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Multiple Choice Answers
Multiple Choice Answers
72.
Concerning the sterilization of anaesthetic equipment:
(a) False; (b) True; (c) False; (d) False; (e) False (a) This is a form of pasteurization and only kills bacteria, not spores. (b) These are conditions used in steam sterilization. (c) Gluteraldehyde 2% is a high-level disinfectant with sporicidal activity on prolonged contact. (d) Ethylene oxide is a slow process and can take up to 12 h. (e) Gas plasma is a relatively new technique of sterilization.
73.
With regard to decontamination procedures:
(a) False; (b) False; (c) False; (d) False; (e) False (a) Cleaning is essential before disinfection or sterilization in order to lower the bioburden. (b) High-level disinfectants kill bacteria, viruses and spores with prolonged exposure. (c) Automated methods are more reliable. (d) Indicators do not guarantee sterility; only that specific conditions of the decontamination process have been met. (e) Chemical indicators on packing (autoclave indicator tape) usually serve this purpose.
74.
Regarding the decontamination of flexible endoscopes:
(a) False; (b) True; (c) True; (d) False; (e) True (a) Chlorine compounds are damaging. (b) Endoscopes should not be immersed in disinfectant if there is a leak with the pressure test for risk of damaging components. (c) Endoscopes are not damaged by the low temperatures utilized. (d) High-level disinfection is required for endoscopes. (e) Flexible endoscopes should be stored vertically after use to keep them straight.
75.
The following statements are correct:
(a) False; (b) False; (c) False; (d) True; (e) True (a) Clonidine is an a-2 agonist. (b) Sufentanil is 4.5 times more potent than fentanyl. (c) Morphine is water-soluble. (e) Morphine is poorly lipid soluble and so remains in the CSF longer, with the potential of causing late respiratory depression.
76.
Concerning local anaesthetics:
(a) False; (b) True; (c) True; (d) False; (e) False (a) LA block intra-cellular voltage-gated fast sodium channels. (d) Ropivacaine 0.15% and bupivacaine 0.1% are equipotent. (e) Bupivacaine is a racemic mixture of S- and R-bupivacaine.
77.
Combined spinal--epidurals:
(a) True; (b) True; (c) True; (d) True; (e) True (b) Although meningitis is a serious risk, it remains rare.
78.
Epidural analgesia in labour is associated with:
(a) True; (b) False; (c) True; (d) False; (e) False (a,b) First stage is increased by an average of 42 min and second stage by 14 min. (d) Epidurals do not increase the risk of postpartum back pain. (e) There is no consistent evidence that epidural analgesia in labour improves neonatal arterial pH or APGAR scores.
136
79.
Concerning epidural analgesia in labour:
(a) True; (b) True; (c) False; (d) True; (e) True (b) Mobile epidurals produce less motor block, even allowing the patient to walk during labour. (c) LDI do not reduce anaesthetic workload when compared with midwife epidural top-ups.
80.
Recognized features of hypovolaemic shock include:
(a) False; (b) True; (c) False; (d) True; (e) False (a) Oliguria is seen in patients with significant hypovolaemia. (c) Cold peripheries are usually seen in hypovolaemic shock. (d) Hypotension is seen in patients with significant hypovolaemia. (e) Routine physical assessment alone, including blood pressure, heart rate, and urine output, often fails to show the true haemodynamic status of the compromised patient.
81.
Concerning CVP:
(a) True; (b) True; (c) True; (d) True; (e) True (a) Central venous catheters are placed to assess volume status via CVP. It is the trend of CVP and not the actual value that is more helpful in assessing the volume status and the response to fluid challenge. (b,c) A sustained increase in CVP of 3 mm Hg or more in response to a rapid fluid challenge indicates that the circulation is adequately full and further fluid challenge is not needed. (d) Central venous catheter placement can be associated with significant complications (e.g. infection, pneumothorax, and air embolism).
82.
Causes of extracellular volume depletion include:
(a) True; (b) False; (c) False; (d) True; (e) True (a) Capillary leak will not alter extravascular volume although the circulating (intravascular) volume will decrease. (b) By rendering the extracellular fluid hypotonic glycine will expand the intracellular volume. (c) This will be at the expense of the extracellular volume.
