Post Operative Care

A 44 year old man undergoes a distal gastrectomy for cancer.
He is slightly anaemic
and therefore receives a transfusion of 4 units of packed red cells to cover both the
existing anaemia and associated perioperative blood loss. He is noted to develop ECG
changes that are not consistent with ischaemia. What is the most likely cause?
A. Hyponatraemia
B. Hyperkalaemia
C. Hypercalcaemia
D. Metabolic alkalosis
E. Hypernatraemia
The transfusion of packed red cells has been shown to increase serum potassium
levels. The risk is higher with large volume transfusions and with old blood.
Blood transfusion reactions
Immune mediated Non immune mediated

Pyrexia Hypocalcaemia
Alloimmunization CCF
Thrombocytopaenia Infections
Transfusion associated lung injury Hyperkalaemia
Graft vs Host disease
Urticaria
Acute or delayed haemolysis
ABO incompatibility
Rhesus incompatibility
Notes:
GVHD: lymphocyte proliferation causing organ failure
Transfusion associated lung injury: neutrophil mediated allergic pulmonary oedema
ABO and Rhesus incompatibility: causes acute haemolytic transfusion reaction
leading to agglutination and haemolysis
Which of the following muscle relaxants will tend to incite neuromuscular excitability
following administration?
A. Atracurium
B. Suxamethonium
C. Vecuronium
D. Pancuronium
E. None of the above
Suxamethonium may induce generalised muscular contractions following

administration. This may raise serum potassium levels.
Muscle relaxants
Suxamethonium  Depolarising neuromuscular blocker

 Inhibits action of acetylcholine at the neuromuscular
junction
 Degraded by plasma cholinesterase and acetylcholinesterase
 Fastest onset and shortest duration of action of all muscle
relaxants
 Produces generalised muscular contraction prior to paralysis
 Adverse effects include hyperkalaemia, malignant
hyperthermia and lack of acetylcholinesterase
Atracurium  Non depolarising neuromuscular blocking drug

 Duration of action usually 30-45 minutes
 Generalised histamine release on administration may
produce facial flushing, tachycardia and hypotension
 Not excreted by liver or kidney, broken down in tissues by
hydrolysis
 Reversed by neostigmine
Vecuronium  Non depolarising neuromuscular blocking drug

 Duration of action approximately 30 - 40 minutes
 Degraded by liver and kidney and effects prolonged in organ
dysfunction
 Effects may be reversed by neostigmine
Pancuronium  Non depolarising neuromuscular blocker

 Onset of action approximately 2-3 minutes
 Duration of action up to 2 hours
 Effects may be partially reversed with drugs such as
neostigmine
A 23 year old man is recovering from an appendicectomy. The operation was

complicated by the presence of perforation. He is now recovering on the ward.
However, his urine output is falling and he has been vomiting. Which of the following
intravenous fluids should be initially administered, pending analysis of his urea and
electrolyte levels?
A. Hartmans solution
B. Dextran 70
C. Pentastarch
D. Gelofusin
E. 5% Dextrose
Theme from January 2011 Exam
He will have sequestration of electrolyte rich fluids in the abdomen and gut lumen.
These are best replaced by use of Hartmans solution in the first instance.
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 Intravenous Fluid Therapy for Adult Surgical
Patients
GIFTASUP (2009)
A 32 year old man presents to the acute surgical unit with acute pancreatitis. He
suddenly becomes dyspnoeic and his saturations are 89% on air. A CXR shows
bilateral pulmonary infiltrates. His CVP pressure is 16mmHg. What is the most likely
diagnosis?
A. Pulmonary oedema
B. Pneumococcal pneumonia
C. Staphylococcal pneumonia
D. Pneumocystis carinii
E. Adult respiratory distress syndrome
Theme from January 2012 Exam
Acute pancreatitis is known to precipitate ARDS. ARDS is characterised by bilateral

pulmonary inflitrates and hypoxaemia. Note that pulmonary oedema is excluded by
the CVP reading < 18mmHg.
Adult respiratory distress syndrome
Defined as an acute condition characterized by bilateral pulmonary infiltrates and

severe hypoxemia (PaO2/FiO2 ratio < 200) in the absence of evidence for cardiogenic
pulmonary oedema (clinically or pulmonary capillary wedge pressure of less than 18
mm Hg).
In is subdivided into two stages. Early stages consist of an exudative phase of inury
with associated oedema. The later stage is one of repair and consists of
fibroproliferative changes. Subsequent scarring may result in poor lung function.
Causes
 Sepsis
 Direct lung injury
 Trauma
 Acute pancreatitis
 Long bone fracture or multiple fractures (through fat embolism)
 Head injury (causes sympathetic nervous stimulation which leads to acute
pulmonary hypertension)
Clinical features
 Acute dyspnoea and hypoxaemia hours/days after event

 Multi organ failure
Management
 Treat the underlying cause

 Antibiotics
 Negative fluid balance i.e. Diuretics
 Mechanical ventilation strategy using low tidal volumes as conventional tidal
volumes may cause lung injury (only treatment found to improve survival
rates)
Which of the anaesthetic agents below is most likely to induce adrenal suppression?
A. Sodium thiopentone
B. Midazolam
C. Propofol
D. Etomidate
E. Ketamine
Etomidate is a recognised cause of adrenal suppression, this has been associated with
increased mortality when used as a sedation agent in the critically ill.
Anaesthetic agents
The table below summarises some of the more commonly used IV induction agents
Agent Specific features
Propofol  Rapid onset of anaesthesia
 Pain on IV injection
 Rapidly metabolised with little accumulation of metabolites
 Proven anti emetic properties
 Moderate myocardial depression
 Widely used especially for maintaining sedation on ITU, total
IV anaesthesia and for daycase surgery
Sodium  Extremely rapid onset of action making it the agent of choice

thiopentone for rapid sequence of induction
 Marked myocardial depression may occur
 Metabolites build up quickly
 Unsuitable for maintenance infusion
 Little analgesic effects
Ketamine  May be used for induction of anaesthesia

 Has moderate to strong analgesic properties
 Produces little myocardial depression making it a suitable
agent for anaesthesia in those who are haemodynamically
unstable
 May induce state of dissociative anaesthesia resulting in
nightmares
Etomidate  Has favorable cardiac safety profile with very little

haemodynamic instability
 No analgesic properties
 Unsuitable for maintaining sedation as prolonged (and even
brief) use may result in adrenal suppression
 Post operative vomiting is common
A patient with tachycardia and hypotension is to receive inotropes. Which of the

following conditions are most likely to be treated with inotropes?
A. Hypovolaemic shock
B. Septic shock
C. Neurogenic shock
D. Cardiogenic shock
Theme from April 2012 Exam

The term septic shock has a precise meaning and refers to refractory systemic arterial
hypotension in spite of fluid resuscitation. Patients will therefore usually require
inotropes. Individuals suffering from neurogenic shock will usually receive
intravenous fluids to achieve a mean arterial pressure of 90mmHg. If this target
cannot be achieved then these patients will receive inotropes. Hypovolaemic shock
requires fluids and the management of cardiogenic shock is multifactorial and
includes inotropes, vasodilators and intra-aortic balloon pumps
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
heme: Feeding options
A. Feeding jejunostomy
B. Percutaneous endoscopic gastrostomy
C. Total parenteral nutrition
D. Naso gastric feeding tube
E. Naso jejunal feeding tube
F. Normal oral intake
Please select the most appropriate method of delivering nutrition in each of the
following scenarios. Each option may be used once, more than once or not at all.
7. A 28 year old man is comatose, from head injuries, on the neurosurgical

intensive care unit. He is recovering well and should be extubated soon.
Naso gastric feeding tube

The feeding of head injured patients was reviewed in a 2008 Cochrane report.
They concluded that the overall evidence base was poor. However, there was a
trend for the enteral route, with NG feeding in the later stages following injury.
This is contra indicated if there are signs of basal skull fractures.
8. A 56 year old man has undergone a potentially curative oesophagectomy for

carcinoma.
Feeding jejunostomy
Feeding jejunostomy is the standard of care in most centres. Naso jejunal tubes
are preferred by some surgeons. However, if they become displaced the only
alternative then becomes TPN.
9. A 43 year old man is recovering from a laparoscopic low anterior resection with
loop ileostomy.
You answered Total parenteral nutrition
The correct answer is Normal oral intake
Early feeding in this situation is both safe and will enhance recovery.
Nutrition options in surgical patients
Oral intake  Easiest option

 May be supplemented by calorie rich dietary
supplements
 May contra indicated following certain procedures
Naso gastric feeding  Usually administered via fine bore naso gastric feeding
tube
 Complications relate to aspiration of feed or misplaced
tube
 May be safe to use in patients with impaired swallow
 Often contra indicated following head injury due to
risks associated with tube insertion
Naso jejunal feeding  Avoids problems of feed pooling in stomach (and risk
of aspiration)
 Insertion of feeding tube more technically complicated
(easiest if done intra operatively)
 Safe to use following oesophagogastric surgery
Feeding jejunostomy  Surgically sited feeding tube

