Mcq Anesthesia

Page 1Exam 1 Question 1 Amiodarone may be associated with the Iollowing complications A. Skin discoloration B. Lung Iibrosis C. Hypothyroidism D. Shortening oI the QT interval E. Reduction oI the serum digoxin level Question 2 Contra-indicators to ß-blockers include A. Raynaud's disease B. WolII-Parkinson-White syndrome C. Chronic obstructive pulmonary disease D. Parkinson's disease E. Intermittent claudication Question 3 Digoxin A. Acts by inhibiting the calcium channel B. Toxicity is precipitated by hyperkalaemia C. Must be stopped Ior 24 hours prior to DC cardioversion D. Loading dose is highly inIluenced by renal Iunction E. Can cause atrial Iibrillation Question 4 Drug combinations that may have signiIicant clinical interaction include A. Trimethoprim an phenytoin B. Etomidate and hydrocortisone C. RiIampicin and propoIol D. CiproIloxacin and aminophylline E. Erythromycin and warIarin Question 5 Regarding the reporting oI suspected adverse drug reactions to the committee on saIety oI medicine (CSM) A. Only serious reactions to new drugs marked with an inverted black triangle should be reported B. Cases oI well known adverse reactions need not be reported C. A small payment is made Ior reporting adverse reactions D. The therapeutic index is a register oI all adverse reactions caused by a drug reported to the CSM E. Reporting can be made by telephone Question 6 RemiIentanil A. Undergoes hepatic metabolism B. Has a halI-liIe oI approximately 20 minutes C. Has a short duration oI action because oI redistribution D. Has a potency similar to Ientanyl E. Has a prolonged duration oI action in patients with pseudocholinesterase deIiciency Question 7 Verapamil A. Is structurally related to papaverine B. Blocks sino-atrial (SA) nodal conduction C. May be used saIely in ventricular arrhythmias D. Is given in approximately the same dose whether orally or intravenously E. Is a prodrug Question 8 Treatment with metIormin A. Is a recognised cause oI hypoglycaemia in an elderly diabetic patient B. Is a recognised cause oI diarrhoea C. Reduces serum triglyceride concentration D. Increases serum insulin concentration E. Is contraindicated in the presence oI liver disease Page 3 Question 9 Pharmacological eIIects oI morphine include A. Constipation B. Biliary spasm C. Histamine release D. Cough E. Release oI antidiuretic hormone Question 10 Fentany1 A. Has a potency 10 times that oI morphine B. Is water-soluble C. Has a large volume oI distribution D. Does not accumulate even aIter repeated doses E. Is metabolised to norIentany1 Question 11 DicloIenac A. Works by inhibiting lipo-oxygenase B. May increase renal blood Ilow C. Has antipyretic properties D. Reversibly promotes platelet aggregation E. May be used in the last trimester oI pregnancy Question 12 AlIentanil A. Is more lipid soluble than pethidine B. Is less lipid soluble than Ientanyl C. Is highly protein bound D. Is more potent than Ientanyl E. Has clinically important active metabolites Question 13 Magnesium A. Has a normal plasma concentration oI 0.81.2 mmol/litre B. Is a cerebral vasodilator C. Has no antiarrhythmic action D. Is an N-methyl-D-aspartate antagonist E. Potentiates neuromuscular blockade Question 14 Tramadol A. Is a controlled drug B. Can be administered intravenously C. Has aIIinity Ior binding at the mu opioid receptor comparable to that oI morphine D. Acts predominantly by inhibiting the reuptake oI noradrenaline and serotonin (5-HT) E. May be used concurrently with a MAOI Question 15 The metabolism oI the Iollowing observe zero-order kinetics in clinical doses A. Phenytoin B. Aspirin C. Ethanol D. Propranolol E. Thiopentone Question 16 The Iollowing are examples oI hepatic enzyme inducer A. Cimetidine B. Erythromycin C. Phenytoin D. Amiodarone E. Dextropropoxyphene Question 17 Hepatic Iirst-pass metabolism A. Is avoided by giving the drug transdermally B. Is avoided by giving the drug sublingually C. Is avoided by giving the drug rectally D. Is avoided by giving an intramuscular iniection oI the drug E. Is seen when a drug has a high hepatic extraction ratio Question 18 The Iollowing are characteristics oI Iirst-order kinetics A. A constant proportion oI drug metabolised in a given time period B. The absolute amount eliminated is greatest when plasma concentration is greatest C. The rate oI elimination and elimination halI-liIe is constant, irrespective oI plasma concentration D. The enzyme responsible Ior the reaction is saturated E. The reaction is represented by a linear relationship Page 5 Question 19 The Iollowing are recognised side-eIIects oI digoxin A. Nausea B. Xanthopsia C. Hypokalaemia D. Hyperuricaemia E. Gynaecomastia Question 20 The eIIicacy oI a drug A. Is greater Ior drug A iI A is eIIective in a dose oI 100 3g than Ior drug B iI B is eIIective in a dose oI 100 mg B. Is a measure oI its therapeutic index C. Is a measure oI the amount oI a drug required to produce a given eIIect D. Describes the ability oI a drug to produce its therapeutic eIIect E. Is a measure oI the bioavailability oI a drug Question 21 The oxyhaemoglobin dissociation curve is shiIted to the right in A. Pregnancy B. Cyanide poisoning C. Carbon monoxide poisoning D. Fetal haemoglobin E. Increasing pH Question 22 The Iollowing drugs readily cross the blood-brain barrier A. Benzylpenicillin B. Hyoscine hydrobromide C. Glycopyrollate D. Atracurium E. PropoIol Question 23 The Iollowing are capable oI directly causing pain when applied to nerve endings A. Prostaglandins B. Bradykinins C. Histamine D. Serotonin (5-HT) E. Potassium Question 24 Factors inIluencing the perception oI pain include A. Anxiety B. Depression C. Muscle tension D. Fatigue E. Age Question 25 The Iollowing are endocrine consequences oI the stress response A. Decreased ACTH secretion B. Increased glucagon secretion C. Increased ADH secretion D. Increased aldosterone secretion E. Decreased growth hormone secretion Question 26 In the third trimester oI pregnancy, the Iollowing are lowered A. PaO 2 B. PaCO 2 C. Functional residual capacity D. Vital capacity E. Lung compliance Question 27 The Iollowing are produced by the adrenal cortex A. Noradrenaline B. Dehydroepiandrosterone C. Angiotensin II D. Deoxycorticosterone E. Aldosterone Question 28 The anterior pituitary gland secretes A. Oxytocin B. Thyrotrophin releasing hormone C. Luteinizing hormone D. Growth hormone E. Somatostatin Question 29 Regarding thyroxine A. Approximately 80° oI circulating thyroxine is bound B. It is predominantly bound to plasma albumin C. It is a Iactor contributing to skeletal growth D. It decreases the sensitivity oI receptors to catecholamines E. It is a Iactor aIIecting the minimum alveolar concentration (MAC) oI inhalational anaesthetic agents Question 30 The pH oI the extracellular Iluid A. Is maintained in health between 7.4 and 7.5 B. Is maintained solely by the buIIering system oI the intra- and extracellular Iluids C. Is increased in hypovolaemic shock D. Decreases abruptly aIter a cardiac arrest E. InIluences the binding oI drugs to plasma proteins Question 31 The total cerebral blood Ilow in normal man is A. Approximately 15° oI the total resting cardiac output B. Increased signiIicantly by an increase in carbon dioxide concentration in the arterial blood C. Reduced signiIicantly iI the mean systemic BP is reduced Irom 120 mmHg to 80 mmHg D. Regulated by sympathetic nerves Irom the cervical sympathetic chain E. Increased during in tense mental activity Question 32 In respiratory muscle weakness involving the intercostal muscles and diaphragm A. The ratio oI Iorced expiratory volume in 1 second (FEV1) to vital capacity (VC) is reduced B. The ratio oI residual volume (RV) to total lung capacity (TLC) is increased C. Gas transIer that is corrected Ior lung volume is reduced D. Hypercapnoea is an early Ieature E. The vital capacity (VC) Ialls when the patient is moved Irom an upright to a supine position Question 33 Isovolumetric ventricular contraction oI the heart A. Starts when the aortic valve closes B. Starts when the mitral valve closes C. Takes up most oI the time the heart spends in ventricular systole D. Coincides with the 'c' wave in the right atrial pressure trace E. Coincides with the T wave oI the electrocardiogram Question 34 Regarding the cerebrospinal Iluid (CSF) A. It is a plasma ultraIiltrate B. The rate oI its Iormation is dependent on the intraventricular pressure over the normal range C. It has greater buIIering capacity than plasma D. Its main Iunction is in deIence against inIection E. It has a similar chloride concentration to plasma Question 35 In the proximal tubule oI the nephron A. Sodium is actively reabsorbed B. Bicarbonate is secreted C. All oI the reabsorption oI glucose occurs D. The vast proportion oI Iiltered water is reabsorbed E. Water reabsorption is under the control oI aldosterone Question 36 Increased urine volume occurs with A. Glycosuria B. Increased aldosterone secretion C. Damage to the posterior pituitary D. Alcohol consumption E. Carbonic anhydrase inhibitors Question 37 Concerning carbon dioxide transport in blood A. Carbonic anhydrase is present in plasma B. 25° oI carbon dioxide is dissolved C. 50° is carried as bicarbonate D. Transport oI carbon dioxide is Iacilitated by deoxygenated haemoglobin E. Some oI the carbon dioxide reacts with haemoglobin to Iorm carbamino compounds Question 38 Voluntary hyperventilation produces A. Carpopedal spasm B. Acidosis C. Increased cerebral blood Ilow D. Peripheral vasodilatation E. Increased cardiac output Question 39 The Iollowing muscles are responsible Ior inspiration A. Internal intercostal muscles B. External intercostal muscles C. Diaphragm D. Muscles oI the anterior abdominal wall E. Sternocleidomastoid Question 40 There is an increased alveolar-arterial oxygen partial pressure diIIerence (A-a)PO 2 with A. Hypovolaemia B. Decreased Iunctional residual capacity C. Pneumonia D. Decrease cardiac output E. Anaesthesia Question 41 Regarding critical temperature A. It is the temperature at which a gas exists simultaneously in the gaseous and liquid state at atmospheric pressure B. The critical temperature oI a gas varies with pressure C. It is the temperature below which, the more a gas is cooled, the less the pressure is required to liqueIy it D. Oxygen at room temperature can be liqueIied by 50 bar oI pressure E. OI nitrous oxide is -116°C Question 42 The Iollowing describe Boyle's law A. The pressure oI a gas kept at constant temperature is proportional to its density B. The pressure oI a gas kept at constant temperature varies inversely as the volume C. For a Iixed mass oI gas at constant temperature, the product oI the pressure and the volume is a constant D. The volume oI a given quantity oI gas at constant pressure is directly proportional to the temperature E. The pressure oI a gas kept at constant volume is directly proportional to the temperature Question 43 The Fluotec 4 vaporiser A. It delivers a constant vapour concentration Irom 1 to 15 litres B. Is protected against back pressure C. Uses a bellows mechanism Ior temperature compensation D. Uses wicks to provide a large surIace area Ior vaporisation E. II accidentally inverted, will not spill the liquid agent into the bypass Question 44 The dibucaine test measures the Iollowing A. Activity oI acetylcholinesterase B. Stimulation oI pseudocholinesterase activity C. Inhibition oI pseudocholinesterase activity D. Acetylcholinesterase concentration E. Susceptibility to malignant hyperthermia Page 11 Question 45 Causes oI inaccuracies on pulse oximetry include A. Methaemoglobinaemia B. Fetal haemoglobin C. Hypothermia D. Blue nail polish E. Extraneous lighting Question 46 Laminar Ilow through a tube A. Is proportional to density B. Is inversely proportional to viscosity C. Is inversely proportional to length D. Is proportional to the square oI the radius E. Is proportional to the pressure drop Question 47 Pressure A. Is work per unit time B. Is Iorce multiplied by distance C. Is Iorce multiplied by area D. Can be measured by a column oI Iluid E. Is identiIied by the SI unit, the Newton Question 48 The Iollowing cylinders require reducing valves A. Oxygen B. Nitrous oxide C. Cyclopropane D. Entonox E. Carbon dioxide Question 49 The Iollowing statements are true A. An empty cylinder oI oxygen has an absolute pressure oI 0 bar B. A Iull cylinder oI oxygen has a gauge pressure oI 137 bar C. A diver working 10 metres below sea level is at 2 atmospheres absolute pressure D. Pressure gauges on anaesthetic ventilators usually comprise a simple bellows type oI aneroid gauge E. Pressure gauges on gas cylinders are measured using a Bourdon type oI pressure gauge Causes oI errors on rotameter reading include A. Tube not vertical B. Tube cracked C. Static electricity D. Dirt on tube E. Measuring oxygen on a N 2 O rotameter Question 51 In the measurement oI temperature A. The triple point oI water is approximately - 273°C B. Absolute zero is the temperature at which water exists simultaneously in solid, liquid and gaseous state C. Electrical resistance increases with rising temperature D. A thermistor consists oI two dissimilar conductors E. A thermistor relies on the 'Seebeck eIIect' Ior its operation Question 52 One atmosphere oI pressure is approximately equivalent to A. 100 mmHg B. 10 kPa C. 100 cm water D. 14.7 pound per square inch (p.s.i.) E. 2 atmospheres absolute (ATA) Question 53 The Iollowing statements are true A. The amount oI gas dissolved at any temperature is inversely proportional to its partial pressure B. The boiling point oI a liquid is the temperature at which the saturated vapour pressure equals the ambient atmospheric pressure C. A solution oI 1 osmol/L depresses the boiling point 1.86°C D. Relative humidity is the actual water vapour pressure as a percentage oI the saturated vapour pressure at a given temperature E. Absolute humidity is the mass oI water vapour present in a given volume oI gas Page 13 Question 54 Concerning laboratory investigations oI bleeding disorder A. Bleeding time is prolonged in haemophilia B. Prolonged bleeding time occurs with impaired platelet Iunction C. Activated partial thromboplastin time (APPT) is used to monitor warIarin treatment D. Activated partial thromboplastin time is sensitive to Iactors in the intrinsic coagulation pathway E. Protrombin time (PT) is prolonged in liver Iailure Question 55 Entonox A. In the UK, is stored in blue cylinders with white shoulders B. The pressure gauge does not give a direct indication oI the cylinder content C. The critical temperature oI the mixture is -116°C D. On cooling the cylinder to a temperature below the critical temperature, separation oI the components occur E. At a temperature below the critical temperature, the initial mixture emitted is richer in oxygen Question 56 Regarding scavenging A. The maior component oI soda lime is sodium hydroxide B. Passive scavenging systems require a negative pressure relieI valve C. Activated charcoal may be used to absorb nitrous oxide D. The male connector on scavenging systems has a diameter oI 22 mm E. The Iemale connector on scavenging systems has a diameter oI 30 mm Question 57 An electric current A. Flows more readily through wet skin than dry skin B. Is likely to cause muscle contraction when 10 mA is applied externally C. Is likely to cause arrhythmias when 100 mA is applied externally D. Is more likely to cause burns when transmitted to a large surIace area oI the skin E. Is less likely to be generated in a humid environment Question 58 Oxygen A. Is produced commercially by distilling air B. Is Ilammable C. Has a critical temperature oI -36.5°C D. Is stored in the UK in black cylinders with grey shoulders E. Is stored in the UK in cylinders at a pressure oI approximately 50 bar when Iull Question 59 Concerning osmolality A. It depends on the number rather than the type oI particles present B. One mole oI sodium chloride dissolved in 1 kg oI water has an osmolality oI 1 osmol/kg C. Osmolality oI the ECF compartment is greater than that oI the ICF compartment due to the greater abundance oI sodium D. Glucose does not contribute to the plasma osmolality E. Plasma osmolality is approximately 290 mmol/L Question 60 A rise in temperature A. Increases the vaporisation rate oI volatile agents B. Decreases the density oI Iluids C. Decreases the viscosity oI Iluid D. Decreases the viscosity oI gases E. Decreases the osmotic pressure oI Iluids Page 15 Exam 1 Answers Question 1 A. TRUE B. TRUE C. TRUE D. FALSE E. FALSE Dermatological side-eIIects include slatey grey or blue skin discoloration and photosensitivity. Lung Iibrosis is a rare complication oI long term, very high dose therapy. Hyper and hypothyroidism are both possible. Prolongation oI QT interval may occur. Amiodarone increases digoxin level by displacement. It may be necessary to reduce the maintenance dosage oI digoxin by up to 50° iI the patient is also taking amiodarone concurrently. Ref. W McCaughev. R S J Clarke. J P H Fee. W F M Wallace. Anaesthetic Phvsiologv and Pharmacologv. 1st ed. Churchill Livingstone. 1997. Question 2 A. TRUE B. FALSE C. TRUE D. FALSE E. TRUE The three classic groups oI patients where ß-blockers are contra-indicated are: Peripheral vascular disease and Raynaud's Asthma and COPD Heart Iailure As well as blockade oI ß-receptors, some oI these drugs may have additional Ieatures such as cardioselectivity, partial agonist activity and membrane-stabilising activity. Cardioselective ß-blockers such as acebutalol, atenolol, bisoprolol, metoprolol and esmolol block the ß 1 - receptors to a greater degree than the ß 2 -receptors. Some oI the ß-blocking drugs e.g. acebutalol and oxprenolol have partial agonist activity, sometimes described as intrinsic sympathomimetic activity (ISA). It has been suggested that drugs with this property have a lower incidence oI the undesirable side-eIIects such as bradycardia, heart Iailure, cold extremities and bronchospasm. Propranolol has membrane-stabilising activity, potent local anaesthetic properties and demonstrates class II anti-arrhythmic properties. Ref. W McCaughev. R S J Clarke. J P H Fee. W F M Wallace. Anaesthetic Phvsiologv and Pharmacologv. 1st ed. Churchill Livingstone. 1997. Question 3 A. FALSE B. FALSE C. FALSE D. FALSE E. TRUE Maintenance dose (not loading dose) is highly inIluenced by renal Iunction. Toxicity is precipitated by hypokalaemia and hypercalaemia. It is not essential to stop digoxin Ior 24 Page 16 hours prior to DC cardioversion provided digoxin levels are not in the toxic range. Otherwise there is the risk oI unresponsiveVF. Digoxin acts on the sodium pump by inhibiting the membrane-bound Na/K ATPase enzyme. This results in accumulation oI intracellular sodium and loss oI potassium. It works by prolonging AV conduction. Almost any arrhythmia can occur in digox in toxicity including atrial Iibrillation. Ref. W McCaughev. R S J Clarke. J P H Fee. W F M Wallace. Anaesthetic Phvsiologv and Pharmacologv. 1st ed. Churchill Livingstone. 1997. Question 4 A. TRUE B. FALSE C. TRUE D. TRUE E. TRUE Trimethoprim and phenytoin interIere with Iolate metabolism causing megaloblastic anaemia. RiIampicin is a liver enzyme inducer which will increase the metabolism oI drugs metabolised by the liver. CiproIloxacin and erythromycin are liver enzyme inhibitors which will decrease the metabolism oI drugs metabolised by the liver. Ref. British National Formularv. 