Multiple Choice Questions

Regional anaesthesia for ophthalmic (b). Peribulbar nerve block implies extraconal
injection of local anaesthetic, whilst
surgery retrobulbar placement of local anaesthetic
involves an intraconal injection.
1. Concerning the anatomy of the orbit:
(c). Oxybuprocaine, proxymetacaine, tetracaine,
lidocaine and cocaine are commonly used
(a). The globe lies anteromedially in the orbit with
local anaesthetics for topical anaesthesia.
an axial length of approximately 27 mm.
(d). Hyaluronidase causes hydrolysis of the
(b). Myopic eyes with long axial lengths are at
extracellular matrix and is used in
increased risk of perforation during subtenon −1
concentrations between 5 and 10 IU ml .
injections.
(e). According to patient reports, subtenon block is
(c). The optic nerve is vulnerable to injury,
the most painful of ocular blocks.
particularly with long (38 mm) retrobulbar
needles or if the retrobulbar injection is made
4. Appropriate statements concerning regional
with the eye held looking upwards and
anaesthesia for ophthalmic surgery include:
inwards.
(d). The lacrimal and frontal nerves pass
(a). Chemosis is a rare complication of ophthalmic
intraconally to provide sensory supply to the
nerve blocks requiring surgical intervention.
peripheral conjunctiva.
(b). Optic nerve injury is much more common with
(e). Intraconal injection may result in trochlear
retrobulbar blocks when the eye is held in the
sparing with consequent inadequate akinesis
upward gaze.
of the superior oblique muscle
(c). Intracameral injection is injection of
preservative-free local anaesthetic directly into
2. Appropriate statements concerning regional
the posterior chamber of the eye.
anaesthesia for ophthalmic surgery include:
(d). A subtenon injection uses Westcott scissors to
make a small cut to expose the underlying
(a). In order to improve local anaesthetic (LA)
conjunctival layer.
spread, reduce chemosis or control bleeding,
(e). A scleral explant may be a relative
ocular massage is a recommended technique.
contraindication to placement of subtenon
(b). Normal intraocular pressure (IOP) is 20–30 mm
blocks
Hg
(c). The eye needs to be sterilized using a dilute
solution of 5% povidone iodine before
placement of a nerve block.
(d). The subtenon needle is typically 19 G with a
sharp curved tip.
(e). Subtenon block is the most commonly used
anaesthetic technique for cataract

3. The following statements are true concerning

regional anaesthesia for ophthalmic surgery:

(a). Topical anaesthesia blocks the trigeminal

nerve terminals in the cornea and conjunctiva
and provides anaesthesia to the intraocular
structures.

1
BJA Education | Volume 17 Number 7 | 2017
Published by Oxford University Press on behalf of the British Journal of Anaesthesia 2017

Critical care management of pulmonary
hypertension
1. A 57-year-old female with systemic sclerosis
presents with progressive breathlessness. Her
spirometry is well preserved but the diffusion
capacity of the lungs for carbon monoxide (DLCO)
is 45% of predicted. There is no fibrosis or
thromboembolic disease on computed
tomography (CT) scanning of her lungs. Right
heart catheterization reveals a mean pulmonary
arterial pressure of 42 mm Hg (normal values <25
mm Hg) and a pulmonary arterial wedge pressure
of 12 mm Hg (normal values ≤15 mm Hg) together
with a reduced cardiac output. The likely form of
pulmonary hypertension is:
(a). Pulmonary arterial hypertension (PAH) (group
1).
(b). Pulmonary hypertension associated with left
heart disease (group 2).
(c). Pulmonary hypertension associated with lung
disease (group 3).
(d). Chronic thromboembolic pulmonary
hypertension (group 4).
(e). Pulmonary hypertension associated with
multifactorial mechanisms (group 5).
2. A 34-year-old female presents with a new
diagnosis of severe idiopathic pulmonary arterial
hypertension (PAH). There is no response to
inhaled nitric oxide at right heart catheterization.
She is severely limited (WHO functional class IV).
Use of the following is the most appropriate initial
method of commencing pulmonary vasodilation:
(a). Sildenafil.
(b). Ambrisentan.
(c). High-dose calcium channel blocker.
(d). Intravenous prostanoid.
(e). Riociguat.
3. A 42-year-old with idiopathic pulmonary arterial
hypertension (PAH) who is normally treated with
sildenafil and who is anticoagulated with warfarin
is admitted with a 24-h history of marked
deterioration in exercise capacity. His blood
pressure is 95/60 mm Hg, heart rate 130 beats
−1
min and saturation 95% on room air. Chest X-ray
shows clear lung fields and his C-reactive protein is
−1 −1
3 mg litre (normal range is <8 mg litre ) ECG
2 BJA Education | Volume 17 Number 7| 2017
Multiple Choice Questions
demonstrates new-onset atrial flutter with 2:1
atrioventricular block. The most appropriate
management is:
(a). Addition of an endothelin receptor antagonist.
(b). Commencement of intravenous iloprost.
(c). Commencement of intravenous dobutamine.
(d). DC cardioversion.
(e). Increase in sildenafil dose.
4. A 63-year-old female with pulmonary arterial
hypertension (PAH) associated with systemic
sclerosis is admitted with increased breathlessness.
She is currently treated with sildenafil and
ambrisentan. Her blood pressure is 110/65 mm Hg,
−1
heart rate 95 beats min and saturation 94% on
room air. Her ECG shows sinus rhythm and a chest
X-ray shows a new small right-sided pleural
−1
effusion. Her C-reactive protein is 4 mg litre
−1
(normal range is <8 mg litre ) and her creatinine
−1
is 115 μmol litre (normal range is 49–90 μmol
−1
litre ). She has a raised jugular venous pressure
and pitting oedema to her thigh. The most
appropriate initial treatment is:
(a). Further reduction of right ventricular afterload
with the addition of intravenous prostanoid.
(b). Improvement in right ventricular contractility
with the addition of intravenous dobutamine.
(c). Improvement in systemic perfusion pressures
with the addition of intravenous
norepinephrine.
(d). Optimization of right ventricular preload with
the addition of intravenous loop diuretic.
(e). Optimization of right ventricular preload with a
fluid challenge
 Multiple Choice Questions