83.
Concerning a fluid challenge:
(a) False; (b) False; (c) True; (d) False; (e) True (a) If a hypovolaemic patient shows no increase in filling pressure or stroke volume this may represent failure to increase cardiac filling pressure (and volume) caused by preferential filling of the peripheral vasculature. More fluid is indicated. (b) Although a rule of thumb is that 800--1000 ml crystalloid is required to give a 200 ml increase in blood volume the rapid extravasation of crystalloid to the interstitium means that we cannot rely on a known increment to blood volume with crystalloid infusion. This is particularly true in the critically ill. (d) Although many will fail to show a positive response to a fluid challenge, if there is evidence of circulatory failure a fluid challenge will establish whether there is fluid responsiveness. In chronic heart failure, for instance, higher filling pressures are required to provide adequate end-diastolic volume.
84.
A pneumoperitoneum of 10--20 mm Hg:
(a) True; (b) False; (c) False; (d) False; (e) True (a) A pneumoperitoneum of 10--20 mm Hg causes a reduction in cardiac output, but an increase in SVR; therefore blood pressure may increase.
Continuing Education in Anaesthesia, Critical Care & Pain | Volume 4 Number 4 2004 ª The Board of Management and Trustees of the British Journal of Anaesthesia 2004
DOI 10.1093/bjaceaccp/mkh038
Multiple Choice Answers
(b) Urine output is only markedly reduced when the pneumoperitoneum is >20 mm Hg. (c) There is a reduction in FRC. (d) Airway resistance increases. (e) Cerebral perfusion pressure may be reduced because of an increase in intracranial pressure.
maintained. (c) Rectal thiopental causes deep sedation and appreciable airway effects. (d) The margin of safety is too low and apnoea is common. (e) Apnoea and laryngospasm are seen rarely.
91. 85.
Concerning the use of carbon dioxide for pneumoperitoneum:
(a) True; (b) False; (c) False; (d) False; (e) False (a) Carbon dioxide is more soluble in blood than air, therefore decreasing the risk of venous embolism. (b) In cardiopulmonary compromised patients, there may be a large difference between end-tidal carbon dioxide and PaCO2. (c) Nitrous oxide is flammable so cannot be used with diathermy. (d) Bradycardias are caused by peritoneal stretching, carbon dioxide causes tachycardia. (e) Only necessary if effects are severe.
86.
Concerning anaesthesia for laparoscopic sterilization:
(a) False; (b) False; (c) False; (d) False; (e) True (a) If the patient is neither obese nor has a history of reflux, an LMA may be used. (b) Nitrous oxide anaesthesia can cause significant nausea and vomiting in gynaecological procedures. (c) Laparoscopic sterilization generally requires short-acting opioids only. (d) If an epidural is used, shoulder-tip pain is often the most significant pain. (e) Endobronchial intubation may occur because of the Trendelenburg position.
87.
Regarding oxygen kinetics:
(a) True; (b) False; (c) True; (d) True; (e) False (b) D_ O2 is a calculated variable. V_ O2 can be measured directly from analysis of respiratory gases or calculated from cardiac output and arterial and mixed venous oxygen contents. (d) The myocardium has a high oxygen extraction ratio. (e) By definition histotoxic/cytopathic hypoxia is not improved by increasing D_ O2.
88.
Regarding the Hb concentration:
(a) False; (b) True; (c) True; (d) False; (e) False (a) In vivo the oxygen combining capacity of Hb is thought to be 1.31 ml g 1. (d) Current guidelines state that blood transfusion should be considered at an Hb < 90 g litre 1 in patients with severe ischaemic heart disease. (e) In response to normovolaemic anaemia the increase in cardiac output is primarily attributable to an increased preload and a decreased afterload.
89.
(a) False; (b) False; (c) False; (d) False; (e) False (a) Hypoxia is a deficiency of oxygen at the tissue level. Hypoxaemia is defined as a PaO2 < 8 kPa. (b) Hyperlactataemia and acidosis have multiple aetiologies. (c) A normal DO2 does not ensure against hypoxia especially if VO2 is elevated, or if the patient may have histotoxic/cytopathic hypoxia. (d) Goal-directed therapy is advocated for patients who do not yet have organ failures but are at high risk of developing them or those in the early stages of sepsis. (e) Pathological oxygen supply dependency is less common than previously thought whereas physiological supply dependency is common and the metabolic response to stimulation is often exaggerated.
