An ipsilateral phrenic nerve block will result from a successful interscalene block (ISB).

The phrenic nerve is the diaphragm’s sole motor supply, and ipsilateral hemidiaphragmatic paresis affects up to 100% of patients who receive ISBs. Phrenic nerve palsy is usually well tolerated and goes unnoticed by healthy people. However, forced vital capacity decreases by approximately 25%, which can produce ventilatory compromise in patients with limited pulmonary reserve, requiring assisted ventilation.

Vocal cord palsy occurs when the recurrent laryngeal nerve is inadvertently blocked, causing hoarseness and possibly acute respiratory insufficiency. Unless bilateral laryngeal nerve palsy occurs, which can cause severe laryngeal obstruction, this complication is usually of little consequence.

ISB can also cause cranial nerve X and XII palsy (Tapia’s syndrome). One-sided cord paralysis, aphonia, and the patient’s tongue deviating toward the block’s side are all symptoms.

When a local anaesthetic spreads to the stellate ganglion and its cervical sympathetic nerves, Horner’s syndrome can develop. Ptosis of the eyelid, miosis, and anhidrosis of the face are all symptoms. Horner’s syndrome, on the other hand, may not indicate that the brachial plexus is sufficiently blocked.

The abdominal aorta begins at the level of the body of T12 near the midline, as a continuation of the thoracic aorta. It descends and bifurcates at the level of L4 into the common iliac arteries.

An abdominal aortic aneurysm is a swelling in the abdominal aorta. It most commonly occurs in men over 65 years old of age. Smoking, diabetes, hypertension, and hypercholesterolemia are other risk factors contributing to the disease.

The NHS screening program for abdominal aortic aneurysms involves an ultrasound test for men aged 65 or over if they have not undergone screening for a one-off screening test.

The correct answer is the mean, median and mode of normally distributed data are the same value. This is as a result of the bell shaped curve which is equal on both sides.

The bell-shape indicates that values around the mean are more frequent in occurrence than the values farther away.

In a normal distribution:
1) +/- one standard deviation of the mean accounts for 68% of the data.
2) +/- two standard deviations of the mean accounts for 95% of the data.
3) +/- three standard deviations of the mean accounts for 99.7% of the data.

Elimination of phenytoin from the body follows first-order kinetics. This means that the rate of elimination is proportional to plasma concentration.

The rate of elimination can be described by the equation:

C = C0·e-kt

Where:

C = drug concentration
C0 = drug concentration at time zero (extrapolated)
k = Rate constant
t = Time

Enzyme systems become saturated when phenytoin concentrations exceed the normal range and elimination of the drug becomes zero-order. At this point, the drug is metabolised at a fixed rate and metabolism is independent of plasma concentration.

Aspirin and ethyl alcohol are other drugs that behave this way.

The blood brain barrier (BBB) consists of the ultrafiltration barrier in the choroid plexus and the barrier around cerebral capillaries. The barrier is made by endothelial cells which line the interior of all blood vessels. In the capillaries that form the blood–brain barrier, endothelial cells are wedged extremely close to each other, forming so-called tight junctions.

Outside of the BBB lies the hypothalamus, third and fourth ventricles and the chemoreceptor trigger zone (CTZ).

Water, oxygen and carbon dioxide cross the BBB freely but glucose is controlled. The ability of chemicals to cross the barrier is proportional to their lipid solubility, not their water solubility. It’s ability to cross is inversely proportional to their molecular size and charge.

In neonates, the BBB is less effective than in adults. This is why there is increased passage of opioids and bile salts (kernicterus) into the neonatal brain.

In meningitis, the effectiveness and permeability of the BBB is affected, and as a result, this effect helps the passage of antibiotics which would otherwise not normally be able to cross.

Second messengers relay signals to target molecules in the cytoplasm or nucleus when an agonist interacts with a receptor on the cell surface. They also amplify the strength of the signal. The most ubiquitous and abundant second messenger is calcium and it regulates multiple cellular functions in the body.