 May be used for long term feeding
 Low risk of aspiration and thus safe for long term
feeding following upper GI surgery
 Main risks are those of tube displacement and peritubal
leakage immediately following insertion, which carries
a risk of peritonitis
Percutaneous  Combined endoscopic and percutaneous tube insertion

endoscopic  May not be technically possible in those patients who
gastrostomy cannot undergo successful endoscopy
 Risks include aspiration and leakage at the insertion site
Total parenteral  The definitive option in those patients in whom enteral

nutrition feeding is contra indicated
 Individualised prescribing and monitoring needed
 Should be administered via a central vein as it is
strongly phlebitic
 Long term use is associated with fatty liver and
deranged LFT's
Theme: Anaesthetic agents
A. Etomidate
B. Ketamine
C. Propofol
D. Sodium thiopentone
E. Methohexitone
F. Metaraminol
G. Midazolam
Please select the most appropriate anaesthetic induction agent for the procedure
described. Each option may be used once, more than once or not at all.
10. A 32 year old man is admitted for a trendelenberg procedure for varicose
veins. He is known to have porphyria.
Propofol
This is a daycase procedure for which propofol is ideal. Sodium thiopentone

and etomidate are contraindicated in porphyria.
11. A 77 year old lady with unstable ischaemic heart disease requires an
emergency femoral hernia repair. She is volume depleted and slightly
hypotensive.
You answered Etomidate
The correct answer is Ketamine
Ketamine is not negatively inotropic and will not depress cardiac output.
Propofol and Sodium thiopentone will produce myocardial depression. Some
doctors may also consider etomidate. However, it may cause adrenal
suppression and post operative vomiting- which she is at high risk of
developing.
12. A 22 year old man is brought to theatre for an emergency apppendicectomy for
generalised peritonitis. He is vomiting.
You answered Propofol
The correct answer is Sodium thiopentone
Most anaesthetists would use sodium thiopentone for a rapid sequence

induction (which this man will need).
Propofol- Ideal agent for daycase- wears

off rapidly, good antiemetic effect.
Sodium thiopentone- Fast onset of

action- prone to accumulation. Depresses
cardiac output.
Ketamine- Little haemodynamic
instability. Good analgesic properties.
Nightmares and restlessness.
Anaesthetic agents


unstable
nightmares

A 54-year-old man is admitted for an elective hip replacement. Three days post
operatively you suspect he has had a pulmonary embolism. He has no past medical
history of note. Blood pressure is 120/80 mmHg with a pulse of 90/min. The chest x-
ray is normal. Following treatment with low-molecular weight heparin, what is the
most appropriate initial lung imaging investigation to perform?
A. Pulmonary angiography
B. Echocardiogram
C. MRI thorax
D. Ventilation-perfusion scan
E. Computed tomographic pulmonary

angiography
CTPA is the first line investigation for
PE according to current BTS guidelines
This is a difficult question to answer as both computed tomographic pulmonary

angiography (CTPA) and ventilation-perfusion scanning are commonly used in UK
clinical practice. The 2003 British Thoracic Society (BTS) guidelines, however,
recommended that CTPA is now used as the initial lung imaging modality of choice.
Pulmonary angiography is of course the 'gold standard' but this is not what the
question asks for
Pulmonary embolism: investigation
The British Thoracic Society (BTS) published guidelines in 2003 on the management
of patients with suspected pulmonary embolism (PE)
Key points from the guidelines include:
 computed tomographic pulmonary angiography (CTPA) is now the

recommended initial lung-imaging modality for non-massive PE. Advantages
compared to V/Q scans include speed, easier to perform out-of-hours, a
reduced need for further imaging and the possibility of providing an
alternative diagnosis if PE is excluded
 if the CTPA is negative then patients do not need further investigations or
treatment for PE
 ventilation-perfusion scanning may be used initially if appropriate facilities
exist, the chest x-ray is normal, and there is no significant symptomatic
concurrent cardiopulmonary disease
{Some other points}
Clinical probability scores based on risk factors and history and now widely used to
help decide on further investigation/management
D-dimers
 sensitivity = 95-98%, but poor specificity
V/Q scan
 sensitivity = 98%; specificity = 40% - high negative predictive value, i.e. if
normal virtually excludes PE
 other causes of mismatch in V/Q include old pulmonary embolisms, AV
malformations, vasculitis, previous radiotherapy
 COPD gives matched defects
CTPA
 peripheral emboli affecting subsegmental arteries may be missed
Pulmonary angiography
 the gold standard

 significant complication rate compared to other investigations
Theme: Surgical analgesia
A. Amitriptylline
B. Pregabalin
C. Duloxetine
D. Paracetamol
E. Diclofenac
F. Pethidine
G. Morphine
Please select the most appropriate analgesic modality for the scenario given. Each
option may be used once, more than once or not at all.
14. A 72 year old man attends vascular clinic after having an amputation 2 months
ago. He is having difficulty sleeping at night due to persistent tingling at the
amputation site. He is known to have orthostatic hypotension.
Pregabalin
This patient has phantom limb pain which is a neuropathic pain. First line
management is with amitriptylline or pregabalin. However this patient has
orthostatic hypotension, which is a side effect of amitriptylline, therefore
pregabalin is the treatment of choice.
15. A 64 year old type 2 diabetic is referred to vascular clinic with painful foot
ulcers. His ABPI is 0.6. On further questioning the patient reports a burning
sensation in both of his feet.
You answered Amitriptylline
The correct answer is Duloxetine
This NICE guidelines state that duloxetine should be used as a 1st line agent in
diabetic neuropathic pain.
16. A 24 year old man has had a fracture of the tibia after playing football. He
arrives in the emergency room distressed and in severe pain.
Morphine
This type of injury will require morphine. However, timely fracture splinting
will have a significant analgesic effect.
Management of pain
World Health Organisation Analgesic Ladder
 Initially peripherally acting drugs such as paracetamol or non-steroidal anti-

inflammatory drugs (NSAIDs) are given.
 If pain control is not achieved, the second part of the ladder is to introduce
weak opioid drugs such as codeine or dextropropoxyphene together with
appropriate agents to control and minimise side effects.
 The final rung of the ladder is to introduce strong opioid drugs such as
morphine. Analgesia from peripherally acting drugs may be additive to that
from centrally-acting opioids and thus, the two are given together.
The World Federation of Societies of Anaesthesiologists (WFSA) Analgesic

Ladder
 For management of acute pain

 Initially, the pain can be expected to be severe and may need controlling with
strong analgesics in combination with local anaesthetic blocks and
peripherally acting drugs.
 The second rung on the postoperative pain ladder is the restoration of the use
of the oral route to deliver analgesia. Strong opioids may no longer be required
and adequate analgesia can be obtained by using combinations of peripherally
acting agents and weak opioids.
 The final step is when the pain can be controlled by peripherally acting agents
alone.
Local anaesthetics
 Infiltration of a wound with a long-acting local anaesthetic such as

Bupivacaine
 Analgesia for several hours
 Further pain relief can be obtained with repeat injections or by infusions via a
thin catheter
 Blockade of plexuses or peripheral nerves will provide selective analgesia in
those parts of the body supplied by the plexus or nerves
 Can either be used to provide anaesthesia for the surgery or specifically for
postoperative pain relief
 Especially useful where a sympathetic block is needed to improve
postoperative blood supply or where central blockade such as spinal or
epidural blockade is contraindicated.
Spinal anaesthesia
Provides excellent analgesia for surgery in the lower half of the body and pain relief
can last many hours after completion of the operation if long-acting drugs containing
vasoconstrictors are used.
- Side effects of spinal anaesthesia include: hypotension, sensory and motor block,
nausea and urinary retention.
Epidural anaesthesia
An indwelling epidural catheter inserted. This can then be used to provide a
continuous infusion of analgesic agents. It can provide excellent analgesia. They are
still the preferred option following major open abdominal procedures and help
prevent post operative respiratory compromise resulting from pain.
- Disadvantages of epidurals is that they usually confine patients to bed, especially if a

motor block is present. In addition an indwelling urinary catheter is required. Which
may not only impair mobility but also serve as a conduit for infection. They are
contraindicated in coagulopathies.
Transversus Abdominal Plane block (TAP)

In this technique an ultrasound is used to identify the correct muscle plane and local
anaesthetic (usually bupivicaine) is injected. The agent diffuses in the plane and
blocks many of the spinal nerves. It is an attractive technique as it provides a wide
field of blockade but does not require the placement of any indwelling devices. There
is no post operative motor impairment. For this reason it is the preferred technique
when extensive laparoscopic abdominal procedures are performed. They will then
provide analgesia immediately following surgery but as they do not confine the
patient to bed, the focus on enhanced recovery can begin sooner.
-The main disadvantage is that their duration of action is limited to the half life of the
local anaesthetic agent chosen. In addition some anaesthetists do not have the USS
skills required to site the injections.
Patient Controlled Analgesia (PCA)
- Patients administer their own intravenous analgesia and titrate the dose to their own
end-point of pain relief using a small microprocessor - controlled pump. Morphine is
the most popular drug used.
Strong Opioids
Severe pain arising from deep or visceral structures requires the use of strong opioids
Morphine
 Short half life and poor bioavailability.