90.
(a) True; (b) False; (c) False; (d) False; (e) True (a) Cooperation depends upon the distress of the procedure, patient age and understanding. (b) Respiratory depression is more common in the elderly. (c) There is no evidence for this. (d) Sedation does not gain assent—a degree of compliance is required for successful sedation. (e) Causing a safe sleep by sedation in a child probably is easier than in adults.
92.
Airway obstruction or apnoea is rare with the following sedation techniques:
(a) True; (b) True; (c) False; (d) False; (e) True (a) Absorption is rapid but at doses of 0.2 mg kg 1 appreciable airway effects are rare. (b) Up to 70% nitrous oxide is safe if verbal contact is
The following are contraindications to sedation in children by non-anaesthetists:
(a) False; (b) False; (c) True; (d) False; (e) True (a) Cardiac failure is a contraindication. (b) Staff must be trained. (c) Respiratory depression causes hypercarbia, increases intracranial pressure and irritability; coma and apnoea may follow. (d) Conscious level must be stable before sedation. (e) Blocked nostrils may cause airway obstruction during sedation.
93.
The following have a high success rate:
(a) True; (b) False; (c) False; (d) True; (e) True (a) Dentistry is not usually urgent. (b) Cooperation and analgesia is important in small children. (c) High success rates with midazolam alone have not been reported. (d) Not recommended for non-anaesthetists in the UK. (e) Requiring some cooperation, this can be successful in over 80%.
94.
Common complications of sedation include:
(a) False; (b) False; (c) True; (d) False; (e) True (a,b,d) These complications are recognized but are not common (probably <1 in 100). Triclofos is less of a gastric irritant than chloral hydrate. (c) Ketamine does cause unpleasant dreams or hallucinations in 5%. (e) Sedation in uncooperative patients demands appreciable depression of the gag reflex and the conscious level. The endoscope itself can compress the trachea.
95.
In the critically ill patient:
Children differ from adults as follows:
An anaphylactic reaction:
(a) False; (b) True; (c) False; (d) True; (e) True (a) Anaphylactic reactions are unpredictable and dose independent. (b) An anaphylactic reaction is an example of a Type I hypersensitivity reaction. (c) It involves the production of IgE antibodies after exposure to antigen. (d) Anaphylactic reactions can be identical to anaphylactoid reactions. (e) Females are affected five to ten times more commonly than males.
96.
Concerning anaphylaxis:
(a) False; (b) False; (c) False; (d) True; (e) False (a) Undiluted epinephrine 0.5--1 mg should be given i.m. not i.v. as part of immediate management. (b) The commonest first clinical feature detected is the absence of a pulse and hypotension. (c) The neuromuscular blocking agents are the most common group of drugs to cause the reaction. (d) The reaction often begins 30--60 min after the start of the anaesthetic, not at induction. (e) The estimated mortality once a reaction has started is 5%.
Continuing Education in Anaesthesia, Critical Care & Pain | Volume 4 Number 4 2004
137
Multiple Choice Answers
97.
When investigating the reaction:
(a) False; (b) True; (c) True; (d) True; (e) False (a) Skin prick tests should only be done by the allergist to whom the patient has been referred. (b) The only assay commercially available currently is for succinylcholine. (c) The anaesthetist who administered the drugs is also responsible for ensuring the patient is followed-up appropriately. (d) No previous history of drug exposure is necessary. (e) Screening is of no use clinically.
138
98.
Tryptase:
(a) True; (b) True; (c) False; (d) False; (e) False (a) Tryptase concentration increases after both anaphylactic and anaphylactoid reactions. (b) If kept for >48 h then the sample should be stored at 20 C. (c) Maximum blood concentrations occur within 1 h of a reaction. (d) Normal values are <1 ng ml 1. (e) Tryptase is not present in red or white cells.
Continuing Education in Anaesthesia, Critical Care & Pain | Volume 4 Number 4 2004
72.
