- Email: [email protected]
Multiple Choice Questions
Multiple Choice Questions
Traumatic brain injury: an evidence-based review of management 1. Immediately after traumatic brain injury:
2. Appropriate statements regarding anaesthesia for trauma craniotomy include: (a) A modified rapid sequence induction is rarely performed since it is likely to lead to an increase in intracranial pressure. (b) To avoid displacement of the tracheal tube, a tie should be applied firmly around the patient’s neck. (c) To optimize intraoperative cerebral perfusion, partial pressure of arterial carbon dioxide (PaCO2) should be maintained between 4.0 and 4.5 kPa. (d) In patients undergoing trauma craniotomy, total intravenous anaesthesia with propofol is associated with lower mortality than either isoflurane or sevoflurane anaesthesia. (e) Neurosurgical intervention is necessary in one-third of patients with moderate or severe traumatic brain injury.
(a) Intracranial pressure is reduced by hyperventilation to a PaCO2 ,4.0 kPa. (b) Intracranial pressure is reduced by saline 5%. (c) Intracranial pressure is necessary to calculate cerebral perfusion pressure. (d) Monitoring of intracranial pressure is necessary in patients with severe traumatic brain injury undergoing non-neurosurgical procedures such as fixation of a long bone fracture. (e) Intracranial pressure should be treated if it is persistently in the range 20 –25 mm Hg.
Preinduction techniques to relieve anxiety in children undergoing general anaesthesia 5. Increased preoperative anxiety in children is associated with the following postoperative sequelae: (a) (b) (c) (d) (e)
Emergence delirium. Reduced analgesic requirements. Altered sleep pattern. Enuresis. Separation anxiety.
6. To reduce perioperative anxiety, effective pre-induction techniques are likely to include: (a) Preoperative midazolam. (b) Routine presence of the parents at induction of anaesthesia. (c) Inhalational induction rather than intravenous induction of general anaesthesia. (d) Use of video games. (e) Use of clowns.
3. Appropriate statements concerning patients with traumatic brain injury in the critical care unit include:
7. Appropriate statements regarding sedative premedication include:
(a) A cerebral perfusion pressure of 70 –90 mm Hg is recommended. (b) Management algorithms have reduced mortality rates both in intensive care and in hospital. (c) Pharmacological thromboprophylaxis is often avoided within 24 h of injury. (d) Seizure activity increases the risk of secondary brain injury. (e) Tight glycaemic control (blood glucose 4.5–6.0 mmol litre21) is associated with reduced mortality.
(a) Midazolam is typically administered orally at a dose of 2 mg kg21. (b) The use of midazolam or clonidine results in decreased anxiety, increased cooperation and decreased negative behavioural changes. (c) Clonidine is an a2 agonist with analgesic as well as sedative properties. (d) Antihistamines remain a popular form of pre-medication. (e) The usual dose of intramuscular ketamine is 4–8 mg kg21.
232
doi:10.1093/bjaceaccp/mkt054 Continuing Education in Anaesthesia, Critical Care & Pain | Volume 13 Number 6 2013 # The Author [2013]. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved. For Permissions, please email: [email protected]
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(a) A single episode of hypotension (systolic pressure ,90 mm Hg) is associated with a doubling of mortality. (b) Patients with a deteriorating conscious level, such as a reduction in motor score of .2 points, should be intubated before transfer to a neurosurgical unit. (c) An immediate computed tomography (CT) scan is indicated if the patient’s Glasgow Coma Scale (GCS) score is ,13 on arrival in the emergency room. (d) The initial resuscitation process should focus on establishing a clear airway before treating the brain injury. (e) The GCS is used to assess severity of brain injury before resuscitation.
4. In a patient with a severe traumatic brain injury:
Multiple Choice Questions
8. Appropriate statements regarding the presence of parents at induction of general anaesthesia include:
Propofol infusion syndrome 9. The original definition of propofol infusion syndrome coined by Bray in 1998 includes the presence of the following clinical conditions: (a) Bradycardia of ,40 beats min21. (b) Metabolic acidosis with base excess more negative than 210 mmol litre21. (c) Rhabdomyolysis. (d) C-reactive protein levels .100 mg litre21. (e) White cell count .12 109 litre21. 10. Factors that predispose to propofol infusion syndrome include: (a) (b) (c) (d) (e)
Age ,12 years. Renal failure. Sepsis. A propofol infusion rate of .4 mg kg21 h21. Lipid infusions, such as total parenteral nutrition.