1997 Question 5 A. FALSE B. FALSE C. FALSE D. FALSE E. FALSE Newer drugs: These are indicated by the inverted black triangle. Report all suspected reactions, however minor and irrespective oI whether the reaction is well recognised. Established drugs: Report all serious suspected reactions even iI the eIIect is well recognised, such as anaphylaxis. There is no need to report well known relatively minor side eIIects, such as constipation with opioids. CSM Freephone: Ior more yellow prepaid lettercards, or advice and inIormation on adverse reactions. Ref. British National Formularv. 1997. Question 6 A. FALSE B. FALSE C. FALSE D. TRUE E. FALSE RemiIentanil is the latest opioid to be introduced into clinical practice. It does not undergo hepatic metabolism and is unique in that it is broken down by esterases. It has a halI-liIe oI approximately 9 minutes and a potency similar to Ientanyl. Its duration oI action in patients with pseudocholinesterase deIiciency is not prolonged. Ref. Burkle H. Dunbar S. Jan Aken H. Remifentanil. A Novel. Short-Acting. mu-opioid. Anesthesia Analgesia 1996, 83. 646651. Page 17 Question 7 A. TRUE B. FALSE C. FALSE D. FALSE E. TRUE Verapamil is a papaverine derivative. It works by blocking AV nodal conduction. A much smaller dose is required when given IV (oral administration subiected to signiIicant Iirst-pass metabolism). It is dangerous to give verapamil in the presence oI ventricular arrhythmias. Verapamil is converted in the body to an active metabolite, norverapamil. Other prodrugs: Parent drug Active Drug Carbimazole Codeine Diamorphine Enalapril Isosorbide dinitrate Levodopa Methyldopa Prednisone TerIenadine Methimazole Morphine Monoacetylmorphine and morphine Enalaprilat Isosorbide mononitrate Dopamine --Methyl noradrenaline Prednisolone FexoIenadine Ref. W McCaughev. R S J Clarke. J P H Fee. W F M Wallace. Anaesthetic Phvsiologv and Pharmacologv. 1st ed. Churchill Livingstone. 1997. Question 8 A. FALSE B. TRUE C. TRUE D. FALSE E. TRUE Hypoglycaemia is not a problem with metIormin, in contrast with the sulphonylureas. Side-eIIects may be minimised by gradual increase in the dose. MetIormin has a beneIicial eIIect on the lipid proIile oI the diabetic patient. It is commonly given to NIDDMs who are overweight. Lactic acidosis is rare but may occur in patients with renal or liver Iailure. Ref. W McCaughev. R S J Clarke. J P H Fee. W F M Wallace. Anaesthetic Phvsiologv and Pharmacologv. 1st ed. Churchill Livingstone. 1997. Question 9 A. TRUE B. TRUE C. TRUE D. FALSE E. TRUE Opioids are cough suppressants. Opioids such as codeine, dextromethorphan and pholcodine are ingredients oI cough preparations. Ref. British National Formularv. 1997. Page 18 Question 10 A. FALSE B. FALSE C. TRUE D. FALSE E. TRUE Fentanyl is a synthetic opioid related structurally to pethidine. Its analgesic potency is approximately 100 times that oI morphine. It is very lipid-soluble and thereIore has a large volume oI distribution (Vss 375 litres). AIter repeated doses or inIusion there is accumulation. AIter a single dose, its duration oI action is limited to 2030 minutes due to redistribution. It undergoes hepatic metabolism (N-dealkylation) and is converted to the inactive norIentanyl. Ref. W McCaughev. R S J Clarke. J P H Fee. W F M Wallace. Anaesthetic Phvsiologv and Pharmacologv. 1st ed. Churchill Livingstone. 1997. Question 11 A. FALSE B. FALSE C. TRUE D. FALSE E. FALSE DicloIenac, like other non-steroidal anti-inIlammatory drugs (NSAIDs), works by inhibiting the cyclo- oxygenase enzyme (not lipo-oxygenase). Prostaglandins are involved in the regulation oI renal blood Ilow and the use oI NSAIDs may decrease renal blood Ilow in susceptible individuals. One oI the adverse eIIects oI prostaglandin inhibition is the reversible inhibition oI platelet aggregation. DicloIenac is not recommended in pregnancy. Use oI NSAIDs may result in premature closure oI the ductus arteriosus in the Ioetus. Low dose aspirin, however, has been used in pregnancy. Ref. W McCaughev. R S J Clarke. J P H Fee. W F M Wallace. Anaesthetic Phvsiologv and Pharmacologv. 1st ed. Churchill Livingstone. 1997. Question 12 A. TRUE B. TRUE C. TRUE D. FALSE E. FALSE AlIentanil is more lipid soluble than pethidine, but is less lipid soluble than Ientanyl. It is highly protein bound (8592°) mainly to alpha1-acid glycoprotein.AlIentanil diIIers Irom other opioids in having a pKa value below physiological pH (pKa ÷ 6.8). It is between 5 and 10 times less potent than Ientanyl. There are no clinically important active metabolites. Ref. W McCaughev. R S J Clarke. J P H Fee. W F M Wallace. Anaesthetic Phvsiologv and Pharmacologv. 1st ed. Churchill Livingstone. 1997. Question 13 A. TRUE B. TRUE C. FALSE D. TRUE E. TRUE Magnesium is an N-methyl-D-aspartate antagonist. The normal plasma magnesium concentration ranges between 0.8 and 1.2 mmol/litre. Magnesium is a cerebral vasodilator and has clinically important antiarrhythmic properties. Magnesium potentiates neuromuscular blockade and one oI the important signs oI magnesium toxicity is muscle weakness. Ref. H G W Paw. G R Park. Drug Prescribing in Anaesthesia and Intensive Care. 1st ed. Greenwich Medical Media. 1996. Page 19 Question 14 A. FALSE B. TRUE C. FALSE D. TRUE E. FALSE Tramadol is not a controlled drug. It has a weak aIIinity Ior opioid receptors. The aIIinity Ior binding at the mu receptor is 2.1 3M compared with 0.0003 3M Ior morphine. Its main mode oI action is the modulation oI central monoaminergic pathways. As with pethidine (and possibly other opioids), the use oI tramadol with MAOI is contraindicated. Both drugs delay the removal oI 5-HT Irom its site oI action. The interaction may presents clinically as sudden agitation, unmanageable behaviour, headaches, hypertension or hypotension, rigidity, hyperpyrexia, convulsions and coma. Ref. Zvdol. Searle Drug Information Booklet. 1996. Question 15 A. TRUE B. TRUE C. TRUE D. FALSE E. FALSE The metabolism oI the Iollowing observe zero-order kinetics: Phenytoin Aspirin Ethanol Paracetamol (in toxic doses) Thiopentone (in toxic doses) Ref. J W Dundee. R S J Clarke. W McCaughev. Clinical Anaesthetic Pharmacologv. 1st ed. Churchill Livingstone. 1991. Question 16 A. FALSE B. FALSE C. TRUE D. FALSE E. FALSE Enzyme inducers and inhibitors in clinical use: Inducers Inhibitors Barbiturates Carbamazepine Ethanol (chronic) Inhalational anaesthetics GriseoIulvin Phenytoin Primidone RiIampicin Amiodarone Cimetidine CiproIloxacin Dextropropoxyphene (co-proxamol) Ethanol (acute) Etomidate Erythromycin Fluconazole Ketoconazole Metronidazole Ref. H G W Paw. G R Park. Drug Prescribing in Anaesthesia and Intensive Care. 1st ed. Greenwich Medical Media. 1996. Page 20 Question 17 A. TRUE B. TRUE C. FALSE D. TRUE E. TRUE Transdermal, sublingual and parenteral (IV, IM, SC) routes avoid the hepatic portal circulation and hence the hepatic Iirst pass metabolism. A variable proportion oI the drug given rectally will be absorbed into the portal circulation, thereIore Iirst pass metabolism is not totally avoided. Drugs with high hepatic extraction ratios undergo substantial Iirst pass metabolism. Ref. W McCaughev. R S J Clarke. J P H Fee. W F M Wallace. Anaesthetic Phvsiologv and Pharmacologv. 1st ed. Churchill Livingstone. 1997. Question 18 A. TRUE B. TRUE C. TRUE D. FALSE E. FALSE Zero-order kinetics are observed when the enzyme responsible Ior the reaction is saturated and when the reaction is represented by a linear relationship. Summary oI the diIIerences between zero-order and Iirst-order kinetics: Zero-order: Absolute amount eliminated is the same, regardless oI plasma concentration; Rate oI elimination varies with the plasma concentration; Constant amount oI drug metabolised per unit time; ReIlects saturation oI enzyme: occurs when plasma concentration exceeds capacity oI enzyme. First-order: Constant proportion oI drug metabolised in a given time period; Absolute amount eliminated is greatest when plasma concentration is greatest; Rate oI elimination and elimination halI-liIe are constant, irrespective oI concentration. Ref. J W Dundee. R S J Clarke. W McCaughev. Clinical Anaesthetic Pharmacologv. 1st ed. Churchill Livingstone. 1991. Question 19 A. TRUE B. TRUE C. FALSE D. FALSE E. TRUE Xanthopsia is seeing yellow colours. Hypokalaemia predisposes to toxicity but is not a side-eIIect oI digoxin. Ref. British National Formularv. 1997. Question 20 A. FALSE B. FALSE C. FALSE D. TRUE E. FALSE The dose oI a drug required to produce a given eIIect decribes its potency, not its eIIicacy. In the example described, drug A is more potent than drug B. The therapeutic index oI a drug is a measure oI its saIety (ED50/LD50). EIIicacy, however, is a measure oI the maximal eIIect oI an agonist. Ref. W McCaughev. R S J Clarke. J P H Fee. W F M Wallace. Anaesthetic Phvsiologv and Pharmacologv. 1st ed. Churchill Livingstone. 1997. Question 21 A. TRUE B. FALSE C. FALSE D. FALSE E. FALSE Factors causing a shiIt oI the oxygen dissociation curve: LeIt shiIt: Right shiIt: Fall in temperature Fall in H ¹ (high pH) Fall in red cell 2,3-DPG Stored blood Carbon monoxide Fetal haemoglobin Methaemoglobin Rise in temperature Rise in H ¹ (low pH) Rise in red cell 2,3-DPG Increase CO 2 tension Pregnancy* Haemoglobin S AIter acclimatisation to altitude *P50 is higher in normal pregnancy. In PET, the P50 does not increase. Ref. R D Miller. Anesthesia. 4th ed. Churchill Livingstone. 1994. Question 22 A. FALSE B. TRUE C. FALSE D. FALSE E. TRUE Benzylpenicillin does not cross the blood-brain barrier readily unless the meninges are inIlamed. Hyoscine hydrobromide readily crosses the blood-brain barrier. Hyoscine butylbromide has a quaternary amine group and thereIore does not cross the blood-brain barrier as readily. Ref. J W Dundee. R S J Clarke. W McCaughev. Clinical Anaesthetic Pharmacologv. 1st ed. Churchill Livingstone. 1991. Page 22 Question 23 A. FALSE B. FALSE C. TRUE D. TRUE E. TRUE Prostaglandins and bradykinins sensitise the pain Iibres to painIul stimuli but do not cause pain when directly applied to the nerve endings. Ref. R D Miller. Anesthesia. 4th ed. Churchill Livingstone. 1994. Question 24 A. TRUE B. TRUE C. TRUE D. TRUE E. TRUE Anxiety, depression, muscle tension and Iatigue all increase the perception oI pain. Increasing age inIluences the perception oI pain depending on ones individual experience. Question 25 A. FALSE B. TRUE C. TRUE D. TRUE E. FALSE Endocrine consequences oI the stress response Increased secretion: Decreased secretion: ACTH Cortisol ADH Renin Aldosterone Growth hormone Prolactin Glucagon Insulin Testosterone Ref. . W F Ganong. Review of Medical Phvsiologv. 18th ed. Lange. 1997. Question 26 A. FALSE B. TRUE C. TRUE D. FALSE E. FALSE There is an increase in minute ventilation (tidal volume increases more than the respiratory rate). Despite the increased CO 2 production, the PaCO 2 is reduced Irom 5 kPa to 4 kPa at term. Because oI the greater O 2 consumption and a lowered FRC, there is quicker desaturation when apnoeic. Because oI increased alveolar ventilation and the lowered FRC, there is a more rapid uptake oI inhalational agent. Respiratory changes at term: Total lung capacity (0); Functional residual capacity (20°); Residual Volume (20°); Vital capacity (0); Minute ventilation (¹50°); Tidal volume (¹40°); Respiratory rate (¹15°); Airway resistance (-35°); Lung compliance (0); Chest wall compliance (-45°). Ref. R D Miller. Anesthesia. 4th ed. Churchill Livingstone. 1994. Page 23 Question 27 A. FALSE B. TRUE C. FALSE D. TRUE E. TRUE The adrenal cortex produces cortisol, aldosterone, dehydroepiandrosterone and deoxycorticosterone. Noradrenaline and adrenaline are produced by the adrenal medulla. The conversion oI angiotensin I to angiotensin II via angiotensin-converting enzyme (ACE) occurs predominantly in the lungs. Angiotensin II acts on the adrenal cortex to increase the secretion oI aldosterone. Ref. W F Ganong. Review of Medical Phvsiologv. 18th ed. Lange. 1997. Question 28 A. FALSE B. FALSE C. TRUE D. TRUE E. FALSE The 6 hormones that are secreted by the anterior pituitary are thyroid stimulating hormone (TSH), adrenocorticotropic hormone (ACTH), luteinising hormone (LH), Iollicle-stimulating hormone (FSH), prolactin, and growth hormone. The hormones secrted by the posterior pituitary are oxytocin and vasopressin (ADH). Thyrotrophin releasing hormone and somatostatin (growth hormone- inhibiting hormone) are secreted by the hypothalamus. Ref. W F Ganong. Review of Medical Phvsiologv. 18th ed. Lange. 1997. Question 29 A. FALSE B. FALSE C. TRUE D. FALSE E. TRUE Normally, 99.98° oI circulating thyroxine is bound. Three plasma proteins are responsible Ior binding thyroxine: albumin, thyroxine-binding prealbumin and thyroxine-binding globulin. Although albumin his the largest capacity to bind thyroxine, the globulins have the greater aIIinity Ior thyroxine such that most oI the thyroxine is bound to thyroxine-binding globulin. TBG~TBPA~Albumin ÷ 67:20:13. Hyperthyroidism increases the MAC, whilst hypothyroidism decreases the MAC. Thyroxine increases he sensitivity oI receptors to catecholamines. Ref. W F Ganong. Review of Medical Phvsiologv. 18th ed. Lange. 1997. Question 30 A. FALSE B. FALSE C. FALSE D. TRUE E. TRUE The pH is maintained between 7.35 and 7.42 by the buIIering capacity oI the bicarbonate/carbonic acid system, the phosphate buIIer system and the buIIering properties oI the serum proteins and haemoglobin. Additional regulation is by the lungs and the kidneys. Shock and cardiac arrest result in a metabolic acidosis. Due to absence oI tissue perIusion, there is a rapid Iall in the pH oI the extracellular Iluid. Binding oI drugs to plasma proteins is inIluenced by the pH oI the extracellular Iluid. Ref. W F Ganong. Review of Medical Phvsiologv. 18th ed. Lange. 1997. Question 31 A. TRUE B. TRUE C. FALSE D. FALSE E. FALSE Any substance that increases the acidity oI brain tissue will increase cerebral blood Ilow. Autoregulation oI cerebral blood Ilow between mean arterial pressure limits oI 60 mmHg to 140 mmHg is very successIul. The autonomic nervous system plays an insigniIicant role in the regulation oI cerebral blood Ilow. Regional blood Ilow is increased during intense mental activity, but the total cerebral blood Ilow remains constant. Ref. W F Ganong. Review of Medical Phvsiologv. 18th ed. Lange. 1997. Question 32 A. FALSE B. TRUE C. FALSE D. FALSE E. TRUE Total lung capacity is reduced and residual volume is increased because oI the reduction in inspiratory and expiratory capacity. Both oI these Iactors reduce vital capacity but there is no decrease in Iorced expiratory volume in 1 second suggestive oI air Ilow limitation. The FEV1:VC ratio is normal. Corrected gas transIer is normal. Hypercapnoea is a late Ieature and usually does not occur until VC has Iallen to 50° oI normal. Ref. J B West. Respiratorv Phvsiologvthe essentials. 5th ed. Williams and Wilkins. 1995. Question 33 A. FALSE B. TRUE C. FALSE D. TRUE E. FALSE Isovolumetric ventricular contraction oI the heart starts when the mitral and tricuspid valves close. This period lasts about 0.05 seconds (25° oI ventricular systole), until the pressures in the leIt and right ventricles exceed the pressures in the aorta and pulmonary artery when the aortic and pulmonary valves open. It coincides with the 'c' wave in the right atrial pressure trace and the QRS complex oI the ECG.The 'c' wave results Irom the tricuspid valve bulging into the right atrium, causing a small but sharp rise in right atrial pressure. Ref. W F Ganong. Review of Medical Phvsiologv. 18th ed. Lange. 1997. Question 34 A. TRUE B. FALSE C. FALSE D. FALSE E. FALSE CSF is an ultraIiltrate oI plasma whose composition is modiIied by transport processes in the endothelial cells oI the cerebral capillaries and the choroid epithelium. CSF pressure has no eIIect on the rate oI CSF Iormation up to pressures well above the normal range. CSF absorption is, however, proportional to the pressure. CSF has a reduced buIIering capacity due to its lower protein content when compared to plasma (200 mg/L compared to 6000 mg/L in plasma). The main Iunction oI CSF is to act as a 'cushion' to protect the brain. It does not contain any granulocytes or antibodies to deIend against inIection. The chloride concentration is higher in CSF compared to plasma. Ref. W F Ganong. Review of Medical Phvsiologv. 18th ed. Lange. 1997. Question 35 A. TRUE B. FALSE C. TRUE D. TRUE E. FALSE Na ¹ is actively transported out oI all parts oI the renal tubule except the thin portions oI the loop oI Henle. Na ¹ is pumped into the interstitium by Na ¹ /K ¹ ATPase. In the proximal tubule, bicarbonate, chloride, glucose and amino acids are reabsorbed along with Na ¹ and K ¹ . Up to 70° oI the Iiltered water is reabsorbed in the proximal tubule. Aldosterone acts mainly in the distal tubule by regulating Na ¹ reabsorption. Water then Iollows passively. Ref. W F Ganong. Review of Medical Phvsiologv. 18th ed. Lange. 1997. Question 36 A. TRUE B. FALSE C. TRUE D. TRUE E. TRUE Glucose is normally completely reabsorbed in the proximal tubule. II the renal threshold Ior glucose is exceeded and large quantities oI glucose remain in the renal tubules, this will exert an appreciable osmotic eIIect producing an osmotic diuresis. Increased aldosterone secretion results in increased Na ¹ (and thereIore water) reabsorption. Damage to the posterior pituitary results in lack oI ADH producing diabetes insipidus. Alcohol consumption inhibits ADH secretion and thereIore increases diuresis. Carbonic anhydrase inhibitors such as acetazolamide are only moderately eIIective as diuretic agents. They work by decreasing H ¹ secretion, with resultant increase in Na ¹ and K ¹ secretion. Ref. W F Ganong. Review of Medical Phvsiologv. 18th ed. Lange. 1997. Page 26 Question 37 A. FALSE B. FALSE C. FALSE D. TRUE E. TRUE The reaction CO 2 ¹ H 2 O H 2 CO 3 proceeds slowly unless the enzyme carbonic anhydrase is present. There is no carbonic anhydrase in plasma, but there is an abundant supply in red blood cells. OI the approximately 49 ml oI CO 2 in each 100 ml oI arterial blood, 2.6 ml (5°) is dissolved, 2.6 ml (5°) is in the Iorm oI carbamino compounds and the maiority, 43.8 ml (90°) is in HCO 3 . Since deoxygenated haemoglobin Iorms carbamino compounds much more readily than HbO 2 , transport oI carbon dioxide is Iacilitated in venous blood. Ref. A R Aitkenhead. G Smith. Textbook of Anaesthesia. 3rd ed. Churchill Livingstone. 1996. Question 38 A. TRUE B. FALSE C. FALSE D. FALSE E. TRUE Hyperventilation results in hypocapnia and a respiratory alkalosis. As a result oI the alkalosis, the plasma ionised calcium level decreases producing the signs oI tetany (carpopedal spasm and Chvosteks sign). Cerebral blood Ilow may be reduced by 30° or more. The cerebral ischaemia causes light-headedness, dizziness and paraesthesia. Hypocapnia has a direct constrictor eIIect on blood vessels and also increases cardiac output. Ref. W F Ganong. Review of Medical Phvsiologv. 18th ed. Lange. 1997. Question 39 A. FALSE B. TRUE C. TRUE D. FALSE E. TRUE The diaphragm and the external intercostal muscles are the important muscles during quiet inspiration.The scalene and sternocleidomastoid muscles are accessory inspiratory muscles that help to elevate the thoracic cage during deep laboured respiration. Quiet expiration is passive but the internal intercostals and the muscles oI the anterior abdominal wall act as expiratory muscles during Iorced expiration. Ref. J B West. Respiratorv Phvsiologvthe essentials. 5th ed. Williams and Wilkins. 1995. Question 40 A. TRUE B. TRUE C. TRUE D. TRUE E. TRUE The alveolar-arterial oxygen partial pressure (A-a)PO 2 diIIerence is normally about 10 mmHg (1.3 kPa), but may be over 30 mmHg (4 kPa) in the elderly. There are three maior causes oI a large (A-a)PO 2 gradient: V/Q mismatch DiIIusion deIects Anatomical shunt (right to leIt) Ref. R S Atkinson. G B Rushman. N J H Davies. Lee´s Svnopsis of Anaesthesia. 