Tachyphylaxis is the swiftly declining response to successive drug doses which vastly reduces its effectiveness in a short space of time, mostly as a result of an acute consumption of neurotransmitters.

Tolerance or desensitisation is the slow decline in a person’s reaction to a drug due to continued use. It requires a longer time span than tachyphylaxis, usually over days or weeks.

Down- regulation is a reduction in the amount of receptors available on target cells which decreases the affinity of the agent to the cells. For this to occur, the down-regulation of receptors must occur at a rate faster than receptor synthesis. This down-regulation often occurs with beta1 receptors due to:

1) The transportation or receptors from the cell surface to the interior of the cell

2) Degradation of receptors occurring over time.

In this case, dobutamine is prescribed to treat cardiogenic shock. It is able to function by binding to beta1-adrenergic receptors to increase the contraction of the heart, thereby improving cardiac output. It also binds to beta2- and alpha1-adrenergic receptors to balance out the effects produced by binding to beta1 receptors and reduce the risk of system vasculature responses.

Arrhythmias and/or hypotension are the most common causes of death from tricyclic antidepressant (TCA) overdose.

The quinidine-like actions of tricyclic antidepressants on cardiac tissues are primarily responsible for their toxicity. Conduction through the His-Purkinje system and the myocardium slows as phase 0 depolarisation of the action potential slows. QRS prolongation and atrioventricular block are caused by slowed impulse conduction, which also contributes to ventricular arrhythmias and hypotension.

Arrhythmias can also be caused by abnormal repolarization, impaired automaticity, cholinergic blockade, and inhibition of neuronal catecholamine uptake, among other things.

Acidaemia, hypotension, and hyperthermia can all exacerbate toxicity.

The anticholinergic effects of tricyclic antidepressants, as well as the blockade of neuronal catecholamine reuptake, cause sinus tachycardia. Sinus tachycardia is usually well tolerated and does not require treatment. It can be difficult to tell the difference between sinus tachycardia and ventricular tachycardia with QRS prolongation.

A QRS duration of more than 100 milliseconds indicates a higher risk of arrhythmia and should be treated with systemic sodium bicarbonate.

The tricyclic is dissociated from myocardial sodium channels by serum alkalinization, and the extracellular sodium load improves sodium channel function.

Damping is the reduction of energy in a system achieved by reducing the amplitude of oscillations. It is necessary to some degree to prevent wave overshoots.

Critical damping usually causes the system to be slow, so optimal damping is normally applied to provide a balance between speed and distortion.

Damping can cause errors if excessive (overdamping) or inadequate (Underdamping). The amount of damping in a system can be determined using the damping coefficient (D), where:

Undamped: 0
Critically damped: 1
Optimally damped: 0.64

An overdamped system will cause an artificial decrease in the systolic blood pressure, and an artificial increase in the diastolic blood pressure.

An underdamped system will cause an artificial increase in systolic blood pressure and an artificial decrease in diastolic blood pressure.

Damping can be caused by a number of factors affecting different parts of the system, including:

The tubing/cannula: The presence of air bubbles, increased blood viscosity or formation of blood clots.
The diaphragm/tubing: Increased malleability/compliance
The tubing: Presence of kinks, narrowing or too many ports of injection.

The answer here is a damped system will have a low systolic pressure, a high diastolic pressure with a normal mean pressure.

Cardiopulmonary exercise testing (CPX, CPEX, CPET) is a non-invasive testing method used to determine the performance of the heart, lungs and skeletal muscle. It measures the exercise tolerance of the patient.

The parameters measured include:

ECG and ST-segment analysis and blood pressure
Oxygen consumption (VO2)
Carbon dioxide production (VCO2)
Gas flows and volumes
Respiratory exchange ratio (RER)
Respiratory rate
Anaerobic threshold (AT)

The anaerobic threshold (AT) is an estimate of exercise ability. Any measurement below 11 ml/kg/min is usually related with an increase in mortality, especially when there is a background of myocardial ischaemia occurring during the test.

Peak VO2 <20 mL/kg with a low AT have a correlation with postoperative complications and a 30 day mortality. The CPX test is used for risk-testing patients prior to surgery to determine the appropriate postoperative care facilities. The V slope measured in CPX testing represents VO2 versus VCO2 relationship. During AT, the ramp of V slope increases, but does not provide a picture of postoperative mortality.