11. A 50-year-old patient sedated for head injuries suddenly develops severe metabolic acidosis 2 days after propofol infusion was commenced. The management of suspected propofol infusion syndrome ( propofol infusion syndrome) should include: (a) Continuing the propofol infusion at a lower dose of 2 mg kg21 h21. (b) Stopping propofol and administering an alternative agent, such as midazolam. (c) Commencing renal replacement therapy if creatine kinase levels are .30 000 units litre21 and the creatinine level is .500 mmol litre21. (d) Treating bradycardias (heart rate ,40 beats min21) with external pacing. (e) Commencing a glucose infusion. 12. Appropriate statements regarding the pathophysiology of propofol infusion syndrome include: (a) The function of the endoplasmic reticulum is reduced. (b) Cardiogenic shock occurs as a result of the b-blocking like actions of propofol.
Ethico-legal considerations of teaching 13. In the year 2013, challenges for anaesthetic training of middlegrade doctors resident in the UK include: (a) (b) (c) (d) (e)
The 48 h working week compared with a 60 h working week. The rising number of elderly patients. Use of ultrasound during regional anaesthetic block. Anaesthetic educational goals which remain undefined. Fibre optic intubation in patients who are awake.
14. Despite potential complications, novice anaesthetists are allowed to intubate patients under supervision. Appropriate statements concerning the ethical justification for learning in this situation include: (a) Future generations of patients are likely to benefit from this training. (b) There are likely to be unequivocal benefits to current patients. (c) Doctors are enabling patients to act altruistically. (d) With enhanced attention, there is a reduction in immediate risk of sore throat. (e) Patients are obliged to participate in reciprocal justice. 15. During an all-day theatre session of healthy patients requiring dental extraction, a supervisor teaches fibre optic intubation to a trainee doctor. Statements referring to appropriate patient consent for this process include: (a) The patient considers the risks of this process but agrees voluntarily that training should proceed. (b) As an example of heteronomy, the patient gives consent for training to go ahead. (c) The supervisor informs the patients about what the trainee may be doing and the degree of supervision. (d) Patients who give consent are aware that they are placed early on the list. (e) After consent was obtained initially, training proceeds in a patient who becomes anxious after further reflection about oral damage. 16. Appropriate statements regarding a theatre session on teaching and learning fibre optic intubation in patients having routine dental extraction include: (a) Supervisors should allow the trainee to decide what he or she wishes to learn. (b) Supervisors should inform patients that a doctor-in-training will be undertaking part of the procedure.
Continuing Education in Anaesthesia, Critical Care & Pain j Volume 13 Number 6 2013
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(a) The presence of the parents is superior to preoperative sedation in reducing anxiety and increasing compliance with mask induction. (b) Parents are likely to be satisfied when they are involved during the induction of anaesthesia. (c) Children benefit more from their mother’s presence than their father’s presence at induction. (d) Children of calm parents are most likely to benefit from their presence. (e) There is universal consensus that the presence of parents at induction of anaesthesia is of little benefit.
(c) Mitochondrial failure leads to lactic acidosis and myocyte necrosis. (d) Hyperlipidaemia is attributable to mitochondrial failure and increased levels of catecholamines. (e) Parenteral nutrition may lead to the exacerbation of the syndrome.
Multiple Choice Questions
(c) Because a trainee doctor is performing the procedure, a court of law is likely to expect that the standard of care will be less than that provided by an established consultant. (d) Although supervisors take precautions, they are unlikely to prevent the occurrence of harm, such as trauma to the airway. (e) As the prime consideration, the anaesthetic should be such that there is maximization of benefit to future patients.
