methylene blue is a safe drug at a therapeutic dose of <2 mg/kg; however, when levels are >7 mg/kg, many of the adverse effects it exhibits will occur. Serotonin syndrome has been found to occur when combining serotonergic agents with methylene blue at a dose of 5 mg/kg." Methylene blue: caution serotonin syndrome, G6PD deficiency Indications: vasoplegic syndrome, plasmodium falciparum, methaemoglobinaemia, diagnostic purposes. Safe at doses <2mg/kg. (used in vasoplegic syndrome on CPB at 3mg/kg - Up to date) Serotonin syndrome at >5m/kg Other adverse effects at >7mg/kg.

Answer 17

1st a) Atorvastatin 2nd c) Digoxin source of Atorvastatin > Digoxin https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5818856/ All of the DOACs are avid substrates for the excretory P-gp system of the gastrointestinal epithelial cells, and drugs that inhibit or induce the P-gp system may affect plasma DOAC levels Dabigatran and edoxaban are substrates for P-glycoprotein (P-gp) Apixaban and rivaroxaban are metabolised by cytochrome P450 enzyme CYP3A4 and are substrates for P-gp There is study evidence that among patients taking DOACs for non-valvular atrial fibrillation, concurrent use of amiodarone, fluconazole, rifampicin, and phenytoin compared with the use of DOACs alone, was associated with increased risk of major bleeding It is unlikely that clinically significant interactions occur between dabigatran and other drugs that are merely substrates for P-gp-mediated excretion. When dabigatran was coadministered with digoxin neither digoxin nor dabigatran plasma levels were significantly altered Rivaroxaban and apixaban are metabolised to an extent of 40–50 % in the liver to variable degrees by CYP3A4 and may interact with drugs that inhibit this enzyme. The metabolism of Apixaban and rivaroxaban can be decreased when combined with Atorvastatin which is also metabolised by CYP3A4

Answer 18

a) TXA Hyperfibrinolysis https://derangedphysiology.com/main/required-reading/haematology-and-oncology/Chapter%201.2.0.1/intepretation-abnormal-rotem-data

Answer 19

a) No increased risk of surgical wound infection - Now, the Perioperative Administration of Dexamethasone and Infection Trial (PADDI), led by Professor Tomás Corcoran, Director of Research in the Department of Anaesthesia and Pain Medicine, Royal Perth Hospital has found that administering a low-dose of dexamethasone during anaesthesia for surgical operations does not increase the risk of surgical wound infections.

Answer 20

B) fentanyl Drugs which have the least impact on SSEPs 1. Ketamine 2. Opioids 3. Dexmedetomidine Article in Anaesthesiology https://pubs.asahq.org/anesthesiology/article/99/3/716/40407/Pharmacologic-and-Physiologic-Influences-Affecting o SSEPs = small amplitude potentials measured over the sensory cortex or via epidural electrodes from stimuli applied to the posterior tibial nerves. SSEPs are transmitted via the posterior columns of the spinal cord in the territory of the posterior spinal arteries which supply the posterior 1/3 of the cord. As they are low amplitude they are affected by basal muscle tremor and the signal-to-noise ratio is improved by increasing the depth of muscle relaxation. Their use is not significantly affected by therapeutic concentrations of anaesthetic vapours o MEPs = series of short-duration constant current stimuli of 300-700 V applied to the motor cortex and measured via needle electrodes inserted into tibialis anterior, abductor halluces and vastus medialis muscles along with selected small muscles of the hands for reference. MEPs rely on corticospinal tract integrity which lies in the territory of the anterior spinal artery. MEPs therefore complement SSEPs in their assessment of spinal cord function. MEPs are large amplitude potentials and are incompatible with profound muscle relaxation. Neuromuscular blocking agents are therefore best avoided or given by infusion and dose optomised with discussion with the technicians (or just give remi). o All anaesthetic vapours reduce MEP amplitude in a dose-dependent manner, and more than 0.5 MAC are not compatible with reliable monitoring. Thus Propofol TIVA is preferred. * Remifentanil is commonly used due to low context sensitive half life and negligible effect on intraop evoked responses

Answer 21

C Methionine Synthetase Inhibitor

Answer 22

Give 3mg of Vitamin K and re-check on day of surgery proceed if INR <1.5 on DOS

Answer 23

b) Factor VII Redcross: Cryoprecipitate contains most of the following found in fresh frozen plasma: 1. factor VIII 2. fibrinogen 3. factor XIII 4. von Willebrand factor 5. fibronectin Prothrombinex-VF® is a lyophilised concentrate of human coagulation factors it contains: Factors: II IX X small amount of factor VII. Also contains: plasma proteins (human) Antithrombin III (human) Heparin sodium (porcine) Sodium Phosphate Citrate Chloride

Answer 24

Nitrous oxide Halothane & isoflurane cause catalytic destruction of ozone, but halothane hardly used and isoflurane has short atmospheric lifetime. Desflurane + sevoflurane don’t cause ozone depletion.

Answer 25

Nitrous oxide Halothane & isoflurane cause catalytic destruction of ozone, but halothane hardly used and isoflurane has short atmospheric lifetime. Desflurane + sevoflurane don’t cause ozone depletion.

Answer 26

d) Gentamicin Drugs in the anaesthetic trolley that may unmask or worsen MG: - NMBs - gentamicin - beta blockers (metoprolol) - magnesium Anaesthetic drugs to be cautious with: - dexamethasone - antipsychotics - anticonvulsants - antibiotics (vancomycin, metronidazole)

Answer 27

C. Cryoprecipitate contains Factor VIII, XIII, fibrinogen (factor I), fibronectin, vWF ## Footnote https://www.lifeblood.com.au/health-professionals/products/blood-components/cryoprecipitate

Answer 28

D. 30 ml/kg Identification and Management of Obstetric Hemorrhage Anesthesiology Clinics - Obstetric Anesthesia (2017) https://www.anesthesiology.theclinics.com/article/S1932-2275(16)30074-X/fulltext Although FFP, cryoprecipitate, and fibrinogen concentrates can all be used to increase fibrinogen levels, the optimal strategy for managing hypofibrinogenemia in obstetric hemorrhage is unclear. The relatively low concentration of fibrinogen in FFP limits its usefulness in the treatment of significant hypofibrinogenemia. To increase fibrinogen plasma level by 1 g/L, 30 mL/kg of FFP is necessary, increasing the risk of pulmonary edema and other hypervolemic complications. Cryoprecipitate, which is a concentrated source of fibrinogen, factor VIII, fibronectin, von Willebrand factor (vWF), and factor XIII, will increase fibrinogen levels by ~0.7 to 1 g/L for every 100 mL given. Although cryoprecipitate is associated with a lower transfusion volume, the standard “dose” (10 U) is typically prepared by pooling concentrates from multiple donors. Given the risk of infectious disease transmission and/or an immunologic reaction from exposure to multiple donors, several countries preferentially use purified, pasteurized fibrinogen concentrate for the treatment of congenital and/ or acquired hypofibrinogenemia. Fibrinogen concentrates are also prepared from large donor pools, but subsequent processing removes or inactivates potentially contaminating viruses, antibodies, and antigens. Studies comparing cryoprecipitate and fibrinogen concentrates utilization in hemorrhage resuscitation suggest fibrinogen concentrates are associated with lower blood loss, decreased RBC transfusion, and greater increases in plasma fibrinogen levels. Although the most appropriate method of fibrinogen replacement is somewhat controversial, the critical role of fibrinogen in reversing the coagulopathy accompanying obstetric hemorrhage is clear. As such, close monitoring and replacement of fibrinogen are crucial in the management of the bleeding parturient.

Answer 29

D Na 154, 308 mOsm/L

Answer 30

e Plasma esterases Plasma esterases (not cholinesterase) Esmolol metabolism is via RBC esterases.

Answer 31

B. Normal 2,3 DPG higher Hct-60% No immunimodulation require reinfusion within 6hrs pause with sement, caution metal fragments

Answer 32

c. 5mg/kg Methylene blue due to its monoamine oxidase(MAO) inhibiting property may precipitate potentially fatal serotonin toxicity at doses >5mg/kg. Source: STAT PEARLS - Methylene blue https://www.ncbi.nlm.nih.gov/books/NBK557593/

Answer 33

d) Warfarin Warfarin – no effect on thrombin time Heparin - causes considerable prolongation of TT. LMWH, fondaparinux or direct factor Xa inhibitors have no effect on TT as the predominantly inhibit factor Xa. -> However LMWH in very high concentration can affect TT. Dabigatran, Bivalirudin and other direct thrombin inhibitors prolong TT considerably. The thrombin time (TT), also known as the thrombin clotting time (TCT) is a blood test that measures the time it takes for a clot to form in the plasma of a blood sample containing anticoagulant, after an excess of thrombin has been added. Warfarin prevents thrombin synthesis but does not inhibit it, therefore no effect on TT.

Answer 34

d. Noradrenaline Supportive Management of Massive PE Coexisting left ventricular systolic dysfunction and diastolic dysfunction complicate the management of heart failure patients with massive PE. Although a common strategy in response to systemic arterial hypotension is to prescribe a fluid bolus, volume loading may worsen biventricular failure, pulmonary edema, and hypoxemia. An initial trial of volume expansion, limited to 250 to 500 mL, may be attempted in those heart failure patients without evidence of increased right-sided filling pressures or pulmonary edema.6 Although non–heart failure patients generally respond well to pure vasopressors for hemodynamic support in massive PE, many heart failure patients will not tolerate the isolated increase in systemic vascular resistance. PE patients with heart failure may require an agent with mixed vasopressor and inotropic properties such as norepinephrine, epinephrine, or dopamine. Whereas LV function often becomes hyperdynamic to compensate for RV failure, the presence of underlying LV systolic dysfunction in heart failure patients may limit the patient’s ability to maintain normal systemic cardiac output and may necessitate the addition of inotropes. https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.108.803965

Answer 35

b. Rocuronium 1.2mg/kg Cis not appropriate for intubation Sux with K 6.3 is risky. (I've never heard of reduced dose)

Answer 36

a. Sevoflurane, morphine, phenylephrine Moclobemide = MAOi

Answer 37

e) Protamine The interpretation of this graph is not especially laborious. The cardinal abnormality is the massively prolonged CT and CF of the INTEM graph, which suggests that something has killed the intrinsic pathway of the clotting cascade. The CT returns to normal in the HEPTEM graph, which is essentially just an INTEM test with adde heparinase. The presence of heparinase seems to have reversed all of the coagulopathy - the CFT, alpha-angle and MCF have all returned to normal. Therefore, this patient has no coagulation problems other than the heparin. https://derangedphysiology.com/main/required-reading/haematology-and-oncology/Chapter 1.2.0.1/intepretation-abnormal-rotem-data

Answer 38

c) Vasopressin https://emcrit.org/ibcc/pressors/ - From UP TO DATE: > At low doses of 1 to 3 mcg/kg per min, dopamine acts primarily on dopamine-1 receptors to dilate the renal and mesenteric artery beds > At 3 to 10 mcg/kg per min (and perhaps also at lower doses), dopamine also stimulates beta-1 adrenergic receptors and increases cardiac output, predominantly by increasing stroke volume with variable effects on heart rate. > At medium-to-high doses, dopamine also stimulates alpha-adrenergic receptors, although a small study suggested that renal arterial vasodilation and improvement in cardiac output may persist as the dopamine dose is titrated up to 10 mcg/kg per min *clinically, the haemodynamic effects of dopamine demonstrate individual variability Dobutamine (inodilator): - selective β1-agonist that increases cardiac contractility and reduces pulmonary vascular and systemic vascular resistances Vasopressin: - vasopressin may have pulmonary vasodilatory effects in addition to a systemic vasoconstrictive effect Milrinone (inodilator): - the phosphodiesterase-3 inhibitors, milrinone and enxoimone, have positive inotropic effects combined with the capacity to reduce RV afterload (‘inodilators’) without significant chronotropic effect, but they can be associated with significant systemic hypotension

Answer 39

b. Myaesthenia gravis | ED95 is 0.8mg/kg in a MG patient

Answer 40

Hypophosphataemia Ferric carboxymaltose (Ferinject) for iron-deficiency anaemia https://www.nps.org.au/radar/articles/ferric-carboxymaltose-ferinject-for-iron-deficiency-anaemia In this set of patients administered FCM (n = 5799), treatment-related side effects that occurred in more than 1% of the group included: - nausea (3.1%) - hypophosphataemia (1.9%) - injection-site reactions (1.6%) - headache (1.4%) - hypertension (1.3%) - dizziness (1.2%)

Answer 41

B Morphine Histamine-releasing

Answer 42

Rectal indomethacin APMSE 5th edition 8.6.1.3: Only rectal NSAIDs are effective for reducing post ERCP pancreatitis, particularly indomethacin. Epidural > PCA for severe acute pancreatitis

Answer 43

a. Calcium (unless hyppocalcaemia is causing your seizures) Deranged Physiology: First line agents - Benzodiazepines: boluses every 2-5 minutes - Phenytoin: 20mg/kg loading dose Phenytoin on its own is useless. Or rather, it is inferior to benzodiazepines as a solitary agent. Always, both must be used simultaneously. Second line agents - Midazolam infusion - Phenytoin (well, rather, the American study recommends fosphenytoin) - Phenobarbital and levetiracetam are also in this second line of attack Third line agents: for refractory status epilepticus - Propofol infusion, or midazolam infusion, or thiopentone infusion. - At this stage, continuous EEG monitoring becomes mandatory - The role of traditional antiepileptic drugs is also exhausted at this stage, as there will probably be no benefit from adding them into a situation where a constantly observed burst suppression is already achieved by high dose anaesthetic infusion. Fourth line agents: for these, there is little evidence. - Volatile anaesthetic agents - Desflurane and Isoflurane - Ketamine - Lignocaine - Magnesium - Pyridoxine Fifth line therapies: - Hypothermia - Ketogenic diet - Deep brain stimulation - Surgical management

Answer 44

Phenoxybenzamine UpToDate Phenoxybenzamine is the preferred drug for preoperative preparation to control blood pressure and arrhythmia in most centers in the United States. It is an irreversible, long-acting, nonspecific alpha-adrenergic blocking agent. With their more favorable side-effect profiles and lower financial cost, selective alpha-1-adrenergic blocking agents (eg, prazosin, t erazosin, or d oxazosin) are utilized in many centers or are preferred to phenoxybenzamine when long-term pharmacologic treatment is indicated (eg, for metastatic pheochromocytoma).