 Metabolised in the liver and clearance is reduced in patients with liver disease,
in the elderly and the debilitated
 Side effects include nausea, vomiting, constipation and respiratory depression.
 Tolerance may occur with repeated dosage
Pethidine
 Synthetic opioid which is structurally different from morphine but which has
similar actions. Has 10% potency of morphine.
 Short half life and similar bioavailability and clearance to morphine.
 Short duration of action and may need to be given hourly.
 Pethidine has a toxic metabolite (norpethidine) which is cleared by the kidney,
but which accumulates in renal failure or following frequent and prolonged
doses and may lead to muscle twitching and convulsions. Extreme caution is
advised if pethidine is used over a prolonged period or in patients with renal
failure.
Weak opioids
Codeine: markedly less active than morphine, has predictable effects when given
orally and is effective against mild to moderate pain.
Non opioid analgesics

- Mild to moderate pain.
Paracetamol
 Inhibits prostaglandin synthesis.

 Analgesic and antipyretic properties but little anti-inflammatory effect
 It is well absorbed orally and is metabolised almost entirely in the liver
 Side effects in normal dosage and is widely used for the treatment of minor
pain. It causes hepatotoxicity in over dosage by overloading the normal
metabolic pathways with the formation of a toxic metabolite.
NSAIDs
 Analgesic and anti-inflammatory actions

 Inhibition of prostaglandin synthesis by the enzyme Cyclooxygenase which
catalyses the conversion of arachidonic acid to the various prostaglandins that
are the chief mediators of inflammation. All NSAIDs work in the same way
and thus there is no point in giving more than one at a time. .
 NSAIDs are, in general, more useful for superficial pain arising from the skin,
buccal mucosa, joint surfaces and bone.
 Relative contraindications: history of peptic ulceration, gastrointestinal
bleeding or bleeding diathesis; operations associated with high blood loss,
asthma, moderate to severe renal impairment, dehydration and any history of
hypersensitivity to NSAIDs or aspirin.
Neuropthic pain
National Institute of Clinical Excellence (UK) guidelines:
 First line: Amitriptyline (Imipramine if cannot tolerate) or pregabalin

 Second line: Amitriptyline AND pregabalin
 Third line: refer to pain specialist. Give tramadol in the interim (avoid
morphine)
 If diabetic neuropathic pain: Duloxetine
References
1. http://guidance.nice.org.uk/CG96/Guidance/pdf/English
2. Charlton E. The Management of Postoperative Pain . Update in Anaesthesia. Issue
7 (1997)
A 17 year old man undergoes an elective right hemicolectomy. Post operatively he
receives a total of 6 litres of 0.9% sodium chloride solution, over 24 hours. Which of
the following complications may ensue?
A. Hyperchloraemiac acidosis.
B. Hypochloraemic alkalosis
C. Hyperchloraemic alkalosis
D. Acute renal failure
Excessive infusions of any intravenous fluid carry the risk of development of tissue
oedema and potentially cardiac failure. Excessive administration of sodium chloride is
a recognised cause of hyperchloraemic acidosis and therefore Hartmans solution may
be preferred where large volumes of fluid are to be administered.
Plasma 137-147 4-5.5 95-105 22-25 -
0.9% Saline 153 - 153 - -
Hartmans 130 4 110 - 28

References
Patients
GIFTASUP (2009)
A 28 year old man with Crohn's disease has undergone a number of resections. His
BMI is currently 18 and his albumin is 18. He feels well but does have a small
localised perforation of his small bowel. The gastroenterologists are giving
azathioprine. What is the most appropriate advice regarding feeding?
A. Nil by mouth
B. Nil by mouth and continuous intra venous fluids until surgery
C. Enteral feeding
D. Parenteral feeding
E. Nutritional supplements
This man is malnourished, although he is likely to require surgery it is best for him to
be nutritionally optimised first. As he may have reduced surface area for absorption
and has a localised perforation TPN is likely to be the best feeding modality.
Parenteral feeding-NICE guidelines
Parenteral nutrition: NICE guidelines summary
Identify patients as malnourished or at risk
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
Identify unsafe/inadequate oral intake OR a non functional GI

tract/perforation/inaccessible
Consider parenteral nutrition:
 for feeding < 14 days consider feeding via a peripheral venous catheter
 for feeding > 30 days use a tunneled subclavian line
 continuous administration in severely unwell patients
 if feed needed > 2 weeks consider changing from continuous to cyclical
feeding
 don't give > 50% of daily regime to unwell patients in first 24-48h
Surgical patients: if malnourished with unsafe swallow OR a non functional GI

tract/perforation/inaccessible then consider peri operative parenteral feeding.
A 51 year old man is shot in the abdomen and sustains a significant intra abdominal
injury. A laparotomy, bowel resection and end colostomy are performed. An
associated vascular injury necessitates a 6 unit blood transfusion. He has a prolonged
recovery and is paralysed and ventilated for 2 weeks on intensive care. He receives
total parenteral nutrition and is eventually weaned from the ventilator and transferred
to the ward. On reviewing his routine blood tests the following results are noted:
Full blood count

Hb 11.3 g/dl
Platelets 267 x 109/l
WBC 10.1 x109/l
Urea and electrolytes

Na+ 131 mmol/l
+
K 4.6 mmol/l
Urea 2.3 mmol/l
Creatinine 78 µmol/l
Liver function tests

Bilirubin 25 µmol/l
ALP 445 u/l
ALT 89 u/l
γGT 103 u/l
What is the most likely underlying cause for the abnormalities noted?
A. Delayed type blood transfusion reaction
B. Bile leak
C. Anastomotic leak
D. Total parenteral nutrition
E. Gallstones
TPN is known to result in derangement of liver function tests. Although, cholestasis

may result from TPN, it would be very unusual for gallstones to form and result in the
picture above. Blood transfusion reactions typically present earlier and with changes
in the haemoglobin and although they may cause hepatitis this is rare nowadays.
Total parenteral nutrition
 Commonly used in nutritionally compromised surgical patients

 Bags contain combinations of glucose, lipids and essential electrolytes, the
exact composition is determined by the patients nutritional requirements.
 Although it may be infused peripherally, this may result in thrombophlebitis.
 Longer term infusions should be administered into a central vein (preferably
via a PICC line).
 Complications are related to sepsis, re-feeding syndromes and hepatic
dysfunction.
Which statement regarding post operative cognitive impairment is true?
A. Use of Benzodiazepines preoperatively reduces long-term post

operative cognitive dysfunction
B. Pain does not cause delirium
C. Delirium has no impact on length of hospital stay
D. A regional anaesthetic rather than a general anaesthetic is more likely

to contribute to post operative cognitive impairment
E. Visual hallucinations are not a feature of delirium
Anaesthetic technique and Post operative cognitive impairment (POCD):

Use of benzodiazepines preoperatively reduces long-term POCD (9.9% vs. 5%)
Do not stop drugs for cognitive function
Regional techniques reduce POCD in first week, but no difference at 3 months
Fines DP & Severn A. Anaesthesia and cognitive disturbance in the elderly

Continuing Education in Anaesthesia, Critical Care & Pain 2006 6(1):37-40
Postoperative cognitive management
Definition
 Deterioration in performance in a battery of neuropsychological tests that

would be expected in < 3.5% of controls
Or
 Long term, possibly permanent disabling deterioration in cognitive function

following surgery
Early POCD
 Increasing age
 GA rather than regional
 Duration of anaesthesia
 Reoperation
 Postoperative infection
Late POCD
 Increasing age
 Emboli
 Biochemical disturbances
hich statement is false about pethidine?

A. Has approximately 10% efficacy of morphine
B. Structurally similar to morphine
C. Pethidine has a toxic metabolite (norpethidine) which is cleared by

the kidney
D. Pethidine is metabolized by the liver
E. Can be given intramuscularly
It has a different structure.
Management of pain


Ladder

alone.
Local anaesthetics

Bupivacaine
thin catheter
Spinal anaesthesia


Strong Opioids
Morphine

Pethidine
failure.
Weak opioids

Paracetamol

NSAIDs

Neuropthic pain

morphine)
References
7 (1997)
Which of the following anaesthetic agents is least likely to be associated with
depression of myocardial contractility?
A. Propofol
B. Etomidate
C. Sodium thiopentone
D. Ether
Of the agents mentioned, etomidate has the most favorable cardiac safety profile.
Anaesthetic agents


unstable
nightmares

Theme: Intravenous fluids
A. Dextran 40
B. Human albumin solution 4.5%
C. Dextran 70
D. Dextrose 4%/ Saline 0.19%
E. Dextrose 5%
F. Hartmans solution
G. Dextrose 10%
H. Gelofusin
Please select the most appropriate intravenous fluid for the scenario given. Each
23. A 45 year old lady with cirrhosis of the liver is recovering following an
emergency para umbilical hernia repair. She has been slow to resume oral
intake and has been receiving regular boluses of normal saline for oliguria
You answered Hartmans solution
The correct answer is Human albumin solution 4.5%
In patients who are hypoalbuminaemic the use of albumin solution may help
promote a diuresis and manage fluid overload.
24. A 23 year old lady is severely unwell with pyelonephritis. She is hypotensive
and clinically has septic shock.
Gelofusin
In this situation gelofusin will remain in the circulation for a long time.
Starches are not a popular choice in sepsis as they have been shown to be an
independent risk factor for the development of renal failure.
25. A 24 year old man is recovering from a right hemicolectomy for Crohns
disease. He is oliguric and dehydrated owing to a high output ileostomy. His
electrolytes are normal.
You answered Dextrose 5%
The correct answer is Hartmans solution
Of the solutions given Hartmans is the most suitable. Consideration should

also be given to potassium supplementation.
Starches increase risk of renal failure

when used in septic shock.
Plasma 137-147 4-5.5 95-105 22-25 -
0.9% Saline 153 - 153 - -
Hartmans 130 4 110 - 28