Spirometry measures the total volume of air that can be forced out in one maximum breath, that is the total lung capacity (TLC), to maximal expiration, that is the residual volume (RV).

It is conducted using a spirometer which is capable of measuring lung volumes using techniques of dilution.

During spirometry, the following measurements can be determined:
Forced vital capacity (FVC)/vital capacity (VC): The maximum volume of air exhaled in one single forced breathe.
Forced expiratory volume in one second (FEV1)
FEV1/FVC ratio
Peak expiratory flow (PEF): the maximum amount of air flow exhaled in one blow.
Forced expiratory flow (mid expiratory flow): the flow at 25%, 50% and 75% of FVC
Inspiratory vital capacity (IVC): The maximum volume of air inhaled after a full total expiration.

Anatomical dead space is measured using a single breath nitrogen washout called the Fowler’s method.

Residual volume and total lung capacity are both measured using the body plethysmograph or helium dilution

The functional residual capacity is usually measured using a nitrogen washout or the helium dilution technique.

The patient’s diagnosis is microcytic hypochromic anaemia which is often as a result of iron deficiency and thalassaemia.

Macrocytic anaemia is often caused by folate and B12 deficiencies and alcohol abuse.

Normocytic normochromic anaemia is often caused by acute blood loss, haemolytic anaemia, anaemia of chronic disease and leucoerythroblastic anaemias.

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

The arterial cannula inserted should have parallel walls in order to reduce the risk of interruption of blood flow to distal limbs.

It is essential that the monitor used to display the arterial pressure waves has a frequency capacity of 0.5-40Hz. This is because the pressure waves are a combination of different sine waves of varying frequencies and amplitudes.

The diameter of the catheter is directly proportional to the natural frequency which is the frequency at which the system responsible for monitoring the waves resonates and amplifies the signals. This should be at least ten fold in comparison to the fundamental frequency. The diameter of the catheter is also inversely proportional to the square root of the system compliance, the tubing length and the fluid density within the system.

The presence of an air bubble, a clot or an easily malleable diaphragm and tube can result in wave damping. Increased damping will cause a reduction in the systolic pressure, and an increase in diastolic pressure. The maximum damping value of an appropriate monitoring system would be 0.64.

A rigid, non-malleable diaphragm and tubing can cause a resonance within the system. This resonance will result in an increase in the systolic pressure and a reduction in the diastolic pressure

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).

Capnography is the non-invasive measurement and pictorial display of inhaled and exhaled carbon dioxide (CO2) partial pressure.

It is depicted graphically as the concentration of CO2 over time.

It is used in disease diagnosis, determining disease severity, assessing response to treatment and is the best method to for indicating when an endotracheal tube is placed in the trachea after intubation.

The wavelength of IR light usually absorbed by nitrous oxide is between 4.4-4.6?m (very close to that of CO2). Its absorption of wavelengths at 3.9 ?m is much weaker. It causes a measurable deficit of 0.1% for every 10% of nitrous oxide. The maximal wavelength of infrared (IR) light absorbed by carbon monoxide is 4.7 ?m. The volatile agents have strong absorption bands at 3.3 ?m and throughout the ranges 8-12 ?m.

IR light is not absorbed by oxygen (O2), but O2 and CO2 molecules are constantly colliding which interrupts the absorption of IR light by CO2. This increases the band of absorption, that is the Collison or pressure broadening). An oxygen percentage of 95 will result in a 0.5 percentage fall in CO2 measure.

IR light is also absorbed by water vapour which will result in an overlap of the absorption band, collision broadening and a dilution of partial pressure. This is why water trap and water permeable tubing is recommended for use as it reduces measurement inaccuracies.

The use of multi-gas analysers of modern gases also help reduce the effects of collision broadening.

Beer’s law is also applied in this system as an increase in the concentrations of CO2 causes a decrease in the amount of IR able to pass through the gas. This IR light is what generated the signal that is analysed for display.

The capnograph can indicate oesophageal intubation, but cannot determine if it is endotracheal or endobronchial. For this, auscultation is used.