Concerning the sterilization of anaesthetic equipment:
(a) False; (b) True; (c) False; (d) False; (e) False (a) This is a form of pasteurization and only kills bacteria, not spores. (b) These are conditions used in steam sterilization. (c) Gluteraldehyde 2% is a high-level disinfectant with sporicidal activity on prolonged contact. (d) Ethylene oxide is a slow process and can take up to 12 h. (e) Gas plasma is a relatively new technique of sterilization.
73.
With regard to decontamination procedures:
(a) False; (b) False; (c) False; (d) False; (e) False (a) Cleaning is essential before disinfection or sterilization in order to lower the bioburden. (b) High-level disinfectants kill bacteria, viruses and spores with prolonged exposure. (c) Automated methods are more reliable. (d) Indicators do not guarantee sterility; only that specific conditions of the decontamination process have been met. (e) Chemical indicators on packing (autoclave indicator tape) usually serve this purpose.
74.
Regarding the decontamination of flexible endoscopes:
(a) False; (b) True; (c) True; (d) False; (e) True (a) Chlorine compounds are damaging. (b) Endoscopes should not be immersed in disinfectant if there is a leak with the pressure test for risk of damaging components. (c) Endoscopes are not damaged by the low temperatures utilized. (d) High-level disinfection is required for endoscopes. (e) Flexible endoscopes should be stored vertically after use to keep them straight.
75.
The following statements are correct:
(a) False; (b) False; (c) False; (d) True; (e) True (a) Clonidine is an a-2 agonist. (b) Sufentanil is 4.5 times more potent than fentanyl. (c) Morphine is water-soluble. (e) Morphine is poorly lipid soluble and so remains in the CSF longer, with the potential of causing late respiratory depression.
76.
Concerning local anaesthetics:
(a) False; (b) True; (c) True; (d) False; (e) False (a) LA block intra-cellular voltage-gated fast sodium channels. (d) Ropivacaine 0.15% and bupivacaine 0.1% are equipotent. (e) Bupivacaine is a racemic mixture of S- and R-bupivacaine.
77.
Combined spinal--epidurals:
(a) True; (b) True; (c) True; (d) True; (e) True (b) Although meningitis is a serious risk, it remains rare.
78.
Epidural analgesia in labour is associated with:
(a) True; (b) False; (c) True; (d) False; (e) False (a,b) First stage is increased by an average of 42 min and second stage by 14 min. (d) Epidurals do not increase the risk of postpartum back pain. (e) There is no consistent evidence that epidural analgesia in labour improves neonatal arterial pH or APGAR scores.
136
79.
Concerning epidural analgesia in labour:
(a) True; (b) True; (c) False; (d) True; (e) True (b) Mobile epidurals produce less motor block, even allowing the patient to walk during labour. (c) LDI do not reduce anaesthetic workload when compared with midwife epidural top-ups.
80.
Recognized features of hypovolaemic shock include:
(a) False; (b) True; (c) False; (d) True; (e) False (a) Oliguria is seen in patients with significant hypovolaemia. (c) Cold peripheries are usually seen in hypovolaemic shock. (d) Hypotension is seen in patients with significant hypovolaemia. (e) Routine physical assessment alone, including blood pressure, heart rate, and urine output, often fails to show the true haemodynamic status of the compromised patient.
81.
Concerning CVP:
(a) True; (b) True; (c) True; (d) True; (e) True (a) Central venous catheters are placed to assess volume status via CVP. It is the trend of CVP and not the actual value that is more helpful in assessing the volume status and the response to fluid challenge. (b,c) A sustained increase in CVP of 3 mm Hg or more in response to a rapid fluid challenge indicates that the circulation is adequately full and further fluid challenge is not needed. (d) Central venous catheter placement can be associated with significant complications (e.g. infection, pneumothorax, and air embolism).
82.
Causes of extracellular volume depletion include:
(a) True; (b) False; (c) False; (d) True; (e) True (a) Capillary leak will not alter extravascular volume although the circulating (intravascular) volume will decrease. (b) By rendering the extracellular fluid hypotonic glycine will expand the intracellular volume. (c) This will be at the expense of the extracellular volume.