11th ed. Butterworth- Heinemann. 1993. Question 41 A. FALSE B. FALSE C. TRUE D. FALSE E. FALSE The critical temperature is diIIerent Ior each gas, but is a constant value Ior each gas. Provided the temperature is below the critical temperature, the gas can be liqueIied by pressure. The critical pressure is that which is required to liqueIy a gas at its critical temperature. Above its critical temperature a gas cannot be liqueIied however much pressure is applied. Since the critical temperature oI oxygen is -116°C, it cannot be liqueIied by pressure at room temperature. At -116°C, a pressure oI 50 bar is required to liqueIy it. The critical temperature oI nitrous oxide is 36.5°C and the pressure required to liqueIy it at iust below this temperature is 74 bar. Below the critical temperature, the more the gas is cooled the less the pressure required to liqueIy it. At temperatures lower than the critical temperature the substance may exist as a mixture oI both vapour and liquid, depending on its pressure. Ref. P D Davis. G D Parbrook. G N C Kennv. Basic Phvsics and Measurement in Anaesthesia. 4th ed. Butterworth-Heinemann. 1995. Question 42 A. TRUE B. TRUE C. TRUE D. FALSE E. FALSE Boyle's law can be expressed in the Iollowing ways: At a constant temperature, the volume oI a mass oI gas is inversely proportional to the pressure. Since the density oI a gas is inversely proportional to its speciIic volume, this statement can be reworded: The pressure oI a gas kept at constant temperature is proportional to its density The product oI the pressure and the speciIic volume oI a gas kept at constant temperature is constant. Charles's law ÷ The volume oI a given quantity oI gas at constant pressure is directly proportional to the temperature. Gay-Lussac's law ÷ The pressure oI a gas kept at constant volume is directly proportional to the temperature. Ref. W W Mushin. P L Jones. Phvsics for the Anaesthetist. 4th ed. Blackwell. 1987. Question 43 A. FALSE B. TRUE C. FALSE D. TRUE E. TRUE Back pressure is overcome by the construction oI a long inlet tube to the vaporising chamber so that retrograde Ilow Irom the vaporiser chamber does not reach the bypass channel. Temperature compensation in the Fluotec 4 vaporiser is acheived by way oI a bimetallic strip, which controls the amount oI Ilow through the exit port oI the vaporising chamber. The large surIace area is provided by a concentric helix, which is bounded by the Iabric wicks. II accidentally inverted, the liquid agent will not spill into the bypass. This is one oI the new upgrade Ieatures Irom the Fluotec 3 vaporiser. Ref. A Davev. J T B Movle. C S Ward. Wards Anaesthetic Equipment. 3rd ed. W B Saunders. 1992. Page 28 Question 44 A. FALSE B. FALSE C. TRUE D. FALSE E. FALSE Dibucaine number is a measure oI the percentage inhibition oI the rate oI hydrolysis oI be zoylcholine in the presence oI dibucaine. Dibucaine inhibits the normal pseudocholinesterase enzyme by approximately 80°, but the atypical enzyme remains unaIIected. Atypical cholinesterase Homozygotes: 1 in 3000 oI population 1 2 hours apnoea DN 16 25 Heterozygotes: 1 in 25 population up to 10 mins apnoea DN 50 65 Ref. R S Atkinson. G B Rushman. N J H Davies. Lee´s Svnopsis of Anaesthesia. 11th ed. Butterworth- Heinemann. 1993. Question 45 A. TRUE B. FALSE C. TRUE D. TRUE E. TRUE Bilirubin causes no signiIicant eIIect on pulse oximetry. The absorption coeIIicients Ior haemoglobin F are no diIIerent to those oI HbA, so the presence oI Ietal haemoglobin should not cause an error in pulse oximeter saturation estimates. Pulse oximeters tend to underestimate actual oxygen saturation with signiIicant anaemia. Polycythaemia has no apparent eIIect upon pulse oximetry reading. Blue nail polish, with absorbance near 660 nm, has the greatest eIIect on oxygen saturation reading, an artiIactual decrease. Nail varnish, hypothermia, poor perIusion and deeply pigmented skin cause inaccuracies due to weak signals. Increasing concentrations oI carboxyhaemoglobin make the pulse oximeter reading tend towards 100°, whereas increasing concentrations oI methaemoglobin make the readings tend towards 85°.Other sources oI inaccuracies include diathermy interIerence and extraneous lighting. Ref. R D Miller. Anesthesia. 4th ed. Churchill Livingstone. 1994. Question 46 A. FALSE B. TRUE C. TRUE D. FALSE E. TRUE Factors that determine laminar Ilow through a tube are stated by the Hagen-Poiseuille Iormula: Flow is proportional to the pressure drop and the radius to the Iourth power. Flow is inversely proportional to viscosity and length. Density does not aIIect laminar Ilow, compared to turbulent Ilow. Ref. A R Aitkenhead. G Smith. Textbook of Anaesthesia. 3rd ed. Churchill Livingstone. 1996. Question 47 A. FALSE B. FALSE C. FALSE D. TRUE E. FALSE Pressure is Iorce per unit area (F/A). Pressure is expressed by the SI unit, the Pascal (Pa) ÷ Newtons/square metre Ref. P D Davis. G D Parbrook. G N C Kennv. Basic Phvsics and Measurement in Anaesthesia. 4th ed. Butterworth-Heinemann. 1995. Question 48 A. TRUE B. TRUE C. FALSE D. TRUE E. TRUE Cyclopropane cylinders do not require a reducing valve. Pressure at 15°C (bar) Oxygen Nitrous oxide Cyclopropane Entonox Carbon dioxide 137 44 5 137 50 Ref. A Davev. J T B Movle. C S Ward. Wards Anaesthetic Equipment. 3rd ed. W B Saunders. 1992. Question 49 A. FALSE B. TRUE C. TRUE D. TRUE E. TRUE An empty cylinder oI oxygen has a gauge pressure oI 0 bar but an absolute pressure oI about 1 bar (Absolute pressure ÷ gauge pressure ¹ atmospheric pressure). Lower gas pressures (e.g. on anaesthetic ventilators) are measured using a simple aneroid pressure gauge). High gas pressures (e.g. in medical gas cylinders) are measured using a type oI Bourdon gauge. Ref. P D Davis. G D Parbrook. G N C Kennv. Basic Phvsics and Measurement in Anaesthesia. 4th ed. Butterworth-Heinemann. 1995. Question 50 A. TRUE B. TRUE C. TRUE D. TRUE E. TRUE Static electricity and dirt on the tube or Iloat can cause sticking oI the bobbin, especially when low Ilows are used. The glass tube is slightly smaller on cross-section at the bottom than at the top. Viscosity is important at low Ilows because gas Ilow round the bobbin approximates to tubular Ilow (diameter oI oriIice less than length), but density is important at high Ilows (diameter oI the oriIice greater than length). Ref. A R Aitkenhead. G Smith. Textbook of Anaesthesia. 3rd ed. Churchill Livingstone. 1996. Page 30 Question 51 A. FALSE B. FALSE C. TRUE D. FALSE E. FALSE The triple point oI water is the temperature at which water exists simultaneously in solid, liquid and gaseous state. It is exactly 273.16 K or 0.01°C. The absolute zero is obtained by extrapolation and at this temperature (273.15°C) an 'ideal' gas would contract and is predicted to occupy zero volume. The platinum resistance thermometer consists oI a length oI pure platinum wire. The change in electrical resistance oI the wire when its temperature changes is measured with a Wheatstone bridge circuit. Electrical resistance increases with rising temperature (positive temperature coeIIicient), but this relationship is not linear. A thermistor, on the other hand, is a semiconductor device, which responds to a rise in temperature by a reduction in electrical resistance (negative temperature coeIIicient). Seebeck discovered that when two metal conductors oI dissimilar materials are connected together at each end to Iorm a circuit, an electromotive Iorce (EMF) is generated which is proportional to the diIIerence in temperatures oI the two iunctions. Ref. P D Davis. G D Parbrook. G N C Kennv. Basic Phvsics and Measurement in Anaesthesia. 4th ed. Butterworth-Heinemann. 1995. Question 52 A. FALSE B. FALSE C. FALSE D. TRUE E. FALSE Although the use oI SI units is generally accepted in medicine, pressure is still expressed in a variety oI units. 1 atmosphere is approximately equivalent to: 1 bar 14.7 p.s.i. 101 kPa 760 mmHg 1000 cmH 2 O 1 atmospheric absolute (ATA) Ref. A R Aitkenhead. G Smith. Textbook of Anaesthesia. 3rd ed. Churchill Livingstone. 1996. Question 53 A. FALSE B. TRUE C. FALSE D. TRUE E. TRUE Henry's law states that the amount oI gas dissolved at any temperature is proportional to its partial pressure. The lower the temperature, the more can dissolve. The boiling point oI a liquid is the temperature at which the saturated vapour pressure equals the ambient atmospheric Page 31 pressure. Osmolarity and osmolality oI solutions are measured by the degree to which the Ireezing (not boiling) point is depressed. A solution oI 1 osmol/L depresses the Ireezing point 1.86°C. Relative humidity is the actual water vapour pressure as a percentage oI the saturated vapour pressure at a given temperature. Absolute humidity is the mass oI water vapour present in a given volume oI gas. Ref. P D Davis. G D Parbrook. G N C Kennv. Basic Phvsics and Measurement in Anaesthesia. 4th ed. Butterworth-Heinemann. 1995. Question 54 A. FALSE B. TRUE C. FALSE D. TRUE E. TRUE Bleeding time depends on capillary Iunction, as well as platelet numbers and Iunction. It is normally less than 10 minutes. APTT (PTTK) is sensitive to Iactors in the intrinsic and common pathways. It is used to monitor heparin treatment. The normal APTT is 3040 seconds. PT is sensitive to Iactors in the extrinsic and common pathways. It is used to monitor warIarin treatment and liver Iunction test. Normal PT is 1014 seconds. Haemophilia A and B have a normal bleeding time and prothrombin time, but prolonged APTT. Von Willebrand's disease has a normal protrombin time, but prolonged bleeding time and APTT. Ref. A R Aitkenhead. G Smith. Textbook of Anaesthesia. 3rd ed. Churchill Livingstone. 1996. Question 55 A. FALSE B. FALSE C. FALSE D. TRUE E. TRUE Entonox is a mixture oI 50° oxygen and 50° nitrous oxide. The body oI the cylinder is painted blue with the shoulders painted with white/blue quarters. Since the nitrous oxide is in the gaseous state in the cylinder oI premixed gases, the pressure gauge gives a direct indication oI the cylinder contents. The mixture is compressed into cylinders containing gas at a pressure oI 137 bar at 15°C. The nitrous oxide does not liqueIy because the presence oI oxygen reduces the critical temperature oI nitrous oxide. The critical temperature oI the mixture is - 7°C. Cooling the cylinder to a temperature below 7°C results in separation oI liquid nitrous oxide. This results in an initial mixture rich in oxygen, Iollowed by a hypoxic, nitrous oxide rich mixture. Ref. A Davev. J T B Movle. C S Ward. Ward´s Anaesthetic Equipment. 3rd ed. W B Saunders. 1992. Question 56 A. FALSE B. TRUE C. FALSE D. FALSE E. TRUE A maior component oI soda lime is calcium hydroxide (94°): sodium hydroxide makes up only 5° oI the total. Negative pressure (set at 0.5 cmH 2 O) and positive pressure (set at 10 cmH 2 O) relieI valves must be incorporated in a passive scavenging system to prevent negative or high positive pressures within the system. Activated charcoal placed in the expiratory limb oI the breathing system absorbs halogenated volatile agents (not nitrous oxide). Connectors (male and Iemale) on scavenging systems have a diameter oI 30 mm to ensure that inappropriate connections with anaesthetic apparatus cannot be made. Ref. A Davev. J T B Movle. C S Ward. Wards Anaesthetic Equipment. 3rd ed. W B Saunders. 1992. Question 57 A. TRUE B. FALSE C. TRUE D. FALSE E. FALSE The Irequency adopted in the UK is 50 Hz. A current ·1 mA produces no sensation. Tingling sensation occurs at a current oI 1 mA. Local pain is produced at 5 mA. The 'let-go' threshold is variable, but may occur at 15 mA. Current greater than this 'let-go' threshold will result in greater contraction oI Ilexor to extensor muscles, thereIore the victim cannot let go oI the source. This 'let-go' threshold varies with the Irequency oI the current. The Irequencies adopted in the UK (50 Hz) and the US (60 Hz) are the most dangerous and has a lower threshold than lower or higher Irequencies. Respiratory arrest occurs at 50 mA. Arrhythmias and VF occurs at 80100 mA. The damage to tissue is related to the current density; a current passing through a small area is more dangerous than the same amount passing through a much larger area. Sparks are more Irequent when the air is dry and the barometric pressure high. Sparks are less likely iI the relative humidity is above 60°. The electric current will be generated however, but simply dissipate rather than spark. Ref. M K Svkes. M D Jickers. C J Hull. Principles of Measurement and Monitoring in Anaesthesia and Intensive Care. 3rd ed. Blackwell. 1991. Question 58 A. TRUE B. FALSE C. FALSE D. FALSE E. FALSE Oxygen is produced commercially by distilling air. Oxygen is tasteless, colourless and odourless. It supports combustion, although the gas itselI is not Ilammable. The critical temperature oI oxygen is 119°C. Oxygen cylinders are painted black with white shoulders and are supplied at a pressure oI 137 bar at 15°C. Ref. A R Aitkenhead. G Smith. Textbook of Anaesthesia. 3rd ed. Churchill Livingstone. 1996. Question 59 A. TRUE B. FALSE C. FALSE D. FALSE E. FALSE Osmolality oI a solution is determined by the total concentration oI dissolved or colloid particles within the solution. It depends on the number rather than the type oI particles present. One mole oI sodium chloride dissolved in 1 kg oI water has an osmolality oI 2 osmol/kg, as sodium chloride Ireely dissociates into the 2 particles, Na and Cl. One mole oI urea (which does not dissociate) in 1 kg oI water has an osmolality oI 1 osmol/kg. The concentration oI particles, i.e. the osmolality, within the ICF and the ECF is always equal during equilibrium. Plasma osmolality is approximately 290 mosmol/kg and may be estimated Irom the Iormula: Plasma osmolality (mosmol/kg) ÷ 2|Na| (mmol/L) ¹ Blood glucose (mmol/L) ¹ Blood urea (mmol/L) Read the question careIully! The units Ior osmolality are mmol/kg and not mmol/L. Ref. W F Ganong. Review of Medical Phvsiologv. 18th ed. Lange. 1997. Question 60 A. TRUE B. TRUE C. TRUE D. FALSE E. FALSE A rise in temperature: Increases the vaporisation rate oI volatile agents, with a higher saturated vapour pressure Decreases the density oI Iluids, due to expansion Decreases the viscosity oI Iluids Increases the viscosity oI gases, due to increased molecular activity Page 35 Exam 2 Question 1 The Iollowing drugs readily cross the placenta A. Physostigmine B. Glycopyrrolate C. Naloxone D. Suxamethonium E. Heparin Question 2 In renal impairment A. Frusemide dosage must be reduced B. Action oI vecuronium is prolonged C. Drugs bound to plasma proteins are not removed by dialysis D. Benzylpenicillin may cause convulsions E. Drugs dependent on renal excretion reach steady state sooner than patients with normal renal Iunction Question 3 Regarding the ionisation oI drugs A. The pKa oI a drug is the pH at which the drug is 100° ionised B. Drugs with a pKa near physiological pH will show signiIicant changes in the ratio oI ionised vs unionised drug C. The pKa oI a drug varies with the pH oI the solution D. A drug with an acid pKa will be mainly unionised in the stomach E. Local anaesthetic are less eIIective in an acidic environment Question 4 The metabolism oI morphine involves A. Acetylation B. Demethylation C. Oxidation D. Methylation E. Coniugation with glucuronide Page 36 Question 5 The total daily dose oI the Iollowing drugs should be reduced in patients with mild to moderate renal impairment A. Frusemide B. Enalapril C. CiproIloxacin D. Erythromycin E. Metronidazole Question 6 The cough associated with angiotensin-converting enzyme (ACE) inhibitors A. Is dose dependent B. Is more common in men than women C. Is more common in patients who smoke cigarettes D. Is more likely to occur when treating hypertension E. Improves on changing to a diIIerent ACE inhibitor Question 7 Clonidine A. Is predominantly an --1 adrenergic agonist B. Is poorly absorbed orally C. Lowers the MAC oI volatile anaesthetic agents D. Attenuates the stress response to endotracheal intubation E. Can be used Ior spinal analgesia Question 8 EpileptiIorm activity may be seen with A. PropoIol B. Atracurium C. Neostigmine D. Etomidate E. Ketamine Question 9 The Iollowing are acetylcholinesterase inhibitors A. Malathion B. Physostigmine C. Pyridostigmine D. Edrophonium E. Ecothiopate The Iollowing act as calcium antagonists in smooth muscles A. Dantrolene B. Diltiazem C. Nicardipine D. Hydralazine E. Nitroglycerine Question 11 Factors which may increase the eIIects oI vecuronium include A. Hypermagnesaemia B. Hypokalaemia C. Respiratory acidosis D. Respiratory alkalosis E. Hypothermia Question 12 The minimum alveolar concentration (MAC) oI an inhalational agent is reduced in A. Hypothermia B. Reduced PaCO 2 C. Clonidine D. Duration oI anaesthesia E. Hypothyroidism Question 13 The Iollowing are metabolised by zero-order kinetics in clinical doses A. Phenytoin B. Paracetamol C. Ethanol D. Aspirin E. Thiopentone Question 14 SevoIlurane A. Has a higher blood/gas partition coeIIicient than isoIlurane B. Is more cardiodepressant than isoIlurane C. Has a MAC higher than desIlurane D. Is less pungent than desIlurane E. Has a Iaster washout than halothane Page 38 Question 15 Etomidate A. Is a phencyclidine derivative B. Causes more nausea and vomiting than propoIol C. Is rarely associated with anaphylaxis D. Causes adreno-cortical suppression E. Is contra-indicated in porphyrias Question 16 Droperidol A. Is a phenothiazine B. Has ß-adrenergic actions C. Stimulates - receptors D. Is extensively metabolised by the liver E. Can cause extrapyramidal side eIIects Question 17 Drugs with a prolonged action in the presence oI deIective plasma acetylcholinesterase include A. Atracurium B. Prilocaine C. Procaine D. Trimetaphan E. Esmolol Question 18 Characteristics oI a depolarising block include A. Initial period oI muscle Iasciculation B. Well maintained tetanus during partial block C. Train-oI-Iour ratio less than 0.75 D. Reversal by anticholinesterases E. Post-tetanic potentiation Page 39 Question 19 The relatively rapid awakening aIter a single intravenous bolus dose oI thiopentone is due to A. Metabolism by the liver B. Distribution to Iat C. Distribution to brain, liver and kidneys D. Elimination in the urine E. Ester hydrolysis Question 20 The Iollowing are halogenated ethers A. Halothane B. IsoIlurane C. EnIlurane D. DesIlurane E. SevoIlurane Question 21 Concerning the ABO blood groups A. Type A blood has anti-B antibodies in the plasma B. Type O blood has no anti-A or anti-B antibodies in the plasma C. Type O blood can be given to anyone without risk oI producing a transIusion reaction D. The most common blood group is type AB E. In cross-matching, the donor's plasma is mixed with the recipient's red cells and checked Ior agglutination Question 22 The Iollowing are anterior pituitary hormones A. Prolactin B. Antidiuretic hormone C. Adrenocorticotrophic hormone D. Luteinizing hormone E. Oxytocin Page 40 Question 23 The Iollowing result in reduced plasma cholinesterase activity A. Pregnancy B. Hyperthyroidism C. Renal Iailure D. Nephrotic syndrome E. Burns Question 24 The Iollowing statements regarding the Iluid compartments are true A. An adult Iemale has a greater percentage oI total body water than an adult male B. The intracellular Iluid compartment is approximately 14 litres in a 70 kg man C. II 5° glucose is inIused into a patient it will be equally distributed throughout the Iluid compartments D. II 0.9° saline is inIused into a patient it will remain in the extracellular Iluid compartment E. Newborn inIants have a greater