Wavelength can be computed as follows:

Wavelength = velocity/frequency

In the given problem, the values stated are:

Frequency = 10 x 10^6
Velocity = 1540 meters per second

Wavelength = 1540/(10×10^6)
Wavelength = 1540/10,000,000 meters
Wavelength = 0.15 millimetres

Pulmonary vascular resistance (PVR) refers to the resistance to blood flow to the left atrium from the pulmonary artery.
It is derived mathematically by:

PVR = MPAP – PCWP
CO
where,
MPAP: Mean pulmonary artery pressure
PCWP: Pulmonary capillary occlusion pressure
CO: Cardiac output

For this patient:
PVR = 10 – 5 = 1mmHg
5

Remember, multiply by correction factor 80 to change units:

PVR = 1mmHg x 80 = 80 dynes·s·cm-5

Normal values range between 20-130 dynes·s·cm-5

Thermodilution is the most common dilution method used to measure cardiac output (CO) in a hospital setting.

During the procedure, a Swan-Ganz catheter, which is a specialized catheter with a thermistor-tip, is inserted into the pulmonary artery via the peripheral vein. 5-10mL of a cold saline solution with a known temperature and volume is injected into the right atrium via a proximal catheter port. The solution is cooled as it mixes with the blood during its travel to the pulmonary artery. The temperature of the blood is the measured by the catheter and is profiled using a computer.

The computer also uses the profile to measure cardiac output from the right ventricle, over several measurements until an average is selected.

Cardiac output changes at each point of respiration, therefore to get an accurate measurement, the same point during respiration must be used at each procedure, this is usually the end of expiration, that is the end-expiratory pause.

Oxygen consumption (VO2) refers to the optimal amount of oxygen used by the body during exercise.

It is calculated mathematically by:

VO2 = 3.5 x 50 x 8 = 1400 mL/kg/minute

where,

1 MET = 3.5 mL O2/kg/minute is utilized by the body.

Note:

1 MET Eating
Dressing
Use toilet
Walking slowly on level ground at 2-3 mph
2 METs Playing a musical instrument
Walking indoors around house
Light housework
4 METs Climbing a flight of stairs
Walking up hill
Running a short distance
Heavy housework, scrubbing floors, moving heavy furniture
Walking on level ground at 4 mph
Recreational activity, e.g. golf, bowling, dancing, tennis
6 METs Leisurely swimming
Leisurely cycling along the flat (8-10 mph)
8 METs Cycling along the flat (10-14 mph)
Basketball game
10 METs Moderate to hard swimming
Competitive football
Fast cycling (14-16 mph)

There are different types of temperature measurement. These include:

Thermistor – this is a type of semiconductor, meaning they have greater resistance than conducting materials, but lower resistance than insulating materials. There are small beads of semiconductor material (e.g. metal oxide) which are incorporated into a Wheatstone bridge circuit. As the temperature increases, the resistance of the bead decreases exponentially

Thermocouple – Two different metals make up a thermocouple. Generally, in the form of two wires twisted, welded, or crimped together. Temperature is sensed by measuring the voltage. A potential difference is created that is proportional to the temperature at the junction (Seebeck effect)

Platinum resistance thermometers (PTR) – uses platinum for determining the temperature. The principle used is that the resistance of platinum changes with the change of temperature. The thermometer measures the temperature over the range of 200°C to1200°C. Resistance in metals show a linear increase with temperature

Tympanic thermometers – uses infrared radiation which is emitted by all living beings. It analyses the intensity and wavelength and then transduces the heat energy into a measurable electrical output

Gauge/dial thermometers – Uses coils of different metals with different co-efficient of expansion. These either tighten or relax with changes in temperature, moving a lever on a calibrated dial.

The passive leg raising (PLR) manoeuvre is a method of altering left and right ventricular preload and it is done with real-time measurement of stroke volume. It is a simple, quick, relatively unbiased, and accurate bedside test to guide fluid management and avoid fluid overload.

Pulse pressure variation (PPV), Stroke volume variation (SVV), superior vena cava diameter variation (threshold 36%) and end-expiratory occlusion test are used for dynamic tests of fluid responsiveness.

PPV is derived peripherally from the arterial pressure waveform.

Stroke volume variation (SVV) can be derived peripherally through pulse contour analysis of the arterial waveform. PPV and SVV have a threshold of 12% but since they are not used in patients who have cardiac arrhythmias, are spontaneous breathing, and in ventilated patients with low lung compliance and tidal volumes, they are of limited value.

