A. 24 Hours Pre-Operatively B. 2 Hours Pre-Operatively C. Whilst Making The Skin Incision

A 56 year old lady with idiopathic thrombocytopenic purpura has a platelet count of
50. She is due to undergo a splenectomy. What is the optimal timing of a platelet
transfusion in this case?
A. 24 hours pre-operatively
B. 2 hours pre-operatively
C. Whilst making the skin incision
D. After ligation of the splenic artery
E. On removal of the spleen
ITP causes splenic sequestration of platelets. Therefore a platelet transfusion should

be carefully timed. Too soon and it will be ineffective. Too late and unnecessary
bleeding will occur. The optimal time is after the splenic artery has been ligated.
Splenectomy
Indications
 Trauma: 1/4 are iatrogenic

 Spontaneous rupture: EBV
 Hypersplenism: hereditary spherocytosis or elliptocytosis etc
 Malignancy: lymphoma or leukaemia
 Splenic cysts, hydatid cysts, splenic abscesses
Post splenectomy changes
 Platelets will rise first (therefore in ITP should be given after splenic artery
clamped)
 Blood film will change over following weeks, Howell Jolly bodies will appear
 Other blood film changes include target cells and Pappenheimer bodies
 Increased risk of post splenectomy sepsis, therefore prophylactic antibiotics
and pneumococcal vaccine should be given.
Post splenectomy sepsis
 Typically occurs with encapsulated organisms

 Opsonisation occurs but then not recognised
A 19 year old man has a skin lesion excised from his back. He is reviewed clinically
at 4 months post procedure and the surgeon notes that the scar has begun to contract.
Which of the following facilitates this process?
A. Myofibroblasts
B. Neutrophils
C. Granuloma formation
D. Macrophages
E. Fibroblasts
As wounds mature the fibroblast population differentiates into myofibroblasts, these

have a contractile phenotype and therefore help in contracting the wound. Immature
fibroblasts, though able to adhere to the ECM, do not have this ability.
Wound healing
Surgical wounds are either incisional or excisional and either clean, clean
contaminated or dirty. Although the stages of wound healing are broadly similar their
contributions will vary according to the wound type.
The main stages of wound healing include:
Haemostasis
 Vasospasm in adjacent vessels, platelet plug formation and generation of

fibrin rich clot.
Inflammation
 Neutrophils migrate into wound (function impaired in diabetes).

 Growth factors released, including basic fibroblast growth factor and vascular
endothelial growth factor.
 Fibroblasts replicate within the adjacent matrix and migrate into wound.
 Macrophages and fibroblasts couple matrix regeneration and clot substitution.
Regeneration
 Platelet derived growth factor and transformation growth factors stimulate

fibroblasts and epithelial cells.
 Fibroblasts produce a collagen network.
 Angiogenesis occurs and wound resembles granulation tissue.
Remodeling
 Longest phase of the healing process and may last up to one year (or longer).
 During this phase fibroblasts become differentiated (myofibroblasts) and these
facilitate wound contraction.
 Collagen fibres are remodeled.
 Microvessels regress leaving a pale scar.
The above description represents an idealised scenario. A number of diseases may

distort this process. It is obvious that one of the key events is the establishing well
vascularised tissue. At a local level angiogenesis occurs, but if arterial inflow and
venous return are compromised then healing may be impaired, or simply nor occur at
all. The results of vascular compromise are all too evidence in those with peripheral
vascular disease or those poorly constructed bowel anastomoses.
Conditions such as jaundice will impair fibroblast synthetic function and overall
immunity with a detrimental effect in most parts of healing.
Problems with scars:
Hypertrophic scars
Excessive amounts of collagen within a scar. Nodules may be present histologically
containing randomly arranged fibrils within and parallel fibres on the surface. The
tissue itself is confined to the extent of the wound itself and is usually the result of a
full thickness dermal injury. They may go on to develop contractures.
Image of hypertrophic scarring. Note that it remains confined to the boundaries of the
original wound:
Image sourced from Wikipedia
Keloid scars
Excessive amounts of collagen within a scar. Typically a keloid scar will pass beyond
the boundaries of the original injury. They do not contain nodules and may occur
following even trivial injury. They do not regress over time and may recur following
removal.
Image of a keloid scar. Note the extension beyond the boundaries of the original
incision:
Drugs which impair wound healing:
 Non steroidal anti inflammatory drugs

 Steroids
 Immunosupressive agents
 Anti neoplastic drugs
Closure
Delayed primary closure is the anatomically precise closure that is delayed for a few
days but before granulation tissue becomes macroscopically evident.
Secondary closure refers to either spontaneous closure or to surgical closure after

granulation tissue has formed.
hich of the following blood products can be administered to a non ABO matched
recipient?
A. Whole blood
B. Platelets
C. Packed red cells
D. Fresh frozen plasma

E. Cryoprecipitate
In the UK, platelets either come from pooling of the platelet component from four
units of whole donated blood, called random donor platelets, or by plasmapharesis
from a single donor. The platelets are suspended in 200-300 ml of plasma and may be
stored for up to 4 days in the transfusion laboratory where they are continually
agitated at 22oC to preserve function. One adult platelet pool raises the normal platelet
count (150 - 450 platelets x 109/litre) by 510 platelets x 109/litre. ABO identical or
compatible platelets are preferred but not necessary in adults; but rhesus compatibility
is required in recipients who are children and women of childbearing age to prevent
haemolytic disease of the newborn.
Blood products - cross matching
Whole blood fractions
Fraction Key points

Packed red cells Used for transfusion in chronic anaemia and cases where infusion of
large volumes of fluid may result in cardiovascular compromise.
Product obtained by centrifugation of whole blood.
Platelet rich Usually administered to patients who are thrombocytopaenic and are
plasma bleeding or require surgery. It is obtained by low speed
centrifugation.
Platelet Prepared by high speed centrifugation and administered to patients
concentrate with thrombocytopaenia.
Fresh frozen  Prepared from single units of blood.
plasma  Contains clotting factors, albumin and immunoglobulin.
 Unit is usually 200 to 250ml.
 Usually used in correcting clotting deficiencies in patients
with hepatic synthetic failure who are due to undergo
surgery.
 Usual dose is 12-15ml/Kg-1.
 It should not be used as first line therapy for hypovolaemia.
Cryoprecipitate  Formed from supernatant of FFP.

 Rich source of Factor VIII and fibrinogen.
 Allows large concentration of factor VIII to be administered
in small volume.
SAG-Mannitol Removal of all plasma from a blood unit and substitution with:
Blood
 Sodium chloride
 Adenine
 Anhydrous glucose
 Mannitol
Up to 4 units of SAG M Blood may be administered. Thereafter

whole blood is preferred. After 8 units, clotting factors and platelets
should be considered.
Cross matching
Must be cross matched Can be ABO incompatible in adults
Packed red cells Platelets
Fresh frozen plasma
Cryoprecipitate
Whole blood
Which of the following would be the optimal fluid management option for a 45 year
old man due to undergo an elective right hemicolectomy?
A. Remain "nil by mouth" for at least 6 hours preoperatively and avoid

intra venous fluids.
B. Remain "nil by mouth" for at least 6 hours pre operatively and receive
supplementary intravenous 5% dextrose to replace lost calories
C. Allow him free access to oral fluids only until 30 minutes prior to
surgery
D. Administer a carbohydrate based loading drink 3 hours pre

operatively, and avoid intravenous fluids.
E. Administer a carbohydrate based loading drink 6 hours pre

operatively and administer 5% dextrose saline thereafter
Patients for elective surgery should not have solids for 6 hours pre operatively.
However, clear fluids may be given up to 2 hours pre operatively. Enhanced recovery
programmes are now the standard of care in many countries around the world and
involve administration of carbohydrate loading drinks.
The routine administration of 5% dextrose in the scenarios given above would convey
little in the way of benefit and increase the risks of electrolyte derangement post
operatively.
Pre operative fluid management
Fluid management has been described in the British Consensus guidelines on IV

fluid therapy for Adult Surgical patients (GIFTASUP)
The Recommendations include:
 Use Ringer's lactate or Hartmann's when a crystalloid is needed for

resuscitation or replacement of fluids. Avoid 0.9% N. Saline (due to risk of
hyperchloraemic acidosis) unless patient vomiting or has gastric drainage.
 Use 0.4%/0.18% dextrose saline or 5% dextrose in maintenance fluids. It
should not be used in resuscitation or as replacement fluids.
 Adult maintenance fluid requirements are: Na 50-100 mmol/day and K 40-80
mmol/day in 1.5-2.5L fluid per day.
 Patients for elective surgery should NOT be nil by mouth for >2 hours (unless
has disorder of gastric emptying).
 Patients for elective surgery should be given carbohydrate rich drinks 2-3h
before. Ideally this should form part of a normal pre op plan to facilitate
recovery.
 Avoid mechanical bowel preparation.
 If bowel prep is used, simultaneous administration of Hartmann's or Ringer's
lactate should be considered.
 Excessive fluid losses from vomiting should be treated with a crystalloid with
potassium replacement. 0.9% N. Saline should be given if there is
hypochloraemia. Otherwise Hartmann's or Ringer lactate should be given for
diarrhoea/ileostomy/ileus/obstruction. Hartmann's should also be given in
sodium losses secondary to diuretics.
 High risk patients should receive fluids and inotropes.
 An attempt should be made to detect pre or operative hypovolaemia using
flow based measurements. If this is not available, then clinical evaluation is
needed i.e. JVP, pulse volume etc.
 In Blood loss or infection causing hypovolaemia should be treated with a
balanced crystalloid or colloid (or until blood available in blood loss). A
critically ill patient is unable to excrete Na or H20 leading to a 5% risk of
interstitial oedema. Therefore 5% dextrose as well as colloid should be given.
 Give 200mls of colloid in hypovolaemia, repeat until clinical parameters
improve.
heme: Local anaesthetics
A. 1% xylocaine with 1 in 200,000 adrenaline

