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Ocular Anatomy and Physiology Relevant to Anaesthesia
January 2017 18:1
Article Extract

‘The recti (superior, inferior, medial and lateral) arise from a ring-shaped thickening of periosteum surrounding the optic canal. They pass forward, getting wider as they do so, to attach onto the surface of the globe anterior to the coronal equator of the eyeball (Figure 1). These four muscles form the ‘muscle cone’ (or simply ‘the cone’). The distinction between intraconal and extraconal is important to anaesthetists when performing regional blocks.’

Q1. Associated MTF

Which of the following are true regarding the anatomy of eye?
A. The superior rectus muscle is supplied by the abducens nerve
B. With sub-Tenon's block the trochlear nerve is spared, leading to some rotational movement of the eyeball.
C. Sphincter pupillae is supplied by postganglionic sympathetic nerve fibres
D. The central retinal artery is a branch of the ophthalmic artery
E. The lens receives its nutrients from the aqueous humor

(*Answer below)

Hypoxic-ischaemic brain injury following cardiac arrest
May 2017 18:5
Article Extract

‘MRI undertaken between 2 and 5 days after the acute event may be particularly helpful in revealing the extent of damage. Diffusion weighted imaging (DWI) and fluid-attenuated inversion recovery (FLAIR) images show widespread hyperintensity initially involving the basal ganglia, caudate and striatum and thalamus followed by the cortex and subcortical white matter, cerebellum and hippocampus. Conventional T1 and T2 weighted scans are normal. Diffusely abnormal findings on DWI and FLAIR correlate with a poor outcome.’

Q2. Associated MTF

Which of the following statements are true regarding the prognosis and neurological outcomes following cardiac arrest?
A. Successful resuscitation may be followed by reduced cerebral blood flow and failure of autoregulation
B. More recent studies have shown that patients treated with therapeutic hypothermia have improved overall outcomes
C. The best outcome is generally seen in patients who have had only a short period of impaired consciousness following resuscitation
D. Early myoclonic seizures following resuscitation may indicate adverse outcome
E. Neuron-specific enolase (NSE) is a highly specific biomarker used in assessing the prognosis following HIBI

(*Answer below)

Perioperative fluid therapy for anaesthetists and intensivists
September 2018 19:9
Article Extract

‘Recently there has been discussion of employing restrictive fluids in place of goal-directed therapy, with a basis in improved outcomes seen in enhanced recovery programmes. From UK-based perioperative fluid studies available, it is evident that there is significant variation in volumes of fluid administered to patients preoperatively even within goal-directed regimes, with quoted variations from 1 ml/kg/h to 10 ml/kg/h. The description of restrictive fluid therapy (RFT) is to maintain euvolaemia and efficient tissue perfusion with no perioperative weight gain, thereby avoiding tissue oedema. It is proposed in pre-clinical studies that hypervolaemia disrupts the endothelial glycocalyx increasing fluid shifts to the interstitial space.’

Q3. Associated MTF

Which of the following regarding various fluids used in anaesthetic practice are true?
A. A multicentre randomized controlled trial in ICU patients demonstrated safety of 4.5% HAS compared with 0.9% saline in resuscitation
B. Gelatins compared with other colloids have a larger molecular weight leading to prolonged intravascular half life
C. Hydroxyethylstarch when used in ICU populations may decrease the need for renal replacement therapy in sepsis
D. Dextrans when infused may interfere with the coagulation test results
E. 0.18% sodium chloride/4% glucose is the intravenous fluid of choice in children for maintenance

(*Answer below)



 



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*Multiple choice question answers

Q1. Answers B, D, and E are true.

A - The superior, inferior and medial recti, and the inferior oblique muscle are all supplied by the oculomotor nerve. The lateral rectus is supplied by the abducens nerve, and superior oblique by the trochlear nerve.

B – The trochlear nerve is situated outside the muscle cone and is often spared in retrobulbar and sub-Tenon’s blocks. This leads to some rotational movement of the eyeball following these blocks.

C - Dilator pupillae is supplied by postganglionic sympathetic nerve fibres originating in the cervical plexus. The innermost portion of the iris comprises the circular sphincter muscle fibres, which cause pupillary constriction. Sphincter pupillae is supplied by postganglionic parasympathetic nerve fibres originating in the ciliary ganglion.

D – The ophthalmic artery is a branch of the internal carotid artery. The most clinically significant branch of the ophthalmic artery is the central retinal artery, which supplies the innermost layer of the retina and is an end-artery.

E – The lens has no blood supply and receives its nutrients from the aqueous humor.


Q2. Answers A, C, and D are true.

A - After successful resuscitation there is a brief period of brain hyperaemia, but this may be followed by reduced cerebral blood flow as a result of microvascular thrombotic occlusion leading to failure of autoregulation.

B - The use of therapeutic hypothermia in patients after cardiac arrest with a goal temperature of 32C to 34C became standard practice in the early 2000s based on two randomized controlled trials demonstrating improved survival and long-term neurological outcome. More recent studies have shown that patients treated with therapeutic hypothermia were more likely to survive than patients who were not; however, no difference in outcome (overall survival was survival with good outcome) was found based on the target temperature of either 32C or 36C.

C - The clinical effects and consequences of hypoxic-ischaemic brain injury (HIBI) are highly variable. The best outcome is generally seen in patients who have had only a short period of impaired consciousness following resuscitation. Regaining purposeful motor movements and awareness with preserved memory within a few hours is usually associated with a good recovery and functional independence.

D – If early assessment following HIBI is possible, the outcome worsens if the patient suffers myoclonic seizures.

E - Various biomarkers in the blood or cerebrospinal fluid have been studied in HIBI. A marked elevation in neuron-specific enolase (NSE) and the glial S-100 protein are associated with a poor outcome but there is great variability and the effects of hypothermia are also uncertain. At present biomarkers do not have adequate specificity or sensitivity to be used in assessing the prognosis following HIBI.

Q3. Answers A and D are true.

A – Albumin is available as 4.5% or 20%, is negatively charged promoting its maintenance within the circulation, but is a biological product with a potential risk for infection transmission. A multicentre randomized controlled trial in ICU patients demonstrated safety of 4.5% HAS compared with 0.9% saline in resuscitation. (NEJM 2018; 378:829-39)

B - Gelatins (Gelofusin), synthesized usually from bovine collagen, are still in use. Compared with other colloids, the molecular weight is small leading to a shorter intravascular time (1-2 hours).

C - Starches (hydroxyethylstarch/HES) are moderate molecular weight colloids. They are no longer licensed for use in the UK due to clinical trials comparing crystalloid with HES 6% in ICU populations demonstrating increased need for renal replacement therapy and increased 90-day mortality.

D - Dextrans, due to concerns over coagulopathy and renal failure, are no longer in frequent use.

E - Dextrose/saline solutions can be utilized but with the associated risk of hyponatraemia in large volumes. Dextrose/saline solutions with sodium content below plasma become hypotonic when the glucose is metabolized.





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