percentage oI body water than adults Question 25 In pregnancy, the Iollowing are normal Iindings A. Elevated urea B. Elevated alkaline phosphates C. Elevated erythrocyte sedimentation rate (ESR) D. Raised white cell count E. Reduced pseudocholinesterase activity Question 26 The autoregulation oI cerebral blood Ilow A. Remains constant over a range oI systolic blood pressures Irom 60 to 140 mmHg B. Curve shows a shiIt to the leIt in chronic hypertension C. Is altered in the acute phase Iollowing subarachnoid haemorrhage D. Is impaired under hypoxic conditions E. Is impaired in hypercapnia Question 27 EIIects oI hypothermia include A. The presence oI a J wave in the ECG B. A shiIt oI the oxyhaemoglobin dissociation curve to the right C. Metabolic acidosis D. A greater solubility oI oxygen and carbon dioxide in plasma E. Impaired coagulation Question 28 Physiological changes in obesity include A. A decrease in total body water B. Increased gastric emptying C. Increased total lung capacity D. Increased oxygen consumption E. Increased in cardiac output Question 29 Aldosterone secretion is controlled by A. Plasma sodium concentration B. Plasma potassium concentration C. Plasma calcium concentration D. Adrenocorticotrophic hormone (ACTH) E. Angiotensin II Question 30 Renin secretion is controlled by A. Intrarenal baroreceptors oI the eIIerent arterioles B. Potassium load reaching the macula densa C. Renal sympathetic nerve activity D. Angiotensin E. ACTH Question 31 The Iollowing statements are true regarding the kidneys A. There are approximately 1.3 billion nephrons in each kidney B. They produce aldosterone C. In a resting state, the kidneys receive 12° oI the cardiac output D. The blood Ilow in the renal cortex is greater than that in the medulla E. Autoregulation oI renal blood Ilow occurs Question 32 Concerning water excretion by the kidneys A. Over 99° oI Iiltered water is reabsorbed by the kidney B. Water is actively transported out oI the proximal tubule C. 50° oI the Iiltered water is removed at the end oI the proximal tubule D. The Iiltered Iluid in the distal tubule is hypertonic E. Antidiuretic hormone decreases the permeability oI the collecting duct to water Page 42 Question 33 Concerning the withdrawal reIlex A. It is a polysynaptic reIlex B. An example is the knee ierk reIlex C. The sense organ is the muscle spindle D. As the strength oI the stimulus is increased, the reaction time is shortened E. The response is Ilexor muscle contraction and inhibition oI extensor muscles Question 34 The Iollowing are methods oI measuring extracellular Iluid volume A. Labelled albumin B. Deuterium oxide C. Labelled inulin D. Labelled creatinine E. Labelled glucose Question 35 Regarding the electrolyte composition oI body Iluids A. Cl- is largely intracellular B. K ¹ is largely intracellular C. Na ¹ is the second most abundant intracellular cation D. The extracellular Iluid has a greater Mg 2¹ concentration than the intracellular space E. PO 4 3- is largely intracellular Question 36 The Iollowing solutions are isotonic A. 0.9° saline B. 5° glucose C. 4° glucose and 0.18° saline D. Mannitol 10° E. Hartmann's (compound sodium lactate) solution Question 37 The chemical mediator released at the Iollowing sites is acetylcholine A. Parasympathetic preganglionic neurones B. Sympathetic preganglionic neurones C. Parasympathetic postganglionic neurones D. Sympathetic postganglionic neurones which innervate sweat glands E. Sympathetic postganglionic neurones which innervate the heart Question 38 The Iollowing are examples oI buIIer systems in the body A. Haemoglobin B. Glycine C. Proteins D. Phosphate E. Bicarbonate Question 39 The Iollowing statements regarding the anion gap are correct A. The cations used in the calculation oI the anion gap are sodium and potassium B. The anions used in the calculation oI the anion gap are chlorides and phosphates C. The normal anion gap is between 8 and 10 mmol/l D. Lactic acidosis causes a metabolic acidosis with a normal anion gap E. Renal Iailure causes a metabolic acidosis with a high anion gap Question 40 The Iollowing occur as a response to maior surgery A. Enhanced natriuresis B. Hyperglycaemia C. Reduced lipolysis D. Increased peripheral glucose uptake E. Potassium retention Question 41 In the measurement oI CVP and PCWP, the Iollowing are generally expected A. Low CVP and a normal PCWP in hypovolaemia B. High CVP and a normal PCWP in leIt ventricular Iailure C. Normal CVP and high PCWP in pulmonary hypertension D. High CVP and normal PCWP in tricuspid incompetence E. High CVP and a normal PCWP in pulmonary embolus Question 42 Thermodilution cardiac output measurement is inaccurate A. II the iniection is slow (10 ml over 5 seconds) B. II the iniection is erratic C. II the iniectate is at room temperature D. In the presence oI tricuspid regurgitation E. In the presence oI intra-cardiac shunts Page 44 Question 43 Gastric intramucosal pH A. Is calculated using the Bohr equation B. Values above 7.25 are considered normal C. Is calculated assuming mucosal bicarbonate is equal to arterial bicarbonate D. Is lower in splanchnic hypoperIusion E. Is Ialsely lowered iI air is introduced during sampling Question 44 Volatile anaesthetic agent concentration may be measured using the Iollowing A. Mass spectrometry B. InIrared absorption C. Ultraviolet absorption D. Polarographic electrode E. Paramagnetic analyser Question 45 The Iollowing statements regarding transcranial Doppler are true A. This technique is non-invasive B. It is most commonly perIormed through the temporal window C. It can be perIormed using the transorbital approach D. Using transcranial Doppler to estimate cerebral blood Ilow requires the assumption that the pulse rate is regular E. It is a sensitive method Ior detecting cerebral emboli Question 46 Laser radiation has the Iollowing properties A. It is conIined to the invisible portion oI the spectrum B. It is monochromatic C. It is coherent D. It is collimated E. It has a low energy density Question 47 In magnetic resonance imaging A. A lead apron needs to be worn by operators B. The magnetic Iield created is less than the earth's magnetic Iield C. Nickel iewellery will not be attracted by the magnetic Iield D. Patients with cardiac pacemakers are contraindicated E. ECG monitoring may show arrhythmias Question 48 Electroencephalography (EEG) may be altered by the Iollowing A. Temperature B. Arterial carbon dioxide tension C. Hypoxia D. Uraemia E. Thiopentone Question 49 The Iollowing measure gas volume A. Benedict Roth spirometer B. Vitalograph C. Wright respirometer D. Fleisch pneumotachograph E. Rotameter Question 50 The Iollowing are measured directly in a blood gas analyser A. Oxygen saturation B. Oxygen tension C. Carbon dioxide tension D. Hydrogen ion concentration E. Bicarbonate concentration Question 51 The Iollowing parameters are needed to determine the anatomical dead space in Fowler's method A. Arterial oxygen tension B. Inspired oxygen tension C. Inspired carbon dioxide tension D. Expired carbon dioxide tension E. Nitrogen analysis oI expired air Question 52 The Iollowing parameters are needed to determine the physiological dead space in Bohr's method A. Tidal volume B. Respiratory rate C. Arterial oxygen tension D. Inspired oxygen tension E. Alveolar carbon dioxide tension Question 53 The percentage oI oxygen in the alveolar air A. Depends on the atmospheric pressure B. Depends on the ambient humidity C. May be increased by giving supplementary oxygen D. May be increased during induction oI anaesthesia with a mixture oI 21° oxygen in nitrous oxide E. Is greater than the mixed expired air Question 54 Soda lime in the anaesthetic circuit A. Is mainly composed oI sodium carbonate B. Needs moisture to absorb carbon dioxide C. Gets hot in use D. Can be used to absorb nitrous oxide E. Produces carbon monoxide iI dry Question 55 A volatile anaesthetic agent has a SVP oI 243 mmHg. II the total Iresh gas Ilow is 5 l/min oI which 200 ml/min is directed through the vaporising chamber, the inspired conc. will be approximately A. 0.25° B. 0.5° C. 1.0° D. 1.5° E. 2.0° Page 47 Question 56 Concerning the relationship between end-tidal CO 2 and PaCO 2 A. In healthy lungs the P ET CO 2 is approximately 0.5 kPa greater than the PaCO 2 B. P ET CO 2 and PaCO 2 diIIerence is reduced when ventilated with larger tidal volumes C. P ET CO 2 and PaCO 2 diIIerence is reduced in pregnancy D. A reduction in pulmonary blood Ilow by 50° would produce approximately a 50° reduction in P ET CO 2 E. In COPD, the P ET CO 2 and PaCO 2 diIIerence can be reduced by reducing ventilator Irequency and increasing tidal volume Question 57 The Magill circuit in spontaneous ventilation A. Is an example oI a Mapleson A circuit B. Requires the Iresh as Ilow rate to equal the patient's minute volume ventilation to prevent rebreathing C. Can be made more eIIicient by placement oI the expiratory valve close to the reservoir bag D. Improves its rebreathing characteristics iI the length oI tubing is doubled E. Is suitable Ior children weighing over 15 kg Question 58 The saturated vapour pressure oI a liquid A. Is the pressure exerted at the critical temperature B. Increases with increase temperature C. Is directly proportional to the atmospheric pressure D. Is equal to atmospheric pressure at its boiling point E. Can be greater than its boiling point Question 59 The Iollowing techniques may be used to monitor cerebral Iunction during carotid endarterectomy A. Somatosensory evoked potentials B. Transcranial Doppler C. Cerebral oximetry D. Carotid stump pressure E. Coniunctival oxygen tension Page 48 Question 60 When taking blood pressure with a sphygmomanometer, a Ialsely high reading may result Irom A. Using a standard cuII on an obese person B. Using too narrow a cuII C. Letting the cuII down slowly D. Arteriosclerosis E. Placement oI the sphygmomanometer above the level oI the heart Page 49 Exam 2 Answers Question 1 A. TRUE B. FALSE C. TRUE D. FALSE E. FALSE Physostigmine, being a tertiary amine, readily crosses the placenta. Glycopyrrolate is a quarternary ammonium compound and is highly ionized, thus making membrane penetration diIIicult. Naloxone, because oI its high lipid solubility, is easily transIerred to the Ioetus and can be administered to the mother to counteract anticipated respiratory depression in the inIant. Suxamethonium and heparin are highly ionized and thereIore do not readily cross the placenta. Ref. W McCaughev. R S J Clarke. J P H Fee. W F M Wallace. Anaesthetic Phvsiologv and Pharmacologv. 1st ed. Churchill Livingstone. 1997. Question 2 A. FALSE B. TRUE C. TRUE D. TRUE E. FALSE Higher doses oI Irusemide are needed although the risk oI toxicity is increased. Benzylpenicillin is predominantly excreted by the kidneys, thereIore higher levels are reached in renal Iailure. Ref. W McCaughev. R S J Clarke. J P H Fee. W F M Wallace. Anaesthetic Phvsiologv and Pharmacologv. 1st ed. Churchill Livingstone. 1997. Question 3 A. FALSE B. TRUE C. FALSE D. TRUE E. TRUE The pKa oI a drug is the pH at which the drug is 50° ionised. Due to the steepness oI the graph, drugs with a pKa near physiological pH will show signiIicant changes in the percentage oI drug that is ionised versus unionised. The pKa is a constant Ior each drug. The stomach has a very low pH and a drug with an acid pKa such as aspirin (pKa 3.5), will be mainly unionised, and thus will be readily absorbed across the gastric membrane. Local anaesthetics are weak bases, and in an acidic environment (localised inIection, acidotic or poorly perIused tissues) where the pH is below the pKa, the ionised Iorm predominates and thus crosses the neural membrane less readily. Ref. W McCaughev. R S J Clarke. J P H Fee. W F M Wallace. Anaesthetic Phvsiologv and Pharmacologv. 1st ed. Churchill Livingstone. 1997. Page 50 Question 4 A. FALSE B. TRUE C. TRUE D. TRUE E. TRUE Morphine metabolism involves demethylation, oxidation, coniugation with glucuronide, and methylation to codeine. Ref. J W Dundee. R S J Clarke. W McCaughev. Clinical Anaesthetic Pharmacologv. 1st ed. Churchill Livingstone. 1991. Question 5 A. FALSE B. TRUE C. TRUE D. FALSE E. FALSE CiproIloxacin and enalapril undergo signiIicant renal excretion. Although Irusemide is potentially nephrotoxic, it is necessary to increase the dose in renal impairment to produce the same eIIect. The main route oI excretion Ior erythromycin and metronidazole is hepatic. Ref. .. British National Formularv. 1997. Question 6 A. FALSE B. FALSE C. FALSE D. FALSE E. FALSE A dry, tickly, non-productive cough has been reported in up to 15° oI patients treated with ACE inhibitors. The incidence oI ACE inhibitor-induced cough is twice as common in women as in men, but there is no diIIerence between smokers and non-smokers, or in patients being treated Ior hypertension or heart Iailure Changing to a diIIerent ACE inhibitor is unlikely to have a signiIicant eIIect on the cough. There is no evidence oI dose dependency. Withdrawal oI the oIIending drug leads to complete recovery within days. Recurrence occurs on rechallenge. Ref. Prescribers Journal. 31(4). 1991. Question 7 A. FALSE B. FALSE C. TRUE D. TRUE E. TRUE Clonidine is an --2 adrenergic agonist whose action is predominantly central. The ratio oI -2:-1 activity is 200:1. The analgesic action oI clonidine is exerted centrally, although the precise site and mechanism are uncertain. It is also eIIective when administered via the intrathecal and epidural routes. Clonidine results in a reduction in anaesthetic agent requirements by up to 50°. Clonidine attenuates the increase in blood pressure and heart rate in response to stressIul stimuli (laryngoscopy, endotracheal intubation, skin incision). Clonidine is rapidly and almost completely absorbed when given orally, reaching a peak plasma level within 6090 mins. Ref. W McCaughev. R S J Clarke. J P H Fee. W F M Wallace. Anaesthetic Phvsiologv and Pharmacologv. 1st ed. Churchill Livingstone. 1997. Page 51 Question 8 A. TRUE B. FALSE C. FALSE D. TRUE E. FALSE There is now no doubt that propoIol can cause epileptic Iits in those who are susceptible and may be delayed aIter stopping its administration. In addition, propoIol has anti-convulsant action, although this is less marked than that oI thiopentone. It has been shown to inhibit electroconvulsive therapy (ECT) convulsions and has been used to suppress convulsions in a variety oI conditions, some oI them reIractory to barbiturates and phenytoin. One oI the breakdown products oI atracurium, laudanosine (but not atracurium per se) has been shown to cause Iits in dogs above a threshold oI 17 µg/ml. In humans, the threshold Ior Iits has not been established. Neostigmine does not cross the blood brain barrier. Rare cases oI Iits have been reported with etomidate. Ketamine is not epileptogenic but enhanced skeletal muscle tone may be maniIested by tonic and clonic movements sometimes resembling Iits. Ref. W McCaughev. R S J Clarke. J P H Fee. W F M Wallace. Anaesthetic Phvsiologv and Pharmacologv. 1st ed. Churchill Livingstone. 1997. Question 9 A. TRUE B. TRUE C. TRUE D. TRUE E. TRUE Malathion is a constituent oI some headlice shampoos and is also used in sheepdips. Edrophonium is used in the diagnosis oI myasthenia gravis (the tensilon test). Physostigmine is used in the treatment oI myasthenia gravis. Physostigmine and ecothiopate eyedrops are used as miotics in the treatment oI glaucoma. Donepezil (Aricept), another inhibitor oI acetylcholinesterase, is the Iirst speciIic drug Ior treating Alzheimer's disease. Ref. W McCaughev. R S J Clarke. J P H Fee. W F M Wallace. Anaesthetic Phvsiologv and Pharmacologv. 1st ed. Churchill Livingstone. 1997. Question 10 A. FALSE B. TRUE C. TRUE D. FALSE E. FALSE Dantrolene is a direct-acting skeletal muscle relaxant. It uncouples the excitation-contraction process by inhibiting the release oI ionised calcium Irom the terminal cisternae oI the sarcoplasmic reticulum into the sarcoplasm. It does not act on smooth muscles and has no action on the neuromuscular iunction. Diltiazem and nicardipine are calcium- channel blockers acting on myocardial cells, conducting system oI the heart, and cells oI the vascular smooth muscle. Hydralazine and nitroglycerine are both vasodilators but not calcium antagonists. Ref. W McCaughev R S J Clarke. J P H Fee. W F M Wallace. Anaesthetic Phvsiologv and Pharmacologv. 1st ed. Churchill Livingstone. 1997. Question 11 A. TRUE B. TRUE C. TRUE D. FALSE E. TRUE Factors which may increase the eIIects oI vecuronium are: Hypermagnesaemia, hypokalaemia, hypocalcaemia, hypoproteinaemia, dehydration, acidosis, hypercapnoea, cachexia, hypothermia, prior use oI suxamethonium, and concurrent use oI aminoglycoside antibiotics, --adrenergic blocking agents, ß-adrenergic blocking agents and MAO inhibiting agents. Ref. W McCaughev. R S J Clarke. J P H Fee. W F M Wallace. Anaesthetic Phvsiologv and Pharmacologv. 1st ed. Churchill Livingstone. 1997. Question 12 A. TRUE B. FALSE C. TRUE D. FALSE E. TRUE Factors aIIecting the MAC. Decrease MAC: Age, benzodiazepines, opioids, nitrous oxide, neuromuscular blockers, alpha-2 agonists, hypothermia, severe hypotension, hypoxaemia, hypothyroidism, pregnancy, increase atmospheric pressure, chronic use oI amphetamine Increase MAC: Hyperthermia, hyperthyroidism, acute usage oI amphetamine No change: Sex, hypercarbia, hypocarbia, duration oI anaesthesia Ref. R D Miller. Anesthesia. 4th ed. Churchill Livingstone. 1994. Question 13 A. TRUE B. FALSE C. TRUE D. TRUE E. FALSE Paracetamol and barbiturates are metabolised by zero-order kinetics only in toxic doses. Ref. J W Dundee. R S J Clarke. W McCaughev. Clinical Anaesthetic Pharmacologv. 1st ed. Churchill Livingstone. 1991. Question 14 A. FALSE B. FALSE C. FALSE D. TRUE E. TRUE SevoIlurane has a lower blood/gas partition coeIIicient than isoIlurane (0.6 vs 1.4). It does not sensitise the myocardium to catecholamines and has relatively little eIIect on the cardiovascular system.The MAC oI sevoIluarane is approximately 2° compared to 6° Ior desIlurane. It is less pungent than desIlurane and is thereIore suitable Ior inhalational induction. Because oI the Page 53 lower blood/gas and oil/gas partition coeIIicients, sevoIlurane has a Iaster washout than halothane. Ref. A R Aitkenhead. G Smith. Textbook of Anaesthesia. 3rd ed. Churchill Livingstone. 1996. Question 15 A. FALSE B. TRUE C. TRUE D. TRUE E. TRUE Etomidate is a carboxylated imidazole. Ketamine is a phencyclidine derivative. The incidence oI nausea and vomiting is very much higher than propoIol. Allergic reactions are extremely rare (1 in 450,000). Etomidate causes adreno- corticol suppression even aIter a single bolus dose. Etomidate is contraindicated in porphyrias. Ref. W McCaughev. R S J Clarke. J P H Fee. W F M Wallace. Anaesthetic Phvsiologv and Pharmacologv. 1st ed. Churchill Livingstone. 1997. Question 16 A. FALSE B. FALSE C. FALSE D. TRUE E. TRUE Droperidol is a butyrophenone and it acts by interIering with dopaminergic transmission in the brain. Because it blocks dopamine receptors, it may cause extrapyramidal side eIIects. In addition, it blocks the --adrenergic receptors but has no eIIect on the ß-adrenergic receptors. It is extensively metabolised by the liver. Ref. W McCaughev. R S J Clarke. J P H Fee. W F M Wallace. Anaesthetic Phvsiologv and Pharmacologv. 1st ed. Churchill Livingstone. 1997. Question 17 A. FALSE B. FALSE C. TRUE D. TRUE E. FALSE Suxamethonium, mivacurium, procaine and trimetaphan are broken down by plasma acetylcholinesterase and a prolonged action may be expected in the presence oI deIective acetylcholinesterase enzyme. Esmolol is broken down by non-speciIic esterases. Ref. W McCaughev. R S J Clarke. J P H Fee. W F M Wallace. Anaesthetic Phvsiologv and Pharmacologv. 