B. 1% Lignocaine
C. 0.5% Bupivacaine with 1 in 200,000 adrenaline
D. 0.5% Bupivicaine
E. Prilocaine 1%
F. Procaine 1%
G. Cocaine 25%
H. Cocaine 10%
Please select the local anaesthetic formulation most appropriate to the procedure
indicated. Each option may be used once, more than once or not at all.
5. A 25 year old male presents with epistaxis, the ENT SpR plans to cauterise the
bleeding point with silver nitrate.
1% xylocaine with 1 in 200,000 adrenaline
Historically cocaine was popular for the management of epistaxis. Some

surgeons will still routinely use cocaine paste for this indication. Its popularity
stems from the fact that it causes vasospasm. However, systemic absorption
carries the risk of adverse reactions. Where it is used the correct dose is 4%.
Topically applied short acting local anaesthetic agents with adrenaline may
produce similar effects, with lower risks of toxicity.
6. An 18 year old boy requires a Zadeks procedure.
1% Lignocaine
This is excision of the toe nail and a fast acting local anaesthetic is indicated.
Adrenaline should be avoided in this setting as it can cause digital ischaemia
7. A 72 year old women fracture her distal radius. A Biers Block is planned to
facilitate reduction of the fracture.
Prilocaine 1%
This is the best local anaesthetic for this. Bupivicaine may cause cardiotoxicity
and should be avoided.
Local anaesthetics: avoid use of

adrenaline in extremities
Local anaesthetic agents
Lidocaine
 An amide
 Local anaesthetic and a less commonly used antiarrhythmic (affects Na
channels in the axon)
 Hepatic metabolism, protein bound, renally excreted
 Toxicity: due to IV or excess administration. Increased risk if liver
dysfunction or low protein states. Note acidosis causes lidocaine to detach
from protein binding.
 Drug interactions: Beta blockers, ciprofloxacin, phenytoin
 Features of toxicity: Initial CNS over activity then depression as lidocaine
initially blocks inhibitory pathways then blocks both inhibitory and activating
pathways. Cardiac arrhythmias.
 Increased doses may be used when combined with adrenaline to limit systemic
absorption.
Cocaine
 Pure cocaine is a salt, usually cocaine hydrochloride. It is supplied for local
anaesthetic purposes as a paste.
 It is supplied for clinical use in concentrations of 4 and 10%. It may be applied
topically to the nasal mucosa. It has a rapid onset of action and has the
additional advantage of causing marked vasoconstriction.
 It is lipophillic and will readily cross the blood brain barrier. Its systemic
effects also include cardiac arrhythmias and tachcardia.
 Apart from its limited use in ENT surgery it is otherwise used rarely in
mainstream surgical practice.
Bupivicaine
 Bupivacaine binds to the intracellular portion of sodium channels and blocks

sodium influx into nerve cells, which prevents depolarization.
 It has a much longer duration of action than lignocaine and this is of use in
that it may be used for topical wound infiltration at the conclusion of surgical
procedures with long duration analgesic effect.
 It is cardiotoxic and is therefore contra indicated in regional blockage in case
the tourniquet fails.
 The co-administration of adrenaline concentrates it at the site of action and
allows the use of higher doses.
Prilocaine
 Similar mechanism of action to other local anaesthetic agents. However, it is

far less cardiotoxic and is therefore the agent of choice for intravenous
regional anaesthesia e.g. Biers Block.
All local anaesthetic agents dissociate in tissues and this contributes to their
therapeutic effect. The dissociation constant shifts in tissues that are acidic e.g. where
an abscess is present and this reduce the efficacy.
Doses of local anaesthetics

Agent Dose plain Dose with adrenaline
Lignocaine 3mg/Kg 7mg/Kg
Bupivicane 2mg/Kg 2mg/Kg
Prilocaine 6mg/Kg 9mg/Kg
These are a guide only as actual doses depend on site of administration, tissue
vascularity and co-morbidities.
References
An excellent review is provided by:
French J and Sharp L. Local Anaesthetics. Ann R Coll Surg Engl 2012; 94: 76-80.
Which statement relating to the peri operative management of patients with diabetes
mellitus is false?
A. They should be placed first on the operating list
B. An intravenous sliding scale should be used in all cases
C. Potassium supplementation is likely to be required in diabetics on a

sliding scale
D. Electrolyte abnormalities are more common after major visceral

resections
E. Blood glucose monitoring is required during general anaesthesia
This is not the case and some type 2 diabetics may be managed using a watch and
wait policy with regular blood glucose monitoring. The cellular shifts of potassium
with sliding scales may cause problems with electrolyte management which should be
anticipated.
Preparation for surgery
Elective and emergency patients require different preparation.
Elective cases
 Consider pre admission clinic to address medical issues.

 Blood tests including FBC, U+E, LFTs, Clotting, Group and Save
 Urine analysis
 Pregnancy test
 Sickle cell test
 ECG/ Chest x-ray
Exact tests to be performed will depend upon the proposed procedure and patient
fitness.
Risk factors for development of deep vein thrombosis should be assessed and a plan
for thromboprophylaxis formulated.
Diabetes
Diabetic patients have greater risk of complications.
Poorly controlled diabetes carries high risk of wound infections.
Patients with diet or tablet controlled diabetes may be managed using a policy of
omitting medication and checking blood glucose levels regularly. Diabetics who are
poorly controlled or who take insulin will require a intravenous sliding scale.
Potassium supplementation should also be given.
Diabetic cases should be operated on first.
Emergency cases
Stabilise and resuscitate where needed.
Consider whether antibiotics are needed and when and how they should be
administered.
Inform blood bank if major procedures planned particularly where coagulopathies are
present at the outset or anticipated (e.g. Ruptured AAA repair)
Don't forget to consent and inform relatives.
Special preparation
Some procedures require special preparation:
 Thyroid surgery; vocal cord check.

 Parathyroid surgery; consider methylene blue to identify gland.
 Sentinel node biopsy; radioactive marker/ patent blue dye.
 Surgery involving the thoracic duct; consider administration of cream.
 Pheochromocytoma surgery; will need alpha and beta blockade.
 Surgery for carcinoid tumours; will need covering with octreotide.
 Colorectal cases; bowel preparation (especially left sided surgery)
 Thyrotoxicosis; lugols iodine/ medical therapy.
References
Management of adults with diabetes undergoing surgery and elective procedures.
NHS Diabetes. April 2011.
Theme: Surgical complications
A. Anastamotic leak
B. Chyle leak
C. Air leak
D. Biliary leak
E. Deep vein thrombosis
F. Portal vein thrombosis
G. Biliary obstruction
Please select the most likely complication for the scenario given. Each option may be
used once, more than once or not at all.
9. A 67 year old female undergoes an oesophagogastrectomy for carcinoma of

the distal oesophagus. She complains of chest pain. The following day there is
brisk bubbling into the chest drain when suction is applied.
Air leak
Damage to the lung substance may produce an air leak. Air leaks will manifest
themselves as a persistent pneumothorax that fails to settle despite chest
drainage. When suction is applied to the chest drainage system, active and
persistent bubbling may be seen. Although an anastomotic leak may produce a
small pneumothorax, a large volume air leak is more indicative of lung injury.
10. A 20 year old man has a protracted stay on ITU following a difficult
appendicectomy for perforated appendicitis with pelvic and sub phrenic
abscesses. He has now deteriorated further and developed deranged liver
function tests.
You answered Biliary obstruction
The correct answer is Portal vein thrombosis
Such marked intra-abdominal sepsis may well produce coagulopathy and the
risk of portal vein thrombosis.
11. A 63 year old man undergoes an Ivor - Lewis oesophagogastrectomy for

carcinoma of the distal oesophagus. The following day a pale opalescent liquid
is noted to be draining from the right chest drain.
Chyle leak
Damage to the lymphatic duct may occur during this procedure and some
surgeons administer a lipid rich material immediately prior to surgery to
facilitate its identification in the event of iatrogenic damage.
Surgical complications
Complications occur in all branches of surgery and require vigilance in their

detection. In many cases anticipating the likely complications and appropriate
avoidance will minimise their occurrence. For the purposes of the MRCS the
important principles to appreciate are:
 The anatomical principles that underpin complications

 The physiological and biochemical derangements that occur
 The most appropriate diagnostic modalities to utilise
 The principles which underpin their management
This is clearly a very broad area and impossible to cover comprehensively. There is
considerable overlap with other topic areas within the website.
Avoiding complications
Some points to hopefully avert complications:
 World Health Organisation checklist- now mandatory prior to all operations

 Prophylactic antibiotics - right dose, right drug, right time.
 Assess DVT/ PE risk and ensure adequate prophylaxis
 MARK site of surgery
 Use tourniquets with caution and with respect for underlying structures
 Remember the danger of end arteries and in situations where they occur avoid
using adrenaline containing solutions and monopolar diathermy.
 Handle tissues with care- devitalised tissue serves as a nidus for infection
 Be very wary of the potential for coupling injuries when using diathermy
during laparoscopic surgery
 The inferior epigastric artery is a favourite target for laparoscopic ports and
surgical drains!
Anatomical principles
Understanding the anatomy of a surgical field will allow appreciation of local and
systemic complications that may occur. For example nerve injuries may occur
following surgery in specific regions the table below lists some of the more important
nerves to consider and mechanisms of injury
Nerve Mechanism
Accessory Posterior triangle lymph node biopsy
Sciatic Posterior approach to hip
Common peroneal Legs in Lloyd Davies position
Long thoracic Axillary node clearance
Pelvic autonomic nerves Pelvic cancer surgery
Recurrent laryngeal nerves During thyroid surgery
Hypoglossal nerve During carotid endarterectomy
Ulnar and median nerves During upper limb fracture repairs
These are just a few. The detailed functional sequelae are particularly important and
will often be tested. In addition to nerve injuries certain procedures carry risks of
visceral or structural injury. Again some particular favourites are given below:
Structure Mechanism
Thoracic duct During thoracic surgery e.g. Pneumonectomy, oesphagectomy
Parathyroid During difficult thyroid surgery
glands
Ureters During colonic resections/ gynaecological surgery
Bowel perforation Use of Verres Needle to establish pneumoperitoneum
Bile duct injury Failure to delineate Calots triangle carefully and careless use of
diathermy
Facial nerve Always at risk during Parotidectomy
Tail of pancreas When ligating splenic hilum
Testicular vessels During re-do open hernia surgery
Hepatic veins During liver mobilisation
Again many could be predicted from the anatomy of the procedure.
Physiological derangements
A very common complication is bleeding and this is covered under the section of
haemorrhagic shock. Another variant is infection either superficial or deep seated.
The organisms are covered under microbiology and the features of sepsis covered
under shock. Do not forget that immunocompromised and elderly patients may
present will atypical physiological parameters.
Selected physiological and biochemical issues are given below:
Complication Physiological/ Biochemical Problem

Arrhythmias following Susceptibility to hypokalaemia (K+ <4.0 in cardiac
cardiac surgery patients)
Neurosurgical electrolyte SIADH following cranial surgery causing hyponatraemia
disturbance
Ileus following Fluid sequestration and loss of electrolytes
gastrointestinal surgery
Pulmonary oedema Loss of lung volume makes these patients very sensitive
following pneumonectomy to fluid overload
Anastamotic leak Generalised sepsis causing mediastinitis or peritonitis
depending on site of leak
Myocardial infarct May follow any type of surgery and in addition to direct
cardiac effects the decreased cardiac output may well
compromise grafts etc.
Try making a short list of problems and causes specific to your own clinical area.
Diagnostic modalities
Depends largely on the suspected complication. In the acutely unwell surgical patient
the following baseline investigations are often helpful:
 Full blood count, urea and electrolytes, C- reactive protein (trend rather than
absolute value), serum calcium, liver function tests, clotting (don't forget to
repeat if on-going bleeding)
 Arterial blood gases
 ECG (+cardiac enzymes if MI suspected)
 Chest x-ray to identify collapse/ consolidation
 Urine analysis for UTI
These will often identify the most common complications.