References
Patients
GIFTASUP (2009)
Theme: Intravenous access
A. 14 G peripheral cannula
B. Intraosseous infusion
C. Triple lumen central line (internal jugular route)
D. Triple lumen central line (femoral vein route)
E. Swann Ganz Catheter
F. Swann Ganz Introducer (7G)
G. 22 G peripheral cannula
H. Hickman line
Please select the most appropriate modality of intravenous access for the scenario
given. Each option may be used once, more than once or not at all.
26. A 45 year old man with liver cirrhosis is admitted with a brisk upper GI bleed.
Multiple infusions are required and he is peripherally shut down.
You answered Triple lumen central line (internal jugular route)
The correct answer is Triple lumen central line (femoral vein route)
A central line is the most sensible option. He is highly likely to be

coagulopathic and a femoral insertion route is safest in these circumstances.
Multiple infusions and absence of peripheral veins are the compelling
indications for central access in this case.
27. A 3 year old is injured in a road traffic accident and is hypotensive and
tachycardic due to a suspected splenic injury, she is peripherally shut down.
Intraosseous infusion
Intraosseous infusions are the preferred route in this situation as peripheral

cannulation will be difficult and unreliable.
28. A 73 year old man with Dukes C colonic cancer requires a long course of
chemotherapy. He has poor peripheral veins.
Hickman line
A Hickman line is the most reliable long term option. Most Hickman lines are
inserted under local anaesthesia with image guidance. They have a cuff that
usually becomes integrated with the surrounding tissues. This requires a brief
dissection during line removal.
Intravenous access
Venous access
A number of routes for establishing venous access are available.
Peripheral venous cannula

Easy to insert with minimal morbidity. Wide lumen cannulae can provide rapid fluid
infusions. When properly managed infections may be promptly identified and the
cannula easily re sited. Problems relate to their peripheral sites and they are unsuitable
for the administration of vaso active drugs, such as inotropes and irritant drugs such
as TPN (except in the very short term setting).
Central lines
Insertion is more difficult and most operators and NICE advocate the use of ultra
sound. Coagulopathies may lead to haemorrhage following iatrogenic arterial injury.
Femoral lines are easier to insert and iatrogenic injuries easier to manage in this site
however they are prone to high infection rates. Internal jugular route is preferred.
They have multiple lumens allowing for administration of multiple infusions. The
lumens are relatively narrow and thus they do not allow particularly rapid rates of
infusion.
Intraosseous access This is typically undertaken at the anteromedial aspect of the

proximal tibia and provides access to the marrow cavity and circulatory system.
Although traditionally preferred in paediatric practice they may be used in adults and
a wide range of fluids can be infused using these devices.
Which of the following is a not a diagnostic criteria for brain death?

A. No response to sound
B. No corneal reflex
C. Absent oculo-vestibular reflexes
D. No response to supraorbital pressure
E. No cough reflex to bronchial stimulation
Brain death
Criteria for brain death
 Fixed pupils which do not respond to sharp changes in the intensity of incident
light
 No corneal reflex
 Absent oculo-vestibular reflexes - no eye movements following the slow
injection of at least 50ml of ice-cold water into each ear in turn (the caloric
test)
 No response to supraorbital pressure
 No cough reflex to bronchial stimulation or gagging response to pharyngeal
stimulation
 No observed respiratory effort in response to disconnection of the ventilator
for long enough (typically 5 minutes) to ensure elevation of the arterial partial
pressure of carbon dioxide to at least 6.0 kPa (6.5 kPa in patients with chronic
carbon dioxide retention). Adequate oxygenation is ensured by pre-
oxygenation and diffusion oxygenation during the disconnection (so the brain
stem respiratory centre is not challenged by the ultimate, anoxic, drive
stimulus)
The test should be undertaken by two appropriately experienced doctors on two

separate occasions.
Theme: Airway management
A. Cricothyroidotomy
B. Laryngeal mask
C. Endotracheal intubation
D. Tracheostomy
E. Oropharyngeal airway
Please select the most appropriate method of airway access for the scenario given.
Each option may be used once, more than once or not at all.
30. A 63 year old man has been on the intensive care unit for a week with adult
respiratory distress syndrome complicating acute pancreatitis. He has required
ventilation and is still being mechanically ventilated.
Tracheostomy
Tracheostomy is often used to facilitate long term weaning. The percutaneous

devices are popular. These involve a seldinger type insertion of the tube. A
second operator inserts a bronchoscope to ensure the device is not advanced
through the posterior wall of the trachea. Complications include damage to
adjacent structures and bleeding (contra indication in coagulopathy).
31. A 23 year old man is undergoing an inguinal hernia repair as a daycase

procedure and is being given sevoflurane.
You answered Endotracheal intubation
The correct answer is Laryngeal mask
This procedure will be associated with requirement for swift onset of

anaesthesia and recovery. Muscle paralysis is not required and this would an
ideal case for laryngeal mask airway.
32. A 48 year old man is due to undergo a laparotomy for small bowel obstruction.
Endotracheal intubation
Patients who are due to undergo laparotomies for bowel obstruction have
either been vomiting or at high risk of regurgitation of gastric contents on
induction of anaesthesia. A rapid sequence induction with cricothyroid
pressure applied to occlude the oesophagus is performed. A cuffed
endotracheal tube is then inserted. Once correct placement of the ET tube is
confirmed the cricothyroid pressure can be removed.
Airway management
Oropharyngeal  Easy to insert and use

airway  No paralysis required
 Ideal for very short procedures
 Most often used as bridge to more definitive airway
Laryngeal mask  Widely used

 Very easy to insert
 Device sits in pharynx and aligns to cover the airway
 Poor control against reflux of gastric contents
 Paralysis not usually required
 Commonly used for wide range of anaesthetic uses,
especially in day surgery
 Not suitable for high pressure ventilation (small amount
of PEEP often possible)
Tracheostomy  Reduces the work of breathing (and dead space)

 May be useful in slow weaning
 Percutaneous tracheostomy widely used in ITU
 Dries secretions, humidified air usually required
Endotracheal tube  Provides optimal control of the airway once cuff inflated
 May be used for long or short term ventilation
 Errors in insertion may result in oesophageal intubation
(therefore end tidal CO2 usually measured)
 Paralysis often required
 Higher ventilation pressures can be used
You are the cardiothoracic surgical registrar reviewing a patient referred for an aortic
valve replacement. The 40-year-old man is being investigated for progressive
breathlessness in a previous respiratory clinic. The notes show he has smoked for the
past 25 years. Pulmonary function tests reveal the following:
FEV1 1.4 L
FVC 1.7 L
FEV1/FVC 82%
What is the most likely explanation?
A. Asthma
B. Bronchiectasis
C. Kyphoscoliosis
D. Chronic obstructive pulmonary disease
E. Laryngeal malignancy
These results show a restrictive picture, which may result from a number of
conditions including kyphoscoliosis. The other answers cause an obstructive picture.
Pulmonary function tests

Pulmonary function tests can be used to determine whether a respiratory disease is
obstructive or restrictive. The table below summarises the main findings and gives
some example conditions:
Obstructive lung disease Restrictive lung disease

FEV1 - significantly reduced FEV1 - reduced
FVC - reduced or normal FVC - significantly reduced
FEV1% (FEV1/FVC) - reduced FEV1% (FEV1/FVC) - normal or increased
Asthma Pulmonary fibrosis
COPD Asbestosis
Bronchiectasis Sarcoidosis
Bronchiolitis obliterans Acute respiratory distress syndrome
Infant respiratory distress syndrome
Kyphoscoliosis
Neuromuscular disorders
Theme: Management of pain
A. Paracetamol
B. Non steroidal anti inflammatory drugs
C. Fentanyl patch
D. Carbamazepine
E. Pregabalin
F. Duloxetine
G. Radiotherapy
H. Chemotherapy
I. Spinal block
For each scenario please select the most appropriate analgesic modality. Each option
may be used once, more than once or not at all.
34. A 52 year old man with prostate cancer is admitted to urology with urinary
retention. He complains of back pain which is not responding to ward
analgesia. A lumbar xray confirms lumbar spine metastases.
Radiotherapy
This patient needs radiotherapy for pain relief. Bisphosphonates may also be
effective.
35. A 42 year old woman complains of shooting pains in her left arm after a
mastectomy.
You answered Fentanyl patch

