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Year 6 Anaesthetics/ITU Revision ANAESTHETICS CT3Plan for evening Example MCQ questions Core topics in anaesthesia and intensive care medicine from UKMLA content map Not covered – OSCE revisionLearning objectives Recognise and explain the initial management for acute or emergency conditions presenting in anaesthesia and intensive care Explain the ASA grading system Recognise drugs used in anaesthesia and intensive care Perform a medicine reconciliation and be aware of drugs to stop in the peri-operative periodQuestion 1 A nurse on the ward asks you attend immediately as her patient has become unwell following administration of antibiotics. He is audibly wheezy and blood pressure is unrecordable. What is the most appropriate treatment? A – IV Hydrocortisone 100mg B – IV Adrenaline 50 mcg C – IV Chlorphenamine 4mg D – IM Adrenaline 500 mcg E – IM Adrenaline 50 mcgQuestion 1 A nurse on the ward asks you attend immediately as her patient has become unwell following administration of antibiotics. He is audibly wheezy and blood pressure is unrecordable. What is the most appropriate treatment? A – IV Hydrocortisone 100mg B – IV Adrenaline 50 mcg C – IV Chlorphenamine 4mg D – IM Adrenaline 500 mcg E – IM Adrenaline 50 mcgAnaphylaxis Type I hypersensitivity reaction Clinical features Primarily IgE mediated ◦ Hypotension ◦ Bronchospasm degranulation + release of ◦ Tachycardia inflammatory mediators ◦ Cardiovascular collapse + cardiac arrest Common triggers ◦ Urticarial rash ◦ Antibiotics ◦ Latexmuscular blocking agents ◦ Chlorhexidine ◦ Contrast, dyes ◦ HeparinQuestion 2 You are the FY1 on the cardiac arrest team overnight. You are called to a cardiac arrest. The patient has had a witnessed cardiac arrest with initial rhythm of Ventricular Fibrillation, he has received one DC shock of 160 J. At the next rhythm check the monitor shows Ventricular Fibrillation. Chest compressions are restarted. What is the next step in management? A – Give 300mg Amiodarone IV B – Give Atropine 600 mcg IV C – Give 1mg Adrenaline IV D – Give shock at 200 J E – Check rhythm in 2 minutesQuestion 2 You are the FY1 on the cardiac arrest team overnight. You are called to a cardiac arrest. The patient has had a witnessed cardiac arrest with initial rhythm of Ventricular Fibrillation, he has received one DC shock of 160 J. At the next rhythm check the monitor shows Ventricular Fibrillation. Chest compressions are restarted. What is the next step in management? A – Give 300mg Amiodarone IV B – Give Atropine 600 mcg IV C – Give 1mg Adrenaline IV D – Give shock at 200 J E – Check rhythm in 2 minutesQuestion 3 You are the FY1 covering the stroke ward. You are bleeped to review a patient who is complaining of dizziness. When you arrive the obs show a HR of 34 and BP of 75/40 and ECG is as shown. What is the most appropriate management? A – Atropine 500mcg IV B – Adrenaline 100 mcg IV C – Adrenaline 500 mcg IM D – Synchronised DC Cardioversion E – 500ml PlasmalyteQuestion 3 You are the FY1 covering the stroke ward. You are bleeped to review a patient who is complaining of dizziness. When you arrive the obs show a HR of 34 and BP of 75/40 and ECG is as shown. What is the most appropriate management? A – Atropine 500mcg IV B – Adrenaline 100 mcg IV C – Adrenaline 500 mcg IM D – Synchronised DC Cardioversion E – 500ml PlasmalyteQuestion 4 A 23 year-old female presents for an elective laparoscopy. She has never previously had surgery. During the procedure it is apparent that her EtCO2 is high and it becomes increasingly difficult to maintain within a normal range. She is also becoming progressively tachycardic and dysrhythmic. Underneath the drapes she is found to be sweating profusely. What is the most likely diagnosis? A – Sepsis B – Serotonin syndrome C – Neuroleptic malignant syndrome D – Malignant hyperthermia E – Inadequate depth of anaesthesiaQuestion 4 A 23 year-old female presents for an elective laparoscopy. She has never previously had surgery. During the procedure it is apparent that her EtCO2 is high and it becomes increasingly difficult to maintain within a normal range. She is also becoming progressively tachycardic and dysrhythmic. Underneath the drapes she is found to be sweating