ANZCA Final Examination: Clinical Decisions and Applied Practice Study Guide

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A patient with limited respiratory reserve needs painful surgery. Compare analgesic benefit, ventilation risk and available postoperative observation, then state which risk determines your technique and what deterioration would trigger escalation to a higher level of care.

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A professional singer is particularly concerned about voice changes after airway instrumentation. Explain the airway options and relevant risks in accessible terms, explore acceptable alternatives and document how this concern influenced the shared anaesthetic decision.

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A patient arrives in recovery with increasing bilateral leg weakness and new back pain during epidural analgesia. Communicate the baseline examination, progression, drug and anticoagulant exposure, and explicitly transfer ownership of urgent spinal imaging and specialist assessment.

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During rapidly rising carbon dioxide and rigidity after triggering anaesthesia, announce suspected malignant hyperthermia. Assign separate clinicians to obtain dantrolene, manage ventilation, contact additional support and record events while you coordinate reassessment and the response.

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A rural patient reports unreliable transport and difficulty understanding written medication instructions. Arrange an understandable preparation plan and coordinated follow-up, then check that travel and support arrangements permit the proposed timing and postoperative care to occur.

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In a hypothetical trial, complications occur in 12% of controls and 8% of treated patients over 30 days. Calculate a four-percentage-point absolute reduction and an NNT of 25, then explain the outcome and follow-up period to a patient.

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A hypothetical study reports a complication risk ratio of 0.80 with a 95% confidence interval of 0.45–1.40. Explain that the estimate favours benefit but remains compatible with substantial benefit or harm, making a confident efficacy claim unjustified.

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Before any sedative is given, a competent adult in a New Zealand theatre clearly withdraws consent for an elective procedure. Pause preparation, clarify their concerns and inform the procedural team that the intervention cannot proceed on the earlier consent.

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An incorrectly selected syringe is recognised immediately after injection. Identify its contents and administered amount, assess the patient and institute appropriate monitoring, then document the event and arrange transparent communication and a review of how selection failed.

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A department reviews whether quantitative neuromuscular recovery is documented before extubation. Define eligible cases and the monitoring standard, measure compliance, introduce a practical workflow change and repeat measurement using the same definitions to evaluate the effect.

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A patient has restricted mouth opening, progressive upper-airway symptoms and limited access for emergency rescue. Explain why preserving spontaneous ventilation during airway securing may be preferable, and prepare a supported awake approach with an explicit unsuccessful-attempt plan.

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After major chest and pelvic trauma, a patient loses cardiac output with substantial bleeding and suspected tension pneumothorax. Allocate simultaneous haemorrhage control, volume restoration, airway support and chest decompression; chest compressions must not prevent these interventions. A witnessed collapse before a minor collision would instead raise suspicion of a primary medical arrest.

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A tube has been advanced over an awake flexible scope, but the operator did not clearly see its final position. Keep the patient awake, obtain visual confirmation and establish an appropriate capnographic trace before administering induction medication.

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Three attempts have failed during an elective case. Maintain oxygenation and reassess with a more experienced operator, who may make one further attempt if conditions remain suitable. If that fails, or trauma makes another attempt unsafe, stop instrumentation and consider postponement rather than automatically inducing anaesthesia.

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After a gas-delivery adjustment, the inspired-oxygen alarm sounds while saturation remains normal. Check the delivered mixture and breathing system promptly; do not wait for saturation to fall before addressing the abnormal oxygen concentration reaching the patient.

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Immediately after repositioning an intubated patient, the capnogram disappears. Check the patient, tube and circuit while ensuring ventilation, then assess sampling equipment and circulation according to the accompanying findings rather than attributing the change to an alarm fault.

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After rocuronium, a patient follows commands but has a reliable adductor-pollicis electromyographic ratio of 0.72. Continue ventilation support, manage residual blockade according to its depth and prior reversal, and confirm a ratio of at least 0.9 before extubation. A reassuring facial-muscle response should not override the appropriate recovery-site measurement.

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During procedural sedation, a patient stops responding meaningfully and requires repeated airway support. Recognise the deeper-than-intended state, stop further sedative administration and institute airway and ventilation support with appropriate assistance rather than continuing under the original label.

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A patient with multiple comorbidities is booked for major elective surgery, and the first assessment reveals unresolved symptoms. Arrange timely evaluation while there is opportunity to change preparation, and ensure the treating anaesthetist reviews subsequent findings before proceeding.

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An asymptomatic patient with good exercise tolerance is scheduled for a low-risk noncardiac procedure. Explain why routine stress testing would add little. Contrast this with a higher-risk patient whose result could change the operation or cardiovascular management.

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A patient scheduled for elective abdominal surgery reports new orthopnoea and worsening breathlessness with evidence of congestion. Treat this as a possible active cardiac problem requiring assessment and management, rather than relying on an older reassuring preoperative review.

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After laparotomy, an adult receiving paracetamol remains painful on movement and increasingly drowsy with opioid escalation. Acute kidney injury and previous NSAID-induced bronchospasm make an NSAID unsuitable. Assess ventilation immediately and withhold further opioid while drowsiness is evaluated. Once stable, an acute pain service can introduce monitored low-dose ketamine. Reassess coughing, mobilisation, opioid requirement, sedation, ventilation and adverse effects.