The correct answer is Pregabalin
Pregabalin is the 1st line treatment described in the NICE guidelines.
36. A 2 year old boy is recovering following an uncomplicated appendicectomy.
Paracetamol
Paracetamol is an extremely effective analgesic in children.
Management of pain


Ladder

alone.
Local anaesthetics

Bupivacaine
thin catheter
Spinal anaesthesia


Strong Opioids
Morphine

Pethidine
failure.
Weak opioids

Paracetamol

NSAIDs

Neuropthic pain

morphine)
References
7 (1997)
Which of the following statements relating to the use of human albumin solution is
false?
A. When administered in the peri operative period it does not increase

the length of stay compared with crystalloid solutions
B. Concentrated solutions may produce diuresis in patients with liver

failure
C. It may restore plasma volume in cases of sodium and water overload
D. It may be associated with risk of acquiring new variant Creutzfeld-

Jacob disease
E. Hepatitis C remains a concern when large volumes are infused
Human albumin solution went out of vogue following the Cochrane review in 2004
that showed it increased mortality. This view has been challenged and subsequent
studies have confirmed it to be safe for use. Viruses are inactivated during the
preparation process. However, theoretical risks regarding new varient CJD still exist.
Outcomes in the peri operative setting are similar whether colloid, crystalloid or
albumin are used.
Plasma 137-147 4-5.5 95-105 22-25 -
0.9% Saline 153 - 153 - -
Hartmans 130 4 110 - 28

References
Patients
GIFTASUP (2009)
Which statement is true when prescribing nutritional support?
A. For severely ill patients aim to give < 50% energy needs in the first
24-48 hours
B. For patients at risk of refeeding syndrome, they should be given 35

kcal/kg/day initially
C. For severely ill patients aim to give the full energy needs in the first
24-48 hours
D. Patients on diuretics are unlikely to need thiamine
E. Patients on chemotherapy are unlikely to need thiamine
So correct answer is A
In the NICE guidelines they recommend that enteral or parenteral nutrition is
cautiously introduced in seriously ill or injured people. They suggest that nutrition is
started at no more than 50% of the estimated target energy and protein needs and
build up to meet full needs over the first 2448 hours. Provide full requirements of
fluid, electrolytes, vitamins and minerals from the outset. Diuretics and chemotherapy
increase the risk of refeeding syndrome.
Nutrition prescriptions
National institute of clinical excellence (NICE) guidelines
For people not severely ill and not at risk of refeeding syndrome aim to give
 25-35 kcal/kg/day (lower if BMI > 25)

 0.8-1.5g protein /kg/day
 30-35 ml fluid/kg/day
 Adequate electrolytes, minerals, vitamins
 Severely ill patients aim to give < 50% of the energy and protein levels over
the first 24-48h.
For people at high risk of refeeding syndrome:
 Start at up to 10 kcal/kg/day increasing to full needs over 4-7 days

 Start immediately before and during feeding: oral thiamine 200-300mg/day,
vitamin B co strong 1 tds and supplements
 Give K+ (2-4 mmol/kg/day), phosphate (0.3-0.6 mmol/kg/day), magnesium
(0.2-0.4 mmol/kg/day)
A 78 year old man presents with a ruptured aortic aneurysm. This is repaired but the
operation is difficult as it has a juxtarenal location. A supra renal cross clamp is
applied. Post operatively he is found to be oliguric and acute renal failure is
suspected. Which of the following statements relating to acute post-operative renal
failure are untrue?
A. Intravenous dopamine does not prevent acute

renal failure.
B. It is more common after emergency surgery.
C. Use of excessive amounts of intravenous fluids

may lead to falsely normal serum creatinine
measurements.
D. Vasopressor drugs have a strong

renoprotective effect
E. It is minimised by normalisation of
haemodynamic status.
Key points : Renal injury and acute
renal failure: RIFLE Classification.
R=Risk (Serum Creatinine x1.5)
I=Injury (Serum Creatinine x 2)
F=Failure (Serum Creatinine x3)
L=Loss (Loss of renal function
>4weeks)
E=End stage kidney disease
Vasopressor use is linked to renal failure as they are a marker of haemodynamic

compromise.
Acute Renal Failure
 Final pathway is tubular cell death.

 Renal medulla is a relatively hypoxic environment making it susceptible to
renal tubular hypoxia.
 Renovascular autoregulation maintains renal blood flow across a range of
arterial pressures.
 Estimates of GFR are best indices of level of renal function. Useful clinical
estimates can be obtained by considering serum creatinine, age, race, gender
and body size. eGFR calculations such as the Cockcroft and Gault equation
are less reliable in populations with high GFR's.
 Nephrotoxic stimuli such as aminoglycosides and radiological contrast media
induce apoptosis. Myoglobinuria and haemolysis result in necrosis. Overlap
exists and proinflammatory cytokines play and important role in potentiating
ongoing damage.
 Post-operative renal failure is more likely to occur in patients who are elderly,
have peripheral vascular disease, high BMI, have COPD, receive
vasopressors, are on nephrotoxic medication or undergo emergency surgery.
 Avoiding hypotension will reduce risk of renal tubular damage.
 There is no evidence that administration of ACE inhibitors or dopamine
reduces the incidence of post-operative renal failure.
A 45 year old man develops acute respiratory distress syndrome during an attack of
severe acute pancreatitis. Which of the following is not a feature of adult respiratory
distress syndrome?
A. It usually consists of type I respiratory failure.
B. Patients typically require high ventillatory pressures.
C. A Swann Ganz Catheter would typically have a reading in excess of

18mmHg.
D. It may complicate acute pancreatitis.
E. It may heal with fibrosis.
Right heart pressure should be normal.

Adult respiratory distress syndrome
Defined as an acute condition characterized by bilateral pulmonary infiltrates and

severe hypoxemia (PaO2/FiO2 ratio < 200) in the absence of evidence for cardiogenic
pulmonary oedema (clinically or pulmonary capillary wedge pressure of less than 18
mm Hg).
In is subdivided into two stages. Early stages consist of an exudative phase of inury
with associated oedema. The later stage is one of repair and consists of
fibroproliferative changes. Subsequent scarring may result in poor lung function.
Causes
 Sepsis
 Direct lung injury
 Trauma
 Acute pancreatitis
 Long bone fracture or multiple fractures (through fat embolism)
 Head injury (causes sympathetic nervous stimulation which leads to acute
pulmonary hypertension)
Clinical features
 Acute dyspnoea and hypoxaemia hours/days after event

 Multi organ failure
Management
 Treat the underlying cause

 Antibiotics
 Negative fluid balance i.e. Diuretics
 Mechanical ventilation strategy using low tidal volumes as conventional tidal
volumes may cause lung injury (only treatment found to improve survival
rates)
Which of the following fulfills the criteria for malnutrition based on the NICE
guidelines?
A. Hypoalbuminaemia
B. BMI < 17.5 kg/m2 and unintentional weight loss of > 5% over 3-6/12
C. BMI < 17.5 kg/m2
D. Reduced skin turgor
E. Unintentional weight loss of > 10% over 3- 6 months

Nutrition Screening-NICE guidelines
NICE Screening for malnutrition: A summary
 To be performed by an appropriate professional.

 All new hospital admissions, new GP patients, new care home patients and
patients attending their first clinic should be screened. Afterwards hospital in
patients should be screened weekly.
Nutritional support i.e. oral, enteral or parenteral
 Given to patients identified as being malnourished:

 BMI < 18.5 kg/m2
 Unintentional weight loss of > 10% over 3-6/12
NB BMI= weight (kg)/height (m<sup<2< sup="">)
 Considered in people identified as being 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
NB if considering feed withdrawal refer to GMC guidance 'withholding and

withdrawing life prolonging treatment'.
</sup<2<>
A 52 year old man is recovering following an elective right hemicolectomy for
carcinoma of the caecum. His surgery is uncomplicated, when should oral intake
resume?
A. Only once bowels have been opened to stool
B. Only once the patient has passed flatus
C. Between 24 and 48 hours of surgery
D. More than 48 hours after surgery
E. Within 24 hours of surgery
As part of the enhanced recovery principles oral intake in this setting should resume
soon after surgery. Administration of liquid and even light diet does not increase the
risk of anastomotic leak.
Oral Nutrition
Oral nutrition: a summary of NICE guidelines
 Identify patients who are or at risk of being malnourished (see below for
definitions)
 Check for dysphagia
 If safe swallow, provide food and fluid in adequate quantity and quality
 Give a balanced diet
 Offer multivitamins and minerals
Surgical patients:
 If malnourished and safe swallow and post op caesarean, gynaecological or

abdominal surgery, aim for oral intake within 24h
Patients identified as being malnourished:
 BMI < 18.5 kg/m2