Postoperative management of the 4. Concerning the management of the difficult

airway on the intensive care unit (ICU):
difficult airway
(a). When managing a difficult airway
1. Regarding postoperative management of the postoperatively, keeping the patient intubated
difficult airway: and sedated on the ICU is without risk.
(b). A positive leak test assures postoperative
(a). Analysis of American Society of airway patency.
Anesthesiologists (ASA) closed claims found (c). A positive fluid balance should be maintained.
that problems at tracheal extubation are (d). The routine use of capnography is essential.
infrequent. (e). An airway strategy should be agreed when the
(b). Human factors are not an important patient has been transferred to the ICU
consideration.
(c). All theatre personnel should be aware of the
possibility of postoperative airway difficulty. Anaesthesia for laryngo-tracheal surgery,
(d). Close monitoring is essential to allow early including tubeless field techniques
intervention.
(e). The risk of mediastinitis is low with patients
1. The Hunsacker Mon-Jet tube:
who have Ludwig’s angina and deeper
infection of the airway
(a). Is an example of a transglottic catheter that
allows direct monitoring of end-tidal CO2
2. Regarding the Difficult Airway Society (DAS)
(ETCO2) and airway pressures.
extubation guideline:
(b). Allows unimpeded access to the entire glottis
and trachea.
(a). All patients should be given 100% oxygen
(c). Would not be safe to use during planned laser
before extubation.
removal of vocal cord lesions.
(b). The laryngeal mask airway exchange technique
(d). Can be used in conjunction with both manual
is recommended in patients who may be
and automated jet ventilation devices.
difficult to reintubate after extubation.
(e). Would be a suitable choice for oxygenation
(c). The use of remifentanil to aid extubation
during removal of human papilloma virus
should only be undertaken by those trained
(HPV)-associated large vocal cord papilloma.
and experienced in its use.
(d). The safest technique for a patient with a
2. When planning for elective microlaryngoscopy
difficult airway is to have a tracheostomy.
and biopsies of an anterior vocal cord lesion in a
(e). Handover and communication are vital to the
patient with predicted difficulty with tracheal
successful postoperative management of the
intubation secondary to previous neck
difficult airway.
radiotherapy, the following steps would be
recommended in your strategy:
3. Regarding the airway exchange catheter (AEC):
(a). Ultrasound imaging of the neck to identify and
(a). There is no evidence for the use of staged
mark the cricothyroid membrane.
extubation in patients with difficult airways.
(b). Aiming to provide a tubeless field for
(b). Oxygen should be routinely administered via
adequate surgical access.
the AEC.
(c). Planning to carry out your anaesthetic strategy
(c). The catheter should not be advanced further
for securing the airway in the anaesthetic
than 30 cm.
room.
(d). A chest X-ray is not useful for identifying the
(d). Awake fibre-optic intubation (AFOI) using an
position of the AEC.
uncut flexometallic (reinforced) tracheal tube.
(e). AECs are well tolerated by patients.
(e). Planned ‘awake’ extubation using a titrated
remifentanil infusion.