Special tests
 CT scanning for identification of intra-abdominal abscesses, air and if luminal

contrast is used an anastamotic leak
 Gatrograffin enema- for rectal anastamotic leaks
 Doppler USS of leg veins- for identification of DVT
 CTPA for PE
 Sending peritoneal fluid for U+E (if ureteric injury suspected) or amylase (if
pancreatic injury suspected)
 Echocardiogram if pericardial effusion suspected post cardiac surgery and no
pleural window made.
Management of complications
The guiding principal should be safe and timely intervention. Patients should be
stabilised and if an operation needs to occur in tandem with resuscitation then
generally this should be of a damage limitation type procedure rather than definitive
surgery (which can be more safely undertaken in a stable patient the following day).
Remember that recent surgery is a contra indication to thrombolysis and that in some
patients IV heparin may be preferable to a low molecular weight heparin (easier to
reverse).
As a general rule laparotomies for bleeding should follow the core principle of
quadrant packing and then subsequent pack removal rather than plunging large
clamps into pools of blood. The latter approach invariable worsens the situation is
often accompanied by significant visceral injury particularly when done by the
inexperienced. If packing controls a situation it is entirely acceptable practice to leak
packs in situ and return the patient to ITU for pack removal the subsequent day.
Theme: Wound closure
A. Split thickness skin grafting
B. Full thickness skin graft
C. Local flap
D. Leave wound as it is and apply a simple dressing
E. Primary closure using interrupted 3/0 silk
F. Primary closure using 4/0 interrupted nylon
G. Use of vacuum assisted closure device
Please select the most appropriate wound closure modality for the scenario given. Each
option may be used once, more than once or not at all.
12. A 68 year old man undergoes a wide local excision of a squamous cell carcinoma
from the lateral aspect his nose. At the completion of the operation the alar cartilage
is visible.
You answered Full thickness skin graft
The correct answer is Local flap
This type of wound should be managed with a local rotational flap.

This question has been used in the EMQ paper several times
13. A 68 year old man has a seborrhoiec wart on his left cheek this is removed by use of
curretage leaving a superficial defect approximately 1cm in diameter
You answered Primary closure using interrupted 3/0 silk
The correct answer is Leave wound as it is and apply a simple dressing
This type of superficial wound will re-epithelialise satisfactorily without grafting.
14. A 2 year old child accidentally falls onto a hot iron. He sustains a 5cm full thickness
burn to dorsum of his hand.
You answered Local flap
The correct answer is Full thickness skin graft
Grafting is indicated as the wound will invariably contract during the scarring
process.
Wound healing
Surgical wounds are either incisional or excisional and either clean, clean contaminated or
dirty. Although the stages of wound healing are broadly similar their contributions will vary
according to the wound type.
Haemostasis
 Vasospasm in adjacent vessels, platelet plug formation and generation of fibrin rich
clot.
Inflammation

Regeneration

Remodeling
The above description represents an idealised scenario. A number of diseases may distort
this process. It is obvious that one of the key events is the establishing well vascularised
tissue. At a local level angiogenesis occurs, but if arterial inflow and venous return are
compromised then healing may be impaired, or simply nor occur at all. The results of
vascular compromise are all too evidence in those with peripheral vascular disease or those
poorly constructed bowel anastomoses.
Conditions such as jaundice will impair fibroblast synthetic function and overall immunity
with a detrimental effect in most parts of healing.
Hypertrophic scars
containing randomly arranged fibrils within and parallel fibres on the surface. The tissue
itself is confined to the extent of the wound itself and is usually the result of a full thickness
dermal injury. They may go on to develop contractures.
original wound:
Keloid scars
Excessive amounts of collagen within a scar. Typically a keloid scar will pass beyond the
boundaries of the original injury. They do not contain nodules and may occur following even
trivial injury. They do not regress over time and may recur following removal.
Image of a keloid scar. Note the extension beyond the boundaries of the original incision:

 Steroids
Closure
Delayed primary closure is the anatomically precise closure that is delayed for a few days but
before granulation tissue becomes macroscopically evident.

Which of the following statements relating to pre operative fluid management is
false?
A. 5% dextrose should be given cautiously in the elderly
B. Patients undergoing elective colonic resections may continue to drink

water up to 2 hours prior to surgery
C. Normal saline increases the risk of hyperchloraemic acidosis
D. A 70kg man will need approximately 100mmol of sodium daily
E. Carbohydrate rich beverages and loading drinks can cause ileus

therefore should be avoided
Carbohydrate loading is one of the enhanced recovery principles.


recovery.
improve.
 heme: ASA scoring
A. ASA 1
B. ASA 2
C. ASA 3
D. ASA 4
E. ASA 5

The American society of anaesthesiologists physical status scoring system is a
popular method for stratifying patients physical status. Please select the most
appropriate ASA grade for each of the following scenarios. Each option may
be used once, more than once or not at all.
16. A 66 year old man is admitted following a collapse whilst waiting for a bus.
Clinical examination confirms a ruptured abdominal aortic aneurysm. He is
moribund and hypotensive
ASA 5
Theme from 2009 Exam
Patients who are moribund and will not survive without surgery are graded as
ASA 5.
17. A 23 year old man with a 4cm lipoma on his flank is due to have this removed
as a daycase. He is otherwise well.
ASA 1
Absence of co-morbidities and small procedure with no systemic compromise

will equate to an ASA score of 1.
18. A 72 year old man is due to undergo an inguinal hernia repair. He suffers from
COPD and has an exercise tolerance of 10 yards. He also has pitting oedema to
the thighs.
You answered ASA 3
The correct answer is ASA 4
Severe systemic disease of this nature is a constant threat to life. Especially as

he also has evidence of cardiac failure.

 American Society of anesthesiologists physical status scoring system
(ASA)

ASA Description
grade
1 No organic physiological, biochemical or psychiatric disturbance. The
surgical pathology is localised and has not invoked systemic disturbance.
2 Mild or moderate systemic disruption caused either by the surgical disease
process or though underlying pre-existing disease
3 Severe systemic disruption caused either by the surgical pathology or pre-
existing disease
4 Patient has severe systemic disease that is a constant threat to life
5 A patient who is moribund and will not survive without surgery
Theme: Wound infections
A. <5%
B. 5-10%
C. 15-25%
D. 25-40%
E. 0%
F. 75-100%
Please select the anticipated risk of surgical site infections for the procedures
described. Each option may be used once, more than once or not at all.
19. A patient is undergoing a Hartmans procedure for perforated sigmoid

diverticular disease.
You answered 75-100%
The correct answer is 25-40%
This is a 'dirty' procedure and carries an SSI risk of 25-40 %.
20. A 23 year old male is undergoing an elective inguinal hernia repair.
<5%
This is a clean procedure and carries the lowest risk of SSI.
21. A 43 year old women is undergoing a laparoscopic choelcystectomy for

uncomplicated biliary colic.
5-10%
This is a clean contaminated procedure as the cystic duct is divided.

Inadvertent spill of bile converts the operation to a contaminated one and the
risk of infection rises.
Surgical site infection

 Surgical site infections may occur following a breach in tissue surfaces and
allow normal commensals and other pathogens to initiate infection. They are a
major cause of morbidity and mortality.
 Surgical site infections (SSI) comprise up to 20% of all healthcare associated
infections and at least 5% of patients undergoing surgery will develop an SSI
as a result.
 In many cases the organisms are derived from the patient's own body.
Measures that may increase the risk of SSI include:
 Shaving the wound using a razor (disposable clipper preferred)
 Using a non iodine impregnated incise drape if one is deemed to be necessary
 Tissue hypoxia
 Delayed administration of prophylactic antibiotics in tourniquet surgery
Preoperatively
 Don't remove body hair routinely

 If hair needs removal, use electrical clippers with single use head (razors
increase infection risk)
 Antibiotic prophylaxis if:
- placement of prosthesis or valve

- clean-contaminated surgery
- contaminated surgery
 Use local formulary

 Aim to give single dose IV antibiotic on anaesthesia
 If a tourniquet is to be used, give prophylactic antibiotics earlier
Intraoperatively
 Prepare the skin with alcoholic chlorhexidine (Lowest incidence of SSI)

 Cover surgical site with dressing
 A recent meta analysis has confirmed that administration of supplementary
oxygen does not reduce the risk of wound infection. In contrast to previous
individual RCT's(1)
Post operatively
Tissue viability advice for management of surgical wounds healing by secondary
intention
Use of diathermy for skin incisions

In the NICE guidelines the use of diathermy for skin incisions is not advocated(2).
Several randomised controlled trials have been undertaken and demonstrated no
increase in risk of SSI when diathermy is used(3).
References
1. Brar M et al. Perioperative supplemental oxygen in colorectal patients: a meta
analysis. J Surg Res 2011 (166): 227 -235.
2. http://www.nice.org.uk/CG74
3. Ahmad N and Ahmed A. Meta-analysis of the effectiveness of surgical scalpel or
diathermy in making abdominal skin incisions. Ann Surg 2011, 253(1):8-13.
Theme: Intravenous fluids
A. Gelofusine
B. Dextran 70
C. 0.4%/0.18% dextrose saline
D. 5% dextrose
E. 0.9% Normal saline
F. Hartmann's solution
G. Pentastarch
H. Fluid restriction 500mls
I. Fluid restriction 1L
Which of the following is the best fluid management for the scenario given? Each
option may be used once, more than once or not at all.
22. A 53 year old alcoholic male presents with acute pancreatitis. He is clinically
dehydrated. His blood results show normal renal function and electrolytes.
Hartmann's solution
This patient needs fluid replacement due to large third space losses.
Hartmann's solution is recommended. N. Saline would put this patient at risk
of hyperchloraemic acidosis.
23. A 45 year old man with previous laparotomy is admitted with adhesional small
bowel obstruction. He is managed with prolonged nasogastric drainage.
0.9% Normal saline
This man will be hypochloraemic, therefore treatment is with 0.9% sodium

chloride.
24. A 19 year old lady is admitted with pyelonephritis. She is in septic shock with
a blood pressure of 95/60 and pulse rate of 110. Apart from an allergy to corn
she has no other significant medical history.
Gelofusine
In patients with septic shock volume expansion should be considered with an

agent that remains in the intra vascular space for a prolonged period. Dextran
70 has been associated with adverse outcomes when used in this setting.
Pentastarch should not be used in patients with an allergy to corn. Therefore
gelofusine is the most appropriate agent.


