Multiple Choice Questions

The future of general anaesthesia in (c). For a 70-kg patient, a 1.2 mg kg−1 dose of
rocuronium can be reversed using 280 mg of
obstetrics sugammadex.
(d). Indirect laryngoscopes should not be used in
1. The following statements are correct regarding
obstetric patients.
accidental awareness during general anaesthesia
(e). Second-generation supraglottic devices should
(AAGA):
be used for first-line airway management in
the obstetric patient
(a). Difficult airway management is not a risk
factor.
4. The following statements are correct regarding
(b). Increased cardiac output increases the
general anaesthesia in obstetrics:
intravenous–inhalational interval.
(c). ‘Overpressure’ of volatile agents is not
(a). Blood loss from reduced uterine tone may be
recommended.
minimized by using an end-tidal minimum
(d). The overall incidence of AAGA for caesarean
alveolar concentration (MAC) of volatile agent
section is 1:670.
of 0.5.
(e). The Fifth National Audit Project (NAP5) report
(b). Human factors have been implicated in
recommended a dose of thiopental of 4 mg
−1 morbidity and mortality during general
kg
anaesthesia in obstetrics.
(c). Most general anaesthetics administered for
2. The following statements are correct regarding the
caesarean section are in elective patients.
use of induction agents in obstetric patients:
(d). Multidisciplinary simulation of emergency
obstetric scenarios can reduce errors through
(a). Propofol has more adverse effects on the
human factors.
neonate compared with thiopental.
(e). Physiological changes of pregnancy can mask
(b). There was evidence of overdosing with
the clinical signs of inadequate anaesthesia
thiopental in the Fifth National Audit Project
(NAP5) report.
(c). Thiopental–antibiotic syringe swap has been Ketamine: an old drug revitalized in pain
reported in obstetric patients. medicine
(d). Thiopental causes less cardiovascular
compromise than propofol.
1. The N-methyl-D-aspartate (NMDA) receptor is
(e). Thiopental has a longer duration of action
involved in the following neurological phenomena:
than propofol
(a). Colour vision.
3. The following statements are correct regarding
(b). Hallucination.
obstetric airway management:
(c). Opioid-induced hyperalgesia.
(d). Consciousness.
(a). SAirway management and time to
(e). Central sensitization.
desaturation after induction of general
anaesthesia are improved in the ramped
2. It is appropriate to use ketamine for pain relief in
position.
the following scenarios:
(b). Failed intubation in obstetrics has an incidence
of 1:1200.
(a). Intravenous ketamine for post-mastectomy
pain.
(b). Oral ketamine for chronic sciatica.

1
BJA Education | Volume 17 Number 3 | 2017
Published by Oxford University Press on behalf of the British Journal of Anaesthesia 2017
 Multiple Choice Questions

(c). Subcutaneous ketamine before elective (b). Peritoneal dialysis is a commonly used mode
gastrectomy. of RRT for adults in the UK.
(d). Intrathecal ketamine for elderly hip fracture. (c). For continuous renal replacement therapy a
−1 −1
(e). Intramuscular ketamine for dysuria with dose of 35 ml kg h is associated with
substance abuse. reduced mortality compared with
−1 −1
20 ml kg h .
3. The following might be related to ketamine use for (d). The femoral vein site should be avoided as a
postoperative analgesia: port of access.
(e). The dose of β-lactam antibiotics should be
(a). Sedation. reduced when providing RRT in the critically ill.
(b). Dysuria.
(c). Airway obstruction. 3. Continuous modes of renal replacement therapy
(d). Distress with unrelieved pain. (RRT) offer the following benefits:
(e). Hypotension.
(a). More stable cerebral perfusion in acute brain
4. Ketamine might augment the drug actions of injury.
(b). Better preservation of renal function.
(a). Fentanyl. (c). Shortened length of intensive care unit stay.
(b). Epinephrine. (d). Improved outcomes in sepsis as a result of
(c). Atracurium. increased clearance of inflammatory mediators.
(d). Gabapentin. (e). Superior fluid balance management
(e). Paracetamol
4. The following are indications for commencing
renal replacement therapy (RRT) within critical
Renal replacement therapy in critical care care:

1. Concerning the physical process of renal (a). Hyperkalaemia.

replacement therapy (RRT): (b). Fluid overload.
(c). Temperature control.
(a). Haemofiltration achieves clearance of waste (d). Control of inflammatory mediators.
products by diffusion across a semipermeable (e). Methanol poisoning
membrane.
(b). Smaller molecules are more reliably cleared by
haemodialysis whilst haemofiltration improves
clearance of middle-sized molecules.
(c). The dose of RRT during continuous
haemodiafiltration can be calculated without
knowledge of the volume of fluid being
removed.
(d). Cellulose-based membranes are preferred.
(e). During continuous venovenous
haemodiafiltration (CVVHDF) two different
fluids are required: one to act as a dialysate
and another to replace fluid removed during
haemofiltration.

