2012年度台湾麻醉专科医师甄审题目(欢迎在线自我测试)

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2012年度台湾麻醉专科医师甄审测试，欢迎大家进行自我测试，看看是否具备台湾麻醉专科医师执业水平。笔试题目在线测试地址：试卷(1): 2012年度台湾麻醉专科医师甄审试题 下面为现场口试题目及参考答案。

一、出处: Miller 7th Chap53 p1679-1698 超音波指引在区域麻醉之运用

1. Echo下如何分辨周边神经(10%)

A: 越周边的神经越是Typical honey comb structures ，若是single nerve root 则以hypoechoic structures 呈现。

2. ultrasound transducer manipulation skills (15%)

A: slicing, tilting, compression, rotation

3. 使用ultrasound nerve block之优点 (各15%)

A: 1. More complete block
2. Local anesthetics volume sparing
3. Fewer vascular puncture

4. 举例说明临床实例 以femoral nerve block 说明 (各15%)

1.Surface landmark

2.Ultrasound image of femoral nerve and related anatomy

3.If profunda femoral artery is identifed, is it a proper injection site?

4.注射local anesthetics后如何assess block effect under US image

5.Clinical application of the (femoral) nerve block

Ans:

1.lateral to femoral pulse, best depiction of femoral nerve is from 10cm proximal to 5 cm distal to the inguinal ligment.

2.The nerve: oval or triangular.Femoral nerve is cover by bright fasci iliaca, lateral to femoral artery

3.Transducer is too distal for complete block

4.Tracing the nerve form proximal to distal along the nerve. Local anesthetic surrounds the nerve after injection.

5.Ex: Postoperative analgeisa for total knee replacement, BK amputation.

2.出处: Miller 7th Chap 52 当执行神经阻断时如何减少并发症之发生及发生后之因应？

(以下为参考答案,请考官以逻辑性考虑答案的适当性与否)

ANS

(1)Measures to minimize risk of toxicity from neural blockade (40 %)


Patient evaluation


Identification of significant systemic disease, age, and other factor, to permit individualization of local anesthetic dose


Premedication


Preparation


Resuscitative drugs


Equipment


Ensure adequate IV available


Prevention


Personally check dose of local anesthetic and vasoconstrictor


Use effective test dose and incremental injection with repeated aspiration thereafter


Monitor cardiovascular sign


Constant verbal contact with patient past time of peak plasma concentration

(2)Treatment of acute local anesthetic toxicity (60%)


Airway patency


Breathing :


Oxygen with face mask


Encourage adequate ventilation (avoid↑ CO2↓O2) acidosis which potentiate cardiotoxicity


Artificial ventilation, if required


Circulation


Elevate legs


Increase IV fluids if ↓BP


CVS support drug if ↓BP persists or ↓HR


Drugs


Anticonvulsant


Muscle relaxant:


CVS support

Treat arrhythmias using standard life support protocols and consider lipid infusion (若能说出intralipid 的使用及剂量尤佳, 剂量如下)

(3)Recommendations for the use of intralipid in local anesthetic-induced cardiac arrest unresponsive to standard resuscitation procedures

1.Bolus of intralipid 20% 1.5 ml/kg over 1 minute

2.Infusion of intralipid at a rate of 0.25 ml/kg/min

3.Chest compressions ( lipid must circulate)

4.Repeated bolus of intralipid 20% every 3 to 5 minutes, up to 3 ml/kg total dose until circulation is restored

5.Intralipid infusion continued until hemodynamic stability is restored and infusion rate increased to 0.5 ml/kg/min if the BP declines

6.A maximum total dose of 8 ml/kg is recommended

3.出处: Miller 7th 一位50岁男性，2年前接受了心脏移植手术。因车祸造成右侧胫骨开放性骨折，紧急安排骨折固定手术。请问有何麻醉注意事项？

1. 免疫抑制剂可能造成何种影响？

2. 心血管药物的反应有何不同？

3. 全身/半身麻醉的考虑分别为何？

Ans.

