‘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. What is the best option for maintenance of his airway? Nasotracheal tube Endotracheal tube Guedel airway Laryngeal mask 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). Improve 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 + 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 + Provides optimal control of the airway once cuff inflated tube + May be used for long or short term ventilation + Errors in insertion may result in oesophageal intubation (therefore end tidal CO, usually measured) + Paralysis often required ‘+ Higher ventilation pressures can be used Bilaea@W&W- #22 Tr & @ o ‘Save my notes Search Search textbook B Q Google search on “Airway management" + uggest tink suggest media Dashboard " 12 13 14 15 MEQPCUCICIR C0 eee 400 eeo Question 2 of 70 v p ©} A 82 year old man is recovering following an elective right hemicolectomy for carcinoma of the caecum. His surgery Is uncomplicated, when should oral intake resume? Only once bowels have been opened to stool Only once the patient has passed flatus Between 24 and 48 hours of surgery More than 48 hours after 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. | ® | improve Oral Nutrition * ral 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/m? + Unintentional weight loss of > 10% over 3-6/12 + BMI < 20 kg/m? 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Oo Question 3 of 70, v B So A117 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? Hypochloraemic alkalosis Hyperchloraemic alkalosis Acute renal failure None of the above 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. | | Improve Post operative fluid management * Composition of commonly used intravenous fluids mmol? Na K cl Bicarbonate Lactate Plasma 137147 45,5 95105 (22-25 : 0.9% Saline 153 : 153 - : Dextrose / saline 30.6 - 30.6 - - Hartmans. 130 4 110 : 28 Post operative fluid management In the UK the GIFTASUP and NICE (C6174 2013) guidelines (see reference below) were devised to try and provide some consensus guidance as to how intravenous fluids should be administered. A decade ago it was a commonly held belief that little harm would occur as a result of excessive administration of normal saline and many oliguric post operative patients received enormous quantities of lV fluids. As a result they developed hyperchloraemic acidosis. Withgreater understanding of this potential complication, the use of electrolyte balanced solutions (Ringers lactate/ Hart mans) is now favored over normal saline. The other guidance includes: ‘+ Fluids given should be documented clearly and easily available ‘+ Assess the patient's fluid status when they leave theatre + Ifa patient is haemodynamically stable and euvolaemic, aim to restart oral fluid intake as soon as possible ‘+ Review patients whose urinary sodium is < 20 + Ifa 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 NICE guidance C6174, Intravenous fluid therapy In adults. December 2013. British Consensus Guidelines on Intravenous Fluid Therapy for Adult Surgical Patients. GIFTASUP. (2009) ‘Save my notes Search Search textbook Q Google search on “Post operative fluid management” Suggest nk + suggest media Dashboard £4686°e Question 4 of 70 v B © Which of the drugs listed below confers the greatest risk of malignant hyperthermia? Decamethonium halides Benzquinonium Gallamine Vecuronium ‘Suxamethonium may cause malignant hyperthermia and 1 in 2800 will have abnormal cholinesterase enzyme and prolonged clinical effect. Improve Muscle relaxants Suxamethonium + Atracurium . Vecuronium, . * Depolarising neuromuscular blocker Inhibits action of acetylcholine at the neuromuscular Junction Degraded by plasma cholinesterase and acetyicholinesterase (affected by lack of 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, delayed recovery 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 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 Bt em < ve my notes Search Search textbook cy Q Google search on "Muscle relaxants” + Suogest ink 4 suggest mestia Dashboard e@Yanewona u 12 13 4 15 16 CHECECCCREAEKA CES° Question 5 of 70 v b >) Administration of neostigmine to a patient who has received a non depolarizing muscle relaxant is most likely to result in which of the following? Prolongation of muscle relaxation @ Tachycardia Hypertension e Decreased gut peristalsis e Neostigmine can cause bradycardia and atropine is often administered concomitantly to counter this effect. & | improve | Muscle relaxants ‘Suxamethonium . Vecuronium . Ne Depolarising neuromuscular blocker Inhibits action of acetylcholine at the neuromuscular junction Degraded by plasma cholinesterase and acetylcholinesterase (affected by lack of 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, delayed recovery 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 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 Bees Save my notes Search Search textbook GB Q Google search on “Muscle relaxants* *# Suggest Ink suggest media Dashboard u 12 13 14 15 16 PERT ER Cs) 0 RRR: < Ce,°o Question 6 of 70 v Bp © ‘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. What is the most appropriate analgesic modality? Amitriptyline | a rr | e Duloxetine oe Morphine eo Diclofenac. e This patient has phantom limb pain which is a neuropathic pain. First ine management is with amitriptyline or pregabalin. However this patient has orthostatic hypotension, which is a side effect of amitriptyline, therefore pregabalin is the treatment of choice. | @ | Improve 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 f 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 itis 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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, inthe 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 ltte ant-inflammatory effect, + Itis 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 antiinflammatory 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.Neuropathic 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 (avold morphine) + If diabetic neuropathic