Anaesthesia for elective open abdominal aortic aneurysm repair (a) Directly and linearly related to the aneurysmal diameter. (b) Similar in male and female patients with aneurysms of comparable diameter. (c) Similar in smokers and non-smokers in patients with similar sized aortic aneurysms. (d) Likely to be lower in diabetic patients than in non-diabetic patients. (e) Is about 5% annually for aneurysms between 3.0 and 4.5 cm in diameter. 18. Appropriate statements regarding preoperative management in patients with abdominal aortic aneurysm include: (a) If tolerated, statins should be administered to all high-risk patients. (b) b-Blockers should be started for patients of both low and high cardiovascular risk. (c) Patients with stable cardiovascular risk factors are likely to require coronary arterial catheterization and stress echocardiography. (d) Patients with stable heart failure should be referred for a cardiology opinion. (e) In the presence of coronary stents placed 12 months previously, asymptomatic patients may stop taking clopidogrel to reduce the risk of intraoperative bleeding. 19. Appropriate statements regarding the anaesthetic management of open repair for infrarenal abdominal aortic aneurysm include: (a) To reduce metabolic requirements, the patient’s temperature is allowed to decrease to 34.08C. (b) A period of postoperative ventilation is likely to be required. (c) Invasive pressure monitoring is essential. (d) Renal protection strategies are likely to prevent acute kidney injury. (e) Minor haemodynamic changes are likely to occur with aortic cross-clamping and unclamping. 20. Appropriate statements regarding organ protection strategies in open abdominal aortic aneurysm repair include: (a) Intraoperative urine output is a good indicator of postoperative renal impairment.
234
Unintended awareness and monitoring of depth of anaesthesia 21. Appropriate statements concerning unintended awareness include: (a) Awareness is defined as explicit recall after general anaesthesia with pain. (b) Up to 50% of patients who experience awareness may not initially have explicit recall. (c) Cases of awareness involve the use of neuromuscular blockers approximately one-third of the time. (d) Most cases are preventable. (e) Long-term psychological harm occurs in up to one-third of cases. 22. Patients who report awareness during surgery: (a) Should be assumed to be fabricating because of the unreliability of reporting. (b) Are likely to suffer short-term adverse psychological symptoms. (c) Should be offered counselling to reduce the potential for long-term psychological symptoms. (d) Are unlikely to experience prolonged psychological harm provided there is an absence of intraoperative pain. (e) May be looking primarily for an apology. 23. Appropriate statements regarding prevention of awareness include: (a) During unexpected light anaesthesia, midazolam should be administered to prevent retrospective recall. (b) Bispectral index (BIS) values of 40 –60 are unlikely to be associated with awareness. (c) A depth-of-anaesthesia monitor is necessary for all total intravenous anaesthesia. (d) Educational programmes and audit are expected to reduce the incidence of awareness by approximately 50%. (e) Persistent hypertension and tachycardia are likely to signify inadequate depth of anaesthesia. 24. Appropriate statements regarding depth of anaesthesia monitoring include: (a) Auditory evoked potentials have low signal-to-noise ratio and are detected at amplitudes of 10– 100 mV.
Continuing Education in Anaesthesia, Critical Care & Pain j Volume 13 Number 6 2013
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17. The risk of abdominal aortic aneurysm rupture is:
(b) The main myocardial protective property of glyceryl trinitrate is mediated by coronary vasodilatation. (c) Organ-protective strategies focus on maintaining organ blood flow and perfusion pressure. (d) Compared with infrarenal application, cross-clamping of the aorta in the suprarenal position is associated with a higher postoperative dialysis rate. (e) Vasoconstrictors are expected to increase blood pressure without necessarily improving cardiac output and organ perfusion.
Multiple Choice Questions
(b) The Narcotrend index is a measure of the spontaneous cortical EEG. (c) BIS monitors are sensitive to the hypnotic effects of xenon and ketamine anaesthesia. (d) In the context of reducing awareness during volatile anaesthesia with muscle relaxation, a BIS protocol (40 –60) is superior to an end-tidal agent (ETAG) protocol (MAC .0.7). (e) BIS values can be affected by surgical diathermy and temperature.
25. Appropriate statements regarding neuropsychological tests for postoperative cognitive dysfunction include: (a) The letter digit coding test analyses speed of processing of information. (b) When there is a reduction of .20% from the baseline measurement in one neuropsychological test, postoperative cognitive dysfunction is diagnosed. (c) Trail-making tests assess memory. (d) There is common agreement on what battery of tests should be used for diagnosis of postoperative cognitive dysfunction. (e) The variable incidence of postoperative cognitive dysfunction is attributable to the timing of measurements of neuropsychological tests. 26. Factors associated with postoperative cognitive dysfunction are likely to include: (a) (b) (c) (d) (e)
Age. Systemic inflammation and neuroinflammation. Macroemboli. Absence of pre-existing cognitive impairment. A high level of education.