recovery.
improve.
A 48 year old lady has a metallic heart valve and requires a paraumbilical hernia
repair. Perioperatively she is receiving intra venous unfractionated heparin. To
perform the surgery safely a normal coagulation state is required. Which of the
following strategies is routine standard practice?
A. Administration of 10 mg of vitamin K the night prior to surgery and

stopping the heparin infusion 6 hours pre operatively
B. Stopping the heparin infusion 6 hours pre operatively
C. Stop the heparin infusion on induction of anaesthesia
D. Stopping the heparin infusion 6 hours pre operatively and

administration of intravenous protamine sulphate on commencing the
operation
E. None of the above
Patients with metallic heart valves will generally stop unfractionated heparin 6 hours
pre operatively. Unfractionated heparin is generally cleared from the circulation
within 2 hours so this will allow plenty of time and is the method of choice in the
elective setting. Protamine sulphate will reverse heparin but is associated with risks of
anaphylaxis and is thus not generally used unless immediate reversal of
anticoagulation is needed, e.g. coming off bypass.
Heparin
 Causes the formation of complexes between antithrombin and activated

thrombin/factors 7,9,10,11 & 12
Advantages of low molecular weight heparin
 Better bioavailability
 Lower risk of bleeding
 Longer half life
 Little effect on APTT at prophylactic dosages
 Less risk of HIT
Complications
 Bleeding
 Osteoporosis
 Heparin induced thrombocytopenia (HIT): occurs 5-14 days after 1st exposure
 Anaphylaxis
In surgical patients that may need a rapid return to theatre administration of

unfractionated heparin is preferred as low molecular weight heparins have a longer
duration of action and are harder to reverse.
heme: Management of complications
A. Intra venous calcium

B. Intra venous potassium
C. Immediate removal of skin clips on ward
D. Removal of skin clips in theatre
E. Laryngoscopy
F. Intravenous thyroxine
Please select the most appropriate intervention for the scenario given. Each option
may be used once, more than once or not at all.
1. A 22 year old lady undergoes a total thyroidectomy for Graves disease. 6 hours
post operatively she develops respiratory stridor and develops a small
haematoma in the neck
You answered Removal of skin clips in theatre
The correct answer is Immediate removal of skin clips on ward
This is true emergency and evacuation and release of pressure must be

performed immediately, in this case by removal of skin clips on the ward
2. A 44 year old lady undergoes a total thyroidectomy for recurrent multinodular

goitre. 3 days post operatively she is still troubled by a hoarse voice.
Laryngoscopy
Unfortunately one of the laryngeal nerves may have been injured and this will
be best demonstrated by laryngoscopy.
3. A 48 year old lady undergoes a redo thyroidectomy for a multinodular goitre. 24

hours post operatively she develops oculogyric crises and diffuse muscle spasm.
Intra venous calcium
She has most likely developed hypocalcaemic tetany and will require immediate
calcium supplementation.


surgical drains!
Nerve Mechanism
Structure Mechanism
glands
diathermy

disturbance
Special tests

 CTPA for PE
reverse).
heme: Use of blood products in surgery
A. Wait and see

B. Vitamin K
C. Fresh frozen plasma
D. Cryoprecipitate
E. Platelet cells
F. Packed red cells
G. Human Prothrombin Complex
H. Blood from the cell saver salvaged during surgery
I. Human Prothrombin Complex and vitamin K
For each coagulation or bleeding problem please select the most appropriate item.
Each item may be used once, more than once or not at all.
4. A 74 year old male is admitted with a ruptured aortic aneurysm. He is

hypotensive and tachycardic. He is urgently transferred to theatre for a repair.
Blood from the cell saver salvaged during surgery
This is an emergency situation. There will be a huge volume of blood in the

abdomen which would be drained and filtered. This can be reinfused into the
patient.
5. A 74 year old male with colon cancer sustains an iatrogenic splenic injury
during surgery. He is bleeding profusely.
You answered Fresh frozen plasma
The correct answer is Packed red cells
The cell saver is inappropriate because the cells will be contaminated with
malignant cells and faecal matter from the open bowel.
6. A 53 year old cleaner is admitted with a fall. She is haemodynamically unstable

and a CT has shown a massive retroperitoneal haematoma. She is on warfarin.
You answered Fresh frozen plasma
The correct answer is Human Prothrombin Complex and vitamin K
Each hospital has different protocols and would recommend discussion with a
haematologist. However Human Prothrombin Complex with vitamin K is
indicated in this situation, as the condition is life threatening.
Blood products
Whole blood fractions
Fraction Key points

Packed red cells Used for transfusion in chronic anaemia and cases where infusion of
large volumes of fluid may result in cardiovascular compromise.
Product obtained by centrifugation of whole blood.
Platelet rich Usually administered to patients who are thrombocytopaenic and are
plasma bleeding or require surgery. It is obtained by low speed
centrifugation.
Platelet Prepared by high speed centrifugation and administered to patients
concentrate with thrombocytopaenia.
Fresh frozen  Prepared from single units of blood.
plasma  Contains clotting factors, albumin and immunoglobulin.
 Unit is usually 200 to 250ml.
 Usually used in correcting clotting deficiencies in patients
with hepatic synthetic failure who are due to undergo
surgery.
 Usual dose is 12-15ml/Kg-1.
 It should not be used as first line therapy for hypovolaemia.
Cryoprecipitate  Formed from supernatant of FFP.

 Rich source of Factor VIII and fibrinogen.
 Allows large concentration of factor VIII to be administered
in small volume.
SAG-Mannitol Removal of all plasma from a blood unit and substitution with:
Blood
 Sodium chloride
 Adenine
 Anhydrous glucose
 Mannitol
Up to 4 units of SAG M Blood may be administered. Thereafter

whole blood is preferred. After 8 units, clotting factors and platelets
should be considered.
Cell saver devices

These collect patients own blood lost during surgery and then reinfuse it. There are
two main types:
 Those which wash the blood cells prior to reinfusion. These are more
expensive to purchase and more complicated to operate. However, they reduce
the risk of reinfusing contaminated blood back into the patient.
 Those which do not wash the blood prior to reinfusion.
Their main advantage is that they avoid the use of infusion of blood from donors into
patients and this may reduce risk of blood borne infection. It may be acceptable to
Jehovah's witnesses. It is contraindicated in malignant disease for risk of facilitating
disease dissemination.
Blood products used in warfarin reversal

In some surgical patients the use of warfarin can pose specific problems and may
require the use of specialised blood products
Immediate or urgent surgery in patients taking warfarin(1) (2):
1. Stop warfarin
2. Vitamin K (reversal within 4-24 hours)

-IV takes 4-6h to work (at least 5mg)
-Oral can take 24 hours to be clinically effective
3. Fresh frozen plasma

Used less commonly now as 1st line warfarin reversal
-30ml/kg-1
-Need to give at least 1L fluid in 70kg person (therefore not appropriate in fluid
overload)
-Need blood group
-Only use if human prothrombin complex is not available
4. Human Prothrombin Complex (reversal within 1 hour)

-Bereplex 50 u/kg
-Rapid action but factor 6 short half life, therefore give with vitamin K
References
1. Dentali, F., C. Marchesi, et al. (2011). "Safety of prothrombin complex
concentrates for rapid anticoagulation reversal of vitamin K antagonists. A meta-
analysis." Thromb Haemost 106(3): 429-438.
2. http://www.transfusionguidelines.org/docs/pdfs/bbt-03warfarin-reversal-flowchart-
2006.pdf
A 22 year old man presents with a peri anal abscess, which is managed by incision and
drainage. The perineal wound measures 3cm by 3cm. Which of the following is best
management option?
A. Primary closure with interrupted mattress sutures

B. Delayed primary closure with interrupted mattress sutures
C. Allow the wound to heal by secondary intention
D. Insert a seton through the cavity into the rectum to allow a mature fistula
track to develop
E. Perform a V-Y flap 2 weeks later
Peri anal abscess are typically managed by secondary intention healing. Any attempt at early
closure is at best futile and at worst dangerous. Insertion of a seton may be considered by an
experienced colorectal surgeon, and only if the tract is clearly identifiable with minimal
probing. There is seldom a need for flaps, ongoing discharge usually indicates a fistula
(managed separately).
Wound healing
Surgical wounds are either incisional or excisional and either clean, clean contaminated or
dirty. Although the stages of wound healing are broadly similar their contributions will vary
according to the wound type.
Haemostasis
 Vasospasm in adjacent vessels, platelet plug formation and generation of fibrin rich
clot.
Inflammation

Regeneration

Remodeling
The above description represents an idealised scenario. A number of diseases may distort
this process. It is obvious that one of the key events is the establishing well vascularised
tissue. At a local level angiogenesis occurs, but if arterial inflow and venous return are
compromised then healing may be impaired, or simply nor occur at all. The results of
vascular compromise are all too evidence in those with peripheral vascular disease or those
poorly constructed bowel anastomoses.
Conditions such as jaundice will impair fibroblast synthetic function and overall immunity
with a detrimental effect in most parts of healing.
Hypertrophic scars
containing randomly arranged fibrils within and parallel fibres on the surface. The tissue
itself is confined to the extent of the wound itself and is usually the result of a full thickness
dermal injury. They may go on to develop contractures.
original wound:
Keloid scars
Excessive amounts of collagen within a scar. Typically a keloid scar will pass beyond the
boundaries of the original injury. They do not contain nodules and may occur following even
trivial injury. They do not regress over time and may recur following removal.
Image of a keloid scar. Note the extension beyond the boundaries of the original incision:

 Steroids
Closure
Delayed primary closure is the anatomically precise closure that is delayed for a few days but
before granulation tissue becomes macroscopically evident.