Answer 45

e) Hydromorphone

Answer 46

b) Propofol BJA: No evidence for contraindications to the use of propofol in adults allergic to egg, soy or peanut "No connection between allergy to propofol and allergy to egg, soy or peanut was found. The present practice of choosing alternatives to propofol in patients with this kind of food allergy is not evidence based and should be reconsidered."

Answer 47

a. Increases NIRS , decreases peripheral SctO2 up, SpO2 down. Source: Korean Journal Anaesthesia https://www.researchgate.net/publication/274570990_Effects_of_intravenously_administered_indocyanine_green_on_near-infrared_cerebral_oximetry_and_pulse_oximetry_readings

Answer 48

a. codeine Oxycodone B Morphine C Tramadol C Fentanyl C

Answer 49

b. 100mg QID 42mg IV Morphine = 126mg Oral Morphine 126/8= 15.75 15.75 x 25 = 393.75 (*400mg/day Tapentadol) Oral Tapentadol 25mg = 8mg Oral Morphine Oral Oxycodone 5mg = 8mg Oral Morphine Oral Tramadol 25mg = Oral Morphine 5mg Oral Hydromorphone 4mg = Oral Morphine 20mg S/L Buprenorphine 200mcg = 8mg Oral Morphine IV Oxycodone 5mg = Oral Morphine 15mg IV Morphine 5mg = Oral Morphine 15mg IV Hydromorphone 1mg = Oral Morphine 15mg

Answer 50

Tramadol APMSE 5th edition: Tramadol is an effective treatment for neuropathic pain with NNT of 4.4 (95%CI 2.9 to 8.8) Alpha-2-delta ligands (gabapentinoids) are the only anticonvulsants with proven efficacy in the treatment of chronic neuropathic pain. At doses of 1,800 mg to 3,600 mg/d, gabapentin is effective in treating neuropathic pain, in particular caused by postherpetic neuralgia (NNT 6.7; 95%CI 5.4 to 8.7) Pregabalin Postherpetic neuralgia: 300 mg/d pregabalin (NNT 5.3; 95%CI 3.9 to 8.1) (4 RCTs, n=713) and 600 mg/d (NNT 3.9; 95%CI 3.1 to 5.5) (4 RCTs, n=732); * Painful diabetic neuropathy: 600 mg/d pregabalin (NNT 7.8; 95% CI 5.4 to 14) (5 RCTs, n=1,015); * Mixed or unclassified post-traumatic neuropathic pain: 600 mg/d pregabalin (NNT 7.2; 95%CI 5.4 to 11) (4 RCTs, n=1,367); * Central neuropathic pain (mainly SCI): 600 mg/d pregabalin (NNT 9.8; 95%CI 6.0 to 28) (3 RCTs, n=562). Amitriptyline NNT 4.6 (TCAs are effective in treatment of neuropathic pain (amitrip NNT 4.6)) Amitriptyline By order of favourable NNT: 1. TCAs (amitriptyline) NNT: 3.6, NNH: 9 2. Strong opioids NNT 4.3 NNH 11.7 3. Tramadol NNT: 4.7, NNH 12.6 4. SNRIs (duloxetine and venlafaxine) NNT 6.4, NNH 11.8 5. Gabapentin NNT: 7.2 NNH 25.6 6. Pregabalin NNT:7.7, NNH 13.9 ANZCA Pain book Treatment of chronic neuropathic pain after SCI (Guy 2016 GL). These guidelines recommend: * First line: pregabalin, gabapentin and amitriptyline; * Second line: tramadol and lamotrigine (in incomplete SCI); * Third line: Transcranial direct current stimulation (tDCS) alone and combined with visual illusion; * Fourth line: TENS, oxycodone and dorsal root entry zone lesions.

Answer 51

b. valsalva Fluid and magnesium - fixes all. But could also be conscious VT or something stupid....

Answer 52

CP b. Cerebral palsy ->sux and volatiles are not contraindicated -> presence of extrajunctional receptors may cause hyperkalaemia a. Becker muscular dystrophy -> essentially milder Duchenne's (see duchenne response to Sux) b. Cerebral palsy -> Sux and volatiles not contraindicated -> reduced MAC requirement -> increased sensitivity to muscle relaxants c. Guillain Barre -> sux contraindicated due to risk of hyperkalaemia -> increased sensitivity to Non depolarising NB d. Frederich’s ataxia -> sux should be avoided due to risk of hyperkalaemia e. Duchenne muscular dystrophy -> sux and volatiles contraindicated due to rick of hyperkalaemia and rhabdomyolysis

Answer 53

d) Reduced time to resumption of oral intake The effect of preoperative dexamethasone on early oral intake, vomiting and pain after tonsillectomy https://pubmed.ncbi.nlm.nih.gov/15979735/ Conclusion: Preoperative dexamethasone use significantly reduces early posttonsillectomy pain, improves oral intake and facilitates meeting the discharge criteria while using standard anesthesia technique and sharp dissection tonsillectomy without any significant side effects.

Answer 54

E. Upper GI bleed Incompressible sites, large volume blood loss and mortality risk are a few of the things that made GI bleeds seem like a natural fit for TXA administration. Early research seemed promising, but trials were small. The HALT-IT trial examined over 15,000 patients to see if TXA reduced death [14]. Not only did TXA have no effect on mortality, it increased the risk of seizure and thromboembolic events. Take home: No demonstrated benefit with TXA in GI bleeding ## Footnote https://www.ems1.com/research-reviews/articles/understanding-txa-AFkqRLajUv46X7xV/

Answer 55

d) myasthenia gravis In contrast to other neuromuscular disorders, succinylcholine may be used in myasthenia gravis. The required dose may need to be increased by up to two-fold, as those with the disease show a relative resistance to the drug. Sux is not recommended in patients with neuromuscular disease due to: 1. presence of extrajunctional receptors and risk of hyperkalaemia and rhabodmyolysis 2. fasiculations causing temperomandibular muscle spasm preventing intubation Suxamethonium is contraindicated in patients with recent burns or spinal cord trauma causing paraplegia (can be given immediately after the injury, but should be avoided from approximately day 10 to day 100 after the injury), | ED95 is 0.8mg/kg in a MG patient

Answer 56

Dabigatran definitely, almost entirely renal clearance Warfarin no Rivaroxaban no Clopidogrel yes (renal excretion) Apixaban yes

Answer 57

Fluoxetine

Answer 58

c. dobutamine ## Footnote UTD

Answer 59

b. COHb level 10%

Answer 60

increased incidence of major bleeding

Answer 61

photosensitivity Gliolan (PI): - Aminolevulinic acid hydrochloride (ALA) - Natural precurore of haeme, metabolised into fluorescent prophyrins - The fluorescence in certain tissue targets for photodynamic diagnosis - Increased fluorescent porphyrin formation by malignant glioma tissue (i.e. GBM) - After excitation with blue light (λ=400‑410 nm), PPIX is strongly fluorescent (peak at λ=635 nm) and can be visualised after appropriate modifications to a standard neurosurgical microscope. - Avoid exposure of eyes and skin to light sources afterwards (photosensivity). Contraindications: - hypersensitivity - porphyria - pregnancy Precautions: - After administration of Gliolan, exposure of eyes and skin to strong light sources (e.g. operating illumination, direct sunlight or brightly focused indoor light) should be avoided for 24 hours. - Co-administration with other potentially phototoxic substances (e.g. tetracyclines, sulfonamides, fluoroquinolones, hypericin extracts) should be avoided - Within 24 hours after administration, other potentially hepatotoxic medicinal products should be avoided. - In patients with pre-existing cardiovascular disease, Gliolan should be used with caution since literature reports have shown decreased systolic and diastolic blood pressures, pulmonary artery systolic and diastolic pressure as well as pulmonary vascular resistance.

Answer 62

c) Prothrombinex | Has factors 2, 9, 10, heparin, ATIII

Answer 63

d) No difference Repeat Conclusions In patients undergoing mechanical ventilation, the rate of survival at 90 days associated with the use of an energy-dense formulation for enteral delivery of nutrition was not higher than that with routine enteral nutrition. (Funded by National Health and Medical Research Institute of Australia and the Health Research Council of New Zealand; TARGET ClinicalTrials.gov number, NCT02306746. opens in new tab.) https://www.nejm.org/doi/full/10.1056/NEJMoa1811687

Answer 64

c. Doxycycline 400mg Insertion of Mirena-> no antibiotics exception is acute PID-> clindamycin https://ranzcog.edu.au/wp-content/uploads/2022/05/Prophylactic-Antibiotics-in-Obstetrics-and-Gynaecology.pdf

Answer 65

b) Desflurane Atmospheric heat absorbed by a substance compared with CO2 is its GWP GWP CO2 = 1 GWP N20 = 265 (atmospheric lifetime of 114yrs) GWP sevo = 130 (atmospheric lifetime of 1.1yrs) GWP desflurane = 2540 (atmospheric lifetime of 14yrs)

Answer 66

c) 1.0 Clinicians should consider DKA/euDKA in patients taking SGLT2i who have one or more of: - symptoms of abdo pain, nausea, vomiting, fatigue or metabolic acidosis (a normal or only modestedly elevated plasma glucose level does not exclude diagnosis) - finger prick capillary blood ketone ( or blood beta-hydroxybutyrate) level >1/0mmol/l with or without hyperglycaemia - Low (negative) Base Excess <-5mmol/l indicating metabolic acidosis on arterial or venous blood gasses If the blood ketone leve is >1.0mmol/l in an unwell patient on SGLT2i, take arterial or venous blood gases to measure the BE. If ketones >1.0mmol/l and BE <-5mmol/l the patient has presumed DKA If the BSL is <14mmol/l it is presumed euDKA > for a ward patient a MET team should be activated or ICU contacted for review in collaboration with endocrinology services > management priorities include: 1. Rehydration 2. IV insulin with added dextrose if BSL <15mmol/l 3. hourly monitoring of blood glucose, ketones and blood gases 4. All should be reviewed by an endocrinologist or on-call physician and critical care specialist

Answer 67

Cefazolin A first-generation cephalosporin is recommended, such as 2g intravenous cefazolin. The dose should be increased to 3g for women weighing over 120kg. Consideration should also be given to a repeat dose if the procedure is prolonged (over 3 hours). * For women with a history of immediate or delayed nonsevere hypersensitivity to penicillins, cefazolin, as above, remains appropriate. * For women with a history of immediate or delayed severe hypersensitivity to penicillins, use Clindamycin 600mg iv plus Gentamicin 2mg/kg iv. * For women colonised with Methicillin-resistant Staphylococcus aureas (MRSA) or at increased risk of being colonised with MRSA, add Vancomycin 15mg/kg iv. * Azithromycin may be considered at caesarean sections performed during labour or at least four hours after rupture of membranes (2). Administration of azithromycin 500mg has been shown to reduce a composite outcome of endometritis, wound infection or other infection (3). However, a strong recommendation in favour of routine use is not yet warranted given the concerns around the external validity of the paper, inducing resistance to azithromycin and possible effects on the establishment of the indigenous microbiome.