The tests of fluid responsiveness’ accuracy is determined by calculating the area under the receiver operating characteristic curve (UROC) obtained by plotting the sensitivity of the parameter in predicting fluid responsiveness vs. 1-specificity.

Under optimal conditions, the ability to determine the need for fluid is best with PPV>SVV>LVEDA>CVP.

Central venous pressure (CVP) is a static test of preload (not preload responsiveness) and a key determinant of cardiac function. The left ventricular end-diastolic area (LVEDA) a static test of fluid responsiveness, is derived using echocardiography

Ferromagnetism is the property of a substance that is magnetically attracted and can be magnetised indefinitely. A material is said to be paramagnetic if it is attracted to a magnetic field. A substance is said to be diamagnetic if it is repelled by a magnetic field.

Cobalt, iron, gadolinium, neodymium, and nickel are ferromagnetic.

Gadolinium is a ferromagnetic rare earth metal that is ferromagnetic below 20 degrees Celsius (its Curie temperature). MRI scans are enhanced with gadolinium-based contrast media.

When ferromagnetic materials are exposed to a magnetic field, they can cause a variety of issues like magnetic field interactions, heating, and image artefacts.

Titanium, lead, chromium, copper, aluminium, silver, gold, and tin are non ferromagnetic.

Peak expiratory flow rate (PEFR) is the maximum speed of air flow generated during a single forced exhaled breath. It is most useful when expressed as a percentage of the best value obtained from the patient.

Forced expiratory volume over 1 second (FEV1) is a lung parameter measured using spirometry. It is the amount of air forced out of the lung in one exhaled breath. It is a more accurate measure of lung obstructions as it doesn’t rely on effort like PEFR

PEFR and FEV1 are usually similar, but become more different in asthmatic patients as airflow becomes increasingly obstructed.

Acute severe asthma is most often diagnosed on history taking and examinations:

Respiratory rate: >25 breaths/min
Heart rate: >110 beats/min
PEFR: 33 – 50% predicted (<200L/min)
Patient state: Unable to complete a sentence in a single breath.

A chest x-ray is not routinely required, and is only indicated in specific circumstances, which are:

If a pneumomediastinum or pneumothorax is suspected
Possible life threatening asthma
Possible consolidation
Unresponsive asthma
If ventilation is required.

An echocardiograph (ECG) is not necessary in this case

Routine haematological and biochemical investigations are not urgent in this case as any abnormalities they detect will be secondary to the patient’s presentation.

An arterial blood gas (ABG) will only be indicated if SPO2 was <92% or if patient presented with life threatening symptoms.

A pulse oximeter is a piece of medical equipment used as a non-invasive method of measuring the oxygen saturation of blood.

It works by measuring the ratio of absorption of red and infrared light in a section of blood flow, as red light is largely absorbed by deoxygenated blood, and infrared light is largely absorbed by oxygenated blood.

Pulse oximetry relies on photoplethysmography (PPG) waveforms. The oximeter has 2 sides, with different functions. One side houses light-emitting diodes which are responsible for transmitting 2 light wavelengths, 660nm for red light and 940nm for near infrared light. The other side is a photodetector. The light emitted travels through the body and the amount that is not absorbed is measured by the photodetector.

Smokers often have increased levels of carboxy haemoglobin (COHb). This leads to artificial increases in pulse oximeter readings as it is unable to differentiate between COHb and oxyhaemoglobin (O2HB) as they both absorb red light at 660nm. Every 1% increase of circulating carboxyhaemoglobin, results in a correlative 1% increase in oximeter readings.

Prilocaine toxicity will cause an artificial decrease in oximeter readings. This is because prilocaine metabolites cause methemoglobinemia (MetHB), which are dysfunctional haemoglobins unable to properly transport oxygen. In this case, a laboratory multiwavelength co-oximeter is recommended for a more accurate reading.

Anaemia will not affect oximeter readings as long as haemoglobins in the blood are normal.

Sickle cell disease does not affect oximeter readings despite its ability to cause hypoxia and shift the oxygen dissociation curve to the right.

Brown-red fingernail polish will cause an underestimation of pulse oximeter readings.

A damped sine wave is a smooth, periodic oscillation with an amplitude that approaches zero as time goes to infinity. In other words, the wave gets flatter as the x-values become larger.