A surgeon is considering using lignocaine to provide local anaesthesia for a minor
surgical procedure. Which of the following may attenuate its action?
A. Hyperkalaemia
B. Administration with adrenaline
C. Administration with bupivicaine
D. Administration with sodium bicarbonate
E. Use in tissues which are infected

Do not use lignocaine with adrenaline in extremity surgery e.g ring blocks- risk of
ischaemia.
Most anaesthetic agents are amine bases that become ionised due to the relative
alkalinity of tissues. In active infection there may acidosis of the tissues and therefore
local anasthetics may be less effective. Some surgeons mix sodium bicarbonate as it is
reported to reduce the pain experienced by patients during administration.
Lidocaine
 An amide
absorption.
Cocaine

Bupivicaine

Prilocaine


References
French J and Sharp L. Local Anaesthetics. Ann R Coll Surg Engl 2012; 94: 76-80
Which of the following statements relating to use of total parenteral nutrition is
untrue?
A. It may cause steatosis and derangement of liver function tests
B. Administration via a central line or PICC line is preferable to

peripheral administration
C. It is highly irritant to vessel walls
D. It should be administered when a patient has an albumin less than15
E. Administration of TPN for periods of less than 1 week are unlikely to

produce noticable benefits
Albumin is a poor indicator of overall nutrition and the decision to start TPN should
not be based on this parameter alone. Patients should ideally be fed enterally where
possible and if this is likely to occur within 5-7 days then starting TPN is unlikely to
confer benefit.
Nutrition Monitoring-NICE guidelines
 Weight: daily if fluid balance concerns, otherwise weekly reducing to monthly

 BMI: at start of feeding and then monthly
 If weight cannot be obtained: monthly mid arm circumference or triceps skin
fold thickness
 Daily electrolytes until levels stable. Then once or twice a week.
 Weekly glucose, phosphate, magnesium, LFTs, Ca, albumin, FBC, MCV
levels if stable
 2-4 weekly Zn, Folate, B12 and Cu levels if stable

 3-6 monthly iron and ferritin levels, manganese (if on home parenteral regime)
 6 monthly vitamin D
 Bone densitometry initially on starting home parenteral nutrition then every 2
years
Which of the following statements relating to use of tourniquets in surgery is false?
A. The use of an esmarch bandage tourniquet to exsanguinate the limb

reduces the incidence of neuropraxia.
B. Excessive inflation pressures are amongst the commonest causes of

nerve injury related to tourniquet use.
C. Tourniquet deflation causes a fall in CVP.
D. Children require lower inflation pressures than adults.
E. In patients developing neuropraxia related to tourniquets the radial

nerve is most frequently affected.
The use of esmarch bandage tourniquet increases the risk of nerve injury as it
increases pressure in the limb. Limb elevation is safer.
Tourniquets
 These may be applied to reduce blood loss during a procedure or to prevent

bleeding obscuring vital structures.
 As a rule they should not be used to control traumatic bleeding. Direct
pressure is the preferred method.
Side effects/ complications
 Skin friction injuries

 Neuropraxia (greatest risk in upper limb, usually radial nerve)
 Direct injury to underlying muscle
 Cardiovascular changes due to limb exsanguination using Esmarch bandage,
usually increased circulating blood volume-may cause problems in patients
with pre-existing vascular disease.
n relation to patients with type 1 diabetes mellitus undergoing surgery, which of the
following statements is untrue?
A. They should not receive oral carbohydrate loading drinks as part of

enhanced recovery programmes
B. When a variable rate insulin infusion is required 0.45% sodium

chloride with either 0.15% or 0.3% potassium are the fluids of choice
C. Hourly intraoperative blood glucose measurements are required
D. Insulin infusions are only required in patients who will miss more than
two meals or who are nil by mouth for greater than 12 hours
E. Blood glucose levels persistently greater than 12 should initiate a

change in therapy
Insulin should not be stopped in patients with type 1 diabetes and omission of more
than one meal will usually require a variable rate insulin infusion
Type 1 diabetics who take insulin should have this continued through the
perioperative period.
Fluid guidelines in diabetics differ and are not well covered in NPSA fluid guidelines.
Elective cases

 Urine analysis
 Pregnancy test
fitness.
Diabetes
Emergency cases
administered.
Special preparation

References
A 72 year old man is recovering from an inguinal hernia repair when he suffers from
an extensive CVA. He is managed on the rehabilitation unit. However, he is still not
able to feed safely and repeated swallowing assessments have shown that he tends to
aspirate. Which of the following is the best option for long term feeding?
A. PEG tube feeding
B. Feeding jejunostomy
C. Total parenteral nutrition
D. Long term naso gastric tube feeding
E. Withold feeding and palliate
A PEG tube is the best long term option although they are associated with a
significant degree of morbidity. A feeding jejunostomy would require a general
anaesthetic. TPN is not a good option. Long term naso gastric feeding is usually
unsatisfactory.
Enteral Feeding
 Identify patients as malnourished or at risk (see below)

 Identify unsafe or inadequate oral intake with functional GI tract
 Consider for enteral feeding
 Gastric feeding unless upper GI dysfunction (then for duodenal or jejunal
tube)
 Check NG placement using aspiration and pH (check post pyloric tubes with
AXR)
 Gastric feeding > 4 weeks consider long-term gastrostomy
 Consider bolus or continuous feeding into the stomach
 ITU patients should have continuous feeding for 16-24h (24h if on insulin)
 Consider motility agent in ITU or acute patients for delayed gastric emptying.
If this doesn't work then try post pyloric feeding or parenteral feeding.
 PEG can be used 4h after insertion, but should not be removed until >2 weeks
after insertion.
Surgical patients due to have major abdominal surgery: if malnourished, unsafe
swallow/inadequate oral intake and functional GI tract then consider pre operative
enteral feeding.
Patients identified as being malnourished
 BMI < 18.5 kg/m2

 unintentional weight loss of > 10% over 3-6/12
 BMI < 20 kg/m2 and unintentional weight loss of > 5% over 3-6/12
AT RISK of malnutrition
 Eaten nothing or little > 5 days, who are likely to eat little for a further 5 days
 Poor absorptive capacity
 High nutrient losses
 High metabolism
Reference
Stroud M et al. Guidelines for enteral feeding in adult hospital patients. Gut 2003;
52(Suppl VII):vii1 - vii12.
Theme: Anaesthetic agents
A. Halothane
B. Propofol
C. Ketamine
D. Etomidate
E. Sodium thiopentone
F. Flumazenil
G. Naloxone
H. Sevoflurane
Please select the drug which most closely matches the description given. Each option
may be used once, more than once or not at all.
13. An agent which reverses the action of midazolam
You answered Ketamine
The correct answer is Flumazenil
Flumazenil antagonises the effects of benzodiazepines by competition at

GABA binding sites. Since may benzodiazepines have longer half lives than
flumazenil patients still require close monitoring after receiving the drug.
14. An agent which is associated with hepatotoxicity
Halothane
Halothane is hepatotoxic. Despite this it remains in mainstream use. It should

be avoided in patients with hepatic dysfunction, and scavengers should be used
in theatres as accumulation of the drug may be injurious to theatre staff.
15. An anaesthetic agent which has anti emetic properties
Propofol
Propofol is rapidly metabolised and has mild/ moderate anti emetic properties.
It is the agent of choice in most day case operations for this r
A 57 year old man is coming off the cardiac bypass circuit following a successful
coronary artery bypass procedure. Which drug should be administered to normalise
the patients clotting prior to decannulation and chest closure?
A. Intravenous vitamin K
B. Protamine sulphate
C. Aprotinin
D. Fresh frozen plasma
Since cardiac bypass circuits are thrombogenic large doses of intravenous heparin are
administered. This is reversed with protamine sulphate. FFP may be effective but
would carry a significant risk of fluid overload.
Heparin

Complications
 Bleeding
 Osteoporosis
 Anaphylaxis

A 34 year old man is suffering from septic shock and receives and infusion of Dextran
70. Which of the following complications may potentially ensue?
A. Anaphylaxis
B. Vomiting
C. Acute hepatic failure
D. Digital necrosis
E. Deep vein thrombosis

Dextran 40 and 70 have higher incidence of anaphylaxis than either gelatins or
starches.
Dextrans are branched polysaccharide molecules. Dextran 40 and 70 are available.

The higher molecular weight dextran 70 may persist for up to 8 hours. They inhibit
platelet aggregation and leucocyte plugging in the microcirculation. Thereby
improving flow through the microcirculation, primarily of use in sepsis.
Unlike many other intravenous fluids Dextrans are a recognised cause of anaphylaxis.
Post operative fluid management
Composition of commonly used intravenous fluids mmol-1
Na K Cl Bicarbonate Lactate
Plasma 137-147 4-5.5 95-105 22-25 -
0.9% Saline 153 - 153 - -
Dextrose / saline 30.6 - 30.6 - -
Hartmans 130 4 110 - 28
A summary of the recommendations for post operative fluid management

 Fluids given should be documented clearly and easily available
 Assess the patient's fluid status when they leave theatre
 If a patient is haemodynamically stable and euvolaemic, aim to restart oral
fluid intake as soon as possible
 Review patients whose urinary sodium is < 20
 If a patient is oedematous, hypovolaemia if present should be treated first.
This should then be followed by a negative balance of sodium and water,
monitored using urine Na excretion levels.
 Solutions such as Dextran 70 should be used in caution in patients with sepsis
as there is a risk of developing acute renal injury.
References
British Consensus Guidelines on I
In relation to operating in the elderly which statement is false?
A. A 30 minute increment in operation length is associated with increase

in mortality in patients over the age of 80
B. Hypoalbuminaemia is associated with increased mortality
C. Statins given preoperatively reduce perioperative cardiac events
D. Elevated brain (or B-type) natriuretic peptide (BNP) levels before

undergoing non cardiac surgery is associated with high risk of cardiac
mortality and all cause mortality
E. Beta blockers should be stopped acutely prior to surgery due to risk of

perioperative hypotension
Beta blockers should not be stopped acutely prior to surgery as there may be a
rebound effect associated with increased complications.
Brain natriuretic peptide is a neurohormone synthesized in the cardiac ventricles.