profusely. What is the most likely diagnosis? A – Sepsis B – Serotonin syndrome C – Neuroleptic malignant syndrome D – Malignant hyperthermia E – Inadequate depth of anaesthesiaMalignant Hyperthermia Progressive, life-threatening hyperthermic reaction occurring during general anaesthesia Inherited condition, autosomal dominant Incidence of 1:50,000 – 1:70,000 in UK Mortality is 4% Triggers include Suxamethonium + volatile (inhaled) anaesthetic agents (Sevoflurane, Isoflurane, Desflurane, Halothane) muscle rigidity clinical features = rise in EtCO2, tachycardia, rise in core body temperature and Treatment is with DantroleneQuestion 5 You are the obstetric FY1 covering labour ward overnight. You are asked urgently to review a patient who has very recently had an epidural sited. She has just received a top up of her epidural and stated she heard a loud ringing in her ears. As you arrive she has had a seizure and is now unconscious. She has a strong palpable pulse. What is the appropriate management? A – 20% Lipid emulsion B – Lorazepam C – Levetiracetam D – Midazolam E – NaloxoneQuestion 5 You are the obstetric FY1 covering labour ward overnight. You are asked urgently to review a patient who has very recently had an epidural sited. She has just received a top up of her epidural and stated she heard a loud ringing in her ears. As you arrive she has had a seizure and is now unconscious. She has a strong palpable pulse. What is the appropriate management? A – 20% Lipid emulsion B – Lorazepam C – Levetiracetam D – Midazolam E – NaloxoneLocal anaesthetic toxicity Systemic absorption or direct IV injection of LA Comprises of various neurological and cardiovascular features CNS toxicity ◦ Excitatory stage -> depressive stage ◦ Perioraltingling, tinnitus, slurred speech, generalized seizures, coma Cardiovascular toxicity ◦ Hypertension + tachycardia ◦ Myocardial depression + hypotension ◦ Peripheralvasodilation, profound hypotension + arrhythmias Treatment – manage ABC and start CPR if cardiac arrest ◦ 20% Lipid emulsion = IntralipidQuestion 6 A 23 year-old male is brought to resus following a road traffic accident, there are concerns regarding head, chest and lower limb injuries. On arrival following a painful stimulus his eyes remain closed, he is grunting and his right arm moves to the area of stimulation. What is his GCS score? A – 6 B – 7 C – 8 D – 9 E – 10Question 6 A 23 year-old male is brought to resus following a road traffic accident, there are concerns regarding head, chest and lower limb injuries. On arrival following a painful stimulus his eyes remain closed, he is grunting and his right arm moves to the area of stimulation. What is his GCS score? A – 6 B – 7 C – 8 D – 9 E – 10Head injuryQuestion 7 A 45 year-old male is brought to A&E resus having been found on the street unresponsive. On arrival his airway is being maintained with jaw thrust and oropharyngeal airway, RR is 8 with SpO2 98% on 15L NRBM, HR 66, BP 114/63, GCS is 3 with pinpoint pupils and T 35.9. He receives 3x 400mcg Naloxone, however GCS remains 3. What is the most appropriate next step in management? A – Flumazenil B – Rapid sequence induction C – Sodium bicarbonate D – Insert nasopharyngeal airway E – Further dose of NaloxoneQuestion 7 A 45 year-old male is brought to A&E resus having been found on the street unresponsive. On arrival his airway is being maintained with jaw thrust and oropharyngeal airway, RR is 8 with SpO2 98% on 15L NRBM, HR 66, BP 114/63, GCS is 3 with pinpoint pupils and T 35.9. He receives 3x 400mcg Naloxone, however GCS remains 3. What is the most appropriate next step in management? A – Flumazenil B – Rapid sequence induction C – Sodium bicarbonate D – Insert nasopharyngeal airway E – Further dose of NaloxoneAirway management Head tilt, chin lift Jaw thrust Nasopharyngeal airway ◦ Sizing ◦ Contraindications + cautions Oropharyngeal airway ◦ Sizing Supraglottic airways ◦ LMA ◦ iGel Endotracheal tube ◦ RSI TracheostomyQuestion 8 A 35 year-old male is brought to A&E resus following a fall from height. He is conscious, talking in full sentences, breath sounds are normal throughout, SpO2 98% on 4L, RR 20. He is warm peripherally with CRT <3s and HR 41, BP 70/40, heart sounds are normal. His abdomen is soft and non tender, with