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A patient reports mild pain at rest but cannot cough or sit out of bed after abdominal surgery. Assess pain during these activities and revise analgesia around recovery goals, while checking whether treatment causes sedation or impairs ventilation.

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Several hours after initially comfortable recovery, a patient develops rapidly increasing pain with a new abnormal examination finding. Seek urgent clinical and surgical review while supporting comfort, rather than treating the change solely as an insufficient opioid prescription.

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A patient used little opioid during the final postoperative day and is functioning well with other analgesia. Base discharge treatment on that trajectory, explain when and how to reduce use and communicate responsibility for review if pain persists.

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Before a regional technique for lower-limb surgery, a patient describes longstanding foot numbness. Characterise and document the distribution and motor findings, discuss their relevance and ensure postoperative assessors can distinguish the baseline problem from a new change.

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Increasing bilateral weakness and new radicular pain develop during epidural analgesia. Review or suspend the infusion as appropriate, document the neurological examination and activate urgent spinal imaging and specialist management. Do not wait for block regression before investigating suspected compression; an abscess may also present days after the procedure.

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A patient needing urgent abdominal surgery took a direct factor Xa inhibitor recently and has impaired renal function. Do not insert the proposed thoracic epidural merely because INR is normal. Establish drug, timing and renal function, consider an appropriate drug-specific assay, and use an anaesthetic and multimodal analgesic plan avoiding an unsafe neuraxial puncture if clinically significant anticoagulant activity remains.

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During a regional procedure, a patient develops a seizure followed by circulatory instability shortly after local anaesthetic injection. Stop administration, summon help and initiate the LAST response rather than assuming the event is an unrelated primary seizure disorder.

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For an adult with suspected LAST, distinguish cardiac arrest requiring CPR from hypotension with a perfusing circulation. The pilot's fixed 1 mg dose applies to adult arrest; it must not be imported into treatment of hypotension with a pulse. An explicitly ASRA-based response follows its smaller starting adrenaline recommendation. Identify the adopted protocol while coordinating lipid rescue and resuscitation. Children require an age-appropriate protocol; ANZCOR paediatric arrest adrenaline dosing is weight based.

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Soon after administration of a perioperative medication, an intubated patient develops profound hypotension and bronchospasm without a visible rash. Treat suspected anaphylaxis promptly while assessing other causes, rather than requiring skin findings before starting appropriate resuscitation.

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During volatile anaesthesia, end-tidal carbon dioxide rises despite increased ventilation and generalised rigidity appears. Activate the malignant hyperthermia response, stop triggers and obtain dantrolene immediately rather than waiting for temperature to reach an extreme value.

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A trauma patient remains hypotensive with continuing internal bleeding despite initial resuscitation. Activate the major haemorrhage protocol, expedite operative or interventional control and coordinate blood components. Repeated crystalloid or escalating vasopressors alone cannot replace the required haemorrhage-control strategy.

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Two syringes have similar appearance but different drugs and concentrations. Read and verify the selected syringe against the intended medication and route immediately before administration, rather than relying on its position in the tray or familiar label colour.

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During major transfusion, ongoing bleeding accompanies fibrinogen 1.1 g/L and ionised calcium 0.8 mmol/L. Arrange fibrinogen replacement and calcium correction within the haemorrhage protocol while continuing source control and blood-component support.

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A patient remains intubated after a complicated procedure and requires transfer to intensive care. Confirm suitable transport monitoring, ventilation support, trained accompaniment and receiving-team readiness before leaving theatre, with an explicit handover of current problems and treatment.

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On bypass, MAP appears acceptable after vasoconstrictor treatment, but venous oxygen saturation falls and lactate rises. With the perfusionist, reassess pump flow, haemoglobin, oxygenation and oxygen demand instead of assuming a higher MAP has corrected delivery. This develops Appendix Five outcome SS_CS 1.17 on care during cardiopulmonary bypass.

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During a catheter intervention, an organised rhythm persists but the arterial waveform collapses and no effective pulse is present. Announce PEA, start CPR and the non-shockable pathway, and coordinate assessment for reversible procedural causes. This develops Appendix Five outcome SS_CS 1.27 on major interventional cardiology complications.

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During upper gastrointestinal endoscopy, a sedated patient becomes unresponsive with ineffective breathing. Stop further sedative delivery, coordinate withdrawal of the endoscope as needed and restore airway patency and ventilation with assistance rather than prioritising completion of the examination.

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After laparotomy with intrathecal morphine, a patient becomes drowsy after systemic opioid rescue. Withhold further opioid, assess and support ventilation, and obtain urgent anaesthetic review. Reassess the pain cause and total opioid exposure before choosing further treatment.

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A patient with a head and neck lesion has progressive breathing symptoms and restricted oral access. Review the available airway information with the surgeon, compare routes and rescue options, and justify whether securing the airway awake offers a safer sequence.

