BT_GS 1.16 Describe alterations to drug response due to ageing

It is uncommon these days for me to have a day where I don’t anaesthetise at least one older patient. Approximately 15% of the Australian population is aged over 65. There are currently almost half a million Australians aged over 85 yrs of age and this number is expected to double in the next 20 yrs !


This elderly person (Fauja Singh) is a fairly amazing older person, completing a marathon aged 100!

Chronological age does not necessarily correspond to physiological age, but there are certain changes which occur fairly consistently with increasing age.  Acute Pain Management: scientific evidence (10.2.3 in case the link doesn’t work) has summary of the changes that occur with ageing and significance for drug dosing.

BT_GS 1.16 Describe alterations to drug response due to physiological change with particular reference to the elderly

A given bolus dose of propofol in an elderly person, compared with a 40yr old, will have an increased effect due to the decreased size of the central compartment   TRUE/FALSE

Changes in cardiac output in the elderly generally slow the rate of induction with volatile anaesthetic agents    TRUE/FALSE

GFR decreases by about 10% per decade after 50 yrs of age   TRUE/FASLE

Oral bioavailability of some drugs may be increased in the elderly due to a reduction in both liver blood flow and metabolic capacity    TRUE/FALSE

Both albumin and alpha1 acid glycoprotein levels fall equally in the elderly, increasing the free fraction of highly protein bound drugs   TRUE/FALSE





SS_PA 1.52 Pharmacokinetic differences in  neonates and children compared with adults and the implications for anaesthesia

A little person I know had an anaesthetic last week having swallowed a curtain hook, probably a couple of months ago. He had not been very keen to eat solid food!!

SS_PA 1.52 Describe how the pharmacokinetics of drugs commonly used in anaesthesia in neonates and children differ from adults and the implications for anaesthesia

Water soluble drugs have a larger volume of distribution in neonates TRUE/FALSE

Drugs that depend on redistribution into fat compartments for their termination of action have longer durations of action in neonates    TRUE/FALSE

The absorption of oral drugs is more rapid in neonates compared with adults   TRUE/FALSE

The relationship between weight and drug elimination is linear in children  TRUE/FALSE

Remifentanil’s half life is unchanged in neonates    TRUE/FALSE

2017.2 SAQ 9

Draw and explain the characteristics of a quantal dose-response curve that describes the major clinical effects of rocuronium. Outline medications and medical conditions that shift the curve to the left or the right.

Neuromuscular blockers and opioids can be used as clinical examples to test candidates’ understanding of the various types of dose response curves. Why do we recommend 2 to 3 times the “ED95” as the intubating dose for muscle relaxants?

T / F  a quantal dose-response curve is semi-logarithmic

T / F  the y-axis shows % twitch height reduction, from 0 to 100%

T / F  for the specific case of muscle relaxants, the ED50 refers to 50% of the population achieving a 95% reduction in twitch height, and is also referred to as the ED95, or ED50(95%)

T / F  a right shift in the curve reflects reduced potency, and could be caused by a recent dose of neostigmine, or one week of bed rest

T / F  hypothermia increases the potency of rocuronium

T / F  patients with myasthenia gravis would have a left shifted curve

BT_PO 1.108 Alteration in drug response due to hepatic disease

If I want to check a registrar’s understanding of a certain topic, I will often ask about the basic physiology or pharmacology and then add a complication. This might be a disease process, a drug or an altered state of physiology. Those who have memorised an answer soon come unstuck when they are asked to apply their knowledge.

When you look through the ANZCA Primary Syllabus, such that it is, you will find a number of LOs related to these “complications”, including this one…..

BT_PO 1.108 Describe alterations to drug response due to hepatic disease

This little guy was in the case with the bears from yesterday’s photo (oh, how times have changed….)



The clearance of propofol is minimally affected by hepatic disease  TRUE/FALSE

Patients with hepatic failure have a hyper-dynamic circulation, which will protect them from the cardiac depression effects of an induction dose of propofol     TRUE/FALSE

Reduced plasma protein levels may result in a longer than expected duration of action for highly protein bound drugs     TRUE/FALSE

All volatile anaesthetic agents have been shown to decrease hepatic blood flow independent of a reduction in mean arterial pressure   TRUE/FALSE

Oral bioavailability of drug with a high extraction ratio, such as morphine, may be markedly reduced in patients with severe liver disease     TRUE/FALSE



BT_GS 1.17 Describe alterations to drug response due to obesity

Ok, I’ve paraphrased that LO a bit, so that we can stay with the topic for one more day.

We give drugs to people with a high BMI on a daily basis (at least at the institution I work in..), so it is important that we know what the implications of a larger lipid load are and how to adjust our dosing…

For today’s picture I have chosen another one of Andy Paiko’s amazing glass works.



BT_PO 1.16 Describe alterations to drug response due to pathological disturbance with particular reference to cardiac, respiratory, renal and hepatic disease


This is a complicated issue [I’m giving you a free true statement]

It is appropriate to dose muscle relaxants, such as vecuronium and rocuronium, based on ideal body weight (IBW)    TRUE/FALSE

When using propofol for maintenance of anaesthesia, calculate the infusion rate based on total body weight (TBW)    TRUE/FALSE

The increased cardiac output seen in morbid obesity, will hasten recovery from volatile anaesthesia TRUE/FALSE

Plasma levels of pseudocholinesterase are increased with morbid obesity TRUE/FALSE

Suxamethonium doses should be based on TBW  TRUE/FALSE

2017.1 : SAQ 4

Outline the genetic variations in the cytochrome P450 2D6 enzyme and discuss the clinical relevance for drugs used in the perioperative period.

BT_GS 1.20

This enzyme is responsible for much of the variation in efficacy and toxicity of some commonly used drugs.

This enzyme metabolises tramadol into a more active metabolite   TRUE/FALSE

Ondansetron may be ineffective with poor metabolisers  TRUE/FALSE

Patients from the middle east are more likely to be ultrarapid metabolisers  TRUE/FALSE

Approximately 90% of caucasians are poor metabolisers  TRUE/FALSE

This enzyme metabolises codeine into a more active metabolite  TRUE/FALSE


SS_OB 1.9 Drug Variability in Pregnancy

SS_OB 1.9 Describe the influence of pregnancy on the pharmacokinetics and pharmacodynamics of drugs commonly used in anaesthesia and analgesia

TRUE/FALSE In pregnancy the average gain of 8 litres of total body water significantly increases the volume of distribution of hydrophilic drugs.

TRUE/FALSE Foetal and placental tissues provide another compartment for drug distribution.

TRUE/FALSE Pseudocholinesterase activity is decreased in pregnancy causing prolongation of succinylcholine block.

TRUE/FALSE Pregnancy reduces MAC by 25-30%.

TRUE/FALSE Nociceptive response thresholds are elevated in pregnancy.