a bruising to his right flank and chest wall. He is GCS 15 and is unable to move his legs. There is marked deformity of both ankles. What is the most likely cause of his low blood pressure? A – Septic shock B – Anaphylactic shock C – Cardiogenic shock D – Hypovolaemic shock E – Neurogenic shockQuestion 8 A 35 year-old male is brought to A&E resus following a fall from height. He is conscious, talking in full sentences, breath sounds are normal throughout, SpO2 98% on 4L, RR 20. He is warm peripherally with CRT <3s and HR 41, BP 70/40, heart sounds are normal. His abdomen is soft and non tender, with a bruising to his right flank and chest wall. He is GCS 15 and is unable to move his legs. There is marked deformity of both ankles. What is the most likely cause of his low blood pressure? A – Septic shock B – Anaphylactic shock C – Cardiogenic shock D – Hypovolaemic shock E – Neurogenic shock Shock Shock is characterized by decreased oxygen delivery and/or increased oxygen consumption or inadequate oxygen utilization leading to cellular and tissue hypoxia. Septic shock – inadequate end-organ perfusion in the setting of acute infection due to systemic vasodilation and capillary dysfunction Anaphylactic shock – inadequate end-organ perfusion in the setting of anaphylaxis due to systemic vasodilation and capillary dysfunction myocardial infarction, severe cardiac failuresion in the setting of reduced cardiac output due to cardiac pathologye.g. acute Neurogenic shock – inadequate end-organ perfusion in the context of central/spinal neurological injury due to loss of sympathetic tone Hypovolaemic shock – inadequateend-organ perfusion in the context of intra-vascular depletion, most commonly severe dehydration or bleedingQuestion 9 A 64-year old female is brought to A&E resus with suspected urosepsis. Initial observations include HR 110 and BP 72/35. Her lactate is 5 and her urine output is 10ml/h. Blood cultures are taken. She is given 4L IV fluids and started on Gentamicin. Following the above her HR is 100 and BP 75/40. Lactate is 1.5 and urine output remains 10ml/h. What is the most appropriate next step in management? A – Further 1L fluid B – 500ml 5% HAS C – Intubate and ventilate D – Further dose of IV antibiotics E – Start Noradrenaline infusionQuestion 9 A 64-year old female is brought to A&E resus with suspected urosepsis. Initial observations include HR 110 and BP 72/35. Her lactate is 5 and her urine output is 10ml/h. Blood cultures are taken. She is given 4L IV fluids and started on Gentamicin. Following the above her HR is 100 and BP 75/40. Lactate is 1.5 and urine output remains 10ml/h. What is the most appropriate next step in management? A – Further 1L fluid B – 500ml 5% HAS C – Intubate and ventilate D – Further dose of IV antibiotics E – Start Noradrenaline infusionQuestion 10 A 26 year-old female presents to A&E with acute shortness of breath. She has a background of asthma and normally takes a steroid inhaler + Salbutamol reliever. She appears in distress with RR of 35 and SpO2 91% on RA. Her peak flow measurement is 30% predicted. She receives oxygen, nebulised Salbutamol + Ipratropium, IV Hydrocortisone and 2g IV Magnesium Sulphate all with minimal effect. What is the mechanism of action of the drug used in the next stage of treatment? A – competitive antagonism at nicotinic acetylcholine receptors B – potentiation of GABA-A receptors C – agonism at beta-1 adrenergic receptors D – inhibition of phosphodiesterase E – agonism at alpha-1 adrenergic receptorsQuestion 10 A 26 year-old female presents to A&E with acute shortness of breath. She has a background of asthma and normally takes a steroid inhaler + Salbutamol reliever. She appears in distress with RR of 35 and SpO2 91% on RA. Her peak flow measurement is 30% predicted. She receives oxygen, nebulised Salbutamol + Ipratropium, IV Hydrocortisone and 2g IV Magnesium Sulphate all with minimal effect. What is the mechanism of action of the drug used in the next stage of treatment? A – competitive antagonism at nicotinic acetylcholine receptors B – potentiation of GABA-A receptors C – agonism at beta-1 adrenergic receptors D – inhibition of phosphodiesterase E – agonism at alpha-1 adrenergic receptorsAcute asthma management Initial observations