Answer 68

b) diclofenac LIthium perioperative concerns: - Prolongation of NMB - Reduction in anaesthetic agent requirement - Avoid NSAIDs - No withdrawl symptoms - Discontinue 24hrs before surgery NSAIDs differentially alter lithium concentrations by multiple mechanisms, and one of these is to reduce prostaglandin E2 BJA: perioperative advice for psychotropic drugs

Answer 69

b. Procainamide BJA: Perioperative cardiac arrhythmias https://academic.oup.com/bja/article/93/1/86/265716 - Paroxysmal SVT (PSVT) due to re‐entrant circuits that involve accessory pathways (congenital electrical connections between the atrium and ventricle that bypass the AV node, such as Wolff–Parkinson–White Syndrome) pose caveats in the management of SVT. - It should be noted that patients with accessory pathways, in addition to PSVT, may also develop atrial fibrillation, and in the latter situation are at increased risk for developing ventricular fibrillation (VF) upon exposure to classic AV‐nodal blocking agents (digoxin, calcium channel blockers, beta blockers, adenosine) because these agents reduce the accessory bundle refractory period. - In such cases, i.v. procainamide, which slows conduction over the accessory bundle, is an acceptable option. Flecainide and amiodarone should also be considered, and cardiology consultation may be helpful.2

Answer 70

c) propofol https://anaesthetists.org/Portals/0/PDFs/Guidelines%20PDFs/Guideline_management_severe_local_anaesthetic_toxicity_v2_2010_final.pdf?ver=2018-07-11-163755-240&ver=2018-07-11-163755-240

Answer 71

a) Dopamine receptor MOA: central acting anticholinergic

Answer 72

D Inhalational anaesthetic https://resources.wfsahq.org/atotw/emergence-delirium-in-pediatric-patients/

Answer 73

neurological damage due to methionine deficit

Answer 74

c) pharyngeal muscles Millers Anaesthesia: Reference artyicle from Millers: https://pubs.asahq.org/anesthesiology/article/92/4/977/710/The-Incidence-and-Mechanisms-of-Pharyngeal-and An adductor pollicis TOF ratio of 0.90 or less was associated with impaired pharyngeal function and airway protection, resulting in a four- to fivefold increase in the incidence of pharyngeal dysfunction causing misdirected swallowing. Moreover, pharyngeal function and airway protection may be impaired, even if the adductor pollicis muscle has recovered to a TOF ratio of more than 0.90.

Answer 75

c) Increased mortality Use of perioperative metoprolol was associated with: * Decreased rate of myocardial infarction * Decreased rate of revascularisation * Decreased rate of developing new atrial fibrillation * INCREASED rate of death * INCREASED rate of stroke * INCREASED rate of significant hypotension INCREASED rate of significant bradycardia

Answer 76

e) Fluconazole Among patients taking NOACs for nonvalvular atrial fibrillation, concurrent use of amiodarone, fluconazole, rifampin, and phenytoin compared with the use of NOACs alone, was associated with increased risk of major bleeding JAMA 2017 ACC/AHA

Answer 77

a) 15 mins 50UI/kg, Prothrombinex-VF is able to completely reverse a supratherapeutic INR within 15 minutes however, vitamin K is also required to sustain the reversal effect as the half-lives of the infused clotting factors are similar to endogenous factors. ## Footnote https://www.mja.com.au/journal/2013/198/4/update-consensus-guidelines-warfarin-reversal#:~:text=Prothrombinex%2DVF%20is%20able%20to,similar%20to%20endogenous%20clotting%20factors.

Answer 78

B. bronchospasm Blue book 2017 article (see image) CLASS short acting anti-arrhythmic naturally occurring purine nucleoside MECHANISM OF ACTION depression of SA & AV nodal activity antagonises cAMP-mediated catecholamine stimulation of ventricular muscle -> negative chronotropy & dromotropy direct agonist at specific cell membrane receptors (A1 & A2) A1 = coupled to K+ channels by a guanine nucleotide-binding protein in supraventricular tissue. PHARMACEUTICS clear, colourless 3mg/mL in saline DOSE rapid IV bolus followed by saline flush 3mg -> 6mg -> 12mg (adult) 0.04 to 0.25mg/kg (children) INDICATIONS diagnosis and treatment of paroxysmal SVT ADVERSE EFFECTS bronchospasm flushing SOB Chest pain CONTRAINDICATIONS second and third degree AV block allergy care with asthma and COPD PHARMACOKINETICS Onset – 10 seconds Duration – 10 seconds Absorption – must be given IV Distribution Metabolism – absorbed by RBC’s and endothelium Elimination – t ½ = 10 seconds

Answer 79

c) bradycardia | from PI

Answer 80

c Haemophilia b

Answer 81

A) level of consciousness In any patient who is given an opioid, oversedation should be considered to indicate OIVI until proven otherwise, regardless of a patient’s respiratory rate or oxygen saturation levels. Source ANZCA PS 41

Answer 82

B. Diazepam UTD Discontinuation of all serotonergic agents ●Supportive care aimed at normalization of vital signs ●Sedation with benzodiazepines ●Administration of serotonin antagonists ●Assessment of the need to resume use of causative serotonergic agents after resolution of symptoms

Answer 83

e) 100mg hydrocortisone IV > note: alternatively, 6-8mg dexamethasone IV would suffice

Answer 84

d) myasthenia gravis or d) Cerebral palsy ->sux and volatiles are not contraindicated -> presence of extrajunctional receptors may cause hyperkalaemia if responses remembered incorrectly but of this list CP is probably the answer a. Becker muscular dystrophy -> essentially milder Duchenne's (see duchenne response to Sux) b. Cerebral palsy -> Sux and volatiles not contraindicated -> reduced MAC requirement -> increased sensitivity to muscle relaxants c. Guillain Barre -> sux contraindicated due to risk of hyperkalaemia -> increased sensitivity to Non depolarising NB d. Frederich’s ataxia -> sux should be avoided due to risk of hyperkalaemia e. Duchenne muscular dystrophy -> sux and volatiles contraindicated due to rick of hyperkalaemia and rhabdomyolysis In contrast to other neuromuscular disorders, succinylcholine may be used in myasthenia gravis. The required dose may need to be increased by up to two-fold, as those with the disease show a relative resistance to the drug. Sux is not recommended in patients with neuromuscular disease due to: 1. presence of extrajunctional receptors and risk of hyperkalaemia and rhabodmyolysis 2. fasiculations causing temperomandibular muscle spasm preventing intubation REPEAT

Answer 85

Physical dependence Physical dependence = presence of withdrawal symptoms when the drug is not taken.

Answer 86

a. Teicoplanin

Answer 87

c= Drugs which, owing to their pharmacological effects, have caused or may be suspected of causing, harmful effects on the human fetus or neonate without causing malformations. These effects may be reversible. Category A Drugs which have been taken by a large number of pregnant women and women of childbearing age without any proven increase in the frequency of malformations or other direct or indirect harmful effects on the fetus having been observed. Category B1 Drugs which have been taken by only a limited number of pregnant women and women of childbearing age, without an increase in the frequency of malformation or other direct or indirect harmful effects on the human fetus having been observed. Studies in animals have not shown evidence of an increased occurrence of fetal damage. Category B2 Drugs which have been taken by only a limited number of pregnant women and women of childbearing age, without an increase in the frequency of malformation or other direct or indirect harmful effects on the human fetus having been observed. Studies in animals are inadequate or may be lacking, but available data show no evidence of an increased occurrence of fetal damage. Category B3 Drugs which have been taken by only a limited number of pregnant women and women of childbearing age, without an increase in the frequency of malformation or other direct or indirect harmful effects on the human fetus having been observed. Studies in animals have shown evidence of an increased occurrence of fetal damage, the significance of which is considered uncertain in humans. Category C Drugs which, owing to their pharmacological effects, have caused or may be suspected of causing, harmful effects on the human fetus or neonate without causing malformations. These effects may be reversible. Accompanying texts should be consulted for further details. Category D Drugs which have caused, are suspected to have caused or may be expected to cause, an increased incidence of human fetal malformations or irreversible damage. These drugs may also have adverse pharmacological effects. Accompanying texts should be consulted for further details. Category X Drugs which have such a high risk of causing permanent damage to the fetus that they should not be used in pregnancy or when there is a possibility of pregnancy.

Answer 88

d) Alprostadil https://www.rch.org.au/piper/neonatal_medication_guidelines/Alprostadil_(Prostin_VR)_%E2%80%93_(Prostaglandin_E1)/ Alprostadil (PROSTAGLANDIN E1) is a synthetic prostaglandin used to relax the ductus arteriosus in early post-natal life, where a patent ductus is critical for survival, including Tetralogy of Fallot, pulmonary atresia, pulmonary stenosis, tricuspid atresia and transposition of the great arteries. Dose To open a closed ductus arteriosus: 0.1 micrograms/kg/minute (100 nanograms/kg/min). An effect is usually seen within 30-60 minutes. Reduce the dose once an effect is seen or as directed by a Consultant.1 Doses > 0.1 micrograms/kg/minute are rarely more effective and may cause serious adverse effects.3 To maintain patency of ductus arteriosus: 0.01 to 0.02 micrograms/kg/minute (10-20 nanograms/kg/min).1, 2 For persistent pulmonary hypertension of the newborn (PPHN): 0.01 to 0.05 micrograms/kg/minute (10-50 nanograms/kg/min).2

Answer 89

a) 10 Dose of Dantrolene = 2.5mg/kg Repeat every 10 minutes to a Maximum dose of 10mg/kg (Total Vials = 35) Each Vial Dantrolene = 20mg 80 x 2.5mg = 200mg Therefore 10 Vials of 20mg Dantrolene Or, TBW(kg)/8 = number of vials required for initial dose

Answer 90

b) conscious state No mention of BP or HR in ANZCA OIVI monitoring document In many published reports of patient deaths resulting from OIVI, undue reliance has been placed on respiratory rate as a unidimensional measure of OIVI, either without formal assessment of patient sedation, or without recognising the significance of excessive sedation Respiratory rate and oxygen saturation levels are not direct measures of adequacy of ventilation. Sedation scores should be assessed repeatedly at intervals that are appropriate to the route of opioid administration Continuous measurement of a patient’s carbon dioxide concentrations is more likely to identify OIVI than continuous pulse oximetry

Answer 91

c. Warfarin It is also a potent inducer of hepatic cytochrome P450 CYP3A4 isoform. Hence, it may significantly increase the metabolism of many concomitantly administered drugs such as alfentanil, midazolam, and lidocaine. It also induces the P450 2C9 isoform that results in the reduction in effect of warfarin and NSAIDs

Answer 92

A. 2.5mg/kg/hr Associated with high doses >4mg/kg/hr and prolonged use (>48hrs) Safe doses of propofol infusion for sedation in ICU are considered to be 1-4mg/kg/hr -> fatal Cases pf PRIS have been reported after infusion doses as low as 1.9-2.6mg/kg/hr Risk factors: i. Young age ii. Critical illness iii. High fat and low Carbohydrate intake iv. Inborn errors of mitochondrial fatty acid oxidation v. Catecholamine infusion/ High catecholamine and glucocorticoid levels vi. Steroid therapy vii. Severe head injuries Characteristics: i. Bradycardia ii. Severe metabolic acidosis iii. Cardiovascular collapse iv. Rhabdomyolysis v. Hyperlipidaemia vi. Renal failure vii. Hepatomegaly Management: - Routine monitoring of CK and triglycerides should be performed for the at risk population ○ Daily CK and triglyceridees after 48hrs of propofol infusion ○ Increasing CK in the absence of other pathology triggers suspiscion of PRIS - Propofol immediately stopped and alternative (midazolam and alfentanil) are used - PRIS is difficult to treat once it occurs - CVS support provided as needed - Renal replacement therapy may be required to treat lactic acidosis, clear propofol and its metabolites from the patient rapidly - Catecholamine resistant shock has been reported - Pacing has been used with limited success ECMO has been reported and successfully used in the CVS support of PRIS

Answer 93

D - AB Group AB plasma or group A plasma that is high-titre negative can be given in an emergency when the blood group is unknown. Group AB plasma is universal but in short supply.

Answer 94

b) pKa Onset = pKa Duration = Lipophilicity Offset = protein binding BJA: Basic pharmacology of local anaesthetics https://www.bjaed.org/article/S2058-5349(19)30152-0/fulltext Local anaesthetic agents are amphipathic molecules. They bind primarily to sodium channels but also to potassium and calcium channels, and G-protein-coupled receptors. Structural modifications alter the physicochemical characteristics of a local anaesthetic. Speed of onset, potency, and duration depend on the pKa, lipid solubility and protein binding, respectively. All local anaesthetic agents carry a risk of toxicity.