2. Concerning renal replacement therapy (RRT)

within critical care:

(a). Improvements in technology have led to a

significant reduction in acute kidney injury-
associated mortality in recent years.

2 BJA Education | Volume 17 Number 3| 2017


Perioperative management of patients
with dementia
1. A 71-year-old patient with mild Alzheimer’s
disease who is otherwise fit and well presents on
the emergency list for laparotomy and probable
Hartmann’s procedure for a ruptured diverticulum.
Having been judged to have capacity, she gave
consent the day before surgery. However, in the
anaesthetic room she is clearly disoriented, febrile
and agitated. She is uncooperative and, when
asked, clearly refuses surgery but does not appear
to have the capacity to understand the
consequences of her refusal. Appropriate courses
of action could include:
(a). Call for assistance to physically restrain her and
continue with anaesthesia.
(b). Administer a sedative agent to treat her
delirium and wait for its effects before
continuing with anaesthesia.
(c). If the surgeon agrees, the patient should be
returned to her room and treated with
antibiotics and antipyretics and, once she
regains mental capacity, a ‘Ulysses pact’ should
be negotiated, whereby she gives consent for
the procedure even if she subsequently has a
deterioration in mental capacity and refuses in
future.
(d). Call for a psychiatrist to review her and to
determine her capacity to refuse potentially
life-saving surgery.
(e). Obtain an emergency court order to enable
surgery to proceed in the absence of consent.
2. An 83-year-old gentleman with vascular dementia
and severe gastro-oesophageal reflux disease
(GORD) is listed for emergency bipolar
hemiarthroplasty after a fracture to the neck of his
femur. You note that he is taking donepezil.
Suitable management techniques to anaesthetize
this patient could include:
(a). Stop his donepezil and manage him
conservatively for 2 weeks while the
anticholinesterase washes out of the body.
(b). Avoid the potential for interactions with
neuromuscular blocking drugs by performing a
spinal anaesthetic.
(c). Perform a modified rapid sequence induction
with an increased dose of rocuronium and plan
3 BJA Education | Volume 17 Number 3| 2017
Multiple Choice Questions
to reverse the induced neuromuscular block
with sugammadex.
(d). Perform a classical rapid sequence induction
and tracheal intubation with thiopental and
suxamethonium followed by boluses of
atracurium as required.
(e). Avoid tracheal intubation by using a second-
generation laryngeal mask.
3. A 49-year-old with early-onset Alzheimer’s
disease of moderate severity and no other
medical history has had a percutaneous
endoscopic gastrostomy inserted under general
anaesthetic. You are called to the recovery suite as
the nurses report that she has become
increasingly agitated and aggressive and is
currently lashing out at staff. Appropriate
treatments for acute delirium in this scenario
include:
(a). Risperidone 0.25 mg orally.
(b). Olanzapine 5 mg orally. Lorazepam 1 mg im.
(c). Lorazepam 1 mg im, repeated as necessary at
2-h intervals.
(d). Haloperidol 1 mg im, repeated as necessary at
2-h intervals.
(e). Diazepam emulsion 2 mg intravenously.
4. A 75-year-old man with Alzheimer’s disease of
moderate severity is scheduled to have a
laparotomy for small bowel obstruction. His past
medical history includes several episodes of
delirium after urinary tract infections and a
cystoscopy under general anaesthetic. You have
requested the Bispectral Index (BIS) monitor to be
used on this patient. With regard to BIS
monitoring:
(a). It prevents unnecessary depth of anaesthesia
being administered to patients.
(b). Low BIS scores are found in patients with
Alzheimer’s disease in the awake state.
(c). Baseline BIS values can be used as guide to
anaesthetic requirements patients with
cognitive impairment.
(d). The EEG pattern of an increase in slow-wave
activity and a decrease in fast-wave activity is
manifested as a reduction in the BIS values.
(e). Use of BIS-guided anaesthesia has been shown
to reduce the incidence of delirium in the
immediate postoperative period.
 Multiple Choice Questions