Initial management of acute spinal cord injury 29. Appropriate statements regarding the spinal column, spinal canal and the spinal cord include: (a) Cauda equina syndrome is associated with injuries above lumbar vertebrae L1–L2. (b) Compared with mid-thoracic fractures, cervical fractures are likely to be associated with cord injury. (c) Spinothalamic tracts carry sensory fibres for pain and temperature to the thalamus from the contralateral side of the body. (d) The anterior complex provides the most support to the system. (e) The most common site of injury to the vertebral column is at the mid-thoracic level. 30. Appropriate statements regarding spinal cord injury include:
27. Methods used to minimize cognitive dysfunction after coronary surgery are likely to include: (a) Identification of patients who are at high risk of developing this condition before surgery. (b) Avoiding cardiopulmonary bypass during coronary revascularization. (c) Ensuring that cerebral oxygen saturation is maintained within 20% of the preinduction baseline reading. (d) Long duration of cumulative deep hypnotic time. (e) Using the pH-stat method of acid – base balance in adults. 28. Appropriate statements regarding cognitive dysfunction after cardiac surgery include: (a) Sevoflurane may offer some protection against cognitive dysfunction.
(a) Hyperextension is a common mode of injury in children and young adults. (b) In the elderly, falls from a height account for a large proportion of injuries. (c) In the UK, the second most frequent cause of traumatic spinal cord injury is violence. (d) Spinal cord injury is four times more likely to occur in males than in females. (e) In the UK, there are around 6000 new cord injuries each year. 31. Appropriate statements regarding spinal cord damage include: (a) Injuries above thoracic vertebra T5 may be associated with a decrease in systemic vascular resistance and a secondary increase in inotropy. (b) As neurogenic shock is associated with a compensatory decrease in vagal activity, there is no change in heart rate. (c) Neurogenic shock manifests itself as the loss of muscle reflexes caudal to the level of injury.
Continuing Education in Anaesthesia, Critical Care & Pain j Volume 13 Number 6 2013
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Postoperative cognitive dysfunction after cardiac surgery
(b) In non-diabetic patients, prevention of hyperglycaemia of blood sugar below 10 mmol litre21 is of benefit in reducing the incidence of post-operative cognitive dysfunction. (c) A 70-yr-old man with a pyrexia of 38.58C, white cell count of 22 109 litre21 and increased greenish sputum production 1 week post cardiac surgery has a high risk of cognitive dysfunction. (d) A patient presenting for coronary bypass grafting with a blood pressure of 200/95 mm Hg is at a higher risk of postoperative cognitive dysfunction compared with a patient with a blood pressure of 125/75. (e) Cognitive dysfunction may be attributable to progression of disease in patients with vascular disease.
Multiple Choice Questions
(d) Paralysis with loss of vibration is attributable to anterior spinal artery syndrome. (e) The neurological level is the most caudal level of normal sensation and motor function on either the left side or right side of the body. 32. Appropriate statements regarding the management of high spinal cord injury include: (a) Application of cricoid pressure is likely to be avoided during intubation.
(b) Spinal immobilization is unlikely to be required after a road traffic accident involving a fully conscious patient whose only complaint is abdominal pain. (c) In patients with an acute high spinal cord injury, the diaphragm is expected to have a greater inspiratory excursion in the upright position than in the supine position. (d) The incidence of pulmonary embolism is 90%. (e) Therapeutic cooling is recommended as it has been shown to be beneficial in patients with spinal cord injury.
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Continuing Education in Anaesthesia, Critical Care & Pain j Volume 13 Number 6 2013
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We no longer publish the answers to the MCQs in the journal. Instead, you are invited to take part in a web-based, self test. Please visit the journal web site: www.ceaccp.oxfordjournals.org to obtain a certificate and CME points.
