Which 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 bleeding or
plasma require surgery. It is obtained by low speed centrifugation.
Platelet Prepared by high speed centrifugation and administered to patients with
concentrate 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.
-1
• Usual dose is 12-15ml/Kg .
• 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.

A 63 year old man undergoes a laparotomy and small bowel resection. Twelve hours post operatively he
is noted to have a decreased urine output. Which of the hormones listed below is most likely to be
responsible?

A. Cortisol

B. Atrial natriuretic hormone

 C. Vasopressin

D. Insulin

E. Glucagon

Theme from January 2013 Exam

Vasopressin is released in increased quantities following most operative procedures and will tend to
cause water retention. Excessive administration of intravenous fluids in an attempt to force a diuresis
may cause fluid overload in post operative patients for this reason.

Response to surgery

Sympathetic nervous system

• Noradrenaline from sympathetic nerves and adrenaline from adrenal medulla

• Blood diverted from skin and visceral organs; bronchodilatation, reduced intestinal motility,
increased glucagon and glycogenolysis, insulin reduced
• Heart rate and myocardial contractility are increased

Acute phase response

• TNF-α, IL-1, IL-2, IL-6, interferon and prostaglandins are released

• Excess cytokines may cause SIRS
• Cytokines increase the release of acute phase proteins

Endocrine response

• Hypothalamus, pituitary, adrenal axis

• Increases ACTH and cortisol production:

increases protein breakdown

increases blood glucose levels

• Aldosterone increases sodium re-absorption

• Vasopressin increases water re-absorption and causes vasoconstriction

Vascular endothelium

• Nitric oxide produces vasodilatation

• Platelet activating factor enhances the cytokine response
• Prostaglandins produce vasodilatation and induce platelet aggregation
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.
• 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.

5. 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.

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

6. 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 4/0 interrupted nylon

 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.

7. 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 Split thickness skin grafting

The correct answer is Full thickness skin graft

Grafting is indicated as the wound will invariably contract during the scarring process.
Theme: 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.

8. 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.

9. 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.

10. 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.

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.

11. 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 %.

12. 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.

13. 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).

heme: 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.

14. A 53 year old alcoholic male presents with acute pancreatitis. He is clinically dehydrated. His
blood results show normal renal function and electrolytes.
 You answered 0.9% Normal saline

The correct answer is 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.

15. A 45 year old man with previous laparotomy is admitted with adhesional small bowel obstruction.
He is managed with prolonged nasogastric drainage.

You answered Hartmann's solution

The correct answer is 0.9% Normal saline

This man will be hypochloraemic, therefore treatment is with 0.9% sodium chloride.

16. 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.

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.

Theme: 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.

17. 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.

18. 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.

19. 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.

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 bleeding or
plasma require surgery. It is obtained by low speed centrifugation.
Platelet Prepared by high speed centrifugation and administered to patients with
concentrate 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 re-infuse it. There are two main types:

• Those which wash the blood cells prior to re-infusion. These are more expensive to purchase and
more complicated to operate. However, they reduce the risk of re-infusing contaminated blood
back into the patient.
• Those which do not wash the blood prior to re-infusion.

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

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

In 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.

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.

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 4 hours 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

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.

23. An agent which reverses the action of midazolam

 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.

24. 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.

25. 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 reason.

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 for rapid
thiopentone 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 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

E. None of the above

Unlike low molecular weight heparins that do not require monitoring unfractionated heparin does
require monitoring, this is done by measuring the APTT.

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.

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.

27. A 45 year old man is due to undergo an Ivor Lewis oesophagectomy for a carcinoma of the distal
oesophagus.

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.

28. A 32 year old man is due to undergo a right hemicolectomy for a large caecal sessile polyp.

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.

29. A 67 year old women is due to undergo a parathyroidectomy for a parathyroid adenoma.

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.
Theme: 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% Bupivacaine
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.

30. A 28 year old man has a sebaceous cyst of the scalp that requires excision.

You answered 1% Lignocaine

The correct answer is 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.

31. 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.

0.5% Bupivacaine

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 bupivacaine
will be active.
32. A 43 year old man is due to undergo a vasectomy.

1% Lignocaine

Plain lignocaine will suffice. This will give rapid onset of action. Bupivacaine 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.

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 tachycardia.
• Apart from its limited use in ENT surgery it is otherwise used rarely in mainstream surgical
practice.

Bupivacaine

• 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
Bupivacaine 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.

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.

33. pH 7.48, pO2 10.1, Bicarbonate 30, pCO2 4.5, Chloride<10meq

Metabolic alkalosis
 This would be typical result of prolonged vomiting.

34. 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).

35. pH 7.20, pO2 7.5, Bicarbonate 22, pCO2 8.1, Chloride 10

Type 2 respiratory failure

This is a sign of acute type 2 respiratory failure (non compensated). This is the result of carbon
dioxide retention.
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.

36. 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.

37. 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).

38. 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 Unfractionated heparin and pneumatic compression stockings

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 doses typically
weight heparin resulting in inhibition given in those with moderate to high risk of thromboembolic
of factor Xa events. It is given as once daily subcutaneous injection
Unfractionated Binds antithrombin III Effective anticoagulation, administered intravenously it has a
heparin with affects thrombin rapid onset and its therapeutic effects decline quickly on
and factor Xa stopping and infusion. Its activity is measured using the
APTT. If need be it can be reversed using protamine sulphate
Dabigatran Orally administered Used prophylaxis in hip and knee surgery. It does not require
direct thrombin therapeutic monitoring. It has no known antidote and should
inhibitor not be used in any patient in whom there is a risk of active
bleeding or imminent likelihood of surgery

Theme: 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.
39. 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.

40. 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.

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.

41. 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 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 glands During difficult thyroid surgery
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 cardiac Susceptibility to hypokalaemia (K+ <4.0 in cardiac patients)
surgery
Neurosurgical electrolyte SIADH following cranial surgery causing hyponatraemia
disturbance
Ileus following gastrointestinal Fluid sequestration and loss of electrolytes
surgery
Pulmonary oedema following Loss of lung volume makes these patients very sensitive to fluid
pneumonectomy 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 leave packs
in situ and return the patient to ITU for pack removal the subsequent day.

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. We remind you to check the wording
of the question, it asks for the "least likely" cause of pyrexia.

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
• Inflammatory markers raised

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
• Inflammatory markers raised

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 4 hours 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

1/3 Question 1-3 of 8

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.

1. A 56 year old man with carcinoma of the rectum requires a low anterior resection.

You answered Rectal lavage with saline

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.

2. A 44 year old man with carcinoma of the hepatic flexure requires a right hemicolectomy.

You answered 60 ml oral lactulose

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.

3. A 34 year old colitic with acute colitis requires a flexible sigmoidoscopy.

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.

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.

Question 4 of 8
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.

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 tachycardia.
• Apart from its limited use in ENT surgery it is
 otherwise used rarely in mainstream surgical practice.

Bupivacaine

• 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
Bupivacaine 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.

Question 5 of 8
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. What is the most likely explanation 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.

Question 6 of 8
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

Question 7 of 8
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

Question 8 of 8
A 62 year old lawyer has a transurethral resection which took 1 hour 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.