AT RISK of malnutrition:
 high metabolism
Theme: Muscle relaxants
A. Atracurium
B. Suxamethonium
C. Pancuronium
D. Vecuronium
E. Curare
Please select the muscle relaxant that applies to the scenario or description supplied.
Each option may be used once, more than once or not at all.
43. An agent that is degraded by hydrolysis and may produce histamine release.
Atracurium
Atracurium is degraded by a process of ester hydrolysis. This uses non specific

plasma esterases.
44. An agent which should be avoided in a 23 year old man with burn and bilateral
tibial fractures are being trapped in a car accident for 2 hours.
You answered Curare
The correct answer is Suxamethonium
Suxamethonium may induce hyperkalaemia as it induces generalised muscular

contractions. In patients with likely extensive tissue necrosis this may be
sufficient to produce cardiac arrest.
45. An agent with a half life of less than 10 minutes.
Suxamethonium
Suxamethonium is extremely rapidly metabolised, acetylcholinesterases

degrade the drug within minutes. In patients who lack this enzyme the drug
may last far longer.
Muscle relaxants

junction
relaxants

hydrolysis

dysfunction

neostigmine
Which of the following is a recognised feature of ketamine when used as an

anaesthetic agent?
A. Malignant hyperpyrexia
B. Adrenal suppression
C. Myocardial depression
D. Dissociative anaesthesia
E. Marked respiratory depression
Unlike most anaesthetic agents ketamine does not cause myocardial or marked
respiratory depression. It is not associated with the adrenal suppression that may
occur with etomidate. It is however, associated with a state of dissociative anaesthesia
which patients may find distressing.
Anaesthetic agents


unstable
nightmares

A 73 year old man undergoes a right below knee amputation for end stage peripheral
vascular disease. He is reviewed in the clinic 8 weeks post operatively and complains
of a persistent, burning discomfort over his amputation site stump. On examination
his wound has healed and proximal pulses have a biphasic signal on doppler
ultrasound. What is the post appropriate management?
A. Commence amitryptyline
B. Commence fentanyl patch
C. Arrange duplex scan
D. Arrange MRI scan of the stump
E. Commence carbamazepine
This patient has neuropathic pain. Amitryptyline is the treatment of choice.

Carbamazepine is mainly used for trigeminal neuralgia.
Neuropathic pain
Neuropathic pain may be defined as pain which arises following damage or disruption
of the nervous system. It is often difficult to treat and responds poorly to standard
analgesia.
Examples include:
 diabetic neuropathy
 post-herpetic neuralgia
 trigeminal neuralgia
 prolapsed intervertebral disc
NICE issued guidance in 2010 on the management of neuropathic pain:
 first-line treatment*: oral amitriptyline or pregabalin

 if satisfactory pain reduction is obtained with amitriptyline but the person
cannot tolerate the adverse effects, consider oral imipramine or nortriptyline as
an alternative
 second-line treatment: if first-line treatment was with amitriptyline, switch to
or combine with pregabalin. If first-line treatment was with pregabalin, switch
to or
combine with amitriptyline
 other options: pain management clinic, tramadol (not other strong opioids),
topical lidocaine for localised pain if patients unable to take oral medication
*please note that for some specific conditions the guidance may vary. For example
carbamazepine is used first-line for trigeminal neuralgia, duloxetine for diabetic
neuropathy
A homeless 42 year old male had an emergency inguinal hernia repair 24 hours
previously. He has a BMI of 15. His electrolytes are normal. What is the best initial
feeding regime?
A. Give 10 kcal/kg/day initially, oral thiamine 200-300mg/day, vitamin

B co strong1 tds and supplements.
B. Give 35 kcal/kg/day initially, oral thiamine 200-300mg/day, vitamin

B co strong 1 tds and supplements.
C. No change to diet needed
D. Oral thiamine 200-300mg/day, vitamin B co strong1 tds and

supplements.
E. Give 35 kcal/kg/day initially
This patient is at high risk of refeeding syndrome.
Nutrition - Refeeding syndrome
Refeeding syndrome describes the metabolic abnormalities which occur on feeding a

person a starved state. The metabolic consequences include:
 Hypophosphataemia
 Hypokalaemia
 Hypomagnesaemia
 Abnormal fluid balance
These abnormalities can lead to organ failure.
Re-feeding problems
If patient not eaten for > 5 days, aim to re-feed at < 50% energy and protein levels
High risk for re-feeding problems

If one or more of the following:
 BMI < 16 kg/m2

 Unintentional weight loss >15% over 3-6 months
 Little nutritional intake > 10 days
 Hypokalaemia, Hypophosphataemia or hypomagnesaemia prior to feeding
(unless high)
If two or more of the following:
 BMI < 18.5 kg/m2

 Unintentional weight loss > 10% over 3-6 months
 Little nutritional intake > 5 days
 PMH alcohol abuse or drug therapy including insulin, chemotherapy,
diuretics, antacids
Prescription
 Start at up to 10 kcal/kg/day increasing to full needs over 4-7 days

 Start immediately before and during feeding: oral thiamine 200-300mg/day,
vitamin B co strong 1 tds and supplements
 Give K+ (2-4 mmol/kg/day), phosphate (0.3-0.6 mmol/kg/day), magnesium
(0.2-0.4 mmol/kg/day)
 A 48 year old man is recovering on the high dependency unit following a long
and complex laparotomy. His preoperative medication includes an ACE
inhibitor for blood pressure control. For the past two hours he has been
oliguric with a urine output of 10ml/hr-1. What the most appropriate course of
action?
A. Stop the ACE inhibitor
B. Administer a fluid challenge
C. Start an infusion of nor adrenaline

D. Administer intravenous frusemide
E. Insert a Swann-Ganz Catheter


Hypovolaemia is the most likely cause for oliguria and a fluid challenge is the
most appropriate action. Blind administration of inotropes to hypovolaemic
patients is unwise, with the possible exception of cardiac patients.
 Hypovolaemia and the surgical patient

Hypovolaemia often represents the end point of multiple pathological
processes. It may be divided into the following categories; overt compensated
hypovolaemia, covert compensated hypovolaemia and decompensated
hypovolaemia. Of these three categories the covert compensated subtype of
hypovolaemia remains the commonest and is accounted for by the fact that
class I shock will often produce no overtly discernible clinical signs. This is
due, in most cases, to a degree of splanchnic autotransfusion. The most useful
diagnostic test for detection of covert compensated hypovolaemia remains
urinanalysis. This often shows increased urinary osmolality and decreased
sodium concentration.
In overt compensated hypovolaemia the blood pressure is maintained although

other haemodynamic parameters may be affected. This correlates to class II
shock. In most cases assessment can be determined clinically. Where
underlying cardopulmonary disease may be present the placement of a CVP
line may guide fluid resuscitation. Severe pulmonary disease may produce
discrepancies between right and left atrial filling pressures. This problem was
traditionally overcome through the use of Swann-Ganz catheters.
Untreated, hypovolaemia may ultimately become uncompensated with

resultant end organ dysfunction. Microvascular hypoperfusion may result in
acidosis with a subsequent myocardial depressive effect, thereby producing a
viscous circle.
The treatment of hypovolaemia is with intravenous fluids. In the first instance

a fluid challenge such as the rapid infusion of 250ml of crystalloid will often
serve as both a diagnostic and resuscitative measure. In the event that this fails
to produce the desired response the patient will need to be re-evaluated
clinically. More fluid may be needed. However, it is important not to overlook
mechanical ureteric obstruction in the anuric, normotensive patient.
Theme: Muscle relaxants
A. Gallamine
B. Benzquinonium
C. Tubocurarine
D. Vecuronium
E. Pancuronium
F. Suxamethonium
G. Decamethonium halides
Please select the most appropriate neuromuscular blocking drugs for the procedure
described. Each option may be used once, more than once or not at all.
50. A 56 year old man is undergoing a distal gastrectomy and just as the surgeon
begins to close the deep abdominal muscle layer the patient develops marked
respiratory efforts and closure cannot continue.
Suxamethonium
Suxamethonium has a rapid onset with short duration of action. As this is the
final stage of the procedure only brief muscle relaxation is needed.
51. An agent that is associated with a risk of malignant hyperthermia.
Suxamethonium
Suxamethonium may cause malignant hyperthermia and 1 in 2800 will have

abnormal cholinesterase enzyme and prolonged clinical effect.
52. An agent that may be absorbed from multiple bodily sites and causes histamine
release.
You answered Pancuronium
The correct answer is Tubocurarine
It can be absorbed orally and rectally, though few would choose this route of
administration. It is now rarely used.
Muscle relaxants

junction
relaxants

hydrolysis

dysfunction

neostigmine
A 52 year old man undergoes a laparotomy for perforated bowel after a colonoscopy.
2 days after surgery the nursing staff report there is pink, serous fluid discharging
from the wound. What is the next most appropriate management step?
A. IV antibiotics for wound infection
B. No further management
C. Examine the wound for separation of the rectus fascia
D. Insert a drain into the wound
E. CT abdomen
The seepage of pink serosanguineous fluid through a closed abdominal wound is an

early sign of abdominal wound dehiscence with possible evisceration. If this occurs,
you should remove one or two sutures in the skin and explore the wound manually,
using a sterile glove. If there is separation of the rectus fascia, the patient should be
taken to the operating room for primary closure.
Abdominal wound dehiscence

 This is a significant problem facing all surgeons who undertake abdominal
surgery on a regular basis. Traditionally it is said to occur when all layers of
an abdominal mass closure fail and the viscera protrude externally (associated
with 30% mortality).
 It can be subdivided into superficial, in which the skin wound alone fails and
complete, implying failure of all layers.
Factors which increase the risk are:

* Malnutrition
* Vitamin deficiencies
* Jaundice
* Steroid use
* Major wound contamination (e.g. faecal peritonitis)
* Poor surgical technique (Mass closure technique is the preferred method-Jenkins
Rule)
When sudden full dehiscence occurs the management is as follows:

* Analgesia
* Intravenous fluids
* Intravenous broad spectrum antibiotics
* Coverage of the wound with saline impregnated gauze (on the ward)
* Arrangements made for a return to theatre
Surgical strategy
 Correct the underlying cause (eg TPN or NG feed if malnourished)

 Determine the most appropriate strategy for managing the wound
Options
Resuturing of the This may be an option if the wound edges are healthy and there is
wound enough tissue for sufficient coverage. Deep tension sutures are
traditionally used for this purpose.
Application of a This is a clear dressing with removable front. Particularly suitable
wound manager when some granulation tissue is present over the viscera or where
there is a high output bowel fistula present in the dehisced wound.
Application of a This is a clear plastic bag that is cut and sutured to the wound edges
'Bogota bag' and is only a temporary measure to be adopted when the wound
cannot be closed and will necessitate a return to theatre for definitive
management.
Application of a These can be safely used BUT ONLY if the correct layer is
VAC dressing interposed between the suction device and the bowel. Failure to
system adhere to this absolute rule will almost invariably result in the
development of multiple bowel fistulae and create an extremely
difficult management problem.
A 63 year old man undergoes a subtotal colectomy and iatrogenic injury to both
ureters is sustained. He develops renal failure and his serum potassium is found to be
elevated at 6.9 mmol/L. An ECG is performed, what is the most likely finding?
A. Increased PR interval
B. Prominent U waves
C. Narrow QRS complexes
D. Peaked T waves
E. Low ST segments
Peaked T waves are the first and most common finding in hyperkalaemia.
ECG features in hyperkalaemia
 Peaking of T waves (occurs first)

 Loss of P waves
 Broad QRS complexes
 Ventricullar fibrillation
Theme: Use of vasoactive drugs
A. Dopexamine
B. Dobutamine
C. Noradrenaline
D. Adrenaline
E. Milrinone
F. Dopamine
Please select the most appropriate inotrope for the scenario given. Each option may be
used once, more than once or not at all.
55. An inotrope with mixed vaso dilating and vaso constricting properties.
Dopamine
Dilating in the case of renal circulating and constricting in other areas. Overall
increases cardiac output. Concept of renal dose dopamine is out of date.
56. An inotrope that is a phosphodiesterase inhibitor.
Milrinone
Milrinone works by increasing intracellular cAMP concentration.

57. An inotrope that would be useful in a 23 year old female with sepsis secondary
to pyelonephritis. She has an increased cardiac output and decreased systemic
vascular resistance.
Noradrenaline
Theme from September 2011 Exam
In a setting of septic shock with normal or high cardiac output and decreased
SVR, a peripherally acting vasoconstrictor such as noradrenaline would be the
primary choice.
Circulatory support of the critically ill
Circulatory support
Impaired tissue oxygenation may occur as a result of circulatory shock. Shock is
considered further under its own topic heading.
Patients requiring circulatory support require haemodynamic monitoring. At its

simplest level this may simply be in the form of regular urine output measurements
and blood pressure monitoring. In addition ECG monitoring with allow the
identification of cardiac arrhythmias. Pulse oximeter measurements will allow quick
estimation haemoglobin oxygen saturation in arterial blood.
Invasive arterial blood pressure monitoring is undertaken by the use of an indwelling

arterial line. Most arterial sites can be used although the radial artery is the
commonest. It is important not to cannulate end arteries. The arterial trace can be
tracked to ventilation phases and those patients whose systolic pressure varies with
changes in intrathoracic pressure may benefit from further intravenous fluids.
Central venous pressure is measured using a CVP line that is usually sited in the
superior vena cava via the internal jugular route. The CVP will demonstrate right
atrial filling pressure and volume status. When adequate intra vascular volume is
present a fluid challenge will typically cause a prolonged rise in CVP (usually greater
than 6-8mmHg).
To monitor the cardiac output a Swan-Ganz catheter is traditionally inserted (other

devices may be used and are less invasive). Inflation of the distal balloon will provide
the pulmonary artery occlusion pressure and the pressure distal to the balloon will
equate to the left atrial pressure. This gives a measure of left ventricular preload.
Because the Swan-Ganz catheter can measure several variables it can be used to
calculate:
 Stroke volume
 Systemic vascular resistance
 Pulmonary artery resistance
 Oxygen delivery (and consumption)
Inotropes
In patients with an adequate circulating volume but on-going circulatory compromise
a vasoactive drug may be considered. These should usually be administered via the
central venous route. Commonly used inotropes include:
 Noradrenaline- A vasopressor with little effect on cardiac output. Acts as an α

agonist.
 Adrenaline-Acts on both α and β receptors thereby increasing cardiac output
and increasing systemic vascular resistance.
 Dopamine- Acts as a β 1 agonist and increases contractility and rate. Renal
dose dopamine is an obsolete concept.
 Dobutamine- Has both β 1 and β 2 effects and will increase cardiac output and
cause decrease in systemic vascular resistance.
 Milrinone- Phosphodiesterase inhibitor with a positive inotropic effect. It has a
short half-life (1-2 hours) and may precipitate arrhythmias. Vasopressors often
co-administered as it is a vasodilator.
 A 56 year old man with chronic schizophrenia undergoes a cholecystectomy.
He receives metoclopramide for post operative nausea. Twenty minutes later
he becomes agitated and develops marked oculogyric crises and
oromandibular dystonia. Which of the following drugs may best alleviate his
symptoms?
A. Procyclidine
B. Lorazepam
C. Chlorpromazine
D. Haloperidol
E. Sulpiride

This man has developed an acute dystonic reaction. Administration of further
anti dopaminergic drugs will worsen the situation. Procyclidine will help to
reverse the event. This is most likely to have occurred because the patient is
on long term anti psychotics and has then received metoclopramide.
 Acute dystonic reaction

The anti dopaminergic drugs (such as antipsychotics) may result in
extrapyramidal side effects. These may range from mild parkinsonian
symptoms such as resting tremor and bradykinesia. Through to acute dystonic
reactions which are characterised by abnormal and involuntary facial and
bodily movements, such as spasmodic torticollis, oculogyric crisis and
oromandibular dystonia.
Chronic cases are generally only encountered in psychiatric units. In surgical
practice the administration of the anti dopaminergic drug metoclopramide may
be sufficient to precipitate an attack.
Treatment may be required if symptoms are sufficiently troublesome;

benzhexol and procyclidine are two drugs which may be used.
Theme: Surgical analgesia
A. TAP block
B. Epidural anaesthatic
C. Spinal block
D. Patient controlled analgesia
E. Paracetamol and diclofenac
F. Pethidine as required
G. Regular nefopam
Please select the most appropriate analgesic modality for the scenario given. Each
59. A 63 year old man with carcinoma of the splenic flexure undergoes an
extended right hemicolectomy through a midline excision. He suffers from
COPD.
You answered TAP block
The correct answer is Epidural anaesthatic
This man is at high risk of atelectasis, hypoventilation can be avoided by

minimising post operative pain through an epidural. A spinal block is short
acting, therefore not appropriate.
60. A 63 year old man with rectal cancer is due to undergo an anterior resection by
laparoscopic approach. He is otherwise well.
TAP block
This is a localised infiltration of the abdominal wall with long acting local
anaesthetic. This will provide optimal analgesia for the more limited pain that
may occur with a laparoscopic procedure.
61. A 52 year old man undergoes an appendicectomy through a lower midline

abdominal incision as the initial laparoscopy shows an appendix mass. He is
otherwise well.
You answered Spinal block
The correct answer is Patient controlled analgesia
This is more painful than a conventional appendicectomy, but conversion to a

limited laparotomy was not anticipated. A PCA is the most effective and
practically applicable modality in this case.
Management of pain


Ladder

alone.
Local anaesthetics

Bupivacaine
thin catheter
Spinal anaesthesia


Strong Opioids
Morphine

Pethidine
failure.
Weak opioids

Paracetamol

NSAIDs

Neuropthic pain

morphine)
References
7 (1997)
Which of the following anaesthetic agents has the strongest analgesic effect?
A. Sodium thiopentone
B. Ketamine
C. Midazolam
D. Etomidate
Ketamine has a moderate to strong analgesic effect. It may be used for emergency
procedures outside the hospital environment to induce anaesthesia for procedures such
as emergency amputation.
Anaesthetic agents


unstable
nightmares

Which statement is true on enteral feeding?
A. A PEG can be used 12h after insertion
B. A motility agent is avoided for ITU patients with an Nasogastric tube
C. A regime of 24h continuous feeding is recommended for ITU patients
D. A long-term gastrostomy is recommended if feeding is likely to be >

8 weeks
E. Enteral feeding is not possible in upper GI dysfunction
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