Traumatic brain injury: an evidence-based review of management 1. Immediately after traumatic brain injury:
2. Appropriate statements regarding anaesthesia for trauma craniotomy include: (a) A modified rapid sequence induction is rarely performed since it is likely to lead to an increase in intracranial pressure. (b) To avoid displacement of the tracheal tube, a tie should be applied firmly around the patient’s neck. (c) To optimize intraoperative cerebral perfusion, partial pressure of arterial carbon dioxide (PaCO2) should be maintained between 4.0 and 4.5 kPa. (d) In patients undergoing trauma craniotomy, total intravenous anaesthesia with propofol is associated with lower mortality than either isoflurane or sevoflurane anaesthesia. (e) Neurosurgical intervention is necessary in one-third of patients with moderate or severe traumatic brain injury.
(a) Intracranial pressure is reduced by hyperventilation to a PaCO2 ,4.0 kPa. (b) Intracranial pressure is reduced by saline 5%. (c) Intracranial pressure is necessary to calculate cerebral perfusion pressure. (d) Monitoring of intracranial pressure is necessary in patients with severe traumatic brain injury undergoing non-neurosurgical procedures such as fixation of a long bone fracture. (e) Intracranial pressure should be treated if it is persistently in the range 20 –25 mm Hg.
Preinduction techniques to relieve anxiety in children undergoing general anaesthesia 5. Increased preoperative anxiety in children is associated with the following postoperative sequelae: (a) (b) (c) (d) (e)
Emergence delirium. Reduced analgesic requirements. Altered sleep pattern. Enuresis. Separation anxiety.
6. To reduce perioperative anxiety, effective pre-induction techniques are likely to include: (a) Preoperative midazolam. (b) Routine presence of the parents at induction of anaesthesia. (c) Inhalational induction rather than intravenous induction of general anaesthesia. (d) Use of video games. (e) Use of clowns.
3. Appropriate statements concerning patients with traumatic brain injury in the critical care unit include:
7. Appropriate statements regarding sedative premedication include:
(a) A cerebral perfusion pressure of 70 –90 mm Hg is recommended. (b) Management algorithms have reduced mortality rates both in intensive care and in hospital. (c) Pharmacological thromboprophylaxis is often avoided within 24 h of injury. (d) Seizure activity increases the risk of secondary brain injury. (e) Tight glycaemic control (blood glucose 4.5–6.0 mmol litre21) is associated with reduced mortality.
(a) Midazolam is typically administered orally at a dose of 2 mg kg21. (b) The use of midazolam or clonidine results in decreased anxiety, increased cooperation and decreased negative behavioural changes. (c) Clonidine is an a2 agonist with analgesic as well as sedative properties. (d) Antihistamines remain a popular form of pre-medication. (e) The usual dose of intramuscular ketamine is 4–8 mg kg21.
232
doi:10.1093/bjaceaccp/mkt054 Continuing Education in Anaesthesia, Critical Care & Pain | Volume 13 Number 6 2013 # The Author [2013]. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved. For Permissions, please email: [email protected]
Downloaded from http://ceaccp.oxfordjournals.org/ at North Dakota State University on June 9, 2015
(a) A single episode of hypotension (systolic pressure ,90 mm Hg) is associated with a doubling of mortality. (b) Patients with a deteriorating conscious level, such as a reduction in motor score of .2 points, should be intubated before transfer to a neurosurgical unit. (c) An immediate computed tomography (CT) scan is indicated if the patient’s Glasgow Coma Scale (GCS) score is ,13 on arrival in the emergency room. (d) The initial resuscitation process should focus on establishing a clear airway before treating the brain injury. (e) The GCS is used to assess severity of brain injury before resuscitation.
4. In a patient with a severe traumatic brain injury:
Multiple Choice Questions
8. Appropriate statements regarding the presence of parents at induction of general anaesthesia include:
Propofol infusion syndrome 9. The original definition of propofol infusion syndrome coined by Bray in 1998 includes the presence of the following clinical conditions: (a) Bradycardia of ,40 beats min21. (b) Metabolic acidosis with base excess more negative than 210 mmol litre21. (c) Rhabdomyolysis. (d) C-reactive protein levels .100 mg litre21. (e) White cell count .12 109 litre21. 10. Factors that predispose to propofol infusion syndrome include: (a) (b) (c) (d) (e)
Age ,12 years. Renal failure. Sepsis. A propofol infusion rate of .4 mg kg21 h21. Lipid infusions, such as total parenteral nutrition.