1st ed. Churchill Livingstone. 1997. Question 18 A. TRUE B. TRUE C. FALSE D. FALSE E. FALSE Characteristics oI a depolarising block include: Initial period oI muscle Iasciculation Well maintained tetanus with no Iade An absence oI post-tetanic potentiation Anticholinesterases may potentiate the block Ref. A R Aitkenhead. G Smith. Textbook of Anaesthesia. 3rd ed. Churchill Livingstone. 1996. Question 19 A. FALSE B. FALSE C. TRUE D. FALSE E. FALSE The mechanism responsible Ior the relatively rapid awakening aIter a single i.v. bolus dose oI thiopentone is the redistribution into well-perIused organs (brain, liver and kidneys). Despite the high lipid solubility oI thiopentone, Iat contributes little to the initial redistribution or termination oI its action because oI the poor blood supply. Ref. A R Aitkenhead. G Smith. Textbook of Anaesthesia. 3rd ed. Churchill Livingstone. 1996. Question 20 A. FALSE B. TRUE C. TRUE D. TRUE E. TRUE Halothane is a halogenated hydrocarbon (CF 3 CHClBr). Ref. A R Aitkenhead. G Smith. Textbook of Anaesthesia. 3rd ed. Churchill Livingstone. 1996. Question 21 A. TRUE B. FALSE C. FALSE D. FALSE E. FALSE Type A blood has anti-B antibodies in the plasma. Type O blood has both anti-A and anti-B antibodies in the plasma. Individuals with type O blood are 'universal donors', and type O blood can be given to anyone without producing a transIusion reaction due to ABO incompatibility. However, the possibilities oI reaction due to incompatibilities other than ABO incompatibilities always exists. The most common blood group is type O. In cross-matching, the donor's red cells are mixed with the recipient's plasma and checked Ior agglutination. Ref. W F Ganong. Review of Medical Phvsiologv. 18th ed. Lange. 1997. Question 22 A. TRUE B. FALSE C. TRUE D. TRUE E. FALSE The anterior pituitary secretes 6 hormones: ACTH, TSH, FSH, LH, growth hormone and prolactin. Antidiuretic hormone and oxytocin are both secreted by the posterior pituitary. Ref. W F Ganong. Review of Medical Phvsiologv. 18th ed. Lange. 1997. Page 55 Question 23 A. TRUE B. FALSE C. TRUE D. FALSE E. TRUE Causes oI altered plas a cholinesterase activity: Decrease activity Increase activity Pregnancy Malignancy Malnutrition Hepatic Iailure Heart Iailure Renal Iailure Hypothyroidism Burns Hyperthyroidism Nephrotic syndrome Mental retardation Depression Hyperlipidaemia Obesity Ref. L Davis. J J Britten. M Morgan. Cholinesterase. its significance in anaesthetic practice. Anaesthesia 1997, 52. 244260. Question 24 A. FALSE B. FALSE C. TRUE D. TRUE E. TRUE Adult males are roughly 60° water and adult Iemales 55°. Females have a greater proportion oI body Iat than males. The average 70 kg male contains 42 litres oI water (60ml/kg), and two-thirds oI this is intracellular Iluid (ICF). The remaining one-third is extracellular (ECF) and is divided between the interstitial Iluid and the vascular compartments. A Iourth ('transcellular') compartment includes cerebrospinal, synovial, pleural and pericardial Iluids, plus water in the gut. Normally the latter represents a small proportion oI the total, but in disease (e.g. in paralytic ileus or massive pleural eIIusion), it can become important. Newborn inIants comprise some 75° water. The proportion oI water decreases with increasing age. All inIused Na ¹ remains in the ECF; Na ¹ cannot gain access to the ICF because oI the sodium pump. As 0.9° saline is isotonic, there is no change in ECF osmolality and thereIore no water exchange occurs across the cell membrane. Ref. A R Aitkenhead. G Smith. Textbook of Anaesthesia. 3rd ed. Churchill Livingstone. 1996. Question 25 A. FALSE B. TRUE C. TRUE D. TRUE E. TRUE The raised white cell count is due mainly to neutrophil leucocytosis. Pseudocholinesterase activity is decreased by up to 30° but this does not prolong the action oI suxamethonium to a clinically signiIicant extent. Ref. A R Aitkenhead. G Smith. Textbook of Anaesthesia. 3rd ed. Churchill Livingstone. 1996. Page 56 Question 26 A. FALSE B. FALSE C. TRUE D. TRUE E. TRUE Cerebral blood Ilow remains constant over a range oI mean systemic (not systolic!) blood pressures Irom 60 to 140 mmHg. Above and below these mean blood pressures, cerebral blood Ilow is increased and decreased respectively. In chronic hypertension, the autoregulation curve is shiIted to the right. Autoregulation is lost around areas oI intracerebral pathology. Autoregulation is impaired by hypoxia and hypercapnia. Cerebral blood Ilow increases when the PaO 2 decreases to 6.7 kPa (50 mmHg) and is doubled at a PaO 2 oI 4 kPa (30 mmHg). Ref. A R Aitkenhead. G Smith. Textbook of Anaesthesia. 3rd ed. Churchill Livingstone. 1996. Question 27 A. TRUE B. FALSE C. TRUE D. TRUE E. TRUE Other ECG changes associated with hypothermia include prolongation oI the P-R interval, widened QRS complex, increased Q-T interval and S-T elevation.The oxyhaemoglobin dissociation curve shiIts to the leIt thus reducing oxygen availability to the tissues. The clotting mechanisms are depressed and there is a Iall in platelet count. Ref. R S Atkinson. G B Rushman. N J H Davies. Lee´s Svnopsis of Anaesthesia. 11th ed. Butterworth-Heinemann. 1993. Question 28 A. TRUE B. FALSE C. FALSE D. TRUE E. TRUE The volume oI distribution oI drugs may be altered signiIicantly by a decrease in total body water and an increase in body Iat. The incidence oI hiatus hernia is increased in the obese and this, together with a rise in intra-abdominal pressure and delayed gastric emptying, puts them at greater risk oI aspiration oI gastric contents under anaesthesia. Changes in lung volume include a decrease in Iunctional residual capacity, total lung capacity, inspiratory capacity, vital capacity and expiratory reserve volume, whilst residual volume remains unchanged. Obese patients have increased oxygen consumption and carbon dioxide production. They have an increased blood volume and cardiac output proportional to their oxygen demand. Ref. R D Miller. Anesthesia. 4th ed. Churchill Livingstone. 1994. Question 29 A. TRUE B. TRUE C. FALSE D. TRUE E. TRUE Aldosterone secretion is controlled by 4 main Iactors: Plasma sodium concentration Plasma potassium concentration ACTH Angiotensin II An increase in plasma sodium concentration inhibits the release oI aldosterone to Iavour salt loss, while increased plasma potassium stimulates aldosterone release. An increase in circulatory ACTH, as in trauma, also stimulates the release oI aldosterone. These three Iactors are oI lesser importance than the Iourththe plasma concentration oI angiotensin II. Ref. W F Ganong. Review of Medical Phvsiologv. 18th ed. Lange. 1997. Question 30 A. FALSE B. FALSE C. TRUE D. TRUE E. FALSE Renin secretion is controlled by: Intrarenal baroreceptors oI the aIIerent (not eIIerent) arterioles Sodium or possibly chloride ions (not potassium) in the macula densa Renal sympathetic nerve activity Angiotensin A Iall in the arteriolar pressure in the aIIerent arterioles and decreased sodium load reaching the macula densa both stimulate release oI renin Irom the iuxta-glomerular apparatus. Renal sympathetic nerve activity causes constriction oI the aIIerent arterioles to give reduced pressure distal to the constriction and thereIore stimulation oI the intrarenal baroreceptors to promote renin release. The glomerular Iiltration rate (GFR) is thereIore lowered and the sodium load reaching the macula densa will consequently decrease. Sympathetic activity thus stimulates renin release indirectly by means oI the Iirst two controlling Iactors, in addition to direct stimulation oI the beta-adrenergic receptors in the renin-secreting granular cells. Angiotensin itselI exerts a direct negative Ieedback on renin release and thereIore on its own production. Ref. W F Ganong. Review of Medical Phvsiologv. 18th ed. Lange. 1997. Question 31 A. FALSE B. FALSE C. FALSE D. TRUE E. TRUE There are approximately 1.3 million nephrons in each kidney. Aldosterone is produced by the adrenal cortex. The kidneys produce prostaglandins, kinins, renin and 1,25-dihydroxycholecalciIerol. In a resting state, the kidneys receive 1.2 L oI blood per minute, which is approximately 25° oI the cardiac output.The blood Ilow in the renal cortex is estimated to be at least 20 times greater than that in the medulla. Renal autoregulation oI renal blood Ilow is present even in denervated and in isolated, perIused kidneys. Ref. W F Ganong. Review of Medical Phvsiologv. 18th ed. Lange. 1997. Question 32 A. TRUE B. FALSE C. FALSE D. FALSE E. FALSE Normally, 180 litres oI Iluid is Iiltered through the glomeruli each day with 179 litres reabsorbed, producing 1 litre urine per day on average. The transport oI water is a passive one: i.e. water moves passively along the osmotic gradients set up by active transport oI solutes. Up to 70° oI the Iiltered water is removed by the time the Iiltrate reaches the end oI the proximal tubule. The Iiltered tubular Iluid in the distal tubule is hypotonic. ADH Irom the posterior pituitary gland increases the permeability oI the collecting duct to water. Percentage oI Iiltered water removed at various parts oI the nephron: Proximal tubule Loop oI Henle Distal tubule Collecting ducts 6070° 15° 5° 10° Changes in the osmolality oI tubular Iluid in various parts oI the nephron: Proximal tubule Descending limb oI the loop oI Henle Ascending limb oI the loop oI Henle Distal tubule Collecting ducts Isotonic Hypertonic Hypotonic More hypotonic Hypertonic Ref. W F Ganong. Review of Medical Phvsiologv. 18th ed. Lange. 1997. Question 33 A. TRUE B. FALSE C. FALSE D. TRUE E. TRUE The withdrawal reIlex is a polysynaptic reIlex that occurs in response to a painIul stimulus. The response is Ilexor muscle contraction and inhibition oI extensor muscles, so that the part stimulated is Ilexed and withdrawn Irom the stimulus. As the strength oI the stimulus is increased, the reaction time is shortened. The knee ierk is a monosynaptic reIlex. The stimulus is stretch oI the muscle, and the response is contraction oI the muscle being stretched. The sense organ in this case is the muscle spindle. Ref. W F Ganong. Review of Medical Phvsiologv. 18th ed. Lange. 1997. Question 34 A. FALSE B. FALSE C. TRUE D. FALSE E. FALSE The extracellular Iluid volume is diIIicult to measure because the limits oI this space are ill deIined and lymph cannot be separated Irom the ECF and is measured with it. Inulin, mannitol and sucrose have been used to measure ECF volume. Albumin labelled with radioactive Page 59 iodine or dyes (Evans blue) that are bound to plasma protein can be used to measure plasma volume. Deuterium oxide (heavy water) is used to measure total body water. Ref. W F Ganong. Review of Medical Phvsiologv. 18th ed. Lange. 1997. Question 35 A. FALSE B. TRUE C. FALSE D. FALSE E. TRUE Na ¹ and Cl- are largely extracellular, whereas K ¹ and PO 4 3- are largely intracellular. Mg2¹ is the Iourth most plentiIul cation and second most abundant intracellular cation (99° oI which is intracellular). Ref. W F Ganong. Reiew of Medical Phvsiologv. 18th ed. Lange. 1997. Question 36 A. TRUE B. TRUE C. TRUE D. FALSE E. TRUE Solutions that have the same osmolality as plasma are said to be isotonic. The Iollowing solutions are isotonic: 0.9° saline, 5° glucose, 4° glucose ¹ 0.18° saline, and Hartmann's (Ringer's lactate) solution. Mannitol 10° and 20° are hypertonic. 5° glucose solution is isotonic when initially inIused intravenously, but the glucose is metabolised, so the net eIIect is that oI inIusing a hypotonic solution. Ref. A R Aitkenhead. G Smith. Textbook of Anaesthesia. 3rd ed. Churchill Livingstone. 1996. Question 37 A. TRUE B. TRUE C. TRUE D. TRUE E. FALSE The cholinergic neurones are: All preganglionic neurones. Parasympathetic postganglionic neurones. Sympathetic postganglionic neurones which innervate sweat glands. Sympathetic postganglionic neurones which end on blood vessels in skeletal muscles and produce vasodilatation when stimulated. The remaining postganglionic sympathetic neurones are noradrenergic. Ref. W F Ganong. Review of Medical Phvsiologv. 18th ed. Lange. 1997. Question 38 A. TRUE B. FALSE C. TRUE D. TRUE E. TRUE Compartment distribution oI the main buIIer systems in the body: Page 60 Interstitial Iluid: Bicarbonate Plasma: Bicarbonate Proteins Inorganic phosphate Red blood cells: Bicarbonate Haemoglobin Inorganic phosphate Organic phosphate 2,3-DPG Ref. W F Ganong. Review of Medical Phvsiologv. 18th ed. Lange. 1997. Question 39 A. TRUE B. FALSE C. FALSE D. FALSE E. TRUE The cations used in the calculation oI the anion gap are sodium and potassium. The anions used in the calculation oI the anion gap are chlorides and bicarbonates. Anion gap ÷ (Na ¹ ¹ K ¹ ) (Cl - ¹ HCO 3 -) The normal anion gap is between 10 and 18 mmol/l. The most useIul application oI the anion gap is in classiIying metabolic acidosis into two types. Metabolic acidosis with high anion gap: Renal Iailure Lactic acidosis Ketoacidosis Poisoning with aspirin, methanol, ethylene glycol, and paraldehyde Metabolic acidosis with normal anion gap: Diarrhoea Ureterosigmoidostomy Renal tubular acidosis Treatment with carbonic anhydrase inhibitors Ref. A R Aitkenhead. G Smith. Textbook of Anaesthesia. 3rd ed. Churchill Livingstone. 1996. Question 40 A. FALSE B. TRUE C. FALSE D. FALSE E. FALSE The stress response results in Sodium and water retention Potassium loss Increased protein breakdown Decreased protein synthesis Increased gluconeogenesis Increased glycogenolysis Decreased perip eral glucose uptake Increased lipolyis Decreased lipogenesis Ref. W F Ganong. Review of Medical Phvsiologv. 18th ed. Lange. 1997. Question 41 A. FALSE B. FALSE C. FALSE D. TRUE E. TRUE CVP PCWP Causes Increased Normal Right Ventricular Failure Pulmonary Embolus Pulmonary Hypertension Tricuspid Incompetence Decreased Decreased Hypovolaemia Normal Increased LeIt Ventricular Failure Increased Increased Congestive Heart Failure Hypervolaemia Question 42 A. TRUE B. TRUE C. FALSE D. TRUE E. TRUE It is not necessary to use iced iniectate in the thermodilution cardiac output measurement, as long as there is a temperature diIIerence between the iniectate and blood temperature.Warmer solutions require higher thermistor sensitivities than do iced solutions. Use oI iced solutions increases the signal-to-noise ratio. Each iniection should be timed to occur at the same point in the respiratory cycle to assure comparability oI measurements. Patients on mechanical ventilation should have the iniection made at the end oI expiration. The iniection should be made as rapidly and as smoothly as possible to create a smooth thermodilution curve. Most computation constants assume iniection in less than 4 seconds. Any Iactors such as valvular lesion or intra-cardiac shunt that might decrease intraventricular mixing or result in streaming oI blood/indicator will result in an over or underestimation oI cardiac output. Ref. C Scurr. S Feldman. N Soni. Scientific Foundations of Anaesthesia. 4th ed. Heinemann. 1990. Page 62 Question 43 A. FALSE B. FALSE C. TRUE D. TRUE E. FALSE The gastric intramucosal pH (pHi) is an indirect estimation oI the pH oI the superIicial mucosal cells oI the stomach wall. It is calculated using the Henderson-Hasselbach equation. A low value reIlects the inability oI the oxygen supply to meet the metabolic demands oI these tissues. The pHi is considered normal iI values are above 7.35. In splanchnic hypoperIusion pHi will be low. The value will be Ialsely raised iI air is introduced during sampling. Studies have shown the potential useIulness oI pHi in identiIying critically ill patients at risk oI poor outcome, as a therapeutic endpoint and guide to adequate resuscitation. Ref. M G Mvthen. A R Webb. The Role of Gut Mucosal Hvpoperfusion in the Pathogenesis of Post-operative Organ Dvsfunction. Intensive Care Medicine 1994, 20. 203209. Question 44 A. TRUE B. TRUE C. TRUE D. FALSE E. FALSE Volatile anaesthetic agent concentration may be measured using mass spectrometry, inIrared absorption and ultraviolet absorption. Polarographic and paramagnetic analysers measure oxygen concentration. Ref. C Scurr. S Feldman. N Soni. Scientific Foundations of Anaesthesia. 4th ed. Heinemann. 1990. Question 45 A. TRUE B. TRUE C. TRUE D. FALSE E. TRUE Transcranial Doppler is most commonly perIormed through the temporal window, where the skull is relatively thin, but can be perIormed using the transorbital, suboccipital or submandibular approaches. Using transcranial Doppler to estimate cerebral blood Ilow requires the assumption that the cross-sectional area oI the insonated vessel and the viscosity oI the blood Ilowing through the vessel remain constant. Ref. K S Drader. I A Herrick. Carotid endarterctomv. Monitoring and its Effect on Outcome. Anesthesiologv Clinics of North America 1997, 15. 613629. Question 46 A. FALSE B. TRUE C. TRUE D. TRUE E. FALSE Laser is an acronym Ior 'light ampliIication by stimulated emission oI radiation'. The radiation may be in the visible or the invisible inIrared part oI the spectrum. It has the Iollowing properties:- Monochromatic: all the photons have the same energy, wavelength, and Irequency Coherent: all the photons are in phase Collimated: the beam does not diverge High energy density: a large amount oI energy is concentrated in a small area Ref. M Sosis. Anesthesia for Laser Surgerv. International Anesthesiologv Clinics 1990, 2(2). 119131. Question 47 A. FALSE B. FALSE C. FALSE D. TRUE E. TRUE Ionising radiation is not used in MRI and lead aprons are thereIore not required. The magnetic Iield created is up to 2 teslas. The earth's magnetic Iield is only 0.00005 teslas or 40,000 times less. Ferromagnetic metals (iron, nickel, cobalt) will be attracted by the magnetic Iield. Ref. R D Miller. Anesthesia. 4th ed. Churchill Livingstone. 1994. Question 48 A. TRUE B. TRUE C. TRUE D. TRUE E. TRUE The EEG reIlects the spontaneous electrical activity oI cortical pyramidal neurones arising Irom inhibitory and excitatory postsynaptic potentials. The EEG may be altered by a large number oI physiological Iactors, including temperature, arterial carbon dioxide tension, hypoxaemia, and electrolyte abnormalities. Anaesthetic drugs also aIIect EEG morphology, depending on the drugs used and the depth oI anaesthesia. Ref. K S Drader. I A Herrick. Carotid endarterctomv. Monitoring and its Effect on Outcome. Anesthesiologv Clinics of North America 1997, 15. 613629. Question 49 A. TRUE B. TRUE C. TRUE D. FALSE E. FALSE The Benedict Roth spirometer,Vitalograph and Wright respirometer all measure gas volume. The Fleisch pneumotachograph and the Rotameter both measure Ilow. Ref. P D Davis. G D Parbrook. G N C Kennv. Basic Phvsics and Measurement in Anaesthesia. 4th ed. Butterworth- Heinemann. 1995. Question 50 A. FALSE B. TRUE C. TRUE D. TRUE E. FALSE Oxygen, carbon dioxide and hydrogen ion concentrations are measured directly in a blood gas analyser. Oxygen saturation, bicarbonate concentration and the base excess are derived values. Question 51 A. FALSE B. FALSE C. FALSE D. FALSE E. TRUE Fowler's method is used to measure the anatomical dead space. 100° oxygen is inspired at the end oI a normal inspiration so that the dead space is Iilled with oxygen. The partial pressure oI nitrogen is measured on expiration. It is initially zero, rising to a plateau as the supplemental oxygen is washed out. The volume oI air expired at the mid point oI the initial rising phase oI nitrogen concentration represents the volume oI the dead space. Ref. J B West. Respiratorv Phvsiologv the essentials. 5th ed. Williams and Wilkins. 