Post-heart transplantation:

免疫抑制剂可能造成何种影响？(30%)


Early: sepsis and rejection (needing transvenous RV endomyocardial biopsy)


Late: allograft CAD and increased incidence of cancers


Appropriate aseptic technique

心血管药物的反应有何不同？(50%)


No sympathetic, parasympathetic, or sensory innervation (no angina)


No vagal effecthigher HR; no effect to carotid sinus massage and Valsalva maneuver


HR responding to circulating catecholamine: epinephrine, isoproterenol, dobutamine


BP responding to Frank-Starling law: Preload vs CO
(dopamineNorEpiEpi)


Atropine is ineffective; pancuronium has no vagolytic effects.

全身/半身麻醉的考虑分别为何？(20%)


GA is usually selected due to impaired response to hypotension after SA or EA.


Immunosuppression  skin aseptic technique during spinal anesthesia

4.出处: 2011年ASA Refresh course P.134-141 一位怀孕妇女，预定进行阑尾切除术，请就怀孕前期/中期/后期，试描述怀孕期间有何可能的生理变化与麻醉处置/考虑。

Ans: Goal: Safety of 2 patients: mother and fetus

I.Maternal safety

	怀孕生理变化(40%)	临床麻醉注意事项(20%)
Respiratory	(10%)↑minute ventilation, O2 consumption; ↓FRC, residual volume Edema of larynx and trachea	(5%) PreoxygenationDiffucult intubationSmaller ET
CV	(10%)↑CO, ↓SVRAortocaval compression	(5%) Supine hypotension syndrome
GI	(10%)↓gastroesophageal sphincter tone↑gastric pressure	(5%) Aspiration pneumonia
CNS	(10%)↑sensitivity to regional and general anesthesia	(5%) ↓MAC

II.Fetal safety

避免uteroplacental perfusion↓、maternal hypoxia and hyperventilation

1.维持uteroplacental perfusion (20%)ü
避免hypotension: uterine displacement, fluid bolus, trendelenberg position, vasopressor, leg elevationü
避免术中uterine contraction

2.Teratogenicity

5.出处: Miller 7th 简述如何治疗malignant hyperthermia

Ans.

※治疗方式大致可分为三大原则

1.移除所有可能引发恶性高热之物质。

2.针对病患出现之症状给予症状治疗，以减轻体内器官之伤害。

3.尽速给予缓解恶性高热之特效药-Dantrolene。※
恶性高热处理步骤

1.求救。因为处理恶性高热需要很多人手之协助。

2.停止所有可能的诱发物质，包括吸入性麻药、肌肉松弛剂等等。同时，在不影响其它急救处置的前提下，更换清洁的管路及呼吸器。

3.增加病人之换气量，以排除体内过多之二氧化碳，至少10 L/min，并提供病患100% 之氧气。

4.尽快结束手术。

5.尽速给予缓解药物-Dantrolene

i.注射部位：最好是中央静脉，以避免周边血管栓塞。

ii.药物稀释：每瓶药物含20毫克Dantrolene，必须与60毫升的稀释液混合。

iii.起始剂量：2~3毫克/公斤快速输入，视症状缓解程度 (例如Hypercarbia, rigidity, tachycardia, fever) 每5分钟追加，总剂量可至10 毫克/公斤。

6.以各种方式降低病人之体温，包括从静脉输入冷的点滴溶液，以冷水冲洗病患体腔，在病患的体表放置冰袋，降低温毯之温度等。

7.监测体内酸血症之现象，在必要的情况下给予碱性药剂（NaHCO3）矫正酸化现象。若缺少动脉气体分析数据，可给予1~2 mEq/kg NaHCO3。

8.治疗心率不整之现象。如已注射 Dantrolene，绝对避免使用钙离子阻断剂。

9.尽量增加尿量，维持每小时每公斤大于两毫升以上，必要时可给予利尿剂。注意！每瓶 Dantrolene 已含3 gm mannitol，最好有中央静脉导管或肺动脉导管监测体液状态。