11. A 50-year-old patient sedated for head injuries suddenly develops severe metabolic acidosis 2 days after propofol infusion was commenced. The management of suspected propofol infusion syndrome ( propofol infusion syndrome) should include: (a) Continuing the propofol infusion at a lower dose of 2 mg kg21 h21. (b) Stopping propofol and administering an alternative agent, such as midazolam. (c) Commencing renal replacement therapy if creatine kinase levels are .30 000 units litre21 and the creatinine level is .500 mmol litre21. (d) Treating bradycardias (heart rate ,40 beats min21) with external pacing. (e) Commencing a glucose infusion. 12. Appropriate statements regarding the pathophysiology of propofol infusion syndrome include: (a) The function of the endoplasmic reticulum is reduced. (b) Cardiogenic shock occurs as a result of the b-blocking like actions of propofol.
Ethico-legal considerations of teaching 13. In the year 2013, challenges for anaesthetic training of middlegrade doctors resident in the UK include: (a) (b) (c) (d) (e)
The 48 h working week compared with a 60 h working week. The rising number of elderly patients. Use of ultrasound during regional anaesthetic block. Anaesthetic educational goals which remain undefined. Fibre optic intubation in patients who are awake.
14. Despite potential complications, novice anaesthetists are allowed to intubate patients under supervision. Appropriate statements concerning the ethical justification for learning in this situation include: (a) Future generations of patients are likely to benefit from this training. (b) There are likely to be unequivocal benefits to current patients. (c) Doctors are enabling patients to act altruistically. (d) With enhanced attention, there is a reduction in immediate risk of sore throat. (e) Patients are obliged to participate in reciprocal justice. 15. During an all-day theatre session of healthy patients requiring dental extraction, a supervisor teaches fibre optic intubation to a trainee doctor. Statements referring to appropriate patient consent for this process include: (a) The patient considers the risks of this process but agrees voluntarily that training should proceed. (b) As an example of heteronomy, the patient gives consent for training to go ahead. (c) The supervisor informs the patients about what the trainee may be doing and the degree of supervision. (d) Patients who give consent are aware that they are placed early on the list. (e) After consent was obtained initially, training proceeds in a patient who becomes anxious after further reflection about oral damage. 16. Appropriate statements regarding a theatre session on teaching and learning fibre optic intubation in patients having routine dental extraction include: (a) Supervisors should allow the trainee to decide what he or she wishes to learn. (b) Supervisors should inform patients that a doctor-in-training will be undertaking part of the procedure.
Continuing Education in Anaesthesia, Critical Care & Pain j Volume 13 Number 6 2013
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Downloaded from http://ceaccp.oxfordjournals.org/ at North Dakota State University on June 9, 2015
(a) The presence of the parents is superior to preoperative sedation in reducing anxiety and increasing compliance with mask induction. (b) Parents are likely to be satisfied when they are involved during the induction of anaesthesia. (c) Children benefit more from their mother’s presence than their father’s presence at induction. (d) Children of calm parents are most likely to benefit from their presence. (e) There is universal consensus that the presence of parents at induction of anaesthesia is of little benefit.
(c) Mitochondrial failure leads to lactic acidosis and myocyte necrosis. (d) Hyperlipidaemia is attributable to mitochondrial failure and increased levels of catecholamines. (e) Parenteral nutrition may lead to the exacerbation of the syndrome.
Multiple Choice Questions
(c) Because a trainee doctor is performing the procedure, a court of law is likely to expect that the standard of care will be less than that provided by an established consultant. (d) Although supervisors take precautions, they are unlikely to prevent the occurrence of harm, such as trauma to the airway. (e) As the prime consideration, the anaesthetic should be such that there is maximization of benefit to future patients.