These include:
Muscle contraction (skeletal, smooth and cardiac)
Exocytosis (neurotransmitter release at synapses and insulin secretion)
Apoptosis
Cell adhesion to the extracellular matrix
Lymphocyte activation
Biochemical changes mediated by protein kinase C.

cAMP is either inhibited or stimulated by G proteins.

The receptors in the body that stimulate G proteins and increase cAMP include:

Beta (?1, ?2, and ?3)
Dopamine (D1 and D5)
Histamine (H2)
Glucagon
Vasopressin (V2).

The second messenger for the action of nitric oxide (NO) and atrial natriuretic peptide (ANP) is cGMP.

The second messengers for angiotensin and thyroid stimulating hormone are inositol triphosphate (IP3) and diacylglycerol (DAG).

Refractometers measure the degree to which the light changes direction, called the angle of refraction. A refractometer takes the refraction angles and correlates them to refractive index (nD) values that have been established. Using these values, you can determine the concentrations of solutions.

According to the Safe Anaesthesia Liaison Group, the most important factor to consider the cannula access, and if the patient is properly receiving the total intravenous anaesthesia. The cannula access must be regularly checked for kinks, leaks and disconnections.

Below are the safety precautions and policies to be followed for total intravenous anaesthesia among children and adults:

When administering TIVA, a non-return valve must be used on any intravenous fluid line;
When using equipment, it is essential that clinical staff know its limitations and uses;
Sites of intravenous infusions should be visible so they may be monitored for disconnection, leaks or perivenous infusion into the subcutaneous tissues; and,
Organisations must give preference to clearly labelled intravenous connectors and valves.

Mixed venous oxygen content (CvO2) is the oxygen concentration in 100mL of mixed venous blood taken from the pulmonary artery. It is usually 12-17 mL/dL (70-75%). It is represented mathematically as:

CvO2 = (1.34 x Hgb x SvO2 x 0.01) + (0.003 x PvO2)

Where,

1.34 = Huffner’s constant
Hgb = Haemoglobin level (g/dL)
SvO2 = % oxyhaemoglobin saturation of mixed venous blood
PvO2 = 0.0225 = mL of O2 dissolved per 100mL plasma per kPa, or 0.003 mL per mmHg

Therefore,

CvO2 = (1.34 x 10 x 70 x 0.01) + (0.003 x 50)

CvO2 = 9.38 + 0.15 = 9.53 mL/100mL

Omitted variable bias occurs when a statistician passes over one or more relevant variables from the study.

Publication bias occurs in publish academic research. it occurs when the results of the study effect the decision whether to publish or not.

Expectation bias occurs when the expectation of a researcher about the results effect the behaviour of the participants. Expectations may come from communication and experiences.

Work up bias occurs in the study of diagnostic test validity, whether a gold standard procedure has been used. work up bias can seriously affect the specificity of the test.

Recall bias introduced when participants in a study are systematically more or less likely to recall and relate information on exposure depending on their outcome status. Recall bias is more potential for Case-control studies.

There are different classes of electrical equipment that can be classified in the table below:

Class 1 – provides basic protection only. It must be connected to earth and insulated from the mains supply

Class II – provides double insulation for all equipment. It does not require an earth.

Class III – uses safety extra low voltage (SELV) which does not exceed 24 V AC. There is no risk of gross electrocution but risk of microshock exists.

Type B – All of above with low leakage currents (0.5mA for Class IB, 0.1 mA for Class IIB)

Type BF – Same as with other equipment but has ‘floating circuit’ which means that the equipment applied to patient is isolated from all its other parts.

Type CF – Class I or II equipment with ‘floating circuits’ that is considered to be safe for direct connection with the heart. There are extremely low leakage currents (0.05mA for Class I CF and 0.01mA for Class II CF)

The mandibular branch of the trigeminal nerve passes through the foramen ovale. Other structures that pass through this foramen are the accessory meningeal artery, and occasionally, the lesser petrosal nerve.