10.治疗高血钾。处置方法：增加换气量、注射NaHCO3、葡萄糖溶液及胰岛素 (10 units regular insulin in 50 mL 50% glucose)、补充钙离子 (10~30 mg/kg of IV calcium chloride)。

11.持续监测至少二十四到四十八小时，项目有：EtCO2、CVP、ABG、K+、Ca2+、CK、serum and blood myoglobin、thyroid function、urine output、clotting factors and blood cultures。※
恶性高热亚急性期后之处置

1.恶性高热可能再复发，加护病房之观察至少24小时。

2.Dantrolene急性期后1~2天，每6小时静脉注射，1 mg/kg。

3.中央体温须持续监测，直到正常且稳定。

4.每6小时测量ABG、K+、Ca2+、CK、serum and blood myoglobin、urine output、clotting factors, 直到正常且稳定。

5.与病患及其家人作完整的谘商及说明，告知恶性高热的家族关联性，以及未来注意事项。

6.出处: Miller 7th Chap46 1478-1480 请叙述在头部外伤（head-injured）病人中，使用SjvO2 (Jugular venous oxygen saturation)之(1)原理、(2)限制、(3)麻醉状况下可改善SjvO2的措施、(4)试举例其它非侵入性之脑部组织氧气血流侦测仪，并说明其原理。

(1)1.A marginal or inadequate CBF results in an increasing oxygen extractraction, a widening arteriovenous content difference, and reduction of SjvO2

2. Normal subjects at rest may have SjvO2 values between 55％~75％，SjvO2＜ 50％ for 5 mins is considered as constitutering “jugular desaturation”

(2)是一个global oxygen extraction assessment，但对于focal event的sensitivity 不足，另外2侧（左侧、右侧）同时测出的SjvO2平均差异在5.3正负5％，而side-to-side difference达15％亦非常常见

(3)使用reducing hyperventilation，increasing MAP， inducing hypervolemia

(4)1.Transcranial Doppler Ultrasound TCD:TCD可monitor middle cerebral artery flow.

　2.Cerebral oximetry

Two sensors on frontal brain through skull/scalp反应local venous oxygen
saturation.

7.出处: Miller 7th　Chap34 一位60岁，158cm，95kg的肥胖病人来到体检中心，准备接受无痛胃镜大肠镜检查。你（妳）是麻醉医师，请问如何处置？

Ans：

History Taking (20%)：

OSAS？BMI？Morbid obesity?

临床症状：持续性的白天昏睡等等

容易引发高血压、肺高压、左心室肥厚、心律不整、认知功能障碍

故病史询问内容应包含是否有上述病态或疾病

OSAS definition (20%)：

lCharacterized by recurrent episodes of upper airway obstruction occurring during sleep

lDefinition:

üOSA: Obstructive sleep apnea is defined as complete cessation of airflow during breathing lasting 10 seconds or longer despite maintainance of neuromuscular ventilatory effort and occurring five or more times per hour of sleep, accompanied by a decrease of at least 4% in SaO2(> 10”; ≧5 times/h; SaO２至少下降4%)

üOSH: Obstructive sleep hypopnea is defined as partial reduction of airflow of greater than 50% lasting at least 10 seconds, occurring 15 or more times per hours of sleep, and accompanied by a decrease of at least 4% in SaO2
(Airflow decrease > 50%; >10”; ≧15 times/h; SaO２至少下降4%)

诊断(10%)：

Only by polysomnography (sleep study): EEG, EKG, EOG, ETCO2, Nasal or oral airflow esophageal pressure, BP, pharyngeal and extremity EMG, pulse oximetry, room noise (monitored and recorded)
Result of polysomnography:

lAHI＝apnea/hypopnea index

lNormal AHI: 5~10 events/h

lMild AHI: 5~15 events/h

lModerate AHI: 15~30 events/h

lSevere AHI: >30events/h

治疗(10%)：中度到重度须治疗

方法：70%的肥胖病人有OSAS男：80%. 女：50%

１．CPAP during sleep

２．减重

３．睡前避免饮酒

４．侧睡

麻醉考虑及处置(40%)：

１．呼吸道评估

２．困难呼吸道装备之准备

３．氧气设备

４．取消此检查？或小量逐次给药(考虑ketamine or midazolam + alfentanil)