Critical damping is defined as the threshold between overdamping and underdamping. In the case of critical damping, the oscillator returns to the equilibrium position as quickly as possible, without oscillating, and passes it once at most.

In overdamping, the system moves slowly towards the equilibrium. An underdamped system moves quickly to equilibrium, but will oscillate about the equilibrium point as it does so.

Optimal damping has a damping coefficient of around 0.64-0.7. It maximizes frequency response, minimizes overshoot of oscillations, and minimizes phase and amplitude distortion.

In an undamped system, the amplitude of the waves that are being generated remain unchanged and constant over time.

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 ASA physical status classification system is a system for assessing the fitness of patients before surgery. It was last updated in October 2014.

ASA I A normal healthy patient
ASA II A patient with mild systemic disease
ASA III A patient with severe systemic disease
ASA IV A patient with severe systemic disease that is a constant threat to life
ASA V A moribund patient who is not expected to survive without the operation
ASA VI A declared brain-dead patient whose organs are being removed for donor purposes

A 20-year old woman who is 39-weeks pregnant with no other medical conditions – ASA II

A 35-year-old man with a BMI of 29 with a good exercise tolerance who smokes-ASA II

A 50-year old man with a BMI of 41 with a reduced exercise tolerance -ASA III

A 65-year old woman with a BMI of 34 with treated hypertension with no functional limitations-ASA II

A 73-year old man who has had a TIA ten-weeks ago but has a good exercise tolerance and is a non-smoker-ASA IV

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)

Closing capacity refers to volume of gas within the lungs at which the conducting small airways begin to close, that is, the point during expiration when small airways close.

It is calculated mathematically as:

Closing capacity = Closing volume (CV) + Residual volume (RV)

Functional residual capacity (FRC) is the volume of gas still present within the lungs post expiration.

Closing capacity is lower than the functional residual capacity in younger adults, but begins to rise to eventually equal, and then exceed it with increasing age (at about middle age), increasing intrabdominal pressure, decreasing blood flow in the pulmonary system and parenchymal disease within the pulmonary system.

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)

Spirometry measures the total volume of air that can be forced out in one maximum breath, that is the total lung capacity (TLC), to maximal expiration, that is the residual volume (RV).

It is conducted using a spirometer which is capable of measuring lung volumes using techniques of dilution.

During spirometry, the following measurements can be determined:
Forced vital capacity (FVC)/vital capacity (VC): The maximum volume of air exhaled in one single forced breathe.
Forced expiratory volume in one second (FEV1)
FEV1/FVC ratio
Peak expiratory flow (PEF): the maximum amount of air flow exhaled in one blow.
Forced expiratory flow (mid expiratory flow): the flow at 25%, 50% and 75% of FVC
Inspiratory vital capacity (IVC): The maximum volume of air inhaled after a full total expiration.

Anatomical dead space is measured using a single breath nitrogen washout called the Fowler’s method.

Residual volume and total lung capacity are both measured using the body plethysmograph or helium dilution

The functional residual capacity is usually measured using a nitrogen washout or the helium dilution technique.

The international system of units, or system international d’unites (SI) is a collection of measurements derived from expanding the metric system.

There are seven base units, which are:

Metre (m): a unit of length
Second (s): a unit of time
Kilogram (kg): a unit of mass
Ampere (A): a unit of electrical current
Kelvin (K): a unit of thermodynamic temperature
Candela (cd): a unit of luminous intensity
Mole (mol): a unit of substance.

Functional residual capacity (FRC) is 1.7 to 3.5L/kg

A capacity is the sum of two or more volumes. The total lung capacity (TLC) is total sum of the volume of gas present in all lung compartments upon maximum inspiration. It is represented mathematically as:

Total lung capacity (TLC) = Vital capacity (VC) + Residual volume (RV)

The residual volume (RV) is the volume of gas still present within the lung post maximum exhalation. It cannot be measured by spirometry, but can be using a body plethysmograph and also with the helium dilution technique.

Closing capacity (CC) is the volume of gas within the lungs at which small airways close upon expiration. It increases with age and is especially important when it surpasses the FRC as it causes changes in ventilation/perfusion mismatch and hypoxia.
In the supine position, a patient with a normal body mass index and no history of lung pathology, the CC equals the FRC at approximately 44, and at approximately 66 at standing position.