Severity – Peak flow Nebulised treatment Steroids Magnesium Aminophylline IV beta agonist Adrenaline Intubation and ventilationQuestion 11 A 57 year-old female has just returned to HDU following a laparotomy for perforated appendix. You are asked to review her because she is very sore. Her background includes alcoholic liver disease, HTN, T1DM, CKD5 secondary to DM and peripheral neuropathy. Which of the following drugs should be avoided with this patient in terms of analgesia? A – Paracetamol B – Fentanyl C – Alfentanil D – Morphine E – KetamineQuestion 11 A 57 year-old female has just returned to HDU following a laparotomy for perforated appendix. You are asked to review her because she is very sore. Her background includes alcoholic liver disease, HTN, T1DM, CKD5 secondary to DM and peripheral neuropathy. Which of the following drugs should be avoided with this patient in terms of analgesia? A – Paracetamol B – Fentanyl C – Alfentanil D – Morphine E – KetamineQuestion 12 surgically very challenging with multiple adhesions from previous operations. Her analgesic regime is Paracetamol QDS and Oxycodone PCA with 1mg bolus. She had been very sore overnight in her lower abdomen. using 6mg Oxycodone per hour. What is the most appropriate next step in management?. She has been A – Naloxone 400mcg IV B – Increase Oxycodone dose to 2mg C – Start a background PCA infusion of 1mg per hour D – Discuss starting a Ketamine infusion with the on-call anaesthetist E – Discuss with the surgical registrar on call for a reviewQuestion 12 surgically very challenging with multiple adhesions from previous operations. Her analgesic regime is Paracetamol QDS and Oxycodone PCA with 1mg bolus. She had been very sore overnight in her lower abdomen. using 6mg Oxycodone per hour. What is the most appropriate next step in management?. She has been A – Naloxone 400mcg IV B – Increase Oxycodone dose to 2mg C – Start a background PCA infusion of 1mg per hour D – Discuss starting a Ketamine infusion with the on-call anaesthetist E – Discuss with the surgical registrar on call for a reviewWHO Pain ladderQuestion 13 A 65 year-old female is scheduled for an elective umbilical hernia repair. She has a PMH of COPD, HTN and OA. She takes Lisinopril, Paracetamol, topical Ibuprofen and a daily Trimbow inhaler. She has no drug allergies. She does not need any mobility aids, however she struggles to walk more than 100 yards without getting short of breath. Her daughter is very helpful and does all her shopping for her. What is her ASA score? A – 1 B – 2 C – 3 D – 4 E – 5Question 13 A 65 year-old female is scheduled for an elective umbilical hernia repair. She has a PMH of COPD, HTN and OA. She takes Lisinopril, Paracetamol, topical Ibuprofen and a daily Trimbow inhaler. She has no drug allergies. She does not need any mobility aids, however she struggles to walk more than 100 yards without getting short of breath. Her daughter is very helpful and does all her shopping for her. What is her ASA score? A – 1 B – 2 C – 3 D – 4 E – 5Question 14 A 57 year old man presents for an elective R hemicolectomy for colorectal carcinoma. He has mild asthma which is controlled with inhalers with no previous hospital admissions, and no other past medical history. What are the most appropriate pre-operative investigations to request? A – FBC only B – FBC, U&E C – FBC, U&E, ECG D – FBC, U&E, Coag, ECG E – FBC, U&E, Coag, ECG, CXRQuestion 14 A 57 year old man presents for an elective R hemicolectomy for colorectal carcinoma. He has mild asthma which is controlled with inhalers with no previous hospital admissions, and no other past medical history. What are the most appropriate pre-operative investigations to request? A – FBC only B – FBC, U&E C – FBC, U&E, ECG D – FBC, U&E, Coag, ECG E – FBC, U&E, Coag, ECG, CXRMajoror complex surgery TEST ASA 1 ASA 2 ASA 3 or 4 FBC Yes Yes Yes Haemostasis Not routinely Not routinely Consider iun chronic liver disease or patients taking anticoagulants Kidney function Consider if risk of AKI Yes Yes ECG Consider for people aged Yes Yes over 65 if none available in last 12 months Lung function/arterial Not routinely Not routinely Seek advice from senior blood gas anaesthetistQuestion 15 A 62 year-old male presents for elective