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.
Which of the following does not need monitoring during home parenteral nutritional
support?
A. Folate levels
B. Zinc levels
C. Vitamin D
D. Thyroid function
E. Bone densitometry
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 is not typically included in total parenteral nutritional

solutions?
A. Fibre
B. Lipid
C. Potassium
D. Glucose
E. Magnesium
There is no indication for inclusion of fibre in solutions of TPN, nor would it be safe
to do so.
Total parenteral nutrition
 Commonly used in nutritionally compromised surgical patients

 Bags contain combinations of glucose, lipids and essential electrolytes, the
exact composition is determined by the patients nutritional requirements.
 Although it may be infused peripherally, this may result in thrombophlebitis.
 Longer term infusions should be administered into a central vein (preferably
via a PICC line).
 Complications are related to sepsis, re-feeding syndromes and hepatic
dysfunction.
A 28 year old man with poorly controlled Crohns disease is nutritionally

compromised. The decision is made to start TPN, via which of the following routes
should it be best administered?
A. Internal jugular vein via a central venous catheter
B. Internal carotid artery
C. Cephalic vein via peripheral cannula
D. Basilic vein via peripheral cannula
E. Common femoral vein via a central venous catheter
Since TPN solutions are irritant to veins they are best administered via a central line.
The femoral route has a higher incidence of line associated sepsis and is thus best
avoided in this setting.
Parenteral feeding-NICE guidelines
Parenteral nutrition: NICE guidelines summary
Identify patients as malnourished or at risk
Patients identified as being malnourished-
 BMI < 18.5 kg/m2

AT RISK of malnutrition-
 high metabolism
Identify unsafe/inadequate oral intake OR a non functional GI

tract/perforation/inaccessible
Consider parenteral nutrition:
 for feeding < 14 days consider feeding via a peripheral venous catheter
 for feeding > 30 days use a tunneled subclavian line
 continuous administration in severely unwell patients
 if feed needed > 2 weeks consider changing from continuous to cyclical
feeding
 don't give > 50% of daily regime to unwell patients in first 24-48h
Surgical patients: if malnourished with unsafe swallow OR a non functional GI

tract/perforation/inaccessible then consider peri operative parenteral feeding.
Theme: Wound management
A. VAC Device
B. Packing with alginate ribbon
C. Packing with ribbon gauze
D. Application of silver nitrate
E. Application of potassium permangenate
F. Use of iodine soaked gauze
G. Gauze soaked in proflavin
For each wound please select the most appropriate management option. Each option
may be used once, more than once, or not at all.
67. A 56 year old man has a superficial dehisence of a midline sternotomy wound
following an aortic valve replacement.
You answered Use of iodine soaked gauze
The correct answer is VAC Device
Provided the sternum is stable a VAC device should promote granulation and
healing. It is not indicated where the sternum has come apart.
68. A 72 year old man has discharge from a healed abdomino-perineal resection
wound. On examination it has almost completely healed but there is prominent
granulation tissue at the apex of the wound. There is no evidence of an
underlying collection and he is otherwise well.
You answered VAC Device
The correct answer is Application of silver nitrate
Silver nitrate will cauterise the exuberant granulation tissue and promote
healing.
69. A 23 year old man has an incision and drainage of an axillary abscess, there is
no residual surrounding tissue infection.
You answered Packing with ribbon gauze
The correct answer is Packing with alginate ribbon
Use of gauze is inappropriate and will be painful to redress.
Methods of wound closure
Method of Indication
closure
Primary closure  Clean wound, usually surgically created or following minor
trauma
 Standard suturing methods will usually suffice
 Wound heals by primary intention
Delayed primary  Similar methods of actual closure to primary closure

closure  May be used in situations where primary closure is either not
achievable or not advisable e.g. infection
Vacuum assisted  Uses negative pressure therapy to facilitate wound closure

closure  Sponge is inserted into wound cavity and then negative
pressure applied
 Advantages include removal of exudate and versatility
 Disadvantages include cost and risk of fistulation if used
incorrectly on sites such as bowel
Split thickness  Superficial dermis removed with Watson knife or dermatome

skin grafts (commonly from thigh)
 Remaining epithelium regenerates from dermal appendages
 Coverage may be increased by meshing
Full thickness  Whole dermal thickness is removed

skin grafts  Sub dermal fat is then removed and graft placed over donor
site
 Better cosmesis and flexibility at recipient site
 Donor site "cost"
Flaps  Viable tissue with a blood supply

 May be pedicled or free
 Pedicled flaps are more reliable, but limited in range
 Free flaps have greater range but carry greater risk of
breakdown as they require vascular anastomosis
A 22 year old fit and well male undergoes an emergency appendicectomy. He is given
suxamethonium. An inflamed appendix is removed and the patient is returned to
recovery. One hour post operatively the patient develops a tachycardia of 120 bpm
and a temperature of 40 ºC. He has generalised muscular rigidity. What is the most
likely diagnosis?
A. Acute dystonic reaction
B. Malignant hyperthermia
C. Pelvic abscess
D. Epilepsy
E. Serotonin syndrome
Anaesthetic agents, such as suxamethonium, can cause malignant hyperthermia in

patients with a genetic defect. Acute dystonic reaction normally is associated with
antipsychotics (haloperidol) and metoclopramide. These lead to marked
extrapyramidal effects. Serotonin syndrome is associated with the antidepressants
selective serotonin reuptake inhibitors (SSRIs) and selective serotonin/norepinephrine
reuptake inhibitors (SSNRIs). This causes a syndrome of agitation, tachycardia,
hallucinations and hyper-reflexia.
Malignant hyperthermia
Overview
 Condition often seen following administration of anaesthetic agents

 Characterised by hyperpyrexia and muscle rigidity
 Cause by excessive release of Ca2+ from the sarcoplasmic reticulum of skeletal
muscle
 Associated with defects in a gene on chromosome 19 encoding the ryanodine
receptor, which controls Ca2+ release from the sarcoplasmic reticulum
 Neuroleptic malignant syndrome may have a similar aetiology
Causative agents
 Halothane
 Suxamethonium
 Other drugs: antipsychotics (neuroleptic malignant syndrome)
Investigations
 CK raised
 Contracture tests with halothane and caffeine
Management
 Dantrolene - prevents Ca2+ release from the sarcoplasmic reticulum

Post Operative Care

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Post Operative Care

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A 44 year old man undergoes a distal gastrectomy for cancer.

Blood transfusion reactions

Immune mediated Non immune mediated

Suxamethonium may induce generalised muscular contractions following

Suxamethonium  Depolarising neuromuscular blocker

Atracurium  Non depolarising neuromuscular blocking drug

Vecuronium  Non depolarising neuromuscular blocking drug

Pancuronium  Non depolarising neuromuscular blocker

A 23 year old man is recovering from an appendicectomy. The operation was

Theme from January 2011 Exam

Post operative fluid management

Composition of commonly used intravenous fluids mmol-1

A summary of the recommendations for post operative fluid management

 Fluids given should be documented clearly and easily available

E. Adult respiratory distress syndrome

Theme from January 2012 Exam

Acute pancreatitis is known to precipitate ARDS. ARDS is characterised by bilateral

Adult respiratory distress syndrome

Defined as an acute condition characterized by bilateral pulmonary infiltrates and

 Acute dyspnoea and hypoxaemia hours/days after event

 Treat the underlying cause

Sodium  Extremely rapid onset of action making it the agent of choice

Ketamine  May be used for induction of anaesthesia

Etomidate  Has favorable cardiac safety profile with very little

A patient with tachycardia and hypotension is to receive inotropes. Which of the

E. None of the above

Theme from April 2012 Exam

Inotropes and cardiovascular receptors

Inotrope Cardiovascular receptor action

Effects of receptor binding

heme: Feeding options

7. A 28 year old man is comatose, from head injuries, on the neurosurgical

Naso gastric feeding tube

Theme from April 2012 Exam

8. A 56 year old man has undergone a potentially curative oesophagectomy for

You answered Total parenteral nutrition

The correct answer is Normal oral intake

Nutrition options in surgical patients

Oral intake  Easiest option

Feeding jejunostomy  Surgically sited feeding tube

Percutaneous  Combined endoscopic and percutaneous tube insertion

Total parenteral  The definitive option in those patients in whom enteral

Theme: Anaesthetic agents

This is a daycase procedure for which propofol is ideal. Sodium thiopentone

You answered Etomidate

The correct answer is Ketamine

You answered Propofol

The correct answer is Sodium thiopentone

Most anaesthetists would use sodium thiopentone for a rapid sequence

Propofol- Ideal agent for daycase- wears

Sodium thiopentone- Fast onset of

Sodium  Extremely rapid onset of action making it the agent of choice

Ketamine  May be used for induction of anaesthesia

Etomidate  Has favorable cardiac safety profile with very little

E. Computed tomographic pulmonary

This is a difficult question to answer as both computed tomographic pulmonary

Pulmonary embolism: investigation

Key points from the guidelines include:

 computed tomographic pulmonary angiography (CTPA) is now the

{Some other points}

 sensitivity = 95-98%, but poor specificity

 peripheral emboli affecting subsegmental arteries may be missed

 the gold standard

Theme: Surgical analgesia