Levels have been used to assess prognosis in heart failure and acute coronary
syndromes. Preoperative elevated brain natriuretic peptide levels identify patients
undergoing non cardiac surgery at high risk of cardiac mortality and all cause
mortality.
All patients with peripheral vascular disease should take statins prior to vascular
surgery as studies have shown a 50% risk reduction and a reduction in perioperative
cardiac events.
Reference
Dernellis J, Panaretou M. Assessment of cardiac risk before non-cardiac surgery:

brain natriuretic peptide in 1590 patients. Heart 2006;92:1645-1650
Poldermans, D et al Fluvastatin and Perioperative Events in Patients Undergoing

Vascular Surgery. NEJM 2009; 361:980-989
Proactive care of older people undergoing surgery (POPS)
 Comprehensive geriatric assessment

 MDT assessment preoperatively
 Main predictors of complications are co-morbidities cardiac disease and
reduced functional capacity - preoperative assessment is the key to preventing
adverse postoperative outcomes
 Patients screened for risk factors (albumin <30, co morbidities)
 Management plan made and disseminated to all involved
 Patients education: pain relief, post op exercises, nutrition
Outcomes:
 Fewer postoperative medical complications

 Reduced length of stay by 4.5 days
References
Proactive care of older people undergoing surgery (POPS)
Danielle Harari et al.
Age and Ageing 2007 36(2):190-196
Which statement is true regarding intra operative fluids?
A. Intra operative fluids reduce the length of hospital stay
B. IV dopamine should be given post operatively as part of enhanced

recovery programmes
C. Intra operative fluids increase surgical complications
D. Fluid should routinely be given for two hours post operatively
E. Fluid should routinely be given for four hours post operatively
The use of dopexamine is advocated as part of the routine care of selected surgical
patients. Dopamine is not part of the enhanced recover process. The British IV Fluid
guidelines references below strongly advocate the use of supplementary fluids during
surgery.
Intra operative fluid management

Composition of commonly used intravenous fluids mmol-1
Na K Cl Bicarbonate Lactate
Plasma 137-147 4-5.5 95-105 22-25 -
0.9% Saline 153 - 153 - -
Dextrose / saline 30.6 - 30.6 - -
Hartmans 130 4 110 - 28
Recommendations for intra operative fluid management
 Intra operative fluids are recommended to optimise cardiac stroke volume.

 Patients undergoing non elective orthopaedic or abdominal surgery should
receive IV fluids for the 1st 8h post operatively. This may be supplemented by
a low dose dopexamine infusion in selected cases.
References
British Consensus Guidelines on Intravenous Fluid Therapy for Adult Surgical
Patients
GIFTASUP (2009) Revised May 2011.
cA 43 year old lady with a metallic heart valve has just undergone an elective
paraumbilical hernia repair. In view of her metallic valve she is given unfractionated
heparin perioperatively. How should the therapeutic efficacy be monitored, assuming
her renal function is normal?
A. Therapeutic monitoring is not required
B. Measurement of APTT
C. Measurement of INR
D. Measurement of Prothromin time
Unlike low molecular weight heparins that do not require monitoring unfractionated
heparin does require monitoring, this is done by measuring the APTT.
Heparin


Complications
 Bleeding
 Osteoporosis
 Anaphylaxis

Theme: Pre operative preparation
A. Methylene Blue intravenously 1 hour pre-operatively

B. Lugol's iodine
C. 100ml single cream given 4 hours prior to surgery
D. Carbohydrate loading drink 2 hours prior to surgery
E. Picolax sachet
F. Fleet enema
G. Intravenous calcium chloride
H. 1mg lorazepam orally 30 minutes pre operatively
I. Patent blue dye intravenously
For each procedure please select the most appropriate procedure specific preparation
required. Each option may be used once, more than once or not at all.
21. A 45 year old man is due to undergo an Ivor Lewis oesophagectomy for a
carcinoma of the distal oesophagus.
You answered Picolax sachet
The correct answer is 100ml single cream given 4 hours prior to surgery
This will facilitate identification of the thoracic duct if it is inadvertently

divided during the operation.
22. A 32 year old man is due to undergo a right hemicolectomy for a large caecal
sessile polyp.
You answered Methylene Blue intravenously 1 hour pre-operatively
The correct answer is Carbohydrate loading drink 2 hours prior to

surgery
This is now a standard feature of colonic enhanced recovery programmes.The

administration of carbohydrate rich loading drinks results in lower incidence of
ileus. The drink is usually administered 2 hours pre-operatively and is rapidly
absorbed from the GI tract.
23. A 67 year old women is due to undergo a parathyroidectomy for a parathyroid

adenoma.
You answered Picolax sachet
The correct answer is Methylene Blue intravenously 1 hour pre-

operatively
Though not universally adopted, many endocrine surgeons will administer

methylene blue as it will facilitate identification of the parathyroid glands.
Elective cases

 Urine analysis
 Pregnancy test
fitness.
Diabetes
Emergency cases
administered.
Special preparation

References
Theme: Local anaesthetics
A. 1% xylocaine with 1 in 200,000 adrenaline

B. 1% Lignocaine
C. 0.5% Bupivicaine with 1 in 200,000 adrenaline
D. 0.5% Bupivicaine
E. Prilocaine 1%
F. Procaine 1%
G. Cocaine 4%
H. Cocaine 10%
Please select the local anaesthetic formulation most appropriate to the procedure
indicated. Each option may be used once, more than once or not at all.
24. A 28 year old man has a sebaceous cyst of the scalp that requires excision.
1% xylocaine with 1 in 200,000 adrenaline
As scalp wounds can bleed profusely an adrenaline containing solution is

preferred. Xylocaine is similar to lignocaine in its onset and duration of action.
25. A 32 year old man has an appendicectomy performed through a Lanz incision,
which anaesthetic would you infiltrate the wound with to provide post
operative analgesia.
You answered 1% Lignocaine
The correct answer is 0.5% Bupivicaine
A long acting local anaesthetic is preferred.There is little advantage to adding

a short acting local anaesthetic agent since by the time the patient has
recovered following surgery the bupivicaine will be active.
26. A 43 year old man is due to undergo a vasectomy.
You answered Prilocaine 1%
The correct answer is 1% Lignocaine
Plain lignocaine will suffice. This will give rapid onset of action. Bupivicaine
will take too long to take effect. There would be little additional benefit
derived for adding adrenaline.
Use of adrenaline with local anaesthetic

agents prolongs duration of actions and
allows administration of larger doses.
Lidocaine
 An amide
absorption.
Cocaine

Bupivicaine

Prilocaine


References
Theme: Acid - base disorders
A. Respiratory alkalosis
B. Type 1 respiratory failure
C. Type 2 respiratory failure
D. Metabolic alkalosis
E. Metabolic acidosis with normal anion gap
F. Metabolic acidosis with increased anion gap
Please match the condition with the blood gas result. Each option may be used once more
than once or not at all.
27. pH 7.48, pO2 10.1, Bicarbonate 30, pCO2 4.5, Chloride<10meq
Metabolic alkalosis
This would be typical result of prolonged vomiting.
28. pH 7.49, pO2 7.1, pCO2 2.4, Bicarbonate 22, Chloride 12meq
Respiratory alkalosis
The hyperventilation results in decreased carbon dioxide levels, causing a respiratory

alkalosis (non compensated).
29. pH 7.20, pO2 7.5, Bicarbonate 22, pCO2 8.1, Chloride 10
You answered Type 1 respiratory failure

The correct answer is Type 2 respiratory failure
This is a sign of acute type 2 respiratory failure (non compensated). This is the result
of carbon dioxide retention.
Disorders of acid - base balance
Disorders of acid- base balance are often covered in the MRCS part A, both in the SBA and
EMQ sections.
The acid-base normogram below shows how the various disorders may be categorised
Metabolic acidosis
 This is the most common surgical acid - base disorder.

 Reduction in plasma bicarbonate levels.
 Two mechanisms:
1. Gain of strong acid (e.g. diabetic ketoacidosis)
2. Loss of base (e.g. from bowel in diarrhoea)
- Classified according to the anion gap, this can be calculated by:
(Na+ + K+) - (Cl- + HCO3-).
- If a question supplies the chloride level then this is often a clue that the anion gap should
be calculated. The normal range = 10-18 mmol/L
Normal anion gap ( = hyperchloraemic metabolic acidosis)
 Gastrointestinal bicarbonate loss: diarrhoea, ureterosigmoidostomy, fistula

 Renal tubular acidosis
 Drugs: e.g. acetazolamide
 Ammonium chloride injection
 Addison's disease
Raised anion gap
 Lactate: shock, hypoxia

 Ketones: diabetic ketoacidosis, alcohol
 Urate: renal failure
 Acid poisoning: salicylates, methanol
Metabolic acidosis secondary to high lactate levels may be subdivided into two types:
 Lactic acidosis type A: (Perfusion disorders e.g.shock, hypoxia, burns)

 Lactic acidosis type B: (Metabolic e.g. metformin toxicity)
Metabolic alkalosis
 Usually caused by a rise in plasma bicarbonate levels.

 Rise of bicarbonate above 24 mmol/L will typically result in renal excretion of excess
bicarbonate.
 Caused by a loss of hydrogen ions or a gain of bicarbonate. It is due mainly to
problems of the kidney or gastrointestinal tract
Causes
 Vomiting / aspiration (e.g. Peptic ulcer leading to pyloric stenosis, nasogastric

suction)
 Diuretics
 Liquorice, carbenoxolone
 Hypokalaemia
 Primary hyperaldosteronism
 Cushing's syndrome
 Bartter's syndrome
 Congenital adrenal hyperplasia
Mechanism of metabolic alkalosis
 Activation of renin-angiotensin II-aldosterone (RAA) system is a key factor

 Aldosterone causes reabsorption of Na+ in exchange for H+ in the distal convoluted
tubule
 ECF depletion (vomiting, diuretics) --> Na+ and Cl- loss --> activation of RAA system
--> raised aldosterone levels
 In hypokalaemia, K+ shift from cells --> ECF, alkalosis is caused by shift of H + into cells
to maintain neutrality
Respiratory acidosis
 Rise in carbon dioxide levels usually as a result of alveolar hypoventilation

 Renal compensation may occur leading to Compensated respiratory acidosis
Causes
 COPD
 Decompensation in other respiratory conditions e.g. Life-threatening asthma /
pulmonary oedema
 Sedative drugs: benzodiazepines, opiate overdose
Respiratory alkalosis
 Hyperventilation resulting in excess loss of carbon dioxide

 This will result in increasing pH
Causes
 Psychogenic: anxiety leading to hyperventilation

 Hypoxia causing a subsequent hyperventilation: pulmonary embolism, high altitude
 Early salicylate poisoning*
 CNS stimulation: stroke, subarachnoid haemorrhage, encephalitis
 Pregnancy
*Salicylate overdose leads to a mixed respiratory alkalosis and metabolic acidosis. Early
stimulation of the respiratory centre leads to a respiratory alkalosis whilst later the direct
acid effects of salicylates (combined with acute renal failure) may lead to an acidosis
Theme: Thromboprophylaxis
A. Oral dabigatran alone

B. Oral dabigatran with compression stockings
C. Low molecular weight heparin and compression stockings
D. Warfarin
E. Low molecular weight heparin and pneumatic compression stockings
F. Low molecular weight heparin alone
G. No thromboprophylaxis
H. Unfractionated heparin and compression stockings
I. Unfractionated heparin alone
J. Unfractionated heparin and pneumatic compression stockings
Please select the most appropriate thromboprophylactic regime in the surgical

scenarios described below. Each regime may be used once, more than once or not at
all.
30. A 30 year old male is admitted electively for a right inguinal hernia repair
under local anaesthesia. He is otherwise well but his grandfather died from a
pulmonary embolism.
No thromboprophylaxis
Inguinal hernia repairs under local anaesthetic have a short operative time and
patients are usually ambulant immediately afterwards. His family history is
unlikely to be significant and he is at very low risk.
31. A 63 year old female is admitted for an open cholecystectomy for recurrent
biliary colic and cholecystitis. She has chronic kidney disease (stage 3) but no
other co-mobidities.
You answered Low molecular weight heparin and compression stockings
The correct answer is Unfractionated heparin and compression stockings
Low molecular weight heparin is contra indicated in chronic renal impairment.