83.
Concerning a fluid challenge:
(a) False; (b) False; (c) True; (d) False; (e) True (a) If a hypovolaemic patient shows no increase in filling pressure or stroke volume this may represent failure to increase cardiac filling pressure (and volume) caused by preferential filling of the peripheral vasculature. More fluid is indicated. (b) Although a rule of thumb is that 800--1000 ml crystalloid is required to give a 200 ml increase in blood volume the rapid extravasation of crystalloid to the interstitium means that we cannot rely on a known increment to blood volume with crystalloid infusion. This is particularly true in the critically ill. (d) Although many will fail to show a positive response to a fluid challenge, if there is evidence of circulatory failure a fluid challenge will establish whether there is fluid responsiveness. In chronic heart failure, for instance, higher filling pressures are required to provide adequate end-diastolic volume.
84.
A pneumoperitoneum of 10--20 mm Hg:
(a) True; (b) False; (c) False; (d) False; (e) True (a) A pneumoperitoneum of 10--20 mm Hg causes a reduction in cardiac output, but an increase in SVR; therefore blood pressure may increase.
Continuing Education in Anaesthesia, Critical Care & Pain | Volume 4 Number 4 2004 ª The Board of Management and Trustees of the British Journal of Anaesthesia 2004
DOI 10.1093/bjaceaccp/mkh038
Multiple Choice Answers
(b) Urine output is only markedly reduced when the pneumoperitoneum is >20 mm Hg. (c) There is a reduction in FRC. (d) Airway resistance increases. (e) Cerebral perfusion pressure may be reduced because of an increase in intracranial pressure.
maintained. (c) Rectal thiopental causes deep sedation and appreciable airway effects. (d) The margin of safety is too low and apnoea is common. (e) Apnoea and laryngospasm are seen rarely.
91. 85.
Concerning the use of carbon dioxide for pneumoperitoneum:
(a) True; (b) False; (c) False; (d) False; (e) False (a) Carbon dioxide is more soluble in blood than air, therefore decreasing the risk of venous embolism. (b) In cardiopulmonary compromised patients, there may be a large difference between end-tidal carbon dioxide and PaCO2. (c) Nitrous oxide is flammable so cannot be used with diathermy. (d) Bradycardias are caused by peritoneal stretching, carbon dioxide causes tachycardia. (e) Only necessary if effects are severe.
86.
Concerning anaesthesia for laparoscopic sterilization:
(a) False; (b) False; (c) False; (d) False; (e) True (a) If the patient is neither obese nor has a history of reflux, an LMA may be used. (b) Nitrous oxide anaesthesia can cause significant nausea and vomiting in gynaecological procedures. (c) Laparoscopic sterilization generally requires short-acting opioids only. (d) If an epidural is used, shoulder-tip pain is often the most significant pain. (e) Endobronchial intubation may occur because of the Trendelenburg position.
87.
Regarding oxygen kinetics:
(a) True; (b) False; (c) True; (d) True; (e) False (b) D_ O2 is a calculated variable. V_ O2 can be measured directly from analysis of respiratory gases or calculated from cardiac output and arterial and mixed venous oxygen contents. (d) The myocardium has a high oxygen extraction ratio. (e) By definition histotoxic/cytopathic hypoxia is not improved by increasing D_ O2.
88.
Regarding the Hb concentration:
(a) False; (b) True; (c) True; (d) False; (e) False (a) In vivo the oxygen combining capacity of Hb is thought to be 1.31 ml g 1. (d) Current guidelines state that blood transfusion should be considered at an Hb < 90 g litre 1 in patients with severe ischaemic heart disease. (e) In response to normovolaemic anaemia the increase in cardiac output is primarily attributable to an increased preload and a decreased afterload.
89.
(a) False; (b) False; (c) False; (d) False; (e) False (a) Hypoxia is a deficiency of oxygen at the tissue level. Hypoxaemia is defined as a PaO2 < 8 kPa. (b) Hyperlactataemia and acidosis have multiple aetiologies. (c) A normal DO2 does not ensure against hypoxia especially if VO2 is elevated, or if the patient may have histotoxic/cytopathic hypoxia. (d) Goal-directed therapy is advocated for patients who do not yet have organ failures but are at high risk of developing them or those in the early stages of sepsis. (e) Pathological oxygen supply dependency is less common than previously thought whereas physiological supply dependency is common and the metabolic response to stimulation is often exaggerated.