Answer 95

b) 20mcg Grade (ANZAAG) 1 - mucocutaneous only (mild) 2 - mucocutaneous and hypotension and/or bronchospasm (moderate) 3 - life threatening hypotension and/or high airway pressure (severe) 4 - arrest For adults, put 3mg into a 50ml syringe (or 6mg into 100mls saline; and running in mls/hr = mcg/min) Doses: - 20mcg = Grade 2 - 100-200mcg = Grade 3 - 1mg = Grade 4 For Paediatrics: - put 1mg into 50ml syringe, (20mcg/ml; run @ 0.3ml/kg/hr = 0.1mcg/kg/min) - 2mcg/kg = Grade 2 (0.1ml/kg of this dilution) - 4-10 mcg/kg = Grade 3 - 10 mcg/kg = Grade 4 (0.1ml/kg of 1:10 000 (i.e. 100mcg/ml concentration)) - IM doses are: > 150mcg if <6 yrs > 300mcg if 6-12yrs;

Answer 96

d) No difference no observed beneficial effect of sevoflurane on the composite endpoint of prolonged ICU stay, mortality, or both in patients undergoing high-risk cardiac surgery

Answer 97

b) Decreased mortality due to bleeding TXA decreased death due to bleeding. No difference in all cause mortality. No difference in use of blood products. No difference in surgical interventions. No difference in thromboembolic events.

Answer 98

a) Less transfusion, same thrombosis ●A 2019 meta-analysis of randomized trials comparing preoperative administration of EPO versus placebo (32 trials; 4750 patients, mostly orthopedic and cardiac surgery) found reduced blood transfusions in the EPO groups. Decreased blood transfusions were seen in the entire population (RR 0.59, 95% CI 0.47-0.73; 28 trials), as well as the subgroups undergoing cardiac surgery (RR 0.55, 95% CI 0.47-0.73; nine trials) and major orthopedic surgery (RR 0.36, 95% CI 0.28-0.46; five trials). In addition, the EPO group had increased hemoglobin levels. There was no increase in the incidence of thromboembolic events with EPO.

Answer 99

b) 20mg hydromorphone PO: morphine PO = 1: 5 So 12mg x 5= 60mg Morphine PO Which to convert to PO morph: IV morph is 3:1, so 60mg/3 = 20mg of parenteral morphine IV hydromorphone: IV hydromorphone 1mg = 15mg PO Morphine = 5mg IV morphine. How to remember this: - hydromorphone PCA is a 200mcg (1ml) bolus; 20mg into 100mls for PCA; therefore 20mg IV hydromorphone = 100mg IV morphine (i.e. 300mg PO morphine) - vial in recovery for pain protocol also comes as 2mg (i.e. 10mg IV morphine equivalent)

Answer 100

a) R1 side chain UP TO DATE: - sensitisation to R1 side chain in cephalosporins important in determining cross reactivity with penicillins.

Answer 101

b) Central retinal occlusion SE's from HBOT: - progressive myopia (reversible) - seizures - hypoglycaemia - sinus bradycardia from stimulation of vagal activity bassociated with hyperbaric pressures

Answer 102

Unclear: age of patient not given in question, real answer for patient >70yrs old appears to be lack of net benefit but this is not a remembered option Answer: A) increased incidence of major bleeding Low-dose aspirin should not be administered on a routine basis for primary prevention of ASCVD among adults >70 years. Low-dose aspirin should not be administered on a routine basis for primary prevention of ASCVD among adults >70 years. 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease Aspirin Candidates — For the secondary prevention of ASCVD in patients with diabetes, we recommend aspirin (75 to 162 mg daily). For the primary prevention of ASCVD in patients with diabetes at increased cardiovascular risk (10-year risk >10 percent), we suggest aspirin (75 to 162 mg daily), although the evidence supporting this approach is weak and needs to be balanced with the increased risk of gastrointestinal bleeding. We do not routinely use aspirin for the prevention of ASCVD in adults with diabetes at low risk (10-year ASCVD risk <10 percent). (See 'Guidelines' below.) 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease Aspirin Aspirin is well established for secondary prevention of ASCVD and is widely recommended for this indication, but recent studies have shown that in the modern era, aspirin should not be used in the routine primary prevention of ASCVD due to lack of net benefit. Most important is to avoid aspirin in persons with increased risk of bleeding including a history of GI bleeding or peptic ulcer disease, bleeding from other sites, age >70 years, thrombocytopenia, coagulopathy, chronic kidney disease, and concurrent use of nonsteroidal anti-inflammatory drugs, steroids, and anticoagulants. The following are recommendations based on meta-analysis and three recent trials: Low-dose aspirin might be considered for primary prevention of ASCVD in select higher ASCVD adults aged 40-70 years who are not at increased bleeding risk. Low-dose aspirin should not be administered on a routine basis for primary prevention of ASCVD among adults >70 years. Low-dose aspirin should not be administered for primary prevention among adults at any age who are at increased bleeding risk.

Answer 103

Codeine Source Appendix ANZCA PG 07

Answer 104

c. 50% 0.25mg/kg (Half) Source: PolioSA And ANZCA bulletin 2015 ‘Anaesthetists need to be wary of post polio syndrome’ -“twice as sensitive to non-depolarising muscle relaxants”

Answer 105

Answer: b. rocuronium anaphylaxis NB RadioAllergoabsorbentSpecificTesting is a serum test for specific IgE antibodies RAST morphine is both more sensitive and more specific than the RAST for individual NMBDs (due to reaction with quaternary ammonium) and is being used increasingly to determine NMBDs as cause of anaphylaxis. IKR! http://www.anzaag.com/anaphylaxis-management/testing-guidelines.pdf

Answer 106

a. Not safe or c. safe only in 1st trimester While relatively safe in early and mid pregnancy, NSAIDs can precipitate fetal cardiac and renal complications in late pregnancy, as well as interfere with fetal brain development and the production of amniotic fluid; they should be discontinued in gestational wk 32 APMSE

Answer 107

Answer: d. Rocuronium BJA Anaphylaxis to neuromuscular blocking drugs: incidence and cross-reactivity in Western Australia from 2002 to 2011 https://academic.oup.com/bja/article/110/6/981/245571 Rocuronium has a higher rate of IgE-mediated anaphylaxis compared with vecuronium, a result that is statistically significant and clinically important. Cisatracurium had the lowest rate of cross-reactivity in patients who had previously suffered anaphylaxis to rocuronium or vecuronium. Anaphylaxis rates (highest to lowest) Primary anaphylaxis: rocuronium > atracurium > vecuronium > pancuronium = cisatracurium Cross-reactivity: suxamethonium > rocuronium > vecuronium > pancuronium > atracurium > cisatracurium

Answer 108

d. none Increase in presence of mycobacterium vaginosis, doxycylcine will kill commensal bacteria Doxycycline is used for copper IUD in the setting of emergency insertion with PID

Answer 109

5 mmol bolus KCl 3.6 Potassium Potassium is an electrolyte essential for membrane stability. Low serum potassium, especially in conjunction with digoxin therapy and hypomagnesaemia, may lead to life threatening ventricular arrhythmias. Consider administration for: * Persistent VF due to documented or suspected hypokalaemia. [Class A; Expert consensus opinion] ANZCOR Guideline 11.5 August 2016 Page 9 of 13 Adverse effects: * Inappropriate or excessive use will produce hyperkalaemia with bradycardia, hypotension and possible asystole * Extravasation may lead to tissue necrosis. Dosage: A bolus of 5 mmol of potassium chloride is given intravenously

Answer 110

5d ANZCA - CrCl >80 (3D) 80-50 (4D) <50 (5D)

Answer 111

e) Prothrombinex may potentiate DIC due to increasing thrombotic tendancy Australian redcross

Answer 112

D. perindopril Acute hypotensive transfusion reaction (AHTR) is characterized by the abrupt onset of hypotension immediately after the start of transfusion and usually resolves when transfusion ceases. Recent studies have shown an association with pre-operative treatment with an angiotensin-converting enzyme (ACE) inhibitor https://www.lifeblood.com.au/health-professionals/clinical-practice/adverse-events/hypotension

Answer 113

20mg 12mg PO hydromorphone = 60mg PO morphine (Factor of 5) PO - IV Morphine = factor of 3 FPM App

Answer 114

e. 60g Each 20mg dantrolene contains 3g mannitol

Answer 115

5 days Previous MCQ2015A – cryoprecipitate once thawed must use within 4 hours. Previous MCQ2015B – FFP must be transfused within 4 hours once thawed, or stored at 2-6 degrees for 5 days.

Answer 116

e) haloperidol Bluebook - suggest antipsychotics with caution

Answer 117

Taking > 1 month https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/full/10.1111/anae.14963 Daily doses of prednisolone of 5 mg or greater in adults and 10–15 mg.m−2 hydrocortisone equivalent or greater in children may result in hypothalamo–pituitary–adrenal axis suppression if administered for 1 month or more by oral, inhaled, intranasal, intra-articular or topical routes; this chronic administration of glucocorticoids is the most common cause of secondary adrenal suppression, sometimes referred to as tertiary adrenal insufficiency All children who have known glucocorticoid deficiency (primary or secondary), or who are at risk of glucocorticoid deficiency (on significant exogenous dose of glucocorticoid >10–15 mg.m-2 per day) 38, should receive an i.v. dose of hydrocortisone at induction (2 mg.kg−1 for minor or major surgery under general anaesthesia).

Answer 118

a) NT ProBNP Sacubitrilat inhibits the enzyme neprilysin, which is responsible for the degradation of atrial and brain natriuretic peptide, two blood pressure–lowering peptides that work mainly by reducing blood volume. In contrast, in comparison with enalapril, patients receiving LCZ696 had consistently lower levels of NTproBNP (reflecting reduced cardiac wall stress) and troponin (reflecting reduced cardiac injury) throughout the trial. ## Footnote https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.114.013748?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%20%200pubmed

Answer 119

c) Decreased clearance – same dose

Answer 120

Chronic neurological symptoms from methionine depletion

Answer 121

a) Alprostadil Prostin (PGE1)

Answer 122

d. 7 days A bolus dose of sugammadex is thought to have the following consequences: (i) the equivalent of missing one daily dose of oral contraceptives, and (ii) reduced efficacy of other hormonal contraceptives (e.g. implant, vaginal ring, or intrauterine system) requiring additional non-hormonal contraception be used for 7 days. https://www.bjanaesthesia.org/article/S0007-0912(18)30198-3/fulltext

Answer 123

c) Continuation leads to increased risk of major bleeding Aspirin in patients undergoing non cardiac surgery https://www.nejm.org/doi/full/10.1056/nejmoa1401105 Conclusions Administration of aspirin before surgery and throughout the early postsurgical period had no significant effect on the rate of a composite of death or nonfatal myocardial infarction but increased the risk of major bleeding. (Funded by the Canadian Institutes of Health Research and others; POISE-2 ClinicalTrials.gov number

Answer 124

Ventilate and wait for recovery

Answer 125

b) fibrinogen concentrate bleeding and low fib = concentrate not bleding and low = cryo

Answer 126

Thrombin rivaroxiban 10 dabigatran thrombin

Answer 127

e) Reversible hypermetropia

Answer 128

a) DDAVP Polyuria Low urine osm High serum osm High Na post transsphenoidal sx = Central DI

Answer 129

d. acetazolamide acetazolamdie has been known to cause lactic acidosis but is less common than the other drugs listed unless there is a 5th option not remembered

Answer 130

c) Alcohol 70% - only suitable for short-term cannulation (<24 hours)

Answer 131

Ergometrin increases PVR and SVR

Answer 132

c) 30ml/kg After a dose of 10 to 15 mL/kg of FFP, plasma clotting factors rise about 15%, and the fibrinogen level rises by 40 mg/dL (0.4g/l) https://www.sciencedirect.com/topics/medicine-and-dentistry/fresh-frozen-plasma 1g/0.4g= 2.5 2.5 x 10ml/kg= 25ml/kg 2.5 x 15ml/kg= 37.5ml/kg 30ml/kg best answer For cryoprecipitate: One unit of Cryo is 15-20 mL in volume and contains 150-250 mg of fibrinogen. Cryo is generally transfused in pools of 10 units, which should increase an adult recipient's fibrinogen level by 50-100 mg/dL. (0.5-1g/l) 10 units of cryo= 200-300ml 200ml/70kg= 2.8ml/kg 300ml/70kg= 4.2ml/kg