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After a brief ECT session, a patient remains weak with inadequate spontaneous ventilation. Continue airway and ventilation support and investigate residual drug effects. Identify which relaxant was used and interpret monitoring accordingly, rather than transferring because the treatment itself is finished.

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An adult with ARDS weighs 120 kg but has a supplied predicted body weight of 60 kg. Calculate an initial tidal volume of approximately 360 mL at 6 mL/kg predicted body weight, then reassess pressures and gas exchange.

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A patient with severe ARDS receives low predicted-body-weight tidal volumes but remains severely hypoxaemic. Review plateau pressure and the overall ventilation strategy, and assess suitability for prolonged prone positioning rather than escalating tidal volume simply to improve the oxygen number.

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A patient with severe traumatic brain injury has a mean arterial pressure of 85 mmHg and intracranial pressure of 25 mmHg. Calculate CPP as 60 mmHg and consider both systemic pressure and intracranial pathology when assessing the next intervention.

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A patient has CPP of 66 mmHg, but a proposed plan would use substantial additional fluid and vasopressors to reach 85 mmHg. Question the routine escalation and assess the cerebral and systemic indications rather than assuming the higher target is protective.

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A patient becomes hypotensive while supine for caesarean delivery. Ensure effective uterine displacement while assessing the anaesthetic, bleeding and other circulatory factors, and treat haemodynamic compromise according to the complete clinical picture rather than positioning in isolation.

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A stable patient with a functioning epidural requires caesarean delivery without immediate life-threatening urgency. Compare extending the established neuraxial technique with alternatives, incorporating adequacy, contraindications and the patient's preference rather than treating the surgical label as an automatic indication for general anaesthesia.

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During strabismus surgery, heart rate falls abruptly when muscle traction begins and improves when traction stops. Identify the stimulus-linked reflex and coordinate release before resuming surgery. This directly develops Appendix Five outcome SS_OP 1.3 on eye reflexes and their management.

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A patient with glaucoma becomes hypotensive during eye surgery while intraocular pressure is elevated. Recognise that both changes threaten the perfusion gradient; correct systemic hypotension and coordinate ophthalmic assessment of the raised intraocular pressure. This develops Appendix Five outcome SS_OP 1.2 on ocular perfusion and intraocular pressure.

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After tibial fracture fixation, pain rises sharply after an initially effective peripheral block and the operated leg becomes increasingly swollen. Seek immediate orthopaedic assessment for a limb complication while providing monitored analgesia. Assess the compartment and neurovascular findings rather than assuming catheter failure and giving another local anaesthetic bolus.

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An adult with a crushed lower limb develops a widening QRS and potassium of 7.2 mmol/L. Start monitored hyperkalaemia treatment, including myocardial protection and intracellular potassium shift, while treating associated trauma. Repeat ECG, potassium and glucose measurements and arrange definitive potassium removal if the response is inadequate.

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A five-week-old infant has ultrasound-confirmed pyloric stenosis, dehydration, chloride 82 mmol/L and bicarbonate 39 mmol/L. Establish IV treatment and repeat biochemical assessment rather than proceeding immediately because the diagnosis is confirmed. This develops Appendix Five outcome SS_PA 1.76 on anaesthesia for pyloromyotomy.

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A haemodynamically stable postoperative child cannot drink and has no measured deficit. Prescribe maintenance separately from any future loss replacement; do not give repeated resuscitation boluses for maintenance. Reassess whether illness warrants less than full maintenance. This develops Appendix Five outcome SS_PA 1.68 on paediatric IV fluid requirements and selection.

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A patient undergoing repeated burns dressing procedures reports severe anticipatory distress and prolonged drowsiness after the previous session. Review both experiences with the patient and team, then adjust the next analgesic plan rather than repeating the same regimen automatically.

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During an eight-hour reconstruction, vasopressor requirements increase while serial haemoglobin falls and lactate rises. Ask the surgical team to reassess blood loss across the operative fields, evaluate circulation and arrange appropriate blood support and haemorrhage control. If bleeding becomes critical, activate the major haemorrhage pathway rather than escalating vasopressor alone.

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After lateral positioning for thoracic surgery, a patient develops poor ventilation and hypoxaemia during one-lung ventilation. Support oxygenation and assess the lung-isolation device bronchoscopically as part of the immediate evaluation rather than assuming the original position remains correct.

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A thoracic list is ready to start, but the only suitable bronchoscope is unavailable in another department. Resolve immediate equipment access and skilled support before relying on a lung-isolation technique that may require urgent bronchoscopic confirmation or correction.

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During open aortic repair, proximal pressure rises after clamping while a patient with impaired ventricular function develops evidence of poor output. Assess ventricular performance and loading conditions rather than treating the pressure rise as proof of improved circulation. This develops Appendix Five outcome SS_VS 1.9 on clamping physiology and anaesthetic implications.

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Pressure falls immediately after aortic unclamping. Coordinate controlled release and circulatory support while assessing filling, ventricular function and surgical bleeding. Vasodilatation may require vasoactive support; actual blood loss requires replacement and control. This develops Appendix Five outcome SS_VS 1.9 rather than treating all post-release hypotension as the same mechanism.