cholecystectomy. He has a PMH of hypertension. Which of his normal medications should be avoided on the morning of surgery? A – Bisoprolol B – Losartan C – Amlodipine D – Doxazosin E – AtenololQuestion 15 A 62 year-old male presents for elective cholecystectomy. He has a PMH of hypertension. Which of his normal medications should be avoided on the morning of surgery? A – Bisoprolol B – Losartan C – Amlodipine D – Doxazosin E – AtenololQuestion 16 He has a background of type 2 diabetes mellitus and hypertension. Their drug history includesctomy. Metformin BD, Gliclazide BD, Ramipril and Atorvastatin. On the morning of the surgery, the nurse on the drug round asks the doctor on the ward whether they should administer the morning dose of gliclazide written up. His surgery is scheduled for 9 am. What is the appropriate response? A – Both morning and afternoon doses of Gliclazide should be withheld on the day of surgery B – Both morning and afternoon doses of Gliclazide can be given on the day of surgery C – The morning dose of Gliclazide should be held but the afternoon dose can be given D – Gliclazide should be withheld for 24h prior to surgery E – Gliclazide should be withheld for 48h prior to surgeryQuestion 16 He has a background of type 2 diabetes mellitus and hypertension. Their drug history includestectomy. Metformin BD, Gliclazide BD, Ramipril and Atorvastatin. On the morning of the surgery, the nurse on the drug round asks the doctor on the ward whether they should administer the morning dose of gliclazide written up. His surgery is scheduled for 9 am. What is the appropriate response? A – Both morning and afternoon doses of Gliclazide should be withheld on the day of surgery B – Both morning and afternoon doses of Gliclazide can be given on the day of surgery C – The morning dose of Gliclazide should be held but the afternoon dose can be given D – Gliclazide should be withheld for 24h prior to surgery E – Gliclazide should be withheld for 48h prior to surgeryQuestion 17 Which of the following is false with regards to stopping anticoagulant medications pre- operatively for elective abdominal surgery which is low risk for bleeding? A – Continue aspirin B – Stop clopidogrel 5 days prior to surgery C – Stop apixaban 24-48h before surgery in the presence of normal renal function D – Stop warfarin 3-5 days prior to surgery + check INR on admission E – Prophylactic Dalteparin continued unless within 12 hours of surgeryQuestion 17 Which of the following is false with regards to stopping anticoagulant medications pre- operatively for elective abdominal surgery which is low risk for bleeding? A – Continue aspirin B – Stop clopidogrel 5 days prior to surgery C – Stop apixaban 24-48h before surgery in the presence of normal renal function D – Stop warfarin 3-5 days prior to surgery + check INR on admission E – Prophylactic Dalteparin continued unless within 12 hours of surgeryQuestion 18 An 84 year-old man is scheduled for fixation of his NOF fracture. He has a past medical history of hypertension, severe aortic stenosis, severe mitral regurgitation, ischaemic heart disease, GORD and lumbar back pain. His drug history includes lansoprazole, aspirin, paracetamol, lisinopril and amlodipine. Which of the following is most significant contraindication to spinal anaesthesia? A – Lumbar back pain B – Aspirin C – Severe aortic stenosis D – Severe mitral regurgitation E – Ischaemic heart diseaseQuestion 18 An 84 year-old man is scheduled for fixation of his NOF fracture. He has a past medical history of hypertension, severe aortic stenosis, severe mitral regurgitation, ischaemic heart disease, GORD and lumbar back pain. His drug history includes lansoprazole, aspirin, paracetamol, lisinopril and amlodipine. Which of the following is most significant contraindication to spinal anaesthesia? A – Lumbar back pain B – Aspirin C – Severe aortic stenosis D – Severe mitral regurgitation E – Ischaemic heart diseaseAortic stenosis Degenerative condition of the aortic valve characterized by calcification of valve leaflets leading to reduced aortic valve area and significant haemodynamic changes within the heart Independent risk factor for increased peri-operative morbidity and mortality Fixed cardiac output which is highly dependent on