90.
(a) True; (b) False; (c) False; (d) False; (e) True (a) Cooperation depends upon the distress of the procedure, patient age and understanding. (b) Respiratory depression is more common in the elderly. (c) There is no evidence for this. (d) Sedation does not gain assent—a degree of compliance is required for successful sedation. (e) Causing a safe sleep by sedation in a child probably is easier than in adults.
92.
Airway obstruction or apnoea is rare with the following sedation techniques:
(a) True; (b) True; (c) False; (d) False; (e) True (a) Absorption is rapid but at doses of 0.2 mg kg 1 appreciable airway effects are rare. (b) Up to 70% nitrous oxide is safe if verbal contact is
The following are contraindications to sedation in children by non-anaesthetists:
(a) False; (b) False; (c) True; (d) False; (e) True (a) Cardiac failure is a contraindication. (b) Staff must be trained. (c) Respiratory depression causes hypercarbia, increases intracranial pressure and irritability; coma and apnoea may follow. (d) Conscious level must be stable before sedation. (e) Blocked nostrils may cause airway obstruction during sedation.
93.
The following have a high success rate:
(a) True; (b) False; (c) False; (d) True; (e) True (a) Dentistry is not usually urgent. (b) Cooperation and analgesia is important in small children. (c) High success rates with midazolam alone have not been reported. (d) Not recommended for non-anaesthetists in the UK. (e) Requiring some cooperation, this can be successful in over 80%.
94.
Common complications of sedation include:
(a) False; (b) False; (c) True; (d) False; (e) True (a,b,d) These complications are recognized but are not common (probably <1 in 100). Triclofos is less of a gastric irritant than chloral hydrate. (c) Ketamine does cause unpleasant dreams or hallucinations in 5%. (e) Sedation in uncooperative patients demands appreciable depression of the gag reflex and the conscious level. The endoscope itself can compress the trachea.
95.
In the critically ill patient:
Children differ from adults as follows:
An anaphylactic reaction:
(a) False; (b) True; (c) False; (d) True; (e) True (a) Anaphylactic reactions are unpredictable and dose independent. (b) An anaphylactic reaction is an example of a Type I hypersensitivity reaction. (c) It involves the production of IgE antibodies after exposure to antigen. (d) Anaphylactic reactions can be identical to anaphylactoid reactions. (e) Females are affected five to ten times more commonly than males.
96.
Concerning anaphylaxis:
(a) False; (b) False; (c) False; (d) True; (e) False (a) Undiluted epinephrine 0.5--1 mg should be given i.m. not i.v. as part of immediate management. (b) The commonest first clinical feature detected is the absence of a pulse and hypotension. (c) The neuromuscular blocking agents are the most common group of drugs to cause the reaction. (d) The reaction often begins 30--60 min after the start of the anaesthetic, not at induction. (e) The estimated mortality once a reaction has started is 5%.
Continuing Education in Anaesthesia, Critical Care & Pain | Volume 4 Number 4 2004
137
Multiple Choice Answers
97.
When investigating the reaction:
(a) False; (b) True; (c) True; (d) True; (e) False (a) Skin prick tests should only be done by the allergist to whom the patient has been referred. (b) The only assay commercially available currently is for succinylcholine. (c) The anaesthetist who administered the drugs is also responsible for ensuring the patient is followed-up appropriately. (d) No previous history of drug exposure is necessary. (e) Screening is of no use clinically.
138
98.
Tryptase:
(a) True; (b) True; (c) False; (d) False; (e) False (a) Tryptase concentration increases after both anaphylactic and anaphylactoid reactions. (b) If kept for >48 h then the sample should be stored at 20 C. (c) Maximum blood concentrations occur within 1 h of a reaction. (d) Normal values are <1 ng ml 1. (e) Tryptase is not present in red or white cells.
Continuing Education in Anaesthesia, Critical Care & Pain | Volume 4 Number 4 2004