Oral dabigatran is not licensed for use following abdominal surgery.
Unfractionated heparin is the safest option (a lower dosing regime is often
used).
32. An 83 year old man is admitted for an abdomino-perineal excision of the colon
and rectum for a distal rectal tumour. His co-mobidities include diabetes and
intermittent claudication. His renal function is normal.
You answered Low molecular weight heparin alone
The correct answer is Low molecular weight heparin and pneumatic

compression stockings
Pelvic cancer surgery carries a very high risk of development of deep vein
thrombosis. In a patient with normal renal function the use of a low molecular
weight heparin is standard. However, many surgeons would only use this in
the post operative setting. Intermittent compression devices in claudicants are
not without risk, but on balence probably outweight the risk of DVT in this
specific case. The perfusion of the feet should be closely monitored and
compression stopped if concerns develop.
Thromboprophylaxis in surgical patients
Deep vein thrombosis may develop insidiously in many surgical patients. Untreated it
may progress to result in pulmonary embolism.
The following surgical patients are at increased risk of deep vein thrombosis:
 Surgery greater than 90 minutes at any site or greater than 60 minutes if the
procedure involves the lower limbs or pelvis
 Acute admissions with inflammatory process involving the abdominal cavity
 Expected significant reduction in mobility
 Age over 60 years
 Known malignancy
 Thrombophilia
 Previous thrombosis
 BMI >30
 Taking hormone replacement therapy or the contraceptive pill
 Varicose veins with phlebitis
Mechanical thromboprophylaxis
 Early ambulation after surgery is cheap and is effective

 Compression stockings (contra -indicated in peripheral arterial disease)
 Intermittent pneumatic compression devices
 Foot impulse devices
Therapeutic agents
Agent Mode of action Uses
Low molecular Binds antithrombin In patients with normal renal function, low
weight heparin resulting in doses typically given in those with moderate to
inhibition of factor high risk of thromboembolic events. It is given
Xa as once daily subcutaneous injection
Unfractionated Binds antithrombin Effective anticoagulation, administered
heparin III with affects intravenously it has a rapid onset and its
thrombin and factor therapeutic effects decline quickly on stopping
Xa and infusion. Its activity is measured using the
APTT. If need be it can be reversed using
protamine sulphate
Dabigatran Orally Used prophylaxis in hip and knee surgery. It
administered direct does not require therapeutic monitoring. It has
thrombin inhibitor no known antidote and should not be used in
any patient in whom there is a risk of active
bleeding or imminent likelihood of surgery
heme: Management of complications
A. Gastrograffin contrast enema

B. Barium enema
C. Oral gastrograffin and CT
D. Barium meal
E. Ultrasound of the thorax
F. Endoanal ultrasound
G. Anorectal physiology studies
H. Biofeedback
Please select the most appropriate intervention from the list given. Each option may
be used once, more than once or not at all.
33. A 65 year old male with carcinoma of the oesophagus undergoes endoscopic
dilatation. Following which he develops pleuritic chest pain and sub cutaneous
emphysema.
Oral gastrograffin and CT
This is consistent with oesophageal perforation. Gastrograffin and CT will

accurately delineate the site of perforation and guide further therapy. Barium
may produce a mediastinitis and should not be used.
34. A 73 year old lady is admitted with large bowel obstruction due to carcinoma
of the rectum. She is undergoes a laparoscopic defunctioning of the rectum
with an end colostomy. 24 hours later her stoma has still not worked.
You answered Biofeedback

The correct answer is Gastrograffin contrast enema
Occasionally the wrong end of bowel is brought up and fashioned as the end
stoma, effectively leaving the bowel obstructed. A gastrograffin enema will
easily demonstrate if this is the case.
35. A 43 year old man develops fast atrial fibrillation 5 days following a low
anterior resection of the rectum for cancer. On examination he has lower
abdominal tenderness and a WCC 19.
Gastrograffin contrast enema
An anastomotic leak is the most likely occurrence and will be demonstrated

using gastrograffin. Barium should not be used for this.



surgical drains!
Nerve Mechanism
Structure Mechanism
glands
diathermy

disturbance
Special tests

 CTPA for PE
reverse).
A 63 year old man is recovering following an open extended right hemicolectomy for
carcinoma of the colonic splenic flexure. Two days post operatively he develops a
persistent pyrexia. What is the least likely cause?
A. Ileus
B. Atelectasis
C. Anastomotic leak
D. Wound infection
E. Urinary tract infection
An ileus in itself is seldom a cause of a pyrexia. It may serve as a proxy marker of

other complications. In this scenario atelectasis would be the most likely underlying
cause, as open extended right hemicolectomies will necessitate a long midline
incision. Anastomotic leaks are less common after right sided colonic surgery and the
timeframe for it is rather short (but are possible). Both wound infections and UTI's
,may complicate major abdominal surgery at any stage.
Pyrexia- post operative
Many surgical patients will develop a pyrexia post operatively. The cause and
investigation depends upon the nature of the infection.
The following scenarios may account for post operative pyrexia:
Cause Features
Anastomotic leak  Swinging pyrexia
 Ileus
 Increasing abdominal pain
 Raised inflammatory markers
Wound infection  Evidence of superficial erythema, discharge of pus or

increasing pain
 Usually mild pyrexia (unless major or deep seated wound
infection)
 May be accompanied by evidence of wound dehisence
 Inflammatory markers raised
Atelectasis  Usually complicates abdominal surgery

 Most common after midline laparotomies (pain impairs
ventilation)
 Pyrexia usually mild and non swinging
 Most patients will have chest signs on examination
Central line sepsis  Patients with complex venous access

 May have marked pyrexia
 Access site may show evidence of erythema
 Diagnosis is by blood culture from line, line removal and
subsequent tip culture
 Groin lines and those for TPN have the highest risk
Urinary tract  Common in surgical patients

infection  Usually occur in patients with indwelling urinary catheters
 Diagnosis is by dipstick and CSU and signs of raised
inflammatory markers
 Treatment is with antibiotics (to cover hospital acquired
organisms)
A 72 year old man is due to undergo an oesophagectomy for malignancy. His BMI is
17.5. What is the best feeding regime immediately following surgery?
A. Total parenteral nutrition.
B. Feeding jejunostomy.
C. Feeding duodenostomy.
D. Liquid diet orally.
E. Soft solids orally.
Theme from April 2012 Exam

This patient has a condition causing poor absorption, loss of nutrients and high
metabolism. Enteral feeds should be used where possible and many surgeons will site
a jejunostomy for this purpose. Oral diet is not permitted following a resection until
the anastamosis has had time to heal.
Enteral Feeding
 Identify patients as malnourished or at risk (see below)

 Identify unsafe or inadequate oral intake with functional GI tract
 Consider for enteral feeding
 Gastric feeding unless upper GI dysfunction (then for duodenal or jejunal
tube)
 Check NG placement using aspiration and pH (check post pyloric tubes with
AXR)
 Gastric feeding > 4 weeks consider long-term gastrostomy
 Consider bolus or continuous feeding into the stomach
 ITU patients should have continuous feeding for 16-24h (24h if on insulin)
 Consider motility agent in ITU or acute patients for delayed gastric emptying.
If this doesn't work then try post pyloric feeding or parenteral feeding.
 PEG can be used 4h after insertion, but should not be removed until >2 weeks
after insertion.
Surgical patients due to have major abdominal surgery: if malnourished, unsafe

swallow/inadequate oral intake and functional GI tract then consider pre operative
enteral feeding.
Patients identified as being malnourished
 BMI < 18.5 kg/m2

 unintentional weight loss of > 10% over 3-6/12
 BMI < 20 kg/m2 and unintentional weight loss of > 5% over 3-6/12
AT RISK of malnutrition
 Eaten nothing or little > 5 days, who are likely to eat little for a further 5 days
 Poor absorptive capacity
 High nutrient losses
 High metabolism
Reference
Stroud M et al. Guidelines for enteral feeding in adult hospital patients. Gut 2003;
52(Suppl VII):vii1 - vii12.
Theme: Bowel preparation
A. No preparation required
B. Phosphate enema
C. Mechanical bowel preparation with oral laxatives (e.g. picolax)
D. Senokot tablets
E. Oral pergolide
F. Rectal lavage with saline
G. 60 ml oral lactulose
Please select the most appropriate form of bowel preparation for the procedures given.
Each agent may be selected once, more than once or not at all.
38. A 56 year old man with carcinoma of the rectum requires a low anterior
resection.
You answered 60 ml oral lactulose
The correct answer is Mechanical bowel preparation with oral laxatives

(e.g. picolax)
Although some enhanced recovery programmes may advocate no preparation,

most surgeons would undertake a defunctioning ileostomy for a low anterior
resection and thus give full prep. A Cochrane review has failed to generate
sufficient evidence to guide bowel preparation for rectal surgery. Many
surgeons do not routinely undertake mechanical bowel preparation for colonic
resections above the peritoneal reflection.
39. A 44 year old man with carcinoma of the hepatic flexure requires a right
hemicolectomy.
You answered Mechanical bowel preparation with oral laxatives (e.g.

picolax)
The correct answer is No preparation required
Formal bowel preparation for right sided colonic resection is unnecessary. The
formal bowel preparation of elective patients for right sided resection results
in increased post operative morbidity and delayed discharge.
40. A 34 year old colitic with acute colitis requires a flexible sigmoidoscopy.
You answered No preparation required
The correct answer is Phosphate enema
For a limited endoscopy a simple enema will suffice. Few acute colitics would
tolerate formal oral prep.
A Cochrane review evaluating the role of

mechanical bowel preparation in colonic surgery
has shown no increase in adverse events in
resections above the peritoneal reflection. At the
present time there is insufficient evidence to guide
surgeons in administering bowel preparation for
rectal surgery. The concept of omitting mechanical
bowel preparation and then defunctioning a low
anterior resection would seem counter intuitive as
the role of loop ileostomy is to reduce the clinical
severity of an anastamotic leak. A benefit that is
attenuated by not administering bowel preparation.
Elective cases

 Urine analysis
 Pregnancy test
fitness.
Diabetes
Emergency cases
administered.
Special preparation

References
The following are contra indications to the use of lignocaine for local anaesthesia
except:
A. Accelerated idioventricular rhythm
B. Current treatment with flecainide
C. 3rd degree heart block without pacemaker
D. Severe sino atrial block
E. Protein C deficiency
Lignocaine is widely used as a local anaesthetic. As a class IB antiarrhythmic it

should not be used in people with unstable disorders of cardiac rhythm and ideally
should not be co-administered with other anti-arhythmics.