preload + afterload aortic stenosis and cause cardiovascular collapseion exacerbating haemodynamic affects of Optimisation may be possible in planned surgery setting, however is limited in emergency situationsQuestion 19 A 75 year-old male has returned to the ward following his elective total knee replacement earlier in the day. This was performed under spinal anaesthetic. He has a background of a previous TIA for which he is taking clopidogrel. He has been complaining of severe back pain and that his legs have not returned to normal following the operation 8 hours ago. You examine him and find that he has a sensory deficit below the level of L3 and 1/5 power in both legs. What is the most appropriate imaging to request? A – Lumbar spine X-ray B – CT lumbar spine C – MRI lumbar spine D – US lumbar spine E – No imaging necessaryQuestion 19 A 75 year-old male has returned to the ward following his elective total knee replacement earlier in the day. This was performed under spinal anaesthetic. He has a background of a previous TIA for which he is taking clopidogrel. He has been complaining of severe back pain and that his legs have not returned to normal following the operation 8 hours ago. You examine him and find that he has a sensory deficit below the level of L3 and 1/5 power in both legs. What is the most appropriate imaging to request? A – Lumbar spine X-ray B – CT lumbar spine C – MRI lumbar spine D – US lumbar spine E – No imaging necessaryQuestion 20 You are assisting in a laparoscopic cholecystectomy, the patient is a 65kg female. The surgeon asks the anaesthetist what is the most Levobupivicaine they can use for wound infiltration for this patient. The max dose of Levobupivicaine is 2mg/kg. What is the correct answer? A – 20ml 0.5% Levobupivicaine B – 26ml 0.5% Levobupivicaine C – 40ml 0.25% Levobupivicaine D – 30ml 0.25% Levobupivicaine E – 30ml 0.5% LevobupivicaineQuestion 20 You are assisting in a laparoscopic cholecystectomy, the patient is a 65kg female. The surgeon asks the anaesthetist what is the most Levobupivicaine they can use for wound infiltration for this patient. The max dose of Levobupivicaine is 2mg/kg. What is the correct answer? A – 20ml 0.5% Levobupivicaine B – 26ml 0.5% Levobupivicaine C – 40ml 0.25% Levobupivicaine D – 30ml 0.25% Levobupivicaine E – 30ml 0.5% LevobupivicaineDrug concentrations 1% solution = 1g of drug in 100g (100ml) of solution = 100mg in 10ml = 10mg/ml 0.5% = 5g/ml Max dose = 130mg 130mg ÷ 5mg = 26mlLearning objectives Recognise and explain the initial management for acute or emergency conditions presenting in anaesthesia and intensive care Explain the ASA grading system Recognise drugs used in anaesthesia and intensive care Perform a medicine reconciliation and be aware of drugs to stop in the peri-operative periodGood luck!!! MATTHEW.PARKS@NHS.SCOTFeedbacklink Resources • Anaphylaxis • Acute asthmamanagement o https://www.resus.org.uk/library/additional-guidance/guidance- o https://cks.nice.org.uk/topics/asthma/management/acute-exacerbation- anaphylaxis of-asthma/ • Adult advanced life support • ASA scoring o https://www.resus.org.uk/library/2021-resuscitation-guidelines/adult- o https://www.bjaed.org/article/S2058-5349(18)30128-8/fulltext advanced-life-support-guidelines o https://www.resus.org.uk/sites/default/files/2021- • Pre-operativeinvestigations 04/Adult%20Advanced%20Life%20Support%20Algorithm%202021.pdf o https://www.nice.org.uk/guidance/ng45/resources/routine-preoperative- tests-for-elective-surgery-pdf-1837454508997 • Adult bradycardia o https://www.resus.org.uk/sites/default/files/2021- • Managementof diabetesin the peri-operativeperiod 04/Bradycardia%20Algorithm%202021.pdf o https://www.cpoc.org.uk/sites/cpoc/files/documents/2021-03/CPOC- Guideline%20for%20Perioperative%20Care%20for%20People%20with%2 • Malignanthyperthermia 0Diabetes%20Mellitus%20Undergoing%20Elective%20and%20Emergency o https://rcoa.ac.uk/sites/default/files/documents/2022- %20Surgery.pdf 06/FS_MaligHyperthermia2021web.pdf • Managementof anticoagulantsperi-operatively o https://www.bjaed.org/article/S2058-5349(17)30064-1/fulltext o https://onlinelibrary.wiley.com/doi/epdf/10.1111/bjh.14344 • Local anaesthetictoxicity o https://www.bjaed.org/article/S2058-5349(17)30154-3/fulltext