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 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 63 year old man is commenced on an infusion of packed red cells following a total hip replacement.
Which of the following adverse events is most likely?

A. ABO mismatching

B. Immune mediated intolerance of rhesus incompatible blood

C. Pyrexia

D. Jaundice

E. Graft versus host disease

Mild pyrexia during blood transfusion is the most common event and commonly occurs during
transfusion.

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

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
 E. None of the above

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

Theme: 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.

4. 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

Theme from April 2012 Exam

Theme from January 2013 Exam
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.

5. 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.

6. A 43 year old man is recovering from a laparoscopic low anterior resection with loop ileostomy.

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 gastrostomy • May not be technically possible in those patients who cannot undergo
successful endoscopy
• Risks include aspiration and leakage at the insertion site

Total parenteral • The definitive option in those patients in whom enteral feeding is
nutrition 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