3 BJA Education | Volume 17 Number 7| 2017


3. You are scheduled to cover the elective afternoon
ear, nose and throat (ENT) surgical day of surgery
admission list. This includes a 71-year-old male
listed for bilateral laser cordotomy with an
expected surgical time of 30 min. His past medical
history includes treated hypertension, atrial
fibrillation and tablet-controlled type 2 diabetes
−2
mellitus. He has a BMI of 32 kg m . He presented
with a 2-month history of hoarseness without
associated dyspnoea and is a non-smoker with
moderate alcohol intake and mild heartburn on a
proton pump inhibitor. Flexible nasendoscopy
(pictured) was performed at the ENT clinic 4
weeks previously. Appropriate statements
regarding management of this case include:
(a). Preoperative assessment should include
bedside airway assessment, 12-lead ECG and
repeat flexible nasendoscopy.
(b). This flexible nasendoscopy demonstrates
posterior vocal cord lesions necessitating a
fully tubeless field for adequate surgical
access.
(c). Jet ventilation approaches should be avoided.
(d). Conventional tracheal intubation with a
microlaryngoscopy tube (MLT) is a safe option.
(e). Topicalization of the glottis with local
anaesthesia using a mucosal atomizer device
would be beneficial.
4. As the on-call anaesthetist, you are asked to
review a 56-year-old female patient in the
emergency department who has presented as an
emergency early on Saturday morning. She has
developed worsening dysphagia and stridor on
exertion over the past 4 weeks. She has now
presented stridulus at rest with peripheral oxygen
saturation of 90% on room air, a respiratory rate
−1
of 18 bpm and a heart rate of 95 beats min . She
is a long-term cigarette smoker (40 pack years)
with a past medical history of alcohol excess and
−2
anxiety. She has a BMI of 19 kg m (weight 49 kg,
height 1.6 m). Flexible nasendoscopy performed
by the ENT registrar in the emergency department
demonstrated a large supraglottic mass obscuring
the view of the glottis, but was cut short as it was
poorly tolerated by the patient. Appropriate
statements regarding management of this case
include:
4 BJA Education | Volume 17 Number 7| 2017
Multiple Choice Questions
(a). Given the acute presentation and signs, this
patient should be taken to theatre for
immediate anaesthetic and surgical
management.
(b). Inhalational induction, using sevoflurane and
nitrous oxide, to maintain spontaneous
ventilation is the safest way to induce
anaesthesia.
(c). Techniques to secure this patient’s airway
awake include awake videolaryngoscopy,
awake fibre-optic intubation (AFOI) and awake
tracheostomy under local anaesthesia.
(d). The maximum volume of lidocaine 4% for
airway topicalization is 5 ml.
(e). Decision-making regarding extubation should
be guided by the ‘At risk’ algorithm of the
Difficult Airway Society (DAS) extubation
guidelines.
Diagnosis and management of malignant
hyperthermia
1. Regarding the pathophysiology of malignant
hyperthermia (MH):
(a). Release of calcium from ‘T’ tubules causes a
conformational change in dihydropyridine
(DHP) receptors.
(b). Nearly 60% of energy released from the
breakdown of adenosine triphosphate (ATP)
generates heat during actin–myosin cross-
bridging.
(c). Activation of myofilaments is responsible for
the initial rise in CO2 production and oxygen
consumption in MH patients.
(d). Disseminated intravascular coagulation (DIC) is
frequently observed in patients who develop
an MH reaction.
(e). All inhaled anaesthetic agents, including
nitrous oxide, are contraindicated in MH-
susceptible patients.
2. Regarding the clinical presentation of malignant
hyperthermia (MH):
(a). An increase in end-tidal CO2 (ETCO2) should
initiate treatment of MH.
(b). Desflurane is more likely than sevoflurane to
trigger an MH reaction soon after induction.
(c). β-Blockers and remifentanil directly affect the
severity of MH reactions.
 Multiple Choice Questions

(d). Masseter spasm is indicative of MH

susceptibility only if it lasts >3 min and is
associated with generalized muscle rigidity.
(e). Unexplained perioperative death or cardiac
arrest has been found to be related to MH in
33% of cases.

3. Concerning the clinical management of malignant

hyperthermia (MH):

(a). Activated charcoal filters should be placed on

the inspiratory limb of the breathing circuit as
soon as an MH reaction is suspected.
−1
(b). The initial dose of dantrolene is 2.5 mg kg .
(c). Features of an MH reaction may recur after an
initial resolution.
(d). All patients who develop a suspected MH
reaction should have an arterial line and a
central line inserted.
(e). Postoperatively, all patients who develop
fulminant MH should be observed in a critical
care environment.

4. Concerning patient counselling and malignant

hyperthermia (MH) diagnosis:

(a). It is the responsibility of the general

practitioner to refer a patient who has a
suspected MH reaction to the MH unit.
(b). The patient should be advised to warn all
relatives about MH, if MH is considered a
possibility.
(c). A negative muscle biopsy test excludes the
clinical risk of MH.
(d). A negative genetic test completely excludes
the possibility of MH.
(e). The main gene defect implicated in MH
susceptibility is in the CANCA1S gene, which
encodes the principal subunit of the
dihydropyridine (DHP) receptor, which is a T-
tubule voltage sensor.

5 BJA Education | Volume 17 Number 7| 2017