The bispectral index (BIS) monitors works to determine the level of consciousness of a patient by processing electroencephalographic (EEG) signals to obtain a value between 0 and 100, where 0 reflects no brain activity, and 100 reflects a patient is completely awake.

The general meaning of BIS values are:

>95: Patient is in an awake state.
65-85: Patient is in a sedated state.
40-65: Patient is in a state that is optimal for general surgery.
<40: Patient is in a deep hypnotic state It is important in measuring the depths of anaesthesia to prevent haemodynamic changes or patient awareness during surgery. The nature of anaesthetic agent used is a determinant factor in resultant BIS values. Intravenous agents, such as propofol, thiopental and midazolam, result in a deeper hypnotic state, whilst inhalation agents have a lesser hypnotic effect at the same BIS values. Certain agents result in inaccurate BIS values such as ketamine and nitrous oxide (NO). These two agents appear to increase the BIS value, whilst putting the patient in a deeper hypnotic state, and should therefore not be used with BIS monitoring. Hypothermia also affects the BIS value as it causes a 1.12 per °C decrease in body temperature.

Arterial pressure waveforms is an invasive form of monitoring cardiac parameters. It provides a lot of information on the performance of the heart from different sections, including:

Cardiac measurements:

Heart rate
Systolic pressure
Diastolic pressure
Mean arterial pressure
Pulse pressure
Change in pulse amplitude corresponding to respiratory changes
Slope of anacrotic limb associated with aortic stenosis

From the shape of the arterial waveform displayed:

Slope of anacrotic limb represents aortic valve and LVOT flow
Indications of aortic stenosis (AS): Slurred wave, collapsing wave
Rapid systolic decline in LVOTO
Bisferiens wave in HOCM
Low dicrotic notch in states with poor peripheral resistance
Position and quality of dicrotic notch as a reflection of the damping coefficient

For this question, the upstroke slope of the pressure wave is indicative of myocardial contractility and is mathematically represented as:

dP/dt, which represents a change of pressure with regards to time.

Coronary perfusion pressure(CPP), the difference between aortic diastolic pressure (Pdiastolic) and the left ventricular end-diastolic pressure (LVEDP), is mainly determined by the formula:

CPP = Pdiastolic -LVEDP
where
Pdiastolic is the lowest pressure in the aorta before left ventricular ejection and
LVEDP is measured directly during a cardiac catheterisation or indirectly using a pulmonary artery catheter. The pulmonary artery occlusion or wedge pressure approximates best with LVEDP.

Using this patient’s haemodynamic data:

CPP = Pdiastolic – MPAWP
COO = 70 – 12 = 58mmHg

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 mixed deficit with a severe obstructive deficit as %FEV1/FVC predicted is 46.9% and a moderate restrictive deficit as %FVC of predicted is 61.3 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 STOP-BANG questionnaire is used to screen patients for obstructive sleep apnoea (OSA).

The scoring system assigns one point for each feature.

S: Snoring (louder than talking or loud enough to be heard through closed doors)
T: Feeling tired, fatigued, or sleepy during daytime
O: Observed apnoeas during sleep
P: Hypertension
B: BMI more than 35 kg/m2
A: Age 50-years of age or greater
N: Neck circumference (male 17 inches / 43cm or greater and female 16 inches / 41 or greater)
G: Gender: Male

Our patient has a score of 5 ( O, P, A, N, G)

The score helps clinicians stratify patients for unrecognized OSA and target appropriate clinical management. It can also help triage patients for further investigation. A STOP-BANG score of 5-8 will identify patients with high probability of moderate to severe OSA in the surgical population.

An echocardiogram provides real-time visualisation of cardiac structures. The ejection fraction (EF) is normally measured using this system.

The ejection fraction (EF) can be deduced mathematically if the patient’s end-diastolic volume (EDV), end-systolic volume (ESV) and stroke volume (SV) are known, as:

SV = EDV – ESV, and

EF = SV/EDV x 100

The normal range for EF is >55-70%.

For this patient,

SV= 40 – 30 = 10 mL, therefore

EF = 10/40 x 100 = 25%

The central venous pressure (CVP) waveform depicts changes of pressure within the right atrium. Different parts of the waveform are:

A wave: which represents atrial contraction. It is synonymous with the P wave seen during an ECG. It is often eliminated in the presence of atrial fibrillation, and increased tricuspid stenosis, pulmonary stenosis and pulmonary hypertension.