1995. Question 52 A. TRUE B. FALSE C. FALSE D. FALSE E. TRUE Bohr's method measures the volume oI the lung which does not eliminate carbon dioxide (physiological dead space). In normal subiects, the physiological dead space and anatomical dead space are very nearly the same. In patients with lung disease, however, the physiological dead space may be considerably larger because oI ventilation/perIusion (V/Q) inequalities with the lung. Bohr's equation can be written as: Where V D ÷ physiological dead space; V T ÷ tidal volume; P A CO 2 ÷ alveolar CO 2 ; P E CO 2 ÷ mixed expired CO 2 . The PCO 2 in alveolar gas and arterial blood (PaCO 2 ) is virtually identical so that the equation is oIten written as: Ref. J B West. Respiratorv Phvsiologv the essentials. 5th ed. Williams and Wilkins. 1995. Question 53 A. FALSE B. FALSE C. TRUE D. TRUE E. FALSE Whatever the outside air humidity, the nose is such an eIIicient humidiIier that air drawn into the respiratory tract becomes Iully saturated in the alveoli at 37°C. The concentration oI water is constant at 44 mg/l which represents a Iractional concentration oI 6.2°. Oxygen supplementation will increase the Iractional inspired oxygen and thereIore the alveolar percentage. Because nitrous oxide is approximately 30 times more soluble in blood than nitrogen, the Page 65 alveolar gas volume is eIIectively reduced. Since the amount oI oxygen remains the same, an increase in the percentage oI oxygen results. Expired air is a mixture oI alveolar and dead space gas, which thereIore has a higher percentage oI oxygen than alveolar air. Ref. A R Aitkenhead. G Smith. Textbook of Anaesthesia. 3rd ed. Churchill Livingstone. 1996. Question 54 A. FALSE B. TRUE C. TRUE D. FALSE E. TRUE Soda lime is approximately 94° calcium hydroxide. As it absorbs carbon dioxide, heat and moisture are produce . Soda lime does not absorb nitrous oxide or volatile anaesthetic agents. Barium hydroxide (Baralyme) produces signiIicantly more carbon monoxide than soda lime when dry. In the UK, baralyme is not available, and anaesthetic machines in current use do not have Iresh gas Ilow placed upstream oI the absorbent canister, which causes the absorbent to become excessively dry. Ref. A R Aitkenhead. G Smith. Textbook of Anaesthesia. 3rd ed. Churchill Livingstone. 1996. Question 55 A. FALSE B. FALSE C. FALSE D. FALSE E. TRUE Plenum vaporisers work on the principle that the part oI the Ilow that goes through the vaporising chamber becomes Iully saturated. Since the SVP is 243 mmHg, Iresh gas passing through the vaporising chamber will have a vapour concentration approximately one-third oI the atmospheric pressure (760 mmHg). Thus 200 ml oI Iresh gas passing through the vaporising chamber will have 100 ml oI vapour added to it. The Iinal vapour concentration is thereIore 100 ml in 5000 ml which is approximately 2°. Note: II you ever get a question like this and you cannot work out the answer, it is best to answer all questions as Ialse. You will then get a score oI at least 3, instead oI zero by not answering the question at all. Ref. P D Davis. G D Parbrook. G N C Kennv. Basic Phvsics and Measurement in Anaesthesia. 4th ed. Butterworth- Heinemann. 1995. Question 56 A. FALSE B. TRUE C. TRUE D. TRUE E. TRUE A sample oI end-tidal gas is assumed to have come Irom the alveoli where it is in equilibrium with pulmonary capillary blood. End-tidal CO 2 is thereIore usually taken to be an indirect measure oI arterial CO 2 , and in adults with healthy lungs, the P ET CO 2 is approximately 0.30.6 kPa less than the PaCO 2 . Following a pulmonary embolus in a previously healthy lung, there is a sudden increase in alveolar dead space because all lung units are ventilated but only some are perIused. Since all these lung units empty at the same rate, there is a constant dilution oI the CO 2 Irom the perIused alveoli by the non-CO 2 containing gas Irom Page 66 the unperIused alveoli. Theoretically, a reduction in pulmonary blood Ilow by 50° would produce a 50° reduction in P ET CO 2 . In COPD, there is widespread V/Q mismatching throughout the lung. A P ET CO 2 - PaCO 2 diIIerence oI over 2 kPa is not unusual. Reducing the Irequency (to allow more time Ior equilibration) and increasing the tidal volume (to maximise the perIusing oI dependent lung segments) oI ventilation minimises this diIIerence. Ref. M Harwick. P Hutton. Capnographv. Fundamentals of Current Clinical Practice. Current Anaesthesia and Critical Care 1990, 1. 176180. Question 57 A. TRUE B. FALSE C. FALSE D. FALSE E. FALSE II the system is Iunctioning correctly and no leaks are present, a Iresh gas Ilow rate equal to the patients alveolar (not minute volume) ventilation is suIIicient to prevent rebreathing during spontaneous ventilation. In practice, a slightly higher Iresh gas Ilow rate is selected in order to compensate Ior leaks. None oI the modiIications indicated will improve the eIIiciency oI Magill's original system. Due to the large dead space it is not suitable Ior children weighing less than 25 kg. Ref. A R Aitkenhead. G Smith. Textbook of Anaesthesia. 3rd ed. Churchill Livingstone. 1996. Question 58 A. FALSE B. TRUE C. FALSE D. TRUE E. FALSE The vapour pressure oI a liquid depends only on the physical properties oI the liquid and the temperature. It does not depend on the barometric pressure within the range oI pressures encountered in anaesthesia. The saturated vapour pressure (SVP) occurs when as many molecules are leaving the liquid phase to escape to the vapour phase as are returning. The SVP oI a liquid is equal to the atmospheric pressure at its boiling point. Ref. A R Aitkenhead. G Smith. Textbook of Anaesthesia. 3rd ed. Churchill Livingstone. 1996. Question 59 A. TRUE B. TRUE C. TRUE D. TRUE E. TRUE Ref. K S Drader. I A Herrick. Carotid endarterctomv. Monitoring and its Effect on Outcome. Anesthesiologv Clinics of North America 1997, 15. 613629. Page 67 Question 60 A. TRUE B. TRUE C. FALSE D. FALSE E. FALSE The width oI the cuII is important - too narrow a cuII gives too high a reading, and too wide a cuII may give too low a reading. The WHO recommends a cuII 14 cm wide Ior an average adult. As a rough guide, the cuII should cover approximately two-thirds oI the upper arm or its width should be about 20° greater than the diameter oI the arm. Arteriosclerotic arteries may produce a high systolic blood pressure, but this is not Ialsely high. When compared to direct methods, indirect measurements tend to overestimate at lower pressures and underestimate at higher pressures. Ref. M K Svkes. M D Jickers. C J Hull. Principles of Measurement and Monitoring in Anaesthesia and Intensive Care. 3rd ed. Blackwell. 1991. Page 69 Exam 3 Question 1 The Iollowing drug may be given via an endotracheal tube A. Adrenaline B. Atropine C. Lignocaine D. Sodium bicarbonate E. Calcium chloride Question 2 Aminophylline A. Is a phosphodiesterase inhibitor B. Is a mixture oI theophylline and ethylenediamine C. Has a wide therapeutic index D. Dosage requirements are increased in smokers E. May be given intramuscularly Question 3 Adenosine A. Is eIIective in ventricular tachycardia B. Has a halI liIe oI a proximately 10 minutes C. Should be given as a slow intravenous bolus D. Can result in wheezing E. Causes coronary vasodilatation Question 4 Nitric oxide A. Was Iormerly known as endothelium-derived relaxing Iactor B. Causes pulmonary vasodilatation C. Inhibits platelet aggregation D. When released into the circulation, results in rapid deactivation E. Should be administered in combination with oxygen Page 70 Question 5 Dopexamine A. Is a precursor oI noradrenaline B. Exerts its predominant eIIect by stimulating ß-1 adrenoceptors C. Is a weak ß-2 adrenoceptor agonist D. Reduces atrial Iilling pressures E. Produces pulmonary hypertension Question 6 The Iollowing drug interactions are synergistic A. PropoIol and midazolam B. PropoIol and ketamine C. PropoIol and thiopentone D. Thiopentone and midazolam E. PropoIol and alIentanil Question 7 The Iollowing drugs may be used as antidotes Ior the treatment oI the associated overdoses or poisonings A. Naloxone and co-proxamol overdose B. Methionine and paracetamol overdose C. Sodium calciumedetate and cyanide poisoning D. DesIerrioxime and lead poisoning E. Pralidoxime mesylate and organophosphorus poisoning Question 8 The Iollowing drugs exhibit signiIicant hepatic Iirst-pass metabolism A. Aspirin B. Morphine C. Propranolol D. Glyceryl trinitrate E. Alcohol Question 9 The Iollowing are positive inotropes A. Verapamil B. Enoximone C. Propranolol D. Amiodarone E. Theophylline Question 10 IsoIlurane A. Is a Iluorinated hydrocarbon B. Has a MAC oI 0.5° in 70° nitrous oxide C. Causes less respiratory depression than halothane D. Should not be used with soda lime E. Has a greater oil/gas partition coeIIicient than enIlurane Question 11 Atropine A. Is more sedative than hyoscine B. Reverses the miosis caused by opioids C. Inhibits sweating D. Readily crosses the blood-brain barrier E. Causes hyperpyrexia in overdose Question 12 The minimum alveolar concentration (MAC) oI an inhalational anaesthetic agent A. Is an index oI anaesthetic potency B. Is proportional to lipid solubility C. Is determined in subiects premedicated with omnopon and scopolamine D. Decreases with increasing duration oI anaesthesia E. Can be determined by Irequent blood sampling Question 13 Drugs with greater than 50° oral bioavailability include A. Morphine B. Propranolol C. Methadone D. Atenolol E. Gentamicin Page 72 Question 14 The Iollowing drugs readily cross the blood-brain barrier A. Physostigmine B. Neostigmine C. Dopamine D. Propranolol E. Glycopyrollate Question 15 Metabolism oI the Iollowing drugs are aIIected by the acetylator status oI the individual A. Hydralazine B. Isoniazid C. Propranolol D. Amiodarone E. Digoxin Question 16 The Iollowing drugs are excreted mostly unchanged by the kidneys A. Digoxin B. Gentamicin C. Theophylline D. Morphine E. Vecuronium Question 17 Adverse eIIects oI amitriptyline overdose include A. Dilated pupils B. Cardiac arrhythmias C. Convulsion D. HyperreIlexia E. Metabolic acidosis Question 18 Protein binding is aIIected by A. pH B. Age C. Renal disease D. Liver disease E. Pregnancy Question 19 Drugs oI use in ventricular extrasystole include A. Verapamil B. Mexiletine C. Amiodarone D. Flecainide E. Digoxin Question 20 The Iollowing statements are true A. In drug intoxication, haemodialysis is more likely to lower plasma concentration oI the drug iI its volume oI distribution is large B. The halI-liIe oI a drug is the time taken Ior the clinical eIIect to be reduced by halI C. Intravenously administered drug has 100° bioavailability D. EIIicacy is the ability oI the drug to bind to the receptor site E. Drugs with long halI-liIe require a loading dose to achieve a rapid therapeutic concentration Question 21 The Iollowing statements are correct A. There is approximately 50° greater resistance to breathing through the nose than through the mouth B. Total airway resistance is greater in the small airways than the trachea C. Type I pneumocytes contain distinctive lamellar vacuoles D. Type I pneumocytes secrete and store surIactant E. The pores oI Kohn are holes in the alveolar wall Question 22 Respiratory physiology in the neonate, compared with the adult, shows A. Lower lung compliance B. Higher airway resistance C. Almost entirely diaphragmatic ventilation D. Higher physiological dead space E. Higher respiratory rate Question 23 Foetal haemoglobin A. Forms approximately 80° oI haemoglobin at birth B. Is made up oI two alpha and two delta chains C. Forms approximately 20° oI haemoglobin at the age oI 6 months D. Has a lower aIIinity Ior oxygen than adult haemoglobin (HbA) E. Is present in ß-thalassaemia maior Question 24 ECG changes in hypokalaemia include A. Reduced P wave B. Widened QRS complex C. Shortened QT interval D. Reduced height oI T wave E. Increased height oI U wave Question 25 Lung surIactant A. Contains mucopolysaccharides B. Increases surIace tension C. Production is decreased when lung blood Ilow to that region oI the lung is stopped D. Increases compliance E. Makes the pressure in connected alveoli identical Question 26 Functional residual capacity A. Increases with obesity B. Increases with anaesthesia C. Decreases with age D. Can be measured by a Helium dilution technique E. Causes regional hypoventilation when less than the closing capacity Question 27 Regarding the composition oI the cerebrospinal Iluid A. The PO 2 is the same as that oI arterial blood B. The pH is lower than arterial blood C. The protein level is higher than venous blood D. The glucose level is lower than venous blood E. The chloride level is higher than venous blood Question 28 The Iollowing statements are correct regarding arterial blood at 30°C compared with 37°C A. Lower PO 2 B. Lower PCO 2 C. Increase in pH D. Decrease in HCO 3 E. Lower oxygen saturation Question 29 Gastric emptying is delayed by A. Fat in the duodenum B. Acid in the duodenum C. Stress D. Volume oI Iluid E. Atropine Question 30 Concerning lung volumes and capacities A. The total volume oI both lungs is the vital capacity B. The sum oI the resting tidal volume and the inspiratory reserve volume is the inspiratory capacity C. The volume which may be Iorcibly exhaled in 1 sec is greater than 85° oI the vital capacity D. The Iunctional residual capacity can be measured with the spirometer E. The sum oI the inspiratory reserve volume and the expiratory reserve volume is the vital capacity Question 31 Concerning coronary blood Ilow A. It is approximately 20° oI the cardiac output at rest B. It is highest during systole C. It is reduced during hypoxia D. Increased myocardial oxygen demand results in increased oxygen extraction but little increase in coronary blood Ilow E. It is reduced in aortic stenosis Question 32 During quiet respiration in a healthy human subiect A. The diaphragm contracts during inspiration B. Alveolar pressure is sub-atmospheric during expiration C. Intrapleural pressure is sub-atmospheric throughout the respiratory cycle D. The volume oI gas exhaled per minute is less than 12 litres E. Dead space ventilation is approximately equal to alveolar ventilation Question 33 Regarding the ventricular action potential A. The rapid phase oI depolarisation is due to sodium inIlux B. The plateau phase is due to a sustained increase in membrane sodium permeability C. Repolarisation is associated with an increase in membrane permeability to potassium D. The absolute reIractory period last Ior approximately 1 millisecond E. The reIractory period is almost as long as the muscle twitch which it elicits Question 34 Cardiac excitation in the normal heart A. Is initiated spontaneously in the sino-atrial (SA) node B. Takes 0.2 ms to be transmitted through the atrium to the atrioventricular (AV) node C. Is transmitted most slowly at the atrioventricular (AV) node D. Is conducted down the interventricular septum in a single tract oI conducting tissuethe bundle oI His E. Spreads Irom the endocardial to the epicardial surIace oI the ventricle at a rate oI about 0.3 m/s Question 35 The speed oI onset oI inhalational anaesthesia depends on A. Blood/gas solubility B. Lipid solubility C. Cardiac output D. Inspired concentration E. Pulmonary blood Ilow Question 36 Potassium A. Concentration in the plasma is a good reIlection oI total body potassium B. In the plasma rises in metabolic acidosis C. Enters cells in the presence oI insulin D. Is excreted in the presence oI aldosterone E. Is depleted by nasogastric suctioning Question 37 The Iollowing are used in calculating the oxygen content oI arterial blood A. Haemoglobin concentration B. Cardiac output C. Arterial oxygen saturation D. Arterial oxygen tension (PaO 2 ) E. Mixed venous oxygen saturation (SvO 2 ) Question 38 The electroencephalogram (EEG) A. Records brain wave potential in the range 35 mV B. Contains alpha waves in a restIul subiect with open eyes C. Produces a characteristic 3 Hz spike pattern in grand mal Iits D. Is predominantly comprised oI delta waves in an alert subiect E. Is generally Ilat during anaesthesia Question 39 In the peripheral nervous system A. Myelinated neurones are devoid oI myelin at the nodes oI Ranvier B. Schawnn cells Iorm myelin sheaths around the myelinated neurones C. Unmyelinated neurones do not contain Schwann cells D. Nodes oI Ranvier are absent in unmyelinated neurones E. The autonomic postganglionic neurones are mostly unmyelinated C Iibres Page 78 Question 40 Concerning the autonomic nervous system A. Sympathetic preganglionic cell bodies lie in the inter-mediolateral columns oI the spinal cord between segments T1 to L3 B. Stimulation oI the sympathetic innervation oI the bronchial smooth muscle causes bronchodilatation C. Stimulation oI the sympathetic innervation oI the stomach causes imhibition oI gastric secretion D. All preganglionic sympathetic neurones synapse in paravertebral ganglia E. There are no discrete parasympathetic ganglia Question 41 The Iollowing gases can be measured using inIrared analysers A. Oxygen B. Nitrous oxide C. Nitrogen D. Carbon dioxide E. SevoIlurane Question 42 Wright's respirometer A. Is a pneumotachograph B. Over-reads at high Ilows C. Under-reads at low Ilow D. Gives slightly higher readings with mixtures oI nitrous oxide and oxygen than Ior air E. Should ideally be mounted in the inspiratory limb oI the breathing system Question 43 A pressure-cycled ventilator A. Is a minute volume divider B. Can be cycled Irom inspiration to expiration aIter a set time C. Compensates Ior small leaks D. The peak inspiratory pressure is determined by compliance oI the patient's lungs E. A reduced tidal volume will be delivered iI the airway resistance increases Page 79 Question 44 The paramagnetic principle is used in the Iollowing A. To measure cardiac output B. In an ultrasonic nebuliser C. To measure nitric oxide concentration D. To measure oxygen concentration E. To measure isoIlurane concentration Question 45 The Severinghaus carbon dioxide electrode A. Has a surrounding medium oI sodium bicarbonate B. Contains a carbon dioxide sensitive glass C. Is more accurate with gases than blood D. Accuracy is aIIected by nitrous oxide E. Is temperature sensitive Question 46 The catheter-transducer system in the direct measurement oI arterial pressure should have the Iollowing Ieatures A. A stiII diaphragm B. A short catheter C. A wide bore catheter D. A critically damped system (D ÷ 1) E. A continuous slow Ilow oI Ilush solution through the catheter Question 47 Concerning the eIIects oI breathing 100° oxygen at normal atmospheric pressure A. The haemoglobin becomes Iully saturated B. The alveolar PO 2 is approximately 200 mmHg C. The alveolar PCO 2 is approximately 40 mmHg D. The oxygen dissolved in the plasma is approximately 20 ml/ 100ml E. The total percentage increase oI oxygen carried in the blood is about 100° Page 80 Question 48 Concerning connections between anaesthetic apparatus A. All adult Iacemasks have a 30 mm Iemale opening B. All adult tracheal tube connectors have a 15 mm male Iitting C. Connectors on scavenging systems have a diameter oI 30 mm D. A size 4 laryngeal mask has a 22 mm diameter connector E. A size 1 laryngeal mask has a 15 mm diameter connector Question 49 The ideal oxygen Iailure warning device A. Depends on the pressure oI a gas other than the oxygen itselI B. Uses a battery rather than mains power C. Should interrupt the Ilow oI all other gases when activated D. Gives an audible signal oI suIIicient duration and volume E. Should give a warning oI impending Iailure and a Iurther warning that Iailure has occurred Question 50 The Iollowing