Anaesthesia for elective open abdominal aortic aneurysm repair (a) Directly and linearly related to the aneurysmal diameter. (b) Similar in male and female patients with aneurysms of comparable diameter. (c) Similar in smokers and non-smokers in patients with similar sized aortic aneurysms. (d) Likely to be lower in diabetic patients than in non-diabetic patients. (e) Is about 5% annually for aneurysms between 3.0 and 4.5 cm in diameter. 18. Appropriate statements regarding preoperative management in patients with abdominal aortic aneurysm include: (a) If tolerated, statins should be administered to all high-risk patients. (b) b-Blockers should be started for patients of both low and high cardiovascular risk. (c) Patients with stable cardiovascular risk factors are likely to require coronary arterial catheterization and stress echocardiography. (d) Patients with stable heart failure should be referred for a cardiology opinion. (e) In the presence of coronary stents placed 12 months previously, asymptomatic patients may stop taking clopidogrel to reduce the risk of intraoperative bleeding. 19. Appropriate statements regarding the anaesthetic management of open repair for infrarenal abdominal aortic aneurysm include: (a) To reduce metabolic requirements, the patient’s temperature is allowed to decrease to 34.08C. (b) A period of postoperative ventilation is likely to be required. (c) Invasive pressure monitoring is essential. (d) Renal protection strategies are likely to prevent acute kidney injury. (e) Minor haemodynamic changes are likely to occur with aortic cross-clamping and unclamping. 20. Appropriate statements regarding organ protection strategies in open abdominal aortic aneurysm repair include: (a) Intraoperative urine output is a good indicator of postoperative renal impairment.
234
Unintended awareness and monitoring of depth of anaesthesia 21. Appropriate statements concerning unintended awareness include: (a) Awareness is defined as explicit recall after general anaesthesia with pain. (b) Up to 50% of patients who experience awareness may not initially have explicit recall. (c) Cases of awareness involve the use of neuromuscular blockers approximately one-third of the time. (d) Most cases are preventable. (e) Long-term psychological harm occurs in up to one-third of cases. 22. Patients who report awareness during surgery: (a) Should be assumed to be fabricating because of the unreliability of reporting. (b) Are likely to suffer short-term adverse psychological symptoms. (c) Should be offered counselling to reduce the potential for long-term psychological symptoms. (d) Are unlikely to experience prolonged psychological harm provided there is an absence of intraoperative pain. (e) May be looking primarily for an apology. 23. Appropriate statements regarding prevention of awareness include: (a) During unexpected light anaesthesia, midazolam should be administered to prevent retrospective recall. (b) Bispectral index (BIS) values of 40 –60 are unlikely to be associated with awareness. (c) A depth-of-anaesthesia monitor is necessary for all total intravenous anaesthesia. (d) Educational programmes and audit are expected to reduce the incidence of awareness by approximately 50%. (e) Persistent hypertension and tachycardia are likely to signify inadequate depth of anaesthesia. 24. Appropriate statements regarding depth of anaesthesia monitoring include: (a) Auditory evoked potentials have low signal-to-noise ratio and are detected at amplitudes of 10– 100 mV.
Continuing Education in Anaesthesia, Critical Care & Pain j Volume 13 Number 6 2013
Downloaded from http://ceaccp.oxfordjournals.org/ at North Dakota State University on June 9, 2015
17. The risk of abdominal aortic aneurysm rupture is:
(b) The main myocardial protective property of glyceryl trinitrate is mediated by coronary vasodilatation. (c) Organ-protective strategies focus on maintaining organ blood flow and perfusion pressure. (d) Compared with infrarenal application, cross-clamping of the aorta in the suprarenal position is associated with a higher postoperative dialysis rate. (e) Vasoconstrictors are expected to increase blood pressure without necessarily improving cardiac output and organ perfusion.
Multiple Choice Questions
(b) The Narcotrend index is a measure of the spontaneous cortical EEG. (c) BIS monitors are sensitive to the hypnotic effects of xenon and ketamine anaesthesia. (d) In the context of reducing awareness during volatile anaesthesia with muscle relaxation, a BIS protocol (40 –60) is superior to an end-tidal agent (ETAG) protocol (MAC .0.7). (e) BIS values can be affected by surgical diathermy and temperature.
25. Appropriate statements regarding neuropsychological tests for postoperative cognitive dysfunction include: (a) The letter digit coding test analyses speed of processing of information. (b) When there is a reduction of .20% from the baseline measurement in one neuropsychological test, postoperative cognitive dysfunction is diagnosed. (c) Trail-making tests assess memory. (d) There is common agreement on what battery of tests should be used for diagnosis of postoperative cognitive dysfunction. (e) The variable incidence of postoperative cognitive dysfunction is attributable to the timing of measurements of neuropsychological tests. 26. Factors associated with postoperative cognitive dysfunction are likely to include: (a) (b) (c) (d) (e)
Age. Systemic inflammation and neuroinflammation. Macroemboli. Absence of pre-existing cognitive impairment. A high level of education.