Answer 133

c. Dobutamine In 2017 a similar questions was asked and an option for metaraminol was given, metaraminol could be a better answer as it will increase systemic pressure and reduce heart rate maintaining RCA perfusion at induction. Dobutamine and Milrinone can cause systemic vasodilation leading to reduction in systemic blood pressure and RCA perfusion pressure, Both adrenaline and Dopamine do not cause pulmonary vasodilation and can lead to tachyarhythmias Pulmonary hypertension and its management in patients undergoing non-cardiac surgery https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/10.1111/anae.12831 Vasoconstrictors, inotropes and inodilators Maintaining the gradient between aorta and right ventricle is achieved by using sympathomimetic and non-sympathomimetic vasopressors. Noradrenaline and vasopressin improve perfusion of the right coronary artery, reduce the pulmonary/systemic vascular resistance ratio, enhance right ventricular performance and marginally improve cardiac output However, the evidence of their impact on mortality related to right heart failure is weak. Inotropes that enhance right ventricular performance, such as adrenaline, dobutamine and levosimendan are effective in treating right-sided heart failure. The use of inotropes has a modest impact in reducing the overall mortality related to PH, and their wide availability and ease of administration make this group of drugs very attractive for use in the peri-operative setting. Inodilators, such as the phosphodiesterase-3 inhibitors milrinone and enoximone, have been shown to be beneficial when compared with conventional inotropic support only. It appears that the influence of phosphodiesterase-3 inhibitors on reducing pulmonary vascular resistance is more pronounced than the reduction in systemic vascular resistance. However, reduction in systemic vascular resistance can compromise right coronary artery blood flow in patients with severe PH and therefore they should be administered cautiously. Treatment of pulmonary hypertensive crisis: General principles - Avoid hypoxic pulmonary vasoconstriction - Avoid hypercarbia, acidosis and hypothermia - Avoid high airway pressures - Optimise right ventricular preload - Reduce right ventricular afterload - Maintain coronary blood flow - Maintain sinus rhythm - Maintain arterial blood pressure and cardiac output Vasopressors– noradrenaline; vasopressin Inotropes– adrenaline; dobutamine Inodilators– milrinone; enoximone Intravenous vasodilators (caution if low systolic blood pressure) - Milrinone (25–50 μg.kg−1 bolus, followed by 0.5–0.75 μg.kg−1.min−1 continuous infusion) - Prostacyclin (4–10 ng.kg−1.min−1 continuous infusion) - Iloprost (1–3 ng.kg−1.min−1 continuous infusion) - Sildenafil (10 mg bolus three times a day) Selective pulmonary vasodilation - Iloprost (5–10 μg diluted in 10 ml saline, nebulised over 10 min, repeated every 2–4 h) - Prostacyclin (25–50 μg diluted in 50 ml saline, nebulised over 15 min, repeated every hour) - Nitric oxide (5–40 ppm continuously)

Answer 134

a) day of and 2 days prior

Answer 135

Dopamine - least likely to cause pulmonary vasodilation (all the others do to my knowledge) - From UP TO DATE: > At low doses of 1 to 3 mcg/kg per min, dopamine acts primarily on dopamine-1 receptors to dilate the renal and mesenteric artery beds > At 3 to 10 mcg/kg per min (and perhaps also at lower doses), dopamine also stimulates beta-1 adrenergic receptors and increases cardiac output, predominantly by increasing stroke volume with variable effects on heart rate. > At medium-to-high doses, dopamine also stimulates alpha-adrenergic receptors, although a small study suggested that renal arterial vasodilation and improvement in cardiac output may persist as the dopamine dose is titrated up to 10 mcg/kg per min *clinically, the haemodynamic effects of dopamine demonstrate individual variability Dobutamine (inodilator): - selective β1-agonist that increases cardiac contractility and reduces pulmonary vascular and systemic vascular resistances Vasopressin: - vasopressin may have pulmonary vasodilatory effects in addition to a systemic vasoconstrictive effect Milrinone (inodilator): - the phosphodiesterase-3 inhibitors, milrinone and enxoimone, have positive inotropic effects combined with the capacity to reduce RV afterload (‘inodilators’) without significant chronotropic effect, but they can be associated with significant systemic hypotension ## Footnote https://pubs.asahq.org/anesthesiology/article/121/5/914/13855/VasopressinThe-Perioperative-Gift-that-Keeps-on

Answer 136

D. Substance P Development of aprepitant, the first neurokinin-1 receptor antagonist for the prevention of chemotherapy-induced nausea and vomiting (2011) https://www.ncbi.nlm.nih.gov/pubmed/21434941 Aprepitant acts centrally at NK-1 receptors in vomiting centres within the central nervous system to block their activation by substance P released as an unwanted consequence of chemotherapy. REPEAT

Answer 137

TXA DDAVP for T1 Factor 8 for T2/3 or unresponsive DDAVP (RCH Guidelines)

Answer 138

Answer: a) Codeine TGA Pregnancy categories https://www.tga.gov.au/prescribing-medicines-pregnancy-database Category A ■ Codeine Category C ■ Methadone ■ Tramadol ■ Oxycodone ■ Morphine

Answer 139

suxamethonium Organophosphate nerve agent poisoning: https://www.bjanaesthesia.org.uk/article/S0007-0912(19)30401-5/fulltext The depolarising neuromuscular blocking agent suxamethonium: - may have a longer onset (i.e. 2 min) and - duration of action (up to 12 h) secondary to the OP inhibition of BuChE. Caution should be exercised with non-depolarising neuromuscular blocking agents for up to 2 yr and lower doses used to avoid prolonged paralysis. Caution should also be exercised when using other BuChE metabolised drugs such as ester local anaesthetics and mivacurium Mainstay of treatment Pralidoxime and Atropine (5-10mg IV every 5-10mins until reversal of 3 B's) Benzodiazepines used for seizure termination Glycopyrolate not mentioned in treatment but could be useful

Answer 140

b. Gelofusin Gelatin

Answer 141

a) Lean body weight FROM SOBA: LBW exceeds IBW in obese and plateaus at ~100kg in men and ~70kg in females IBW used to calculate the adjusted body weight for maintenance infusion of propofol (IBW +40%). IBW calculated using Broca formula (Ht in cm - 100; Ht in cm =105; as optimal weights for men and women respectively in kg)

Answer 142

a) Amiodarone 150mg over 30minutes, then 1mg/min for 6 hours UP TO DATE: Arrhythmias in COPD For patients with atrial fibrillation and COPD, we suggest using verapamil or diltiazem rather than metoprolol in patients who require ventricular rate control (Grade 2C). Metoprolol is reserved for patients who do not respond to the calcium channel blockers and do not have uncontrolled bronchoconstriction. For those with an accessory pathway or heart failure, amiodarone or digoxin may be preferred as outlined in the table (table 3). Addition of Digoxin in this answer stem could be prefered over Amiodarone

Answer 143

30 (2 mg/kg) CEACCP Laryngospasm in anaesthesia (2014) https://academic.oup.com/bjaed/article/14/2/47/271333 Intravenous (IV): - 0.1-2 mg/kg - lower doses used to break laryngospasm, but keep patient spont vent Intramuscular (IM): - 4 mg/kg (max 200 mg) - break laryngospasm: 45-60 seconds - full paralysis: 3-4 minutes Intralingual (IL): - 2 mg/kg - an IM injection into body of tongue - full relaxation after 75 seconds Intraosseous (IO): - 1 mg/kg - onset 35 seconds

Answer 144

d) Hypercalcaemia SGLT2 inhibitors are relatively new and have several side effects that warrant caution, including the unique risks of diabetic ketoacidosis (DKA), mycotic genital infections and possibly lower limb amputations. Also polyuria, volume depletion, hypoT Hypoglycaemia As the glucose-lowering mechanism of SGLT2 inhibitors is glycaemia-dependent, hypoglycaemia risk is low. However, hypoglycaemia may occur when SGLT2 inhibitors are used in conjunction with sulphonylurea or insulin therapy. https://www1.racgp.org.au/ajgp/2021/april/use-of-sodium-glucose-co-transporter-2-inhibitors#:~:text=Safety%20and%20tolerability,and%20possibly%20lower%20limb%20amputations.

Answer 145

repeat a) Less transfusion, same thrombosis ●A 2019 meta-analysis of randomized trials comparing preoperative administration of EPO versus placebo (32 trials; 4750 patients, mostly orthopedic and cardiac surgery) found reduced blood transfusions in the EPO groups. Decreased blood transfusions were seen in the entire population (RR 0.59, 95% CI 0.47-0.73; 28 trials), as well as the subgroups undergoing cardiac surgery (RR 0.55, 95% CI 0.47-0.73; nine trials) and major orthopedic surgery (RR 0.36, 95% CI 0.28-0.46; five trials). In addition, the EPO group had increased hemoglobin levels. There was no increase in the incidence of thromboembolic events with EPO.

Answer 146

b) Rocuronium based on LBW

Answer 147

b) 250mcg IM q15mins, up to 2mg | QLD maternity guidelines Carpoprost 250mcg IM Repeat every 15-90min as r

Answer 148

c. 200mg hydrocortisone 200mg Hydrocortisone or 25mg Prednisolone Conversion Prednisone 1mg = Hydrocortisone 4mg = Dexamethasone 0.15mg = Triamcinolone 0.8mg = Methylprednisolone 0.8mg = Betamethasone 0.15mg = (https://litfl.com/corticosteroids-overview/)

Answer 149

d) >6 Medical emissions of N2O account for <4% of all emissions of N2O, the majority originating from microbial action on nitrogenous fertilizers

Answer 150

C. No Anticoagulation - if male CHA2DS2-VASc score ≥2 to be recommended chronic OAC (Grade 1A). - if female CHA2DS2-VASc score ≥3 to be recommended chronic OAC (Grade 1A). * non-sex risk factor also holds bearing: - For patients with CHA2DS2-VASc score of 1 in males and 2 in females based on age 65 to 74 years, we recommend chronic OAC (Grade 1A). Up to date: Our approach to deciding whether to prescribe anticoagulant therapy for patients with AF (excluding those with rheumatic mitral stenosis that is severe or clinically significant [mitral valve area ≤1.5 cm2], a bioprosthetic valve [surgical or bioprosthetic] within the first three to six months after implantation, or a mechanical heart valve) is as follows: *For a CHA2DS2-VASc score ≥2 in males or ≥3 in females, we recommend chronic OAC (Grade 1A). *For a CHA2DS2-VASc score of 1 in males and 2 in females: -For patients with CHA2DS2-VASc score of 1 in males and 2 in females based on age 65 to 74 years, we recommend chronic OAC (Grade 1A). Age 65 to 74 years is a stronger risk factor than the other factors conferring one CHA2DS2-VASc score point. -For patients with other risk factors, the decision to anticoagulate is based upon the specific nonsex risk factor and the burden of AF. For patients with very low burden of AF (eg, AF that is well documented as limited to an isolated episode that may have been due to a reversible cause such as recent surgery, heavy alcohol ingestion, or sleep deprivation), it may be reasonable to forgo chronic OAC and institute close surveillance for recurrent AF, although it may not be possible to reliably estimate AF burden from surveying symptoms or infrequent monitoring. The frequency and duration of AF episodes vary widely over time, and episodes are often asymptomatic. *For patients with a CHA2DS2-VASc of 0 in males or 1 in females, we suggest against OAC (Grade 2C). Patient values and preferences may impact the decision. For example, a patient who is particularly stroke averse and is not at increased risk for bleeding may reasonably choose anticoagulation, particularly if the patient is a candidate for treatment with a direct oral anticoagulant (DOAC). 2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline

Answer 151

b. Clonidine PROSPECT 2021 https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/full/10.1111/anae.15299 Pre-operative and intra-operative interventions that improved postoperative pain were: - paracetamol; - non-steroidal anti-inflammatory drugs; - intravenous dexamethasone; - ketamine (only assessed in children); - gabapentinoids; - dexmedetomidine; - honey; - acupuncture. Inconsistent evidence was found for: - local anaesthetic infiltration; - antibiotics; - magnesium sulphate. Limited evidence was found for - clonidine. The analgesic regimen for tonsillectomy should include: 1. paracetamol; 2. non-steroidal anti-inflammatory drugs; and 3. intravenous dexamethasone, 4. with opioids as rescue analgesics. Analgesic adjuncts such as: 1. intra-operative and postoperative acupuncture as well as 2. postoperative honey are also recommended. 3. Ketamine (only for children); dexmedetomidine; or gabapentinoids may be considered when some of the first-line analgesics are contra-indicated

Answer 152

e. haloperidol Clonidine-> no mention in the evidence dexmedetomidine-> as an infusion seems to reduce risk of post-op delerium and could be used to treat but not necessarily practical in combative patient Propofol-> not mentioned Midazolam-> avoid benzos as can worsen delerium If pharmacological approaches are required to reduce risk of harm to the person with agitated delirium, then haloperidol can be administered in incremental 0.5-mg doses. Benzodiazepines should be used for people with alcohol-related cognitive disorders or in people with Parkinsonian dementia. There is no evidence to support the use of prophylactic pharmacological measures (cholinesterase inhibitors, antipsychotics, melatonin) in routine peri-operative care for patients at risk of POD https://anaesthetists.org/Portals/0/PDFs/Guidelines%20PDFs/Guideline_Perioperative_care_of_people_with_dementia_2019.pdf?ver=2019-02-11-121238-777×tamp=1549888049165&ver=2019-02-11-121238-777×tamp=1549888049165 Duan and colleagues conducted a meta-analysis of 18 clinical trials and found that intraoperative and postoperative dexmedetomidine administration significantly reduces the risk postoperative delirium (odds ratio 0.35). -> https://www.bjanaesthesia.org/article/S0007-0912(20)30566-3/fulltext

Answer 153

d) less maternal bradycardia (repeat)

Answer 154

a) neostigmine infusion Consider this Ogilve's Syndrome Psuedo-obstruction. If > 9cm dilation, would need surgical management. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3168359/#!po=17.5000