are true oI a gas cylinder valve A. The valve should be regularly greased to prevent sticking B. The valve should be opened quickly to blow oII any dirt that may be present in the outlet C. Should the cylinder valve itselI be leaking, it is possible to tighten the packing nut by turning it in a clockwise direction D. The valve should always be Iully open when the cylinder is in use E. The valve should be leIt Iully open on all empty cylinders Question 51 In the measurement oI a single Iorced expiration using a spirometer, the Iollowing statements are true A. Normally, the Iorced expiratory volume in the Iirst second (FEV1) is about 65° oI the Iorced vital capacity (FVC) B. The FEV1 is reduced much more than the FVC in pulmonary Iibrosis C. Both the FEV1 and FVC are reduced in asthma D. The FEV1 is directly proportional to the expiratory eIIort E. The FVC is oIten slightly more than the vital capacity measured on a slow exhalation Page 81 Question 52 The Bernoulli principle may be utilized in the Iollowing A. Venturi oxygen mask B. Nebuliser C. Ventilator D. TEC 6 vaporiser E. HumidiIier Question 53 Concerning the Rotameter A. It consists oI a vertical tube with even diameter B. The pressure drop across the bobbin increases with increasing Ilow C. At low Ilows, the viscosity oI the gas becomes important D. At high Ilows, the density oI the gas becomes important E. In a hyperbaric chamber, a Ilowmeter will deliver less gas than the setting indicates Question 54 The Iollowing lung volumes can be measured with a simple spirometer A. Vital capacity B. Anatomical dead space C. Functional residual capacity D. Residual volume E. Total lung capacity Question 55 Pressure can be measured with the Iollowing A. Aneroid gauge B. Bourdon gauge C. Rayleigh reIractometer D. Raman gauge E. Displacement oI a Ilexible diaphragm Question 56 The Bourdon gauge A. Consists oI a metal bellows B. Is utilized in anaesthetic ventilators C. Is suitable Ior measuring high pressures D. Can be adapted to measure Ilow E. Can be adapted to measure temperature Page 82 Question 57 Concerning spectrophotometric absorption spectra oI reduced and oxygenated haemoglobin A. At the isobestic point, the absorption coeIIicient is the same B. The isobestic point occurs at a wavelength around 650 nm C. The amount oI oxygenated haemoglobin is directly proportional to the shiIt in the isobestic point D. The maximum diIIerence in the absorption oI the two Iorms oI haemoglobin occurs at a wavelength around 940 nm E. The pulse oximeter uses the diIIerence between the absorption spectra oI the two Iorms oI Hb to quantiIy their relative concentrations Question 58 The Iollowing statements are true regarding the capacitor A. A capacitor consists oI two conductor plates separated by an insulator B. The size oI a capacitor depends upon the number oI turns oI wire wound as a coil C. The size oI a capacitor depends upon the surIace area oI the plates D. The size oI a capacitor depends upon the thickness oI the insulator E. The unit oI capacitance is the ioule Question 59 The Iollowing methods can be used to measure the Iunctional residual capacity oI the lung A. Helium dilution B. Body plethysmograph C. Nitrogen washout D. Fowler's method E. Bohr's method Question 60 The Iollowing are SI base units A. Ampere B. Candela C. Mole D. Newton E. Pascal Page 83 Exam 3 Answers Question 1 A. TRUE B. TRUE C. TRUE D. FALSE E. FALSE II venous access is impossible, the tracheal route may be used Ior adrenaline, atropine and lignocaine. Drug doses are 23 times that oI the intravenous route. Drug absorption may be impaired by atelectasis, pulmonary oedema, and in the case oI adrenaline, local vasoconstriction. Do not give sodium bicarbonate or calcium chloride/gluconate by this route. Ref. H G W Paw. G R Park. Drug Prescribing in Anaesthesia and Intensive Care. 1st ed. Greenwich Medical Media. 1996. Question 2 A. TRUE B. TRUE C. FALSE D. TRUE E. FALSE Aminophylline is a mixture oI theophylline and ethylenediamine, which makes it 20 times more soluble than theophylline alone. Theophylline is a non-speciIic phosphodiesterase inhibitor. There is debate regarding the mode oI action oI theophylline in the airways. The increase in intracellular cAMP as a result oI phosphodiesterase inhibition is no longer thought to be the mechanism Ior the bronchodilatation. Other possible mechanisms include adenosine antagonism, calcium blockade and release oI catecholamines. It has a narrow therapeutic index (margin between the therapeutic and toxic dose). Metabolism is decreased in heart Iailure, cirrhosis, viral inIections, and by drugs such as cimetidine, ciproIloxacin, erythromycin, and oral contraceptive (halI-liIe is increased). Metabolism is increased in smokers, heavy drinkers, and by drugs such as phenytoin, carbamazepine, riIampicin, and barbiturates (halI-liIe is decreased). It must be given by slow intravenous iniection (over at least 20 minutes) and is too irritant Ior intramuscular use. Ref. W McCaughev. R S J Clarke. J P H Fee. W F M Wallace. Anaesthetic Phvsiologv and Pharmacologv. 1st ed. Churchill Livingstone. 1997. Question 3 A. FALSE B. FALSE C. FALSE D. TRUE E. TRUE Adenosine is eIIective in SVTs. It depresses the SA node activity and blocks conduction in the AV node, with little eIIect on conduction through the Purkinie Iibres, atria and ventricular tissues. Although it is ineIIective in VTs, it can serve to distinguish SVT with associated bundle branch block Irom VT in a patient with broad complex tachycardia. It has a very short halI liIe Page 84 (·10 seconds), and should be given as a rapid i.v. bolus, preIerably via a central line. Because oI its short halI liIe, any associated side eIIects (chest discomIort, wheezing and Ilushing) are brieI. It is a potent coronary vasodilator and may cause coronary steal in susceptible patients. Ref. H G W Paw. G R Park. Drug Prescribing in Anaesthesia and Intensive Care. 1st ed. Greenwich Medical Media. 1996. Question 4 A. TRUE B. TRUE C. TRUE D. TRUE E. FALSE When combined with oxygen it results in the Iormation oI nitrogen dioxide which is toxic. This is a maior problem in the use oI nitric oxide. When released into the circulation, nitric oxide is rapidly deactivated by haemoglobin. Ref. R D Miller. Anesthesia. 4th ed. Churchill Livingstone. 1994. Question 5 A. FALSE B. FALSE C. FALSE D. TRUE E. FALSE Dopexamine is a synthetic analogue oI dopamine. Dopamine occurs naturally and is a precursor oI noradrenaline. Dopexamine exerts ß-2 adrenergic and DA-1 dopaminergic eIIects, resulting in renal and splanchnic vasodilatation, increased cardiac output, reduced systemic and pulmonary vascular resistance, and reduced atrial Iilling pressures. It has little ß-1 or --adrenergic activity. Ref. H G W Paw. G R Park. Drug Prescribing in Anaesthesia and Intensive Care. 1st ed. Greenwich Medical Media. 1996. Question 6 A. TRUE B. FALSE C. TRUE D. TRUE E. FALSE The interactions between propoIol and ketamine, and propoIol and alIentanil are additive. Ref. H R Jinik. Intravenous Anaesthetic Drug Interactions. Practical Applications. European Journal of Anaesthesiologv 1995, 12. 1319. Question 7 A. TRUE B. TRUE C. FALSE D. FALSE E. TRUE Co-proxamol (dextropropoxyphene and paracetamol) is widely available Irom the pharmacy and is Irequently taken in overdose. The initial Ieatures are those oI acute opioid overdose with respiratory depression, pinpoint pupils and coma. Naloxone is the antidote Ior dextropropoxyphene. Paracetamol hepatoxicity may develop later and should be treated with either acetylcysteine intravenously or methionine by mouth. Cyanide antidotes include dicobalt edetate, given alone, and sodium nitrite, Iollowed by sodium thiosulphate. Sodium calciumedetate Page 85 and penicillamine are antidotes Ior heavy metal poisoning, especially lead. DesIerrioxamine is the speciIic antidote Ior iron poisoning, which is very common in children. Pralidoxime mesylate, a cholinesterase reactivator, is indicated, as an adiunct to atropine in the treatment oI organophosphorus poisoning. Ref. British National Formularv. 1997 Question 8 A. TRUE B. TRUE C. TRUE D. TRUE E. FALSE Drugs with substantial Iirst pass metabolism include: Aspirin, Codeine, Diltiazem, Glyceryl trinitrate, Hydralazine, Isosorbide dinitrate, Labetalol, Levodopa, Metoprolol , Morphine, Prazosin, Propranolol, TerIenadine, Verapamil. Ref. W McCaughev. S S J Clarke. J P H Fee. W F M Wallace. Anaesthetic Phvsiologv and Pharmacologv. 1st ed. Churchill Livingstone. 1997. Question 9 A. FALSE B. TRUE C. FALSE D. FALSE E. TRUE Drugs which increase myocardial contractility are termed positive inotropes.The mechanism oI action oI positive inotropes can be classiIied into three groups. Increasing intracellular cAMP by activation oI adenylcyclase: catecholamines and sympathetic agents. Inhibiting phosphodiesterase, the enzyme responsible Ior breakdown oI cAMP: theophylline, amrinone, milrinone and enoximone. Increasing intracellular calcium: digoxin. Ref. W McCaughev. R S J Clarke. J P H Fee. W F M Wallace. Anaesthetic Phvsiologv and Pharmacologv. 1st ed. Churchill Livingstone. 1997. Question 10 A. FALSE B. TRUE C. FALSE D. FALSE E. FALSE IsoIlurane is a halogenated methyl ethyl ether. The MAC is 1.15° in 100° O 2 , decreasing to 0.5° in 70° N 2 O. It is stable in soda-lime, unlike halothane and sevoIlurane. It causes slightly more respiratory depression than halothane, although less so than enIlurane. IsoIlurane and enIlurane have the same oil/gas partition coeIIicient (98). Ref. . A R Aitkenhead. G Smith. Textbook of Anaesthesia. 3rd ed. Churchill Livingstone. 1996. Question 11 A. FALSE B. TRUE C. TRUE D. TRUE E. TRUE Hyoscine is more sedative than atropine. Atropine reverses the miosis caused by opioids. The activity oI eccrine sweat glands (innervated by cholinergic sympathetic neurones) is inhibited by atropine. In overdose, atropine causes hyperpyrexia via a central eIIect on temperature-regulating mechanisms but suppression oI sweating is a contributing Iactor. Atropine and hyoscine are both tertiary compounds and readily cross the blood-brain barrier. Summary oI the eIIects oI the three antimuscarinic agents: Atropine Hyoscine Glycopyrrolate Sedation Anti-sialagogue Increase heart rate Relax smooth muscle ¹ ¹ ¹¹¹ ¹¹ ¹¹¹ ¹¹¹ ¹ ¹ 0 ¹¹ ¹¹ ¹¹ Myadriasis Prevent motion sickness ¹ ¹ ¹¹¹ ¹¹¹ 0 0 Ref. W McCaughev. R S J Clarke. J P H Fee. W F M Wallace. Anaesthetic Phvsiologv and Pharmacologv. 1st ed. Churchill Livingstone. 1997. Question 12 A. TRUE B. FALSE C. FALSE D. FALSE E. FALSE MAC is an index oI anaesthetic potency and is inversely proportional to lipid solubility (Meyer-Overton theory). It is determined in unpremedicated subiects and does not change with increasing duration oI anaesthesia. It is not determined by blood sampling. Ref. A R Aitkenhead. G Smith. Textbook of Anaesthesia. 3rd ed. Churchill Livingstone. 1996. Question 13 A. FALSE B. FALSE C. TRUE D. FALSE E. FALSE Morphine and propranolol have low bioavailability due to substantial hepatic Iirst-pass metabolism. Methadone, in contrast to the other opioids, is well absorbed aIter oral administration and does not undergo substantial hepatic Iirst- pass metabolism. It thereIore has high bioavailability. Atenolol and gentamicin have low bioavailability due to poor absorption aIter oral administration. Ref. W McCaughev. R S J Clarke. J P H Fee. W F M Wallace. Anaesthetic Phvsiologv and Pharmacologv. 1st ed. Churchill Livingstone. 1997. Page 87 Question 14 A. TRUE B. FALSE C. FALSE D. TRUE E. FALSE Physostigmine and propranolol are highly lipid-soluble and readily cross the blood-brain barrier. Neostigmine, dopamine and glycopyrollate are highly polar and do not cross the blood-brain barrier readily. Ref. W McCaughev. R S J Clarke. J P H Fee. W F M Wallace. Anaesthetic Phvsiologv and Pharmacologv. 1st ed. Churchill Livingstone. 1997. Question 15 A. TRUE B. TRUE C. FALSE D. FALSE E. FALSE Metabolism oI the Iollowing drugs are aIIected by the acetylator status oI the individual:- Hydralazine Isoniazid Sulphonamides Phenelzine Dapsone Procainamide Rapid acetylator status occurs in approximately 40° oI the UK population and is inherited in an autosomal dominant pattern. Slow acetylator status occurs in approximately 60° oI the UK population and is inherited in an autosomal recessive pattern. Ref. W McCaughev. R S J Clarke. J P H Fee. W F M Wallace. Anaesthetic Phvsiologv and Pharmacologv. 1st ed. Churchill Livingstone. 1997. Question 16 A. TRUE B. TRUE C. FALSE D. FALSE E. FALSE Drugs excreted mostly unchanged by the kidney include: Aminoglycoside antibiotics Cephalosporins Digoxin Ephedrine Lithium Milrinone Neostigmine Penicillins The signiIicance oI these drugs is that they will accumulate in renal impairment. Ref. W McCaughev. R S J Clarke. J P H Fee. W F M Wallace. Anaesthetic Phvsiologv and Pharmacologv. 1st ed. Churchill Livingstone. 1997. Page 88 Question 17 A. TRUE B. TRUE C. TRUE D. TRUE E. TRUE Amitriptyline is a tricyclic antidepressant. In overdose it causes dry mouth, dilated pupils, urinary retention, hypotension, hypothermia, hyperreIlexia, extensor plantar responses, convulsions, respiratory Iailure, cardiac conduction deIects, arrhythmias, metabolic acidosis, and coma oI varying degree. Ref. British National Formularv. 1997 Question 18 A. TRUE B. TRUE C. TRUE D. TRUE E. TRUE Ref. W McCaughev. R S J Clarke. J P H Fee. W F M Wallace. Anaesthetic Phvsiologv and Pharmacologv. 1st ed. Churchill Livingstone. 1997. Question 19 A. FALSE B. TRUE C. TRUE D. TRUE E. FALSE Verapamil and digoxin are used in supraventricular arrhythmias. Ref. British National Formularv. 1997 Question 20 A. FALSE B. FALSE C. TRUE D. FALSE E. TRUE It is diIIicult Ior haemodialysis to remove a drug iI its volume oI distribution is large. The halI-liIe oI a drug is the time taken Ior the plasma concentration (not clinical eIIect) to be reduced by halI. Administering a drug intravenously gives it 100° bioavailability. AIIinity is the ability oI the drug to bind to the receptor site. EIIicacy is the maximal eIIect, which a drug is capable oI producing, and is represented by the plateau oI the dose-response curve. It takes 45 halI-lives Ior a drug to achieve steady-state concentration. ThereIore, drugs with a long halI-liIe require a loading dose to achieve a more rapid therapeutic concentration. Ref. W McCaughev. R S J Clarke. J P H Fee. W F M Wallace. Anaesthetic Phvsiologv and Pharmacologv. 1st ed. Churchill Livingstone. 1997. Question 21 A. TRUE B. FALSE C. FALSE D. FALSE E. TRUE The bronchioles contribute 1020° oI total airway resistance, the bronchi 3040°, and the trachea and more proximal structures 50°. The alveoli are lined by 2 types oI epithelial cells. Type I pneumocytes are Ilat cells with large cytoplasmic extensions and are the primary lin Page 89 ing cells. Type II pneumocytes, although more numerous than type I cells, cover less oI the epithelial lining. These contain numerous lamellar inclusion bodies and are the source oI surIactant. The pores oI Kohn are holes in the alveolar wall allowing communication between alveoli oI adioining lobules. Ref. J B West. Respiratorv Phvsiologvthe essentials. 5th ed. Williams and Wilkins. 1995. Question 22 A. TRUE B. TRUE C. TRUE D. FALSE E. TRUE The neonate has a lower lung compliance but a higher chest wall compliance compared with the adult. Airway resistance is higher as the airways remain relatively narrow. The high airway resistance and low lung compliance result in a short time constant. Ventilation is almost entirely diaphragmatic in comparison with the bucket-handle movement in the adult. Physiological dead space is approximately 30° oI the tidal volume as in the adult, but the absolute volume is small, so that any increase caused by apparatus dead space has a disproportionately greater eIIect on a small child. The respiratory rate is approximately 28 per minute. Ref. A R Aitkenhead. G Smith. Textbook of Anaesthesia. 3rd ed. Churchill Livingstone. 1996. Question 23 A. TRUE B. FALSE C. FALSE D. FALSE E. TRUE Foetal haemoglobin (HbF) Iorms approximately 80° oI haemoglobin at birth. Adult haemoglobin (HbA) haemopoiesis is established Iully at 6 months. HbF is made up oI two - and two chains. HbF has a greater aIIinity Ior oxygen than adult haemoglobin (HbA) because it binds less avidly to 2,3-DPG and the dissociation curve is shiIted to the leIt. HbF is present in ß-thalassaemia maior and sickle cell anaemia. Ref. A R Aitkenhead. G Smith. Textbook of Anaesthesia. 3rd ed. Churchill Livingstone. 1996. Question 24 A. FALSE B. TRUE C. FALSE D. TRUE E. TRUE ECG changes in hypokalaemia include: Widened QRS complex Prolonged QT nterval ST depression Reduced height oI T wave Increased heigh oI U wave Ref. A R Aitkenhead. G Smith. Textbook of Anaesthesia. 3rd ed. Churchill Livingstone. 1996. Page 90 Question 25 A. FALSE B. FALSE C. TRUE D. TRUE E. TRUE Lung surIactant is a mixture oI lipids and proteins (~10°). Phospholipid, phosphatidyl choline is a maior constituent oI surIactant. SurIactant is produced by type II pneumocytes in the alveolar epithelium. The maior Iunction oI surIactant is to reduce surIace tension at the air-liquid interIace in the alveolus and small airways, thereby improving lung compliance, promoting alveolar stability, and reducing the tendency towards atelectasis at low lung volumes. It may also play a part in keeping the lung tissues dry. Ref. J B West. Respiratorv Phvsiologvthe essentials. 5th ed. Williams and Wilkins. 1995. Question 26 A. FALSE B. FALSE C. FALSE D. TRUE E. TRUE Obesity and anaesthesia decreases FRC. FRC remains the same or increases slightly with increasing age. Closing capacity increases to a greater extent than FRC, with increasing age. II closing capacity exceeds FRC (in the supine position aIter 40 years and in the erect position aIter 60 years), there will be dependent airway closure during tidal respiration. Ref. A R Aitkenhead. G Smith. Textbook of Anaesthesia. 3rd ed. Churchill Livingstone. 1996. Question 27 A. FALSE B. TRUE C. FALSE D. TRUE E. TRUE The PO 2 oI the CSF is lower than that oI arterial blood. The pH is lower than arterial blood. There is very little protein in the CSF compared to plasma (300 times less), which makes it a poor buIIer. The glucose level in CSF is two-thirds that oI blood. The chloride level is higher in the CSF. Ref. W F Ganong. Review of Medical Phvsiologv. 18th ed. Lange. 1997. Question 28 A. TRUE B. TRUE C. TRUE D. FALSE E. FALSE There is no change in HCO 3- and oxygen saturation with temperature. Question 29 A. TRUE B. TRUE C. TRUE D. TRUE E. TRUE The rate oI gastric emptying is proportional to the volume oI the stomach contents, with approximately 13° oI the total gastric content reaching the duodenum per minute in an exponential rate. The presence oI Iat, acid or hypertonic solutions in the duodenum initiates a neurally mediated inhibitory enterogastric reIlex, delaying the rate oI gastric emptying. Gastric emptying is also under control oI the autonomic nervous system. Increased vagal tone hastens gastric emptying. Anti-muscarinic agents thereIore delay gastric emptying. Fear, anxiety and pain decrease gastric emptying. Ref. W F Ganong. Review of Medical Phvsiologv. 18th ed. Lange. 1997. Question 30 A. FALSE B. TRUE C. FALSE D. FALSE E. FALSE The total volume oI both lungs is the vital capacity plus the residual volume. The volume which may be Iorcibly exhaled in one second is approximately 7585° oI the vital capacity. The Iunctional residual capacity and residual volume cannot be measured by spirometry. The vital capacity is the sum oI the inspiratory reserve volume, expiratory reserve volume and tidal volume. Ref. J B West. Respiratorv Phvsiologvthe essentials. 