C wave: which represents right ventricle contraction at the point where the tricuspid valve bulges into the right atrium. It is synonymous with the QRS complex seen on ECG.

X descent: which represents relaxation of the atrial diastole and a decrease in atrial pressure, due to the downward movement of the right ventricle as it contracts. It is synonymous with the point before the T wave on ECG.

V wave: which represents an increase in atrial pressure just before the opening of the tricuspid valve. It is synonymous with the point after the T wave on ECG. It is increased in the background of a tricuspid regurgitation.

Y descent: which represents the emptying of the atrium as the tricuspid valve opens to allow for blood flow into the ventricle in early diastole.

Canon waves: which refer to large waves present on the trace that do not correspond to the A, V or C waves. They usually occur in a background of complete heart blocks or junctional arrythmias.

Because the patient has mild systemic disease, he is ASA 2 and the procedure will be performed under local anaesthesia.

The following factors should be considered when requesting preoperative investigations:

Indications derived from a preliminary clinical examination
Whether or not a general anaesthetic will be used, the possibility of asymptomatic abnormalities, and the scope of the surgery.

No special investigations are needed if the patient has no history of significant systemic disease and no abnormal findings on examination during the nurse-led assessment.

A patient presenting with symptomatic asthma should be assessed for severity to determine appropriate management options. Indications of acute severe asthma are:

Peak expiratory flow rate (PEFR): 33-50% best/predicted
Respiratory rate: ≥25/min
Heart rate: ≥110/min
Inability to finish a complete sentence in a single breath.

Oxygen saturation should be measured. Any measurement of an oxygen saturation of 92% or less, either on air or on oxygen, indicates severe, life threatening asthma, and requires an arterial blood gas (ABG) to detect normo- or hypercarbia.

A chest x-ray would not be routine as it will not provide any relevant information. It is only required in specific cases, including:
Diagnosis of a subcutaneous emphysema
Indications of a unilateral pneumothorax
Indications of a lobar collapse of consolidation
Treatment-resistance life-threatening asthma
If mechanical ventilation is indicated

A peak expiratory flow rate (PEFR) can provide relevant information to help distinguish between acute, moderate, severe and life threatening asthma. However, it is not necessary as other parameters exist that can also help make the same distinction.

An ECG is indicated in this case as the patient has tachycardia and tachypnoea which are indicative of acute severe asthma. The ECG would indicate if arrhythmia is also present which would suggest life-threatening asthma.

There are different types of temperature measurement. These include:

Thermistor – this is a type of semiconductor, meaning they have greater resistance than conducting materials, but lower resistance than insulating materials. There are small beads of semiconductor material (e.g. metal oxide) which are incorporated into a Wheatstone bridge circuit. As the temperature increases, the resistance of the bead decreases exponentially

Thermocouple – Two different metals make up a thermocouple. Generally, in the form of two wires twisted, welded, or crimped together. Temperature is sensed by measuring the voltage. A potential difference is created that is proportional to the temperature at the junction (Seebeck effect)

Platinum resistance thermometers (PTR) – uses platinum for determining the temperature. The principle used is that the resistance of platinum changes with the change of temperature. The thermometer measures the temperature over the range of 200°C to1200°C. Resistance in metals show a linear increase with temperature

Tympanic thermometers – uses infrared radiation which is emitted by all living beings. It analyses the intensity and wavelength and then transduces the heat energy into a measurable electrical output

Gauge/dial thermometers – Uses coils of different metals with different co-efficient of expansion. These either tighten or relax with changes in temperature, moving a lever on a calibrated dial.

Since an arterial pressure transducer, and every other measuring apparatus, is prone to errors due to offset and gradient drifts, regular calibration is required to maintain accuracy of the instrument. The two-point calibration pressure values of 0 mmHg and 200 mmHg are within the physiologic range and can best compensate for the gradient drift.

There are different effects of electrocution and these can be shown in the table below.

Current Effect
1 mA Tingling
5 mA Pain
15 mA Tonic muscle contraction
50 mA Respiratory arrest
100 mA Ventricular fibrillation and cardiac arrest