Answer 155

Adenosine (effect is exagerated)

Answer 156

Repeat a) Midazolam Blue Book 2019 RLS Definition -Common neurological sensorimotor disorder characterised by the urge to move ones legs -It is associated with unpleasnat paraesthesias deep within the legs during periods of rest or inactivity, whihc are relieved by movement Pathophysiology > RLS can be primary (idiopathic) or secondary > patients with secondary RLS develop symptoms secondary to another disease process or drug > causes of 2ry RLS include Iron deficiency, pregnancy, kidney disease, rheumatic disease and medications > 1ry RLS Pathophysiology is partially known and includes genteic component along with theories of dopamine and brain iron dysregulation Anaesthetic implications - RLS may worsen recur or present perioperatively - Common triggers include sleep deprivation and immobilisation - Drug therapy for RLS shopuld be continued perioperatively where possible - interuptions to treatment should be for the shortest time possible to prevent rebound effects - if imobilised for a long period of time, dopamine agonists such as rotigotone may be required - premedication with benzodiazepines or pregabalin may be useful - prolonged medical imaging procedures or procedures under local anaesthetic alone may not be possible. - post-op agitation 2ry to akathisia may be misinterpretted as delerium and treated with dopamine antagonists such as haloperidol which will worsen symptoms, Benzodiazepines should be used instead. Drugs that may exacerbate RLS 1. Classic neuroleptics - Haloperidol, prochlorperazine, promethazine 2. Atypical antipsychotics - clozapine, olanzapine, quetiapine 3. Antidepressants - amitriptyline, citalopram, lithium 4. Antihistamines - promethazine 5. Dopamine antagonist anti-emetics - metoclopramide 6. opioids - Tramadol (serotonin), naloxone/naltrexone (antagonists) > Opioids, oxycodone, fentanyl, morphine etc generally have a beneficial effect > IV anaesthetics, Inhalational anaesthetics, muscle relaxants, local anaesthetics, NSAIDs, Antiemetics have no effect Goals: 1. Prevent RLS exacerbation - avoid drug triggers - premedicate with benzos - use benzos for sedation - continue treatment for RLS - consider topical dopamine agonists when oral route unavailable 2. Alleviate post-op exacerbations - use parenteral opioids - Apomorphine - mobilise patient ASAP 3. Alleviate long-term exacerbation of RLS after surgery - monitor ferritin levels - If ferritin level < 75mcg/ml treat with oral or IV iron replacement - transiently increase dopamine agonist dose to TDS or QID if unable to leave bed

Answer 157

a. Diclofenac LIthium perioperative concerns: - Prolongation of NMB - Reduction in anaesthetic agent requirement - Avoid NSAIDs - No withdrawl symptoms - Discontinue 24hrs before surgery NSAIDs differentially alter lithium concentrations by multiple mechanisms, and one of these is to reduce prostaglandin E2 BJA: perioperative advice for psychotropic drugs

Answer 158

a) Smaller bolus smaller total dose

Answer 159

b. Celecoxib The ANZCA pain booklet also references this study: Risk of acute myocardial infarction with NSAIDs in real world use: bayesian meta-analysis of individual patient data With use for one to seven days the probability of increased myocardial infarction risk (posterior probability of odds ratio >1.0) was 92% for celecoxib, 97% for ibuprofen, and 99% for diclofenac, naproxen, and rofecoxib. The corresponding odds ratios (95% credible intervals) were 1.24 (0.91 to 1.82) for celecoxib, 1.48 (1.00 to 2.26) for ibuprofen, 1.50 (1.06 to 2.04) for diclofenac, 1.53 (1.07 to 2.33) for naproxen, and 1.58 (1.07 to 2.17) for rofecoxib. Greater risk of myocardial infarction was documented for higher dose of NSAIDs. With use for longer than one month, risks did not appear to exceed those associated with shorter durations. The ANZCA pain booklet also references this study https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6281031/ Naproxen OR 1, Celecoxib OR 1.3, Ibuprofen OR 1.49, Diclofenac OR 1.63 in UK study 2016 investigating NSAID use in knee OA.

Answer 160

Death in bleeding trauma patients Early administration of TXA safely reduced the risk of death in bleeding trauma patients and is highly cost-effective. Treatment beyond 3 hours of injury is unlikely to be effective. - Reduced death due to bleeding x 0.85 - Equivocal blood transfusion - Equivocal thromboembolism

Answer 161

Answer: 3%. (5%/240) x 160 Principle: If Vaporizer specific for agent with low SVP (Enflurane or Sevoflurane) is misplaced with an agent that has high SVP (halothane or isoflurane) then actual output concentration will be greater than the concentration indicated by dial. (inverse is also true) Administration of sevoflurane using other agent-specific vaporizers: The current study investigated the concentration of sevoflurane that could be achieved when sevoflurane was administered using standard agent-specific halothane, isoflurane, and enflurane vaporizers. An artificial lung analog model was made by attaching the 3-L reservoir bag to the 15-mm end of the anesthesia circle system. The lung analog was attached and ventilated with oxygen and air at flow rates of 2 L/min each (total gas flow = 4 L/min), a tidal volume of 800 mL, a rate of 10 breaths/min, and an inspiratory-to-expiratory ratio of 1:2. The vaporizer was filled with sevoflurane and the dial turned to 1%. After a 10-minute equilibration period, the concentration of sevoflurane was measured. The vaporizer concentration was increased in 1% increments, and after a 10-minute equilibration, the sevoflurane concentration was recorded. The dial was increased from 1% to 5% for the halothane and isoflurane vaporizer and from 1% to 7% for the enflurane vaporizer. Each study was repeated five times at each incremental increase of 1% for each of the three vaporizers. The series of studies were repeated using a total gas flow of 8 L/min (oxygen 4 and air 4) instead of 4 L/min (oxygen 2 and air 2). Using the halothane or isoflurane vaporizers at the 5% setting, the maximum sevoflurane concentrations achieved were 3.0% and 3.1%, respectively. The sevoflurane concentration was a maximum of 6% using the enflurane vaporizer set at 7%. The sevoflurane concentration decreased significantly when using any of the three vaporizers at all concentrations when the gas flow was increased from 4 to 8 L/min. The current study demonstrates that clinically useful concentrations of sevoflurane can be achieved with the administration of sevoflurane through an enflurane vaporizer. Although this is not routinely recommended, in specific circumstances it may allow the use of sevoflurane in third-world countries if sevoflurane vaporizers are not available and the use of sevoflurane is clinically necessary.

Answer 162

a. Calcium gluconate

Answer 163

c. sinus tachy with prolonged QRS

Answer 164

d) contraindicated as it won’t work Type 1: -Quantitative defect of VWF Type 2: -Qualitative Defect of VWF -Type 2 subclassification depending on plt binding function, F8 binding capcacity, number of high molecular weight VWF multimers Type 3: - complete absence of VWF Treatment: - do not need blood components to control haemorrhage -F8 plasma concentration >100 for major surgery and >50 for minor surgery -DDAVP approved for use in Type 1, no use in type 3, discuss its use with haematology in type 2 due to its variable effect -DDAVP given atleast 90mins before operation -TXA may be useful -VWF/F8 concentrates indicated in severe cases, type 3 and qualitiative defects in VWF -Plt infusions should be considered in persistent bleeding -Cryo has an unpredictable effect, only used if other treatments have failed

Answer 165

Serotonin Syndrome Hyper reflexia Usually has hypertension and hyperthermia https://static1.squarespace.com/static/5e6d5df1ff954d5b7b139463/t/617242e2ab18df2dee31f417/1634878179720/ICU_one_pager_hyperthermic_toxidromes.png

Answer 166

labetalol https://www.bjaed.org/article/S2058-5349(20)30114-1/fulltext The threshold for initiating antihypertensive treatment for all hypertensive disorders in pregnancy has been lowered. A sustained BP ≥140/90 mmHg warrants treatment, targeting a BP ≤135/85 mmHg. The main aim of controlling the maternal BP is the prevention of intracerebral haemorrhage and stroke. The rate of stroke during the peripartum period in women with pre-eclampsia is 133 per 100,000, with haemorrhagic stroke being more common than ischaemic stroke. NICE recommends offering oral labetalol as initial therapy, followed by nifedipine and then methyldopa as alternatives. Second- and third-line agents include hydralazine and prazosin. Women with severe hypertension (SBP ≥160 mmHg, DBP ≥110 mmHg, or both) should be admitted to hospital for assessment and treatment in a monitored setting. Hypertensive emergencies can be treated with intravenous labetalol, hydralazine and immediate-release oral nifedipine without the need for invasive cardiac monitoring. Labetalol 20 mg i.v. can be given over 2 min, and increased incrementally up to 80 mg i.v. If the BP remains high, another antihypertensive agent such as hydralazine can be added. An initial dose of hydralazine 5–10 mg i.v. over 2 min can be followed by a further 10 mg i.v. after 20 min if the BP remains high. A suggested initial dose of immediate-release oral nifedipine is 10 mg, followed by a further 20 mg if the BP remains high after 20 min.

Answer 167

a) Suxamethonium

Answer 168

d) Danazol https://www.allergy.org.au/hp/papers/hereditary-angioedema Treatment options: Plasma derived C1-esterase inhibitor = Berinert/Cinryze, Androgens = Danazol B2 Bradykinin REceptor antagonist = Icatibant FFP. Danazol (an androgen) is recommended as first line PROPHYLAXIS for planned procedures (need to give for 5-10 days prior and 2-5 days post) For emergency or high risk procedures C1 esterase inhibitor concentrate (Berinert or Cinryze) is recommended - give 1 hour before procedure - more effective than danazol but more expensive Berinert: - 20units/kg IV over 10 min - Symptoms usually stabilise in 30 mins - 2nd dose uncommon, but may be given 30mins to 2hrs after 1st dose Icatibant: - 30mg slow subcut infusion in abdominal area Due to the risk of precipitating laryngeal oedema, oropharyngeal procedures should usually involve general anaesthesia with endotracheal intubation Short answer: - if you have days before surgery increase danazole, if complex surgery increase danazole and give C1Inh - If you have acute emergency surgery give C1Inh Concentrate (Berinert/Cinryze) before and after - if you have an acute attack use C1Inh or Bradykinin antagonist (Icatibant) - If C1 Inh and Bradykinin antagonoist are not available then use FFP but this may worsen the attack due to the presence of C4 in the FFP - Has Cetirizine been misremembered instead of Cinryze as an option in this question? No it wasn't -> adrenaline, steroids, antihistamines have no role in treatment of HAE acute attack

Answer 169

No remembered options. Answer could be: Traumatic Brain injury Direct allergy Cardiac Failure SAFE trial

Answer 170

c) Cryo Cryo or TXA, TXA first line treatment however patient has low fibrinogen and requires fibrinogen replacement.

Answer 171

d) 0.9% Saline Other fluids are all electrolyte free except 0.9% Saline

Answer 172

a) No increased risk of bleeding There is no evidence that pre-operative aspirin administration resulted in a lower risk of death or thrombotic complications, or a higher risk of haemorrhage. The study aim (and title) was to compare stopping vs continuing aspirin, however the design insisted on all patients stopping aspirin and then being given a single dose of aspirin or placebo prior to surgery (and presumably all patients were given aspirin after surgery) – this method hasn’t really investigated the theory TheBottomLine.org.uk

Answer 173

c) residual sedation https://pubmed.ncbi.nlm.nih.gov/35085107/#:~:text=Conclusions%3A%20The%20use%20of%20dexmedetomidine,sedation%20or%20bradycardia%20in%20PACU

Answer 174

D. Amitriptyline Amitriptyline (used in low doses for 90 days from onset of the herpes zoster rash) reduces the incidence of postherpetic neuralgia N.B Antiviral agents started within 72 hours of onset of the herpes zoster rash accelerate the resolution of acute pain (U) (Level I) but **do not reduce** the incidence, severity and duration of postherpetic neuralgia UTD Both Gabapentinoids and TCAs are effective at TREATING postherpetic neuralgia. The former have lower risk of discontinuation due to adverse side effects. For moderate or severe pain, use gabapentinoids.