５．恢复室密切照顾

8.出处: Miller 7th　眼科手术可能诱发Oculocardiac Reflex，何谓 Oculocardiac Reflex？(20%)

试述其症状(20%)、好发族群(10%)、此反射讯息如何神经传导(afferent and efferent conduction)(20%)、哪些不当临床照护会加剧症状(10%)、如何处置(10%)、如何降低发生率(10%)

参考答案

何谓 Oculocardiac Reflex

Traction on the extraocular muscles [esp. medial rectus muscle (5%)] or pressure on the eye globes (and sometimes anything else of the orbital contents, including the periosteum) causes serial cardiac respone. (15%)

有哪些症状 (20%)

bradycardia,

atrioventricular block,

ventricular ectopy

or rarely asystole.

好发哪些族群 (10%)

patients with a history of conduction block,

patients with a history of vasovagal responses,

patients with β-blocker therapy.

反射讯息如何神经传导

The reflex is trigeminovagal. (10%, 详细回答以下机制 +10%)

Afferent pathway: orbital stimulation → ciliary ganglion → ophthalmic division of the

trigeminal nerve
→ trigeminal nucleus near the fourth ventricle.

Efferent pathway: vagus nerve
→the heart

哪些因素会加重临床症状(10%)

The response is exacerbated by hypercapnia or hypoxemia.

如何处置(10%)

Stop manipulations.

Assess patient’s ventilatory status

Intravenous atropine is administered in 7 g/kg increments, if significant bradycardia persists or recurs.

如何降低发生率(10%)

Pretreatment with intravenous atropine or glycopyrrolate

Retrobulbar block

9.出处: Miller 7th P.2774-2775试述长期使用吗啡类止痛药物的病人接受术后止痛控制之处理原则？

1.如何评估 ( 30 %)

2.计划拟定 (30 %)

3.若是addiction的病人如何处置？(10%)

4.剂量使用及分配 (15 %)

5.出院前之剂量转换工作 (15 %)

Anes:

1. (A). Pain control要处理两个主要问题维持原先术前所需的basal requirment，以及手术带来的incisional pain

(B) 通常病人亦会有high self-reported pain scores的现象, 可预期此类病人对opioid会有一定程度的tolerant；

(C) 要有concept，此时来讨论detoxification是不恰当的时机,

2. (A). 医师应尽早拟定计划与病人、外科team、护理人员一起讨论取得共识, 须有increased in post-operative analgesic requirement的心理准备

(B). 善用(合并使用)adjuvant drugs

(C). 考虑使用regional analgesias的可能性

3. 方向等同于chronic pain with chronic use of opioid or opioid-tolerant patient 不要惧怕 OPIOIDS 使用

4. 尽量少用PRN的order，50~100%的basal opioid requirement使用continuous requirement

5. 稳定后开始朝oral及sustained release制剂(Fentanyl patch)转换(至少50~75%), 其它转换成short-acting opioid for PRN rescue dose

10.出处: Miller 7th P.1097　试问美国American Heart Association/American College of Cardiology关于术前曾接受Percutaneous coronary intervention﹙PCI﹚病患麻醉处置上的建议流程：

1. 说出三种PCI的种类﹙一个3%，三个10%﹚

2. 根据三种PCI，4个参考日程所组成的6种状况及其建议处置﹙每种状况15%﹚﹙总共100%﹚

Ans：

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lbhss

人家考试是以第7版米勒为基础，而我们考试是以好多参考书为准，答案不统一，有差距哦

我是神仙

逼玩样儿！看不懂，怎么答！！！

wjsmz

我们也要有规范培训！

安子尘

额，好吧，米勒麻醉学

刁洁冰

都以米勒麻醉学为基础啊？他们学的都是米勒麻醉学？我们学的教材难道没用么？有难度！还得学英语啊

刘澄清

有难度，还得好好学习努力。 还得学英语啊:kiss:
，好吧，米勒麻醉学