5th ed. Williams and Wilkins. 1995. Question 31 A. FALSE B. FALSE C. FALSE D. FALSE E. TRUE Blood Ilow through the coronary arteries varies throughout the cycle, about two-thirds occurring in diastole. Normal coronary blood Ilow at rest is approximately 250 ml/min or 5° oI the cardiac output. Hypoxia increases coronary blood Ilow 23 Iold. There is a high O 2 extraction rate, thereIore, any increase in O 2 demand must be met by increased delivery by way oI an increase in coronary blood Ilow. In aortic stenosis the pressure in the leIt ventricle must be much higher than that in the aorta to eiect the blood. During systole, the coronary vessels are severely compressed resulting in reduced blood Ilow. Ref. W F Ganong. Review of Medical Phvsiologv. 18th ed. Lange. 1997. Question 32 A. TRUE B. FALSE C. TRUE D. TRUE E. FALSE Alveolar pressure has to be above atmospheric during expiration. Physiological dead space is approximately 30° oI tidal volume. Ref. J B West. Respiratorv Phvsiologvthe essentials. 5th ed. Williams and Wilkins. 1995. Question 33 A. TRUE B. FALSE C. TRUE D. FALSE E. TRUE The rapid phase oI depolarisation is due to an increase in Na ¹ permeability. This is Iollowed by a slower increase in Ca 2¹ permeability, which produces the plateau phase. Repolarisation Page 92 aIter this plateau is due to a delayed increase in K ¹ permeability. The action potential oI cardiac muscle diIIers markedly Irom skeletal muscle. The duration oI depolarisation is approximately 200 ms in contrast to 12 ms in skeletal muscle. Cardiac muscle is inexcitable during this period. The reIractory period is almost as long as the muscle twitch which it elicits. Ref. W F Ganong. Review of Medical Phvsiologv. 18th ed. Lange. 1997. Question 34 A. TRUE B. TRUE C. TRUE D. FALSE E. FALSE The bundle oI His gives oII a leIt bundle branch at the top oI the interventricular septum and continues as the right bundle branch. The leIt bundle branch divides into an anterior Iascicle and a posterior Iascicle. Ref. W F Ganong. Review of Medical Phvsiologv. 18th ed. Lange. 1997. Question 35 A. TRUE B. FALSE C. TRUE D. TRUE E. FALSE Lipid solubility determines the potency oI an inhalational anaesthetic and does not have an inIluence on the speed oI onset oI anaesthesia. Increased cardiac output increases the uptake oI volatile anaesthetic agents Irom the alveoli and slows the onset oI anaesthesia. This is in contrast to intravenous anaesthetic agents, where increase cardiac output increases the onset oI intravenous anaesthetic agents. Ref. A R Aitkenhead. G Smith. Textbook of Anaesthesia. 3rd ed. Churchill Livingstone. 1996. Question 36 A. FALSE B. TRUE C. TRUE D. TRUE E. TRUE Plasma potassium concentration is a poor reIlection oI total body potassium. Plasma potassium rises in metabolic acidosis. Potassium enters cells in the presence oI insulin. Aldosterone causes sodium retention and potassium loss. Ref. W F Ganong. Review of Medical Phvsiologv. 18th ed. Lange. 1997. Question 37 A. TRUE B. FALSE C. TRUE D. TRUE E. FALSE The calculation oI oxygen delivery (DO 2 ) and oxygen consumption (VO 2 ) require in addition the cardiac output, mixed venous oxygen saturation and mixed venous oxygen tension. Ref. A R Aitkenhead. G Smith. Textbook of Anaesthesia. 3rd ed. Churchill Livingstone. 1996. Page 93 Question 38 A. FALSE B. FALSE C. FALSE D. FALSE E. FALSE The electroencephalogram (EEG) measures the electrical activity in the outermost layers oI the grey matter, probably mostly Irom dendrites. The amplitude oI the potential is in the microvolt scale when recorded Irom the scalp. Alpha waves have an amplitude oI approximately 50 microvolts. Alpha rhythm is seen at rest with the mind wandering and eyes closed. The characteristic 3 Hz spike pattern is seen with petit mal. Delta waves are large, slow waves with a Irequency oI between 0.53 Hz. Ref. W F Ganong. Review of Medical Phvsiologv. 18th ed. Lange. 1997. Question 39 A. TRUE B. TRUE C. FALSE D. TRUE E. TRUE Schwann cells Iorm myelin sheaths around the myelinated neurones. Myelinated neurones are devoid oI myelin at the nodes oI Ranvier. Nodes oI Ranvier are absent in unmyelinated neurones. Unmyelinated neurones still contain Schwann cells, but they do not Iorm a myelin sheath around the axon. The autonomic preganglionic neurones are mostly myelinated B Iibres. The postganglionic neurones are mostly unmyelinated C Iibres. Ref. W F Ganong. Review of Medical Phvsiologv. 18th ed. Lange. 1997. Question 40 A. TRUE B. TRUE C. TRUE D. FALSE E. FALSE Sympathetic preganglionic cell bodies lie in the inter-mediolateral columns oI the spinal cord between segments T1 to L2 or L3. Parasympathetic outIlow come Irom the mid brain, medulla and spinal segments S2 to S4. Stimulation oI the sympathetic innervation oI the bronchial smooth muscle causes bronchodilatation. Stimulation oI the sympathetic innervation oI the stomach causes inhibition oI gastric secretion. Some preganglionic sympathetic neurones pass through the paravertebral ganglion chain (without synapsing) and end on postganglionic neurones located in collateral ganglia close to the viscera. Discrete parasympathetic ganglia include ciliary, sphenopalatine, submaxillary and otic ganglia. Ref. W F Ganong. Review of Medical Phvsiologv. 18th ed. Lange. 1997. Question 41 A. FALSE B. TRUE C. FALSE D. TRUE E. TRUE The Iunction oI inIrared analysers is based on the Iact that gases that have two or more dissimilar atoms in the molecule such as N 2 O, CO 2 and all halogenated anaesthetic agents have speciIic and unique absorption specpectra oI inIrared light. The non-polar molecules oI nitrogen, Page 94 oxygen, helium, argon and xenon do not absorb inIrared light and cannot be measured using this technology. Ref. J A Dorsch. S E Dorsch. Understanding Anaesthesia Equipment. Construction. Care and Complications. 3rd ed. Williams and Wilkins. 1994. Question 42 A. FALSE B. TRUE C. TRUE D. TRUE E. FALSE The Wright's respirometer is a vane anemometer. Its Iunction is aIIected by moisture, which causes the pointer to stick. It should ideally be mounted in the expiratory limb oI the breathing system so that leaks which occur in the inspiratory limb are eliminated Irom the evaluation oI expired minute volume. Ref. J A Dorsch. S E Dorsch. Understanding Anaesthesia Equipment. Construction. Care and Complications. 3rd ed. Williams and Wilkins. 1994. Question 43 A. FALSE B. FALSE C. TRUE D. FALSE E. TRUE A pressure-cycled ventilator cycles into expiration when a pre-set airway pressure is achieved. This allows compensation Ior small leaks. However iI the airway resistance increases and/or compliance oI the patient deteriorates, a reduced tidal volume will be delivered at the pre-set cycling pressure. In addition, inspiratory time varies with changes in resistance and compliance. Ref. A R Aitkenhead. G Smith. Textbook of Anaesthesia. 3rd ed. Churchill Livingstone. 1996. Question 44 A. FALSE B. FALSE C. FALSE D. TRUE E. FALSE OI the gases oI interest in anaesthesia, only oxygen is paramagnetic. Paramagnetic oxygen analysers rely on the magnetic property oI the oxygen molecule, whereby it is attracted by a magnetic Iield. In contrast, most other gases, including nitrous oxide and nitrogen, are weakly diamagnetic and are thus repelled by a magnetic Iield. Ref. J A Dorsch. S E Dorsch. Understanding Anaesthesia Equipment. Construction. Care and Complications. 3rd ed. Williams and Wilkins. 1994. Question 45 A. TRUE B. FALSE C. FALSE D. FALSE E. TRUE The Severinghaus carbon dioxide electrode provides a direct method oI PCO 2 measurement Irom the |H ¹ | change. It contains a hydrogen ion sensitive glass, with electrodes either side oI it. A thin Iilm oI sodium bicarbonate solution surrounds this glass. Nitrous oxide does not aIIect the measurement oI PCO 2 using the Severinghaus electrode, but will indeed aIIect the measurement oI end-tidal CO 2 using the inIrared absorption spectrophotometry. Ref. P D Davis. G D Parbrook. G N C Kennv. Basic Phvsics and Measurement in Anaesthesia. 4th ed. Butterworth- Heinemann. 1995. Question 46 A. TRUE B. TRUE C. TRUE D. FALSE E. TRUE A recording system must accurately reproduce both the amplitude and phase diIIerence oI each harmonic present in the waveIorm. To achieve this, it is necessary to design a system with a high undamped natural Irequency (resonant Irequency) and then apply the correct amount oI damping. To obtain a high resonant Irequency, the diaphragm needs to be stiII and the catheter short and wide. Optimal damping is 64° oI critical (D÷0.64). This represents the best compromise that can be obtained between the speed oI response and the accuracy oI registrating the amplitude oI the pressure trace. Overdamped systems (due to air bubble or partial blockage oI catheter) result in underestimation oI systolic pressure and overestimation oI diastolic pressure. Underdamped systems (due to low resonant Irequency) result in overestimation oI systolic pressure and underestimation oI diastolic pressure. The mean pressure is not aIIected by the amount oI damping. An important cause oI excess damping is clotting in the arterial cannula. This is minimised by maintaining a slow Ilow (e.g. 3ml/hr) oI Ilush solution through the catheter using a pressurised reservoir. Ref. M K Svkes. M D Jickers. C J Hull. Principles of Measurement and Monitoring in Anaesthesia and Intensive Care. 3rd ed. Blackwell. 1991. Question 47 A. TRUE B. FALSE C. TRUE D. FALSE E. FALSE The amount oI oxygen dissolved in the plasma is 0.3 ml/ 100ml, and the total oxygen content (dissolved plus combined) is 20 ml/100 ml oI blood. Breathing pure oxygen, the partial pressure oI oxygen in the alveoli rises Irom 100 to 673 mmHg, an increase oI 6.7 times. As a result, the dissolved oxygen rises to 2 ml/100 ml. The haemoglobin becomes Iully saturated and the additional amount oI oxygen now carried in the blood as a result oI breathing pure oxygen is 2.5 ml/100 ml oI blood. The total percentage increase oI oxygen carried in the blood is only about 10°. There is no signiIicant change in the alveolar PCO 2 (approximately 40 mmHg) Irom breathing air. Ref. D W Hill. Phvsics Applied to Anaesthesia. 4th ed. Butterworths. 1980. Question 48 A. FALSE B. TRUE C. TRUE D. FALSE E. TRUE All adult Iacemasks have a 22 mm Iemale opening. All adult tracheal tube connectors have a 15 mm male Iitting. Connectors on scavenging systems have a diameter oI 30 mm to ensure that inappropriate connections with anaesthetic apparatus cannot be made. All laryngeal masks have a 15 mm diameter male connector. Ref. A R Aitkenhead. G Smith. Textbook of Anaesthesia. 3rd ed. Churchill Livingstone. 1996. Question 49 A. FALSE B. FALSE C. TRUE D. TRUE E. TRUE The ideal oxygen Iailure warning device does not depend on the pressure oI any gas other than the oxygen itselI, and does not use a battery or mains power. Ref. A R Aitkenhead. G Smith. Textbook of Anaesthesia. 3rd ed. Churchill Livingstone. 1996. Question 50 A. FALSE B. FALSE C. TRUE D. TRUE E. FALSE Valves, regulators, gauges and Iittings should never be permitted to come into contact with oils, greases, organic lubricants, rubber or any other combustible substance. A cylinder valve should always be opened slowly. II gas passes quickly into the space between the valve and the yoke or regulator, the rapid recompression in this space will generate large amounts oI heat. Because there is little time Ior dissipation oI this heat, this constitutes an adiabatic process (one in which heat is neither lost nor gained Irom the surroundings). Particles oI dust or grease present in this space may be ignited by the heat, causing a Iire or an explosion. The valve should always be Iully open when the cylinder is in use. Marginal opening may result in Iailure to deliver adequate gas. Valves should be completely closed on all empty cylinders. OIten, cylinders are not completely empty and accidents have resulted Irom release oI gas Irom a supposedly empty cylinder. II the valve is leIt open on an empty cylinder, debris and contaminants could be sucked into it when the temperature changes. Ref. J A Dorsch. S E Dorsch. Understanding Anaesthesia Equipment. Construction. Care and Complications. 3rd ed. Williams and Wilkins. 1994 Question 51 A. FALSE B. FALSE C. TRUE D. FALSE E. FALSE A very useIul and simple test oI pulmonary Iunction is the measurement oI a single Iorced expiration. Normally, the Iorced expiratory volume in the Iirst second (FEV1) is about 7580° oI the Iorced vital capacity (FVC). In restrictive diseases such as pulmonary Iibrosis both FEV1 and FVC are reduced, but the FEV1/FVC ratio is normal or increased. In obstructive diseases such as asthma and emphysema, the FEV1 is reduced much more than the FVC, giving a low FEV1/FVC ratio. The FEV1 is reduced by an increase in airway resistance (asthma) or a reduction in elastic recoil oI the lung (emphysema). It is remarkably independent oI expiratory eIIort. The FVC is oIten slightly less than the vital capacity measured on a slow exhalation. Question 52 A. TRUE B. TRUE C. TRUE D. FALSE E. TRUE Ref. A R Aitkenhead. G Smith. Textbook of Anaesthesia. 3rd ed. Churchill Livingstone. 1996. Question 53 A. FALSE B. FALSE C. TRUE D. TRUE E. TRUE The Rotameter consists oI a vertical tapered tube that has its smallest diameter at the bottom. The bobbin Iloats Ireely in the tube at an equilibrium position where the downward Iorce on it caused by gravity is equal to the upward Iorce caused by gas molecules hitting the bottom oI the bobbin. In the variable oriIice Ilowmeter, the annular cross- sectional area varies while the pressure drop across the bobbin remains constant Ior all positions in the tube. With a longer and narrower construction (at low Ilow), Ilow is a Iunction oI the viscosity oI the gas (Poiseuille's law). When the constriction is shorter and wider (at high Ilow), Ilow depends on the density oI the gas (Graham's law). Flowmeters are calibrated at atmospheric pressure. Pressure changes will aIIect both the viscosity and the density oI a gas and so inIluence the accuracy oI the indicated Ilow rate. In a hyperbaric chamber, a Ilowmeter will deliver less gas than the setting indicates. With decreasing barometric pressure (as happens with increasing altitude), the actual Ilow rate will be higher than he Ilowmeter reading. Ref. J A Dorsch. S E Dorsch. Understanding Anaesthesia Equipment. Construction. Care and Complications. 3rd ed. Williams and Wilkins. 1994. Question 54 A. TRUE B. FALSE C. FALSE D. FALSE E. FALSE The volume oI the anatomical dead space can be measured by Fowler's method. Neither the Iunctional residual capacity nor the residual volume can be measured with a simple spirometer. Since the total lung capacity is the sum oI the residual volume, it too cannot be obtained using a simple spirometer. Ref. J B West. Respiratorv Phvsiologvthe essentials. 5th ed. Williams and Wilkins. 1995. Page 98 Question 55 A. TRUE B. TRUE C. FALSE D. FALSE E. TRUE High pressures commonly employed in anaesthetic practice can be measured using a Bourdon gauge. In this gauge, the gas at high pressure causes a tube to uncoil and in doing so moves a pointer over a scale on a dial. Bourdon gauges have the advantage over manometers that there is no liquid to spill, and they are sometimes called anaeroid gauges Irom the Greek 'a-neros' (without liquid). Another Iorm oI anaeroid gauge is based on a bellows or capsule which expands or contracts depending on the pressure across it. The strain gauge pressure transducer involves movement oI a diaphragm with changes in pressure. This movement oI the diaphragm alters the tension in the resistance wire thus changing its resistance. The change oI current Ilow through the resistor can then be ampliIied and displayed as a measure oI pressure on a scale. The Rayleigh reIractometer and Raman spectrophotometer are techniques used Ior anaesthetic gas analysis. Ref. P D Davis. G D Parbrook. G N C Kennv. Basic Phvsics and Measurement in Anaesthesia. 4th ed. Butterworth- Heinemann. 1995. Question 56 A. FALSE B. FALSE C. TRUE D. TRUE E. TRUE The Bourdon gauge consists oI a coiled tube which is Ilattened in cross-section. One end oI the coil is anchored to the case and connected to the source oI pressure, whilst the other end is closed and attached to a mechanism which drives the pointer across a dial. Pressure gauges on anaesthetic ventilators usually comprise a simple bellows oI aneroid gauge whilst high gas pressures (e.g. in medical cylinders) are measured using the Bourdon gauge. It can also be adapted Ior measuring Ilow and temperature. The Bourdon gauge Ilowmeter is used to sense the pressure drop across an oriIice. In the Bourdon gauge thermometer, the change in pressure produced by the alteration in temperature is sensed by the gauge and displayed on the dial. This type oI thermometer is robust but not very accurate. It is generally employed to measure Iairly large temperature changes, e.g. in autoclaves. Ref. M K Svkes. M D Jickers. C J Hull. Principles of Measurement and Monitoring in Anaesthesia and Intensive Care. 3rd ed. Blackwell. 1991. Question 57 A. TRUE B. FALSE C. FALSE D. TRUE E. TRUE At the isobestic point, the absorption coeIIicients are identical. This occurs at a wavelength oI 800 nm. The maximum diIIerence in the absorption oI the two Iorms oI haemoglobin occurs at a wavelength oI about 650 nm. The pulse oximeter probe contains two light-emitting diodes, Page 99 one Ior red (660 nm) and one Ior inIrared (940 nm) light. This technique utilizes the diIIerence between the characteristic absorption spectra oI the two Iorms oI haemoglobin to quantiIy their relative concentrations. Ref. M K Svkes. M D Jickers. C J Hull. Principles of Measurement and Monitoring in Anaesthesia and Intensive Care. 3rd ed. Blackwell. 1991. Question 58 A. TRUE B. FALSE C. TRUE D. TRUE E. FALSE A capacitor consists oI two conductors separated by an insulator, known as the dielectric. In its simplest Iorm, this consists oI two metal plates separated by a thin layer oI air. The size oI a capacitor determines the quantity oI electricity it can store Ior a given charge potential, and depends upon the surIace area oI the plates, the thickness oI the insulator, and its ability to store charge. The unit oI capacitance is the Farad (F). Ref. M K Svkes. M D Jickers. C J Hull. Principles of Measurement and Monitoring in Anaesthesia and Intensive Care. 3rd ed. Blackwell. 1991. Question 59 A. TRUE B. TRUE C. TRUE D. FALSE E. FALSE Fowler's method is used to measure the anatomical dead space, whilst Bohr's method is used to measure physiological dead space. Although Fowler's method is also an analysis oI nitrogen washout, the method oI measurement oI Iunctional residual capacity is diIIerent. To obtain the FRC, 100° oxygen is inspired at the end oI a normal expiration (at FRC).The total volume oI expired gas over several minutes is then analysed Ior its nitrogen content. Since this amount oI nitrogen was originally contained in the FRC to give a nitrogen concentration oI 79°, the FRC can be derived. The two other methods Ior measuring FRC involve the use oI helium dilution and the body plethysmograph. Ref. J B West. Respiratorv Phvsiologvthe essentials. 5th ed. Williams and Wilkins. 1995. Question 60 A. TRUE B. TRUE C. TRUE D. FALSE E. FALSE There are seven base units (ampere, candela, Kelvin, kilogram, metre, mole and second) Irom which several other units are derived. The unit oI Iorce is the newton (N). This is the Iorce required to accelerate a mass oI 1 kg at a rate oI 1 metre per second and is expressed in terms oI m.kg.s- 2 . 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