Answer 175

Idarucizumab (Praxbind) is a monoclonal antibody to dabigatran Dabigatran bleeding may be treated with: - idarucizumab - haemodialysis -PCC 25-50IU/kg - TXA will decrease fibrinolysis and has some effect - FFP also has some effect Humanized monoclonal antibody fragment (Fab) indicated in patients treated with dabigatran (Pradaxa) when reversal of the anticoagulant effects are needed for emergency surgery or urgent procedures, or in the event of life-threatening or uncontrolled bleeding - very high affinity for dabigatran (300x vs affinity for thrombin) - 5 g IV, provided as 2 separate vials each containing 2.5 g/50 mL (see Administration) - RE-VERSE-AD trial: undetectable levels <20ng/ml within minutes and for 24 hours - Limited data support administration of an additional 5 g depending on clinical situation Dosage Modifications Renal impairment: Renal impairment did not impact the reversal effect of idarucizumab; no dosage adjustment required Hepatic impairment: Dosing Considerations This indication is approved under accelerated approval based on a reduction in unbound dabigatran and normalization of coagulation parameters in healthy volunteers; continued approval for this indication may be contingent upon the results of an ongoing cohort case series study

Answer 176

A - GLP1 receptor agonist (rest of options made up) “Dulaglutide binds to glucagon-like peptide 1 receptors, slowing gastric emptying and increases insulin secretion by pancreatic Beta cells. Simultaneously the compound reduces the elevated glucagon secretion by inhibiting alpha cells of the pancreas, as glucagon is known to be inappropriately elevated in diabetic patients. GLP-1 is normally secreted by L cells of the gastrointestinal mucosa in response to a meal” - Wikipedia, Dulaglutide - Once weekly injection, “trulicity” https://www.asahq.org/about-asa/newsroom/news-releases/2023/06/american-society-of-anesthesiologists-consensus-based-guidance-on-preoperative

Answer 177

d) Atropine Blue book 2019

Answer 178

midazolam - Opioids, benzodiazepines and pregabalin may also be used to alleviate symptoms. Perioperative treatment of symptoms If RLS symptoms occur perioperatively, patients should be allowed to walk or move their legs in bed as soon as possible. If prolonged bed rest is required, the frequency of RLS medications may be increased to three times a day. If oral intake is feasible, a patient’s usual oral medication may be given. Levodopa (a dopamine agonist) may be administered by nasogastric tube. Alternatively, parenteral apomorphine or a rotigotine patch may be used. Apomorphine (1 milligram) may be injected subcutaneously on an hourly basis. Nausea is a common side effect so it may need to be given with an antiemetic. Rotigotine patches may be used every 24 hours. Opioids, benzodiazepines and pregabalin may also be used to alleviate symptoms. Patients should be proactively investigated and treated for iron deficiency, targeting ferritin level greater than 300 micrograms/ litre in adults, and 50 micrograms/litre in children.

Answer 179

90mg PO morphine Oral Tapentadol 25mg = 8mg Oral Morphine Oral Oxycodone 5mg = 8mg Oral Morphine Oral Tramadol 25mg = Oral Morphine 5mg Oral Hydromorphone 4mg = Oral Morphine 20mg S/L Buprenorphine 200mcg = 8mg Oral Morphine IV Oxycodone 5mg = Oral Morphine 15mg IV Morphine 5mg = Oral Morphine 15mg IV Hydromorphone 1mg = Oral Morphine 15mg

Answer 180

b) 30mcg Moderate = 2mcg/kg Life threatening = 4-10mcg/kg file:///Users/jbjon/Downloads/Australian_and_New_Zealand_Anaesthetic_Allergy_Gro.pdf

Answer 181

d) 24hrs Extrajunctional receptors are not found in normal active muscle but appear very rapidly whenever muscle activity has ended or after injury has been sustained. They can appear within 18 h of injury and an altered response to neuromuscu- lar blocking drugs can be detected within 24 h of the insult. They disappear when muscle activity returns to normal.

Answer 182

Increased alpha and slow delta power During general anaesthesia with sevoflurane, the EEG shows increased α (8–12 Hz) and slow-δ oscillation power.9 This dynamic also closely approximates the EEG of general anaesthesia with propofol.9 Alpha oscillations are likely to originate from a mechanism similar to that proposed for the β oscillations. An increase in GABAA decay time and conductance results in cortical α oscillations and enhanced rebound spiking of thalamic relay cells, strengthening the intrinsic α oscillatory dynamic of the thalamus. The net result is reciprocal thalamic–cortical α oscillation coupling.13 Mechanisms to explain the slow-δ oscillations are being investigated. However, slow-δ oscillations may be associated with an alternation between ‘on’ states, in which neurones are able to fire, and ‘off’ states, in which neurones are silent.9 Different from propofol, sevoflurane general anaesthesia is also associated with increased frontal θ (4–8 Hz) oscillation power.1,9 The increase in θ oscillation power creates a distinctive pattern of distributed EEG power from the slow-δ oscillation through to the α oscillation range. At an end-tidal sevoflurane concentration of 1.1%, the EEG shows increased slow-δ (0.1–4 Hz) and β (13–33 Hz) oscillations BJA Ed

Answer 183

d) Dopamine Dobutamine (β1 and β2), dopexamine (DA1, some β2) and low-dose dopamine (DA1 and DA2, β1 and β2, α1 in high dose) all have vasodilatory effects on the splanchnic circulation, and have been shown to improve markers of perfusion. For many years, low-dose infusions of dopamine were used as a prophylactic and therapy for acute renal failure, using the logic that DA1- and DA2-mediated vasodilation in renal and splanchnic beds would be protective. https://pubmed.ncbi.nlm.nih.gov/12794401/

Answer 184

a) Torsades 2ry to prolonged QT leading to R on T PETKOV

Answer 185

e) Propofol https://www.bjanaesthesia.org/article/S0007-0912(20)30547-X/pdf

Answer 186

b) Factor VII Redcross: Cryoprecipitate contains most of the following found in fresh frozen plasma: 1. factor VIII 2. fibrinogen 3. factor XIII 4. von Willebrand factor 5. fibronectin Prothrombinex-VF® is a lyophilised concentrate of human coagulation factors it contains: Factors: II IX X small amount of factor VII. Also contains: plasma proteins (human) Antithrombin III (human) Heparin sodium (porcine) Sodium Phosphate Citrate Chloride https://litfl.com/cryoprecipitate/ Fractionated plasma product consisting of Fibrinogen (Factor I), von Willebrand Factor, Factor VIII, and small amounts of Factor XIII and Fibronectin https://www.anzca.edu.au/getattachment/9ec71c61-8a66-4f81-b0f8-c87d65e36298/Australasian-Anaesthesia-2023

Answer 187

c. No need to bridge See ETG recommendations https://www.ahajournals.org/doi/full/10.1161/JAHA.120.017559

Answer 188

d) continue to avoid cognitive decline post-op Donepezil is in a class of medications called cholinesterase inhibitors. It improves mental function https://www.ukcpa-periophandbook.co.uk/medicine-monographs/donepezil

Answer 189

a) propofol

Answer 190

B. 20% 25% (a few studies have higher ranges but typically around 20-25%) https://doi.org/10.1192/bjp.bp.115.165498

Answer 191

D) Mitral Stenosis (Rheumatic, moderate to severe) DOAC use is contraindicated in certain clinical conditions, notably, in patients who have a mechanical heart valve and those with rheumatic mitral stenosis. Moderate to severe renal impairment or significant hepatic disease is also a contraindication to DOAC treatment Bioprosthetic valves are less thrombogenic thus DOAC use is acceptable. https://www.ahajournals.org/doi/epdf/10.1161/JAHA.120.017559

Answer 192

8mg/hr Guidelines for mx of glucocorticoids during the perioperative period for patients with adrenal insufficiency https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/10.1111/anae.14963

Answer 193

e) Liver transplantation - Oxygen therapy for symptom relief - Liver transplant provides long term survival benefit - All other therapies tried but no conclusive evidence of benefit/nil are FDA approved Hepatopulmonary Syndrome Article https://www.ncbi.nlm.nih.gov/books/NBK562169/ Hepatopulmonary syndrome (BJA) - Prevalence up to 20% (end stage liver disease) - Characterised by: disordered pulmonary capillary vasodilation and VQ mismatch - Present with hypoxia, ortheodeoxia (decrease in PaO2 when standing) - Diagnosis w/bubble echocardiography - Risk factor for early post-transplant mortality - If transplant successful, will resolve over time

Answer 194

****D. 20 mins **The time taken to reduce K+ with insulin/dextrose ranges from ~15-30 mins depending on source ** https://www.uptodate.com/contents/treatment-and-prevention-of-hyperkalemia-in-adults Treatment approach to hyperkalemic emergencies — Patients with a hyperkalemic emergency should receive (table 1): Intravenous calcium and insulin are rapidly acting treatments that provide time for the initiation of therapies that remove the excess potassium from the body. ●Intravenous calcium to antagonize the membrane actions of hyperkalemia ●Intravenous insulin (typically given with intravenous glucose) to drive extracellular potassium into cells ●Therapy to rapidly remove excess potassium from the body (ie, loop or thiazide diuretics if renal function is not severely impaired, a gastrointestinal cation exchanger, and/or dialysis [preferably hemodialysis] if renal function is severely impaired) ●Treatment of reversible causes of hyperkalemia, such as correcting hypovolemia and discontinuing drugs that increase the serum potassium (eg, nonsteroidal anti-inflammatory drugs, inhibitors of the renin-angiotensin-aldosterone system) RCH: http://www.rch.org.au/clinicalguide/guideline_index/Hyperkalaemia/ Insulin/glucose to be given at the same time If severe hyperkalaemia: - Dextrose 10% : 5ml/kg IV bolus (if no hyponatremia) - Insulin short action: 0.1 U/kg IV bolus (Max 10 units) Then followed by infusion insulin/glucose (see below) -If moderate hyperkalaemia: - Dextrose 10% IV at maintenance with 0.9% sodium chloride (normal saline) - Insulin short action infusion : 0.1 U/kg/h IV Note: Close monitoring of glucose every 30-60 minutes Onset of Action: 15 minutes, should reduce intravascular K+, reduction of 0.5-1.5mmol/L Duration: peak 60 minutes, 2-3hours American College of Emergency Physicians: Nebulized albuterol by face mask begins to take measurable effect after 15 to 20 minutes and lowers the serum potassium level by up to 1 mEq/L, depending on the dose. β-Agonists are safe despite the side effect of tachycardia. **Insulin, given intravenously in combination with glucose, also results in a similar fall in the potassium level after 20 to 30 minutes **and also lowers levels by up to 1 mEq/L. The combination of nebulized albuterol and intravenous insulin with glucose appears to be additive, lowering serum potassium by a mean of 1.21 mEq/L or more.11 Adult hyperkalemic patients who have ECG changes should receive continuous nebulized albuterol and 50 grams of intravenous dextrose plus 10 units of intravenous regular insulin. Emergency Medicine Journal J Accid Emerg Med. 2000 May; 17(3): 188–191. The management of hyperkalaemia in the emergency department INSULIN WITH GLUCOSE Insulin binds to specific membrane receptors and via an unknown second messenger, stimulates the sodium-potassium (Na-K) adenosine triphosphatase (ATP) pump resulting in intracellular uptake of K.5 This effect is independent of its hypoglycaemic action. Uraemia attenuates the hypoglycaemic response to insulin but does not affect its hypokalaemic action. Insulin has been the traditional temporising treatment against which newer treatments are compared. It is indicated in every case of hyperkalaemia that needs emergency treatment. Ten units (in adults) soluble insulin is given with 40–60 g glucose intravenously as a bolus. In children, a glucose load of 0.5 g/kg/h (2.5 ml/kg/h) should be given. This is because many of these patients increase their endogenous insulin production with the administration of a glucose load. If the blood glucose rises above 10 mml/l, insulin should be added at 0.05 u/kg/h.24 These studies show that the onset of hypokalaemic action is within 15 minutes and lasts for at least 60 minutes. The reduction in K observed is 0.65–1.0 mmol/l.5, 10 Delayed (30–60 minutes post insulin) hypoglycaemia is common (up to 75% of patients10) if less than 30 g glucose is given. LITFL: Treatment of hyperkalaemia involves stabilizing the myocardium to prevent arrhythmias, shifting potassium back into the intracellular space and removing excess potassium from the body. Drive Potassium into the Cell: Insulin & Glucose - Dose: IV fast acting insulin (actrapid) 10-20 units and glucose/dextrose 50g 25-50ml - Insulin drives potassium into cells and administering glucose prevents hypoglycaemia. - Begins to work in 20-30mins reduces potassium by 1mmol/L and ECG changes within the first hour Ca gluconate - should be part of initial treatment but it does not lower either total body or serum potassium, it acts as a membrane stabiliser LITFL: Correct Serious Conduction Abnormalities (Calcium) - Calcium is a very useful agent. It does not lower the serum potassium level, but instead is used to stabilise the myocardium, as a temporising measure. Calcium is indicated if there is widening of QRS, sine wave pattern (when S and T waves merge together), or in hyperkalaemic cardiac arrest. - The ‘cardiac membrane stabilising effects’ take about 15-30mins. Calcium Chloride - Dose: Calcium Chloride 10% 5-10mL = 6.8 mmol - 3 x more potent than Calcium Gluconate - Complication: severe thrombophlebitis - Calcium Gluconate: - Dose: Calcium Gluconate 10% 5-10mL = 2.2 mmol - Less potent, less irritating to veins - Potential Complications of Calcium administration - Bradycardia, hypotension and peripheral vasodilation - Generally these occur if administered too quickly - Avoid in digoxin toxicity (use magnesium as alternative) - salbutamol Drive Potassium into the Cell: Salbutamol - Dose: 10-20mg via nebulizer - Beta 2 agonist therapy lower K via either IV or nebulizer route. - Salbutamol can lower potassium level 1mmol/L in about 30 minutes, and maintain it for up to 2 hours. - Very effective in renal patients that are fluid overloaded - Drive Potassium into the Cell: Sodium Bicarbonate - Dose: 50- 200mmol of 8.4% Sodium Bicarbonate - Bicarbonate is only effective at driving Potassium intracellullarly if the patient is acidotic - Begins working in 30-60 minutes and continues to work for several hours. Eliminate Potassium From the Body: Calcium Resonium - Dose: 15-45g orally or rectally, mixed with sorbitol or lactulose - Calcium polystyrene sulfonate is a large insoluble molecule that binds potassium in the large intestine, where it is excreted in faeces - Effects take 2-3 hours M&M 2016: An intravenous infusion of glucose and insulin (30–50 g of glucose with 10 units of insulin) is also effective in promoting cellular uptake of potassium and lowering plasma [K+], but may take up to 1 h for peak effect