Lidocaine
 An amide
absorption.
Cocaine

Bupivicaine

Prilocaine


References
A 43 year old lady has undergone a total thyroidectomy for multinodular goitre. You
are called to see her because of respiratory distress. On examination she has a marked
stridor, her wound seems healthy but there is a swelling within the operative site.
Which of the following accounts for this problem?
A. Bilateral superior laryngeal nerve injury
B. Hypocalcaemic tetany
C. Anxiety
D. Contained haematoma
E. Unilateral recurrent laryngeal nerve injury
In this setting a contained haematoma is the most likely cause. This will impair
venous return resulting in laryngeal oedema and respiratory compromise.
Thyroid disease
Patients may present with a number of different manifestations of thyroid disease.

They can be broadly sub classified according to whether they are euthyroid or have
clinical signs of thyroid dysfunction. In addition it needs to be established whether
they have a mass or not.
Assessment
 History
 Examination including USS
 If a nodule is identified then it should be sampled ideally via an image guided
fine needle aspiration
 Radionucleotide scanning is of limited use
Thyroid Tumours
 Papillary carcinoma
 Follicular carcinoma
 Anaplastic carcinoma
 Medullary carcinoma
 Lymphoma's
Multinodular goitre
 One of the most common reasons for presentation

 Provided the patient is euthyroid and asymptomatic and no discrete nodules
are seen, they can be reassured.
 In those with compressive symptoms surgery is required and the best
operation is a total thyroidectomy.
 Sub total resections were practised in the past and simply result in recurrent
disease that requires a difficult revisional resection.
Endocrine dysfunction
 In general these patients are managed by physicians initially.

 Surgery may be offered alongside radio iodine for patients with Graves
disease that fails with medical management or in patients who would prefer
not to be irradiated (e.g. pregnant women).
 Patients with hypothyroidism do not generally get offered a thyroidectomy.
Sometimes people inadvertently get offered resections during the early phase
of Hashimotos thyroiditis, however, with time the toxic phase passes and
patients can simply be managed with thyroxine.
Complications following surgery
 Anatomical such as recurrent laryngeal nerve damage.

 Bleeding. Owing to the confined space haematoma's may rapidly lead to
respiratory compromise owing to laryngeal oedema.
 Damage to the parathyroid glands resulting in hypocalcaemia.
Further sources of information

1. http://www.acb.org.uk/docs/TFTguidelinefinal.pdf- Association of Clinical
Biochemistry guidelines for thyroid function tests.
2. British association of endocrine surgeons website- http://www.baets.org.uk

Question 43 of 45
Which of the following drugs is not positively inotropic?
A. Dopamine
B. Glucagon
C. Theophylline
D. Sodium thiopentone
E. Dobutamine
Inotropes are a class of drugs that increase the force or cardiac contractility. This may
improve cardiac output. Increased blood pressure may have direct beneficial effects
for the heart in that it improves myocardial perfusion pressure. Dopamine and
dobutamine are both commonly used inotropes, they should be administered via a
central line and in a monitored setting. Glucagon and theophylline are also positive
inotropes (although not commonly used for this purpose). In contrast sodium
thiopentone causes marked myocardial depression.
Inotropes and cardiovascular receptors
Inotrope Cardiovascular receptor action

Adrenaline α-1, α-2, β-1, β-2
Noradrenaline α-1,( α-2), (β-1), (β-2)
Dobutamine β-1, (β 2)
Dopamine (α-1), (α-2), (β-1), D-1,D-2
Minor receptor effects in brackets
Effects of receptor binding

α-1, α-2 vasoconstriction
β-1 increased cardiac contractility and HR
β-2 vasodilatation
D-1 renal and spleen vasodilatation
D-2 inhibits release of noradrenaline
A 28 year old man undergoes a laparotomy for perforated duodenal ulcer and broad
spectrum antibiotics are administered. Post operatively he has hearing impairment.
Which of the following agents is the most likely underlying culprit?
A. Gentamicin
B. Ciprofloxacin
C. Metronidazole
D. Ampicillin
E. Co-trimoxazole
Ototoxicity is a recognised adverse reaction with the aminoglycoside antibiotics.
Antibiotics: mechanism of action
The lists below summarise the site of action of the commonly used antibiotics
Inhibit cell wall formation
 penicillins
 cephalosporins
Inhibit protein synthesis
 aminoglycosides (cause misreading of mRNA)

 chloramphenicol
 macrolides (e.g. erythromycin)
 tetracyclines
 fusidic acid
Inhibit DNA synthesis
 quinolones (e.g. ciprofloxacin)

 metronidazole
 sulphonamides
 trimethoprim
Inhibit RNA synthesis
 rifampicin
 A 62 year old lawyer has a transurethral resection which took 1h to perform.
The ST2 contacts you as the patient has become agitated. He has a HR 105
bpm and his blood pressure is 170/100 mmHg. He is fluid overloaded. His
blood results reveal a Na of 120mmol/l. What is the most likely cause?
A. Over administration of 0.9% Normal Saline
B. Syndrome of inappropriate antidiuretic hormone

secretion
C. Congestive cardiac failure
D. TUR syndrome
E. Acute renal failure

Complications of Transurethral
Resection: TURP
T ur syndrome
U rethral stricture/UTI
R etrograde ejaculation
P erforation of the prostate

TUR syndrome occurs when irrigation fluid enters the systemic circulation.
The triad of features are:
1. Hyponatraemia: dilutional
2. Fluid overload
3. Glycine toxicity
Management involves fluid restriction and the treatment of the complications

associated with the hyponatraemia.
 Post prostatectomy syndromes

Transurethral prostatectomy is a common and popular treatment for benign
prostatic hyperplasia. The procedure involves insertion of a resectoscope via
the penile urethra. The bladder and prostate are irrigated and strips of prostatic
tissue removed using diathermy.
Complications include haemorrhage, urosepsis, retrograde ejaculation and

electrolyte disturbances from the irrigation fluids used during surgery.

A. 24 Hours Pre-Operatively B. 2 Hours Pre-Operatively C. Whilst Making The Skin Incision

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A. 24 Hours Pre-Operatively B. 2 Hours Pre-Operatively C. Whilst Making The Skin Incision

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A 56 year old lady with idiopathic thrombocytopenic purpura has a platelet count of

C. Whilst making the skin incision

D. After ligation of the splenic artery

E. On removal of the spleen

ITP causes splenic sequestration of platelets. Therefore a platelet transfusion should

 Trauma: 1/4 are iatrogenic

Post splenectomy changes

Post splenectomy sepsis

 Typically occurs with encapsulated organisms

As wounds mature the fibroblast population differentiates into myofibroblasts, these

The main stages of wound healing include:

 Vasospasm in adjacent vessels, platelet plug formation and generation of

 Neutrophils migrate into wound (function impaired in diabetes).

 Platelet derived growth factor and transformation growth factors stimulate

The above description represents an idealised scenario. A number of diseases may

Problems with scars:

Image sourced from Wikipedia

Image sourced from Wikipedia

Drugs which impair wound healing:

 Non steroidal anti inflammatory drugs

Secondary closure refers to either spontaneous closure or to surgical closure after

C. Packed red cells

D. Fresh frozen plasma

Blood products - cross matching

Whole blood fractions

Fraction Key points

Cryoprecipitate  Formed from supernatant of FFP.

Up to 4 units of SAG M Blood may be administered. Thereafter

A. Remain "nil by mouth" for at least 6 hours preoperatively and avoid

D. Administer a carbohydrate based loading drink 3 hours pre

E. Administer a carbohydrate based loading drink 6 hours pre

Pre operative fluid management

Fluid management has been described in the British Consensus guidelines on IV

The Recommendations include:

 Use Ringer's lactate or Hartmann's when a crystalloid is needed for

heme: Local anaesthetics

A. 1% xylocaine with 1 in 200,000 adrenaline

1% xylocaine with 1 in 200,000 adrenaline

Historically cocaine was popular for the management of epistaxis. Some

6. An 18 year old boy requires a Zadeks procedure.

Local anaesthetics: avoid use of

Local anaesthetic agents

 Bupivacaine binds to the intracellular portion of sodium channels and blocks

 Similar mechanism of action to other local anaesthetic agents. However, it is

Doses of local anaesthetics

B. An intravenous sliding scale should be used in all cases

C. Potassium supplementation is likely to be required in diabetics on a

D. Electrolyte abnormalities are more common after major visceral

E. Blood glucose monitoring is required during general anaesthesia

Preparation for surgery

Elective and emergency patients require different preparation.

 Consider pre admission clinic to address medical issues.

 Thyroid surgery; vocal cord check.

9. A 67 year old female undergoes an oesophagogastrectomy for carcinoma of

You answered Biliary obstruction

The correct answer is Portal vein thrombosis

11. A 63 year old man undergoes an Ivor - Lewis oesophagogastrectomy for

Complications occur in all branches of surgery and require vigilance in their

 The anatomical principles that underpin complications

Some points to hopefully avert complications:

 World Health Organisation checklist- now mandatory prior to all operations

Selected physiological and biochemical issues are given below:

Complication Physiological/ Biochemical Problem