Initial management of acute spinal cord injury 29. Appropriate statements regarding the spinal column, spinal canal and the spinal cord include: (a) Cauda equina syndrome is associated with injuries above lumbar vertebrae L1–L2. (b) Compared with mid-thoracic fractures, cervical fractures are likely to be associated with cord injury. (c) Spinothalamic tracts carry sensory fibres for pain and temperature to the thalamus from the contralateral side of the body. (d) The anterior complex provides the most support to the system. (e) The most common site of injury to the vertebral column is at the mid-thoracic level. 30. Appropriate statements regarding spinal cord injury include:
27. Methods used to minimize cognitive dysfunction after coronary surgery are likely to include: (a) Identification of patients who are at high risk of developing this condition before surgery. (b) Avoiding cardiopulmonary bypass during coronary revascularization. (c) Ensuring that cerebral oxygen saturation is maintained within 20% of the preinduction baseline reading. (d) Long duration of cumulative deep hypnotic time. (e) Using the pH-stat method of acid – base balance in adults. 28. Appropriate statements regarding cognitive dysfunction after cardiac surgery include: (a) Sevoflurane may offer some protection against cognitive dysfunction.
(a) Hyperextension is a common mode of injury in children and young adults. (b) In the elderly, falls from a height account for a large proportion of injuries. (c) In the UK, the second most frequent cause of traumatic spinal cord injury is violence. (d) Spinal cord injury is four times more likely to occur in males than in females. (e) In the UK, there are around 6000 new cord injuries each year. 31. Appropriate statements regarding spinal cord damage include: (a) Injuries above thoracic vertebra T5 may be associated with a decrease in systemic vascular resistance and a secondary increase in inotropy. (b) As neurogenic shock is associated with a compensatory decrease in vagal activity, there is no change in heart rate. (c) Neurogenic shock manifests itself as the loss of muscle reflexes caudal to the level of injury.
Continuing Education in Anaesthesia, Critical Care & Pain j Volume 13 Number 6 2013
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Downloaded from http://ceaccp.oxfordjournals.org/ at North Dakota State University on June 9, 2015
Postoperative cognitive dysfunction after cardiac surgery
(b) In non-diabetic patients, prevention of hyperglycaemia of blood sugar below 10 mmol litre21 is of benefit in reducing the incidence of post-operative cognitive dysfunction. (c) A 70-yr-old man with a pyrexia of 38.58C, white cell count of 22 109 litre21 and increased greenish sputum production 1 week post cardiac surgery has a high risk of cognitive dysfunction. (d) A patient presenting for coronary bypass grafting with a blood pressure of 200/95 mm Hg is at a higher risk of postoperative cognitive dysfunction compared with a patient with a blood pressure of 125/75. (e) Cognitive dysfunction may be attributable to progression of disease in patients with vascular disease.
Multiple Choice Questions
(d) Paralysis with loss of vibration is attributable to anterior spinal artery syndrome. (e) The neurological level is the most caudal level of normal sensation and motor function on either the left side or right side of the body. 32. Appropriate statements regarding the management of high spinal cord injury include: (a) Application of cricoid pressure is likely to be avoided during intubation.
(b) Spinal immobilization is unlikely to be required after a road traffic accident involving a fully conscious patient whose only complaint is abdominal pain. (c) In patients with an acute high spinal cord injury, the diaphragm is expected to have a greater inspiratory excursion in the upright position than in the supine position. (d) The incidence of pulmonary embolism is 90%. (e) Therapeutic cooling is recommended as it has been shown to be beneficial in patients with spinal cord injury.
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Continuing Education in Anaesthesia, Critical Care & Pain j Volume 13 Number 6 2013
Downloaded from http://ceaccp.oxfordjournals.org/ at North Dakota State University on June 9, 2015
We no longer publish the answers to the MCQs in the journal. Instead, you are invited to take part in a web-based, self test. Please visit the journal web site: www.ceaccp.oxfordjournals.org to obtain a certificate and CME points.