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c) Vasopressin https://emcrit.org/ibcc/pressors/ - From UP TO DATE: > At low doses of 1 to 3 mcg/kg per min, dopamine acts primarily on dopamine-1 receptors to dilate the renal and mesenteric artery beds > At 3 to 10 mcg/kg per min (and perhaps also at lower doses), dopamine also stimulates beta-1 adrenergic receptors and increases cardiac output, predominantly by increasing stroke volume with variable effects on heart rate. > At medium-to-high doses, dopamine also stimulates alpha-adrenergic receptors, although a small study suggested that renal arterial vasodilation and improvement in cardiac output may persist as the dopamine dose is titrated up to 10 mcg/kg per min *clinically, the haemodynamic effects of dopamine demonstrate individual variability Dobutamine (inodilator): - selective β1-agonist that increases cardiac contractility and reduces pulmonary vascular and systemic vascular resistances Vasopressin: - vasopressin may have pulmonary vasodilatory effects in addition to a systemic vasoconstrictive effect Milrinone (inodilator): - the phosphodiesterase-3 inhibitors, milrinone and enxoimone, have positive inotropic effects combined with the capacity to reduce RV afterload (‘inodilators’) without significant chronotropic effect, but they can be associated with significant systemic hypotension

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e) stop 2 weeks before, start moclobemide and omit Moclobemide day of surgery -> probably in discussion with the patients psychiatrist Tranylcypromine, sold under the brand name Parnate among others, is a monoamine oxidase inhibitor. More specifically, tranylcypromine acts as nonselective and irreversible inhibitor of the enzyme monoamine oxidase. In the elective setting, there is some debate regarding the management of patients on MAOI. Although the risks associated with anaesthesia in those taking this group of drugs are significant, abrupt withdrawal may precipitate serious psychiatric relapse. Traditionally, irreversible MAOIs have been stopped 2 weeks before operation; however, omitting the dose of moclobemide on the day of surgery is acceptable. It has been suggested that in the elective situation, patients could be switched from an irreversible MAOI to moclobemide to avoid a prolonged period of discontinuation.

Answer 197

d) Dexamethasone The ECG shows LONG QT https://litfl.com/qt-interval-ecg-library/

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Factor 7 - Recombinant, made from baby hamster kidney cells Albumin - Alburex® 5 AU (Human Albumin 50 g/L) is an Australian manufactured albumin product Fib con - Lyophilised precipitate. manufactired from cryoprecipitate. PCC - Prothrombinex-VF® is a lyophilised concentrate of human coagulation factors containing factors II, IX and X and a small amount of factor VII. Red cross lifeblood. Correct answer is rVIIa

Answer 199

Moclobemide - Reversible MAOI SSRIs and SNRIs are lower risk Tapentadol - no serotonin effect Tranylcypromine or phenylzine are irreversible blockers and would be the highest risk

Answer 200

c) Inhibits guanylate cyclase Methylene Blue acts by inhibiting guanylate cyclase, thus decreasing C-GMP and vascular smooth muscle relaxation

Answer 201

b) Myotonia congenita Myotonia congenita is a condition characterized by delayed relaxation of the muscles after voluntary contraction. Neostigmine can exacerbate this delayed relaxation, potentially worsening symptoms

Answer 202

Moclobemide - Reversible MAOI SSRIs and SNRIs are lower risk Tapentadol - no serotonin effect Tranylcypromine or phenylzine are irreversible blockers and would be the highest risk

Answer 203

a) FFP FFP - 20mmol/l (associated with highest rate of Citrate toxicity) - cannot find a great reference but is quoted in Citrate Toxicity During CRRT After Massive Transfusion (they then reference 1992 guidelines from Transfusion Med, 1994 article about plasma exchage, and Miller's 2009) Lifeblood - additive for plasmapheresis is highest concentration of 4% - could also argue that even if derived from whole blood donation, most of the citrate likely to be in the plasma anyway and when cellular components separated from plasma it will remain (no evidence for that) These numbers unclear source material Platelets - 15-20mmol/L Plasma - 13-15mmol/L Red cells 5-7.5mm/L Cryo 13-15mmol/L Fib conc - nil

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5 mins - Essentially one circulation time Intravenously administer the dose of 5 g (2 vials, each contains 2.5 g) as o Two consecutive infusions or o Bolus injection by injecting both vials consecutively one after another via syringe Idarucizumab was administered as one 5 g intravenous infusion over five minutes Among the 90 patients with available data, the median maximum reversal of the pharmacodynamic anticoagulant effect of dabigatran as measured by ECT or dTT in the first 4 hours after administration of 5 g idarucizumab was 100%, with most patients (>89%) achieving complete reversal. Reversal of the pharmacodynamics effects was evident immediately after administration. FDA Product Guide See blue book article

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NSAIDS/aspirin should be avoided as it displaces thyroxine from protein and subsequently increases free T3 and T4 levels. Thyroid storm General measures Cooling IVF +/- glucose Paracetamol Propranolol Specific Hydrocortisone 200 mg QID IV PTU after PTU sodium iodide/lugols iodine

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MAYANK Risperidone Avoid antihistamines and steroids TCAs known to interfere Mayo clinic website See allergy.org.au - risp mentioned in appendix b as a med that may need held

Answer 207

d) Flucloxacillin Need remembered options: Black box warning for fluoroquinolones (ciprofloxacin) Probably also avoid Aminoglycosides (Amikacins/gentamicin/streptomycin) and tobramycin although TOBRAMYCIN probably least problematic of these. Macrolides (erythromycin) These antibiotics have not been shown to cause many problems for MG patients Tetracycline (doxycycline, minocycline) – this may worsen MG Sulfonamides (Bactrim), Penicillin – causes rare cases, usually not a problem for majority of MG patients https://myastheniagravis.org/mg-and-drug-interactions/#:~:text=These%20antibiotics%20have%20black%20box,Ketek%20(telithromycin)

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b) Intravascular Volume x Common Adverse Effects - genital infections (eg vulvovaginal candidiasis, balanitis) - polyuria - dysuria - UTI - dyslipidaemia - hypoglycaemia (when used with a sulfonylurea or insulin) - increased haematocrit - constipation - nausea - thirst - renal impairment, eg increased serum creatinine (related to volume depletion, generally occurs early in treatment and is reversible) Australian Medicines Handbook

Answer 209

NAOMI 72 hours ANZCA Blue Book 2023 Oral naltrexone should be stopped at least 24 hours and ideally 72 hours prior to elective surgery. And there is a lack of instruction re Contrave- so best to stop 72 hours prior. And limited evidence re low dose naltrexone for chronic pain - so for consistency blue book says 72 hours. Caution increased opioid sensitivity in patients using perioperative naltrexone.

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MAYANK B Thiopentone BJA article 2018 Propofol infusions have been associated with a brugada like ECG.

Answer 211

REPEAT E. Upper GI bleed Incompressible sites, large volume blood loss and mortality risk are a few of the things that made GI bleeds seem like a natural fit for TXA administration. Early research seemed promising, but trials were small. The HALT-IT trial examined over 15,000 patients to see if TXA reduced death [14]. Not only did TXA have no effect on mortality, it increased the risk of seizure and thromboembolic events. Take home: No demonstrated benefit with TXA in GI bleeding

Answer 212

B. Initially decreases then normalises Oral glucose tolerance test — The most specific dynamic test for establishing the diagnosis of acromegaly is an OGTT. When performing the test, we measure serum GH before and two hours after glucose administration; the criterion for the diagnosis of acromegaly is a GH concentration greater than 1 ng/mL. In normal subjects, serum GH concentrations fall to 1 ng/mL or less within two hours after ingestion of 75 g glucose. In contrast, the post-glucose values are greater than 2 ng/mL in over 85 percent of patients with acromegaly. Following oral glucose administration in humans, a transient suppression of plasma GH levels for 2–3 h is observed followed by a delayed rise occurring at 3–5 h post glucose ingestion. This initial suppression seems to be related to a glucose-mediated increase in hypothalamic somatostatin release. Evidence supporting this hypothesis emerges from the findings that in healthy individuals, GH secretion in response to GHRH or GH secretagogue is diminished after an oral glucose load. Furthermore, the inhibitory effect of glucose is reversed with the acetylcholinesterase inhibitor pyridostigmine, a substance thought to suppress somatostatin release from the hypothalamus. These findings support the hypothesis that oral glucose load is associated with a somatostatin release into the hypophyseal portal blood suppressing GH levels. The delayed GH rise would result from a decrease in somatostatinergic tone and hence an increase in GHRH. Subsequently, the available pituitary stores of GH are released leading to a rebound rise in GH.

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b. 24 hours ASA guidelines -If creatinine clearance >/=30 ml.min-1 (Cockcroft-Gault), proceed with surgery after two half lives (24 h) since the last dose, under general anaesthesia (or spinal anaesthesia if indicated) - If creatinine clearance < 30 ml.min-1, proceed with surgery after four half lives (48 h) since the last dose, under general anaesthesia (or spinal anaesthesia if indicated)

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Absolute most = Insulin, but probably not an option. Sulphonylureas most likely

Answer 215

e Na 140 Mg 1.5 K 5.0 acetate 27 lactate 0

Answer 216

d) 10 minutes - best answer; one of those shit questions that depends on your source. Morgan & Mikhail's (chapter 36: anaesthesia for ophthalmic surgery): " Succinylcholine increases IOP by 5-10mmHg for 5-10 minutes". - due to prolonged contracture of the EOM BARASH: Succinylcholine increases IOP 7 to 10 mmHg reaching a peak pressure 1 to 2 minutes after IV administration and returns to the baseline in 5 to 7 minutes. This increase may be attenuated by pretreatment with anesthetics, although none completely eliminates the increase in IOP. In the presence of a lacerated globe, this increase in IOP may increase the extrusion of intraocular contents although greater increases in IOP may occur during crying and coughing. Yao & Artusio's: - also quotes same information: increases IOP 7 to 10mmHg, returning to baseline in 5 - 7 minutes. Stoelting's: Intraoccular pressure peaks at 2-4 minutes after administration and returns to normal by 6 minutes

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a. Splenomegaly Associated with high doses >4mg/kg/hr and prolonged use (>48hrs) Safe doses of propofol infusion for sedation in ICU are considered to be 1-4mg/kg/hr -> fatal Cases pf PRIS have been reported after infusion doses as low as 1.9-2.6mg/kg/hr Risk factors: i. Young age ii. Critical illness iii. High fat and low Carbohydrate intake iv. Inborn errors of mitochondrial fatty acid oxidation v. Catecholamine infusion/ High catecholamine and glucocorticoid levels vi. Steroid therapy vii. Severe head injuries Characteristics: i. Bradycardia ii. Severe metabolic acidosis iii. Cardiovascular collapse iv. Rhabdomyolysis v. Hyperlipidaemia vi. Renal failure vii. Hepatomegaly Management: - Routine monitoring of CK and triglycerides should be performed for the at risk population ○ Daily CK and triglyceridees after 48hrs of propofol infusion ○ Increasing CK in the absence of other pathology triggers suspiscion of PRIS - Propofol immediately stopped and alternative (midazolam and alfentanil) are used - PRIS is difficult to treat once it occurs - CVS support provided as needed - Renal replacement therapy may be required to treat lactic acidosis, clear propofol and its metabolites from the patient rapidly - Catecholamine resistant shock has been reported - Pacing has been used with limited success ECMO has been reported and successfully used in the CVS support of PRIS

Answer 218

b. 45ml/hr N saline w 5% dextrose Nsaline + 5% dextrose is fluid of choice A guide to paediatric anaesthesia fluid management -421 rule overestimates fluid resus -due to stress response from ADH release -post-op fluid maintenance is 2/3rds calculated due to increased ADH -never use hypotonic fluids https://www.rch.org.au/clinicalguide/guideline_index/Intravenous_fluids/