Current recommendations on adult 4. After return of spontaneous circulation (ROSC):

resuscitation
1. As part of basic life support (BLS):
(a). An automated external defibrillator (AED)
should be requested when calling for help.
(b). Rescue breaths should be given over 2 s.
(c). Resuscitation must be interrupted regularly to
check for pulse and breathing.
(d). The absence of a carotid pulse must be
determined before starting cardiopulmonary
resuscitation (CPR).
(e). The depth of chest compressions is 5–6 cm,
−1
with a rate of 100–120 min .
(a). Blood glucose levels should be kept below
−1
8 mmol litre .
(b). Oxygenation should be titrated to achieve
SaO2 of 94–98%.
(c). Percutaneous coronary intervention (PCI)
should be considered in comatose patients.
(d). Therapeutic hypothermia (TH) with cooling to
32–34°C must be commenced in comatose
patients initially presenting with both
shockable and non-shockable rhythms.
(e). There are reliable clinical indicators and tests
to prognosticate at <24 h after cardiac arrest.

2. When treating cardiac arrest with ventricular

fibrillation (VF)/pulseless ventricular tachycardia
(pVT) as the first monitored rhythm:

(a). Epinephrine 1 mg is given when chest

compressions have restarted after the third
shock.
(b). Amiodarone is no longer recommended.
(c). Chest compressions should continue while the
defibrillator is charged.
(d). Precordial thump is an important intervention.
(e). Three successive (stacked) shocks can be used
in special circumstances.

3. During CPR:

(a). A ratio of 30 chest compressions to two

breaths must continue throughout CPR.
(b). Central venous access is advised if peripheral
venous access cannot be achieved.
(c). Supraglottic airway (SGA) devices have
superseded tracheal intubation.
(d). The use of ultrasound is not recommended.
(e). Waveform capnography is only useful in
confirming tracheal tube placement.

4 BJA Education | Volume 17 Number 3| 2017


Antinociceptive and immunosuppressive
effect of opioids in an acute
postoperative setting: an evidence-based
review
1. In a patient receiving opioid therapy:
(a). An increased opioid dose requirement to
achieve the same level of analgesia may imply
tolerance.
(b). Worsening of the underlying pain while on an
increasing opioid dose may imply opioid-
induced hyperalgesia.
(c). Activation of the N-methyl-D-aspartate
(NMDA) receptor will prevent tolerance and
hyperalgesia.
(d). Tolerance or opioid-induced hyperalgesia, but
rarely both, can develop in an acute setting.
(e). Glial cells are passive cells supporting the
neurones and have no influence on analgesia.
2. Appropriate statements regarding perioperative
immune function include:
(a). It can be improved by analgesics.
(b). 2. It may be adversely affected by pain.
(c). 3. It is known to be improved by neuraxial
anaesthesia and hence, where appropriate,
patients undergoing major cancer surgery
should receive neuraxial block.
(d). 4. It has not been shown to be affected by
opioids in humans.
(e). 5. It may be affected by some opioids as a
result of a direct effect on µ receptors.
3. During a pre-assessment for a 65-year-old lady
due to undergo an anterior resection for colon
cancer, the patient tells you that she has learnt
from her internet search that anaesthetic may
result in the spread of her cancer. She asks you
about the options available to minimize her risk of
cancer spread. The following are appropriate
statements:
(a). Morphine is contraindicated in this patient as it
can worsen cancer spread.
(b). Local anaesthetic-based regional techniques
result in immunosuppression and hence
facilitate cancer spread.
5 BJA Education | Volume 17 Number 3| 2017
Multiple Choice Questions
(c). Some opioids are more clinically advantageous
than others because they cause less
immunosuppression.
(d). Tramadol suppresses NK cell activity and
hence has an immunoprotective effect.
(e). Cyclooxygenase-2 (COX-2) inhibitors have a
favourable effect on the immune system.
4. A 30-year-old patient is undergoing a laparotomy
for ulcerative colitis under general anaesthesia. He
is otherwise fit and well. He usually takes
morphine sulphate 60 mg twice daily.
Intraoperatively, he is initially stable, with his
analgesia maintained using remifentanil 0.2 µg
kg−1 min−1, but then develops tachycardia and
high blood pressure. After ruling out other causes,
including inadequate depth of anaesthesia, the
anaesthetist increases the remifentanil infusion
dose to 0.4 and then to 0.6 µg kg−1 min−1. The
following are appropriate statements:
(a). This increase in remifentanil will improve
perioperative analgesia in all patients.
(b). It is appropriate to consider administering
ketamine to this patient.
(c). Clonidine is a reasonable adjuvant analgesic to
give.
(d). His haemodynamics are best controlled with
an inhalational anaesthetic such as sevoflurane.
(e). Propofol has a favorable modulatory effect in
opioid-induced hyperalgesia.