These are the structures that pass through the other openings in the cranial fossa:

Foramen rotundum – Maxillary branch of the trigeminal nerve

Foramen lacerum – Greater petrosal nerve, traversed by the internal carotid artery

Superior orbital fissure – Oculomotor nerve; trochlear nerve; lacrimal, frontal and nasociliary branches of the ophthalmic branch of the trigeminal nerve; abducens nerve, superior ophthalmic vein

Stylomastoid foramen – facial nerve

Laminar flow can be defined as the motion of a fluid where every particle in the fluid follows the same path of its previous particles. The following are properties of laminar flow of gas or fluids:

1. Smooth unobstructed flow of gas through a tube of relatively uniform diameter
2. Few directional changes
3. Slow, steady flow through straight smooth, rigid, large calibre, cylindrical tube
4. Outer layer flow slower than the centre due to friction, results in discrete cylindrical layers, or streamlines
5. Double flow by doubling pressure as long as the flow pattern remains laminar

Poiseuille’s Law relates the factors that determine laminar flow. It indicates the degree of resistance to fluid flow through a tube. The resistance to fluid flow through a tube is directly related to the length, flow and viscosity; and inversely related to the radius of the tube to the fourth power. This means that, when the radius is doubled, there is increase in flow by a factor of 16.

Bernoulli’s principle states that as the speed of a moving fluid increases, there is a simultaneously decrease in static pressure or a decrease in the fluid’s potential energy.
This is seen in the simultaneous increase in speed and kinetic energy and fall in pressure that causes entrainment of large volumes of air into a flow of 100% oxygen in the nozzle of HAFOE masks.

The reduction in fluid pressure that happens when a fluid flows through a constriction in a tube is the Venturi effect.

When a flow of gas or liquid attaches itself to a nearby surface and remains attached even when the surface curves away from the initial direction of flow, this is the Coanda effect.

The branch of engineering and technology that is concerned with the building of devices that use the flow and pressure of a fluid for functions usually performed by electronic devices is Fluidics . Fluidic logic is used to power some ventilators.

The branch of engineering that utilises pressurised gases is Pneumatics.

The following table shows the compartments and their relative oxygen reserve:
Compartment Factors Room air (mL) 100% O2 (mL)
Lung FAO2, FRC 630 2850
Plasma PaO2, DF, PV 7 45
Red blood cells Hb, TGV, SaO2 788 805
Myoglobin 200 200
Interstitial space 25 160

Oxygen reserves in the body, with room air and after oxygenation.

FAO2-alveolar fraction of oxygen rises to 95% after administration of 100% oxygen (CO2 = 5%)
FRC- Functional residual capacity – (the most important store of oxygen in the body) – 2,500-3,000 mL in medium sized adults
PaO2-partial pressure of oxygen dissolved in arterial blood (80 mmHg breathing room air and 500 mmHg breathing 100% oxygen)
DF -dissolved form (0.3%)
PV-plasma volume (3L)
TG-total globular volume (5L)
Hb-haemoglobin concentration
SaO2-arterial oxygen concentration (98% breathing air and 100% when preoxygenated)

Maintenance therapy aims to replace water and electrolytes lost under ordinary conditions. In the perioperative period, maintenance fluid administration may not sufficiently account for the increased fluid requirements caused by third-space losses into the interstitium and gut. Specific recommendations vary with the patient, the procedure, and the type and amount of fluid administered during the operation. The fluid for maintenance therapy replaces deficits arising primarily from insensible losses and urinary or gastrointestinal (GI) losses.

The maintenance fluid volume can be computed using the Holliday-Segar method.

Body weight Fluid volume
first 10 kg 4 ml/kg/hr
next 10-20 kg 2 ml/kg/hr
>20 kg 1 ml/kg/hr

In the past few years, there has been growing recognition of the increased risk of hyponatremia in hospitalized children in intensive care and postoperative settings who receive hypotonic maintenance fluids. Several studies, including a randomized controlled trial and a Cochrane analysis, found that the use of isotonic fluids is associated with fewer electrolyte derangements and concluded that isotonic maintenance fluids are preferable to hypotonic solutions in hospitalized children.

A European consensus statement suggests that an intraoperative fluid should have an osmolarity close to the physiologic range in children in order to avoid hyponatremia, an addition of 1-2.5% in order to avoid hypoglycaemia, lipolysis or hyperglycaemia and should also include metabolic anions as bicarbonate precursors to prevent hyperchloremic acidosis.

A rate of 40 ml/hr is suboptimal.

If 0.9% NaCl with 0% glucose is given at a rate of 65 ml/hr, despite of the correct infusion rate, large volumes can lead to hyperchloremic acidosis.

If 0.18% NaCl with 4% glucose is given at a rate of 65 ml/hr, infusion of this fluid regimen can lead to hyponatremia because of its hypotonicity.

Ligamentum venosum is an anterior relation of the liver: The ligamentum venosum, the fibrous remnant of the ductus venosus of the fetal circulation, lies posterior to the liver. It lies in the fossa for ductus venosus that separates the caudate lobe and the left lobe of the liver.

The portal triad contains three important tubes: 1. Proper hepatic artery 2. Hepatic portal vein 3. Bile ductules It also contains lymphatic vessels and a branch of the vagus nerve.

The bare area of the liver is a large triangular area that is devoid of any peritoneal covering. The bare area is attached directly to the diaphragm by loose connective tissue. This nonperitoneal area is created by a wide separation between the coronary ligaments.

The porta hepatis is a fissure in the inferior surface of the liver. All the neurovascular structures (except the hepatic veins) and hepatic ducts enter or leave the liver via the porta hepatis. It contains the sympathetic branch to the liver and gallbladder and the parasympathetic, hepatic branch of the vagus nerve. The caudate lobe (segment I) lies in the lesser sac on the inferior surface of the liver between the IVC on the right, the ligamentum venosum on the left, and the porta hepatis in front

When there is a fall in ionised plasma calcium levels, the chief cells of the parathyroid glands are stimulated to secrete parathyroid hormone (PTH).

50% of extracellular calcium occurs as non-ionised, protein- (albumin-)bound calcium.

The degree of ionisation increases with low ph and decreases with high pH.

There is increased renal calcium excretion with secretion of calcitonin.

Even though aprotinin reduces fibrinolysis and therefore bleeding, there is an associated increased risk of death. It was withdrawn in 2007.
Protein C is dependent upon vitamin K and this may paradoxically increase the risk of thrombosis during the early phases of warfarin treatment.

The coagulation cascade include two pathways which lead to fibrin formation:
1. Intrinsic pathway – these components are already present in the blood
Minor role in clotting
Subendothelial damage e.g. collagen
Formation of the primary complex on collagen by high-molecular-weight kininogen (HMWK), prekallikrein, and Factor 12
Prekallikrein is converted to kallikrein and Factor 12 becomes activated
Factor 12 activates Factor 11
Factor 11 activates Factor 9, which with its co-factor Factor 8a form the tenase complex which activates Factor 10

2. Extrinsic pathway – needs tissue factor that is released by damaged tissue)
In tissue damage:
Factor 7 binds to Tissue factor – this complex activates Factor 9
Activated Factor 9 works with Factor 8 to activate Factor 10

3. Common pathway
Activated Factor 10 causes the conversion of prothrombin to thrombin and this hydrolyses fibrinogen peptide bonds to form fibrin. It also activates factor 8 to form links between fibrin molecules.

4. Fibrinolysis
Plasminogen is converted to plasmin to facilitate clot resorption

The costal elements of the seventh cervical vertebrae form projections known as cervical ribs, which are present in approximately 0.5% – 1 % individuals.

A cervical rib commonly comprises of a head, neck and tubercle. The body of the rib varies from person to person. It extends into the posterior triangle of the neck, where it is either free anteriorly, or attached to the first rib / sternum.

Patients with a cervical rib mostly are asymptomatic and it is usually diagnosed as an incidental finding on chest x-ray. However, in some cases, the subclavian artery and the lower trunk of the brachial plexus are compressed where they pass over the cervical rib. This leads to a condition known as ”neurovascular compression syndrome,” in which these neurovascular structures are compressed between the cervical rib and scalenus anterior.

The most common cause of neurogenic symptoms in approximately 80% of the patients with cervical rib is neck trauma.

In most cases, the tingling, numbness and impaired circulation to the upper limb appears only after puberty. This is because the neck elongates, and the shoulders droop slightly.

Therapy with gabapentin requires dose adjustment with renal diseases. However, plasma monitoring of the drug is not necessary.

Gabapentin is not a liver enzyme inducer unlike other anticonvulsants like phenytoin and phenobarbitone

Gabapentin has not been shown to be associated with visual disturbances.

Gabapentin is used for add-on therapy in partial or generalized seizures and used in the management of chronic pain conditions but is of no use in petit mal.

Endothelin-1 is considered as a powerful coronary vasoconstrictor, produced by the endothelium. It acts to counter the effects of Nitric oxide (NO).
Neuropeptide-Y, angiotensin1, cocaine, vasopressin, and nicotine are some other coronary vasoconstrictors.

Chronotrophy and inotrophy occur after the activation of sympathetic nerve fibres, which in turn results in increasing the myocardial oxygen consumption, leading to increased coronary blood flow via local metabolic processes.

An alpha-receptor mediated coronary vasoconstrictor effect is also initiated that usually competes with vasodilation, resulting in decreased coronary vascular resistance. Some of the other dilators include hydrogen ions, CO2, potassium, and lactic acid. The action of endothelial NO synthase (eNOS) on L-arginine results in the formation of NO. This messenger also plays a vital role in the regulation of coronary blood flow via vasodilation, inhibition of platelet aggression, and decreasing vascular resistance.
Adenosine is considered as purine nucleoside that forms after the breakdown of adenosine triphosphate (ATP). Adenosine binds to adenosine type 2A (A2A) receptors in coronary vascular smooth muscles. These are coupled to the Gs protein. This mechanism leads to hyperpolarisation of muscle cells, resulting in relaxation and increased coronary blood flow.

GTN is an veno and arteriolar dilator, which behaves as pro-drug with NO.

Body fluid compartments in a 70kg male:
Total volume=42L (60% body weight)
Intracellular fluid compartment (ICF) =28L
Extracellular fluid compartment (ECF) = 14L

ECF comprises:
Intravascular fluid (plasma) = 3L
Extravascular fluid = 11L

Extravascular fluids comprises:
Interstitial fluid = 10.5L
Transcellular fluid = 0.5L

Exposure to anaesthetic hazards is one among the occupational exposures in manipulating toxic agents or inhaling toxic gases during anaesthetic practices.

Toxic gases mainly nitrous oxide, is one of the most gaseous anaesthetic agents that constitutes an important source of pollution. One of the safe and effective technics used in anaesthesia and reducing the amount of pollution is the Total Intravenous Anaesthesia (TIVA) which consists of using opioids in analgesia and propofol for the induction and the maintenance of anaesthesia. It refers to the administration intravenously of an anaesthetic, sedative, and/or tranquilizer. A less polluting but not the best way to get rid of the toxic aesthetic agents is the scavenger system that collects and expels the gas outside the medical environment. Yet, this technique still represents a hazard for the environment and still increase the risk of exposure for the health workers and clinical staff.

Fume cupboards are also not recommended to use because of their high pollution potency, mainly of the air resulting in a great harm for medical workers.

Supraglottic airways as well as the Air Changes per Hour technics could be harmful for both patients and health workers, increasing the risks of transmitted diseases, namely nosocomial infections.

Therefore, the Total Intravenous Anaesthesia technique (TIVA) is most likely to be safe and recommended to use.

The arterial blood gas analysis indicates presence of acute respiratory acidosis.

Central chemoreceptors are located in the ventral medulla and respond directly to presence of hydrogen ions in the CSF. When stimulated, it causes an increase in respiratory rate.

It is believed that hydrogen ions may be the only important direct stimulus for these neurons, however, CO2 is believed to stimulate these neurons secondarily by changing the hydrogen ion concentration.

Changes in O2 concentration have virtually no direct effect on the respiratory centre itself to alter respiratory drive. Although, O2 changes do have an indirect effect by acting through the peripheral chemoreceptors.

The bifurcation of the abdominal aorta into common iliac arteries occurs at the level of L4. The bifurcation is a common site for atherosclerotic plaques as it is an area of high turbulence.

Leriche Syndrome is an aortoiliac occlusive disease and affects the distal abdominal aorta, iliac arteries, and femoropopliteal vessels. It has a triad of symptoms:
1. Claudication (cramping lower extremities pain that is reproducible by exercise)
2. Impotence (reduced penile arterial flow)
3. Absent/weak femoral pulses (hallmark)

T12 – aorta enters the diaphragm with the thoracic duct and azygous veins

L2 – testicular or ovarian arteries branch off the aorta

L3 – inferior mesenteric artery

Direct laryngoscopy are performed using laryngoscopes and they can be classed according to the shape of the blade as curved or straight.

Miller, Soper, Wisconsin and Seward are examples of straight blade laryngoscopes. Straight blades are commonly used for intubating neonates and infants but can be used in adults too.

The tip of the miller blade is advanced over the epiglottis to the tracheal entrance then lifted in order to view the vocal cords.

The RIGHT-SIDED Macintosh blade is used in adults while the left-sided blade may be used in conditions that make intubation with standard blade difficult e.g. facial deformities.

The McCoy laryngoscope is based on the STANDARD MACINTOSH blade not Robertshaw’s. It has a lever operated hinged tip, which improves the view during laryngoscopy.

Polio blade is mounted at an angle of 120-135 degrees to the handle. Originally designed for use during the polio epidemic ​in intubation patients within iron lung ventilators, it is now useful in patients with conditions like breast hypertrophy, barrel chest, and restricted neck mobility.

The liver receives blood supply from two sources.
1. Hepatic artery proper
It arises from the celiac trunk via the common hepatic artery and brings oxygenated blood to the liver.
It contributes to approximately 30% of the blood supply of the liver.
2. Hepatic portal vein – supplies the liver with partially deoxygenated blood, carrying nutrients absorbed from the small intestine. It gets tributaries from the inferior mesenteric vein, splenic vein, and superior mesenteric vein

The inferior mesenteric artery supplies the hindgut.
The superior mesenteric artery supplies the pancreas and intestine up to the proximal two-thirds of the transverse colon.
The inferior phrenic artery supplies the inferior surface of the diaphragm and oesophagus.

Severity of a reduction in restrictive defect (%FVC) or obstructive defect (%FEV1/FVC) predicted are classified as follows:

Mild 70-80%
Moderate 60-69%
Moderately severe 50-59%
Severe 35-49%
Very severe <35% This patient has a %FVC predicted of 60.4% and this corresponds to a moderate restrictive deficit. %FEV1/FVC ratio is 93.5%. FEV1/FVC ratio 80% < predicted and VC < 80% = mixed picture. FEV1/FVC ratio 80% < predicted and VC > 80% = obstructive picture.

FEV1/FVC ratio 80% > predicted and VC > 80% = normal picture.

FEV1/FVC ratio 80% > predicted and VC < 80% predicted= restrictive picture. The integrity of the alveolar-capillary barrier is measured by carbon monoxide transfer factor (TLCO) and carbon monoxide transfer coefficient (KCO). These values are seen to be reduced in emphysema, interstitial lung diseases and in pulmonary vascular pathology. However, the KCO (as % predicted) is high in extrapulmonary restriction (pleural, chest wall and respiratory neuromuscular disease), and in loss of lung units provided the structure of the lung remaining is normal. The KCO distinguishes extrapulmonary (high KCO) causes of ‘restriction’ from intrapulmonary causes (low KCO).

Bupivacaine is used to decrease sensation in a specific area. It is injected around a nerve that supplies the area, or into the spinal canal’s epidural space.

The maximum volume of 0.5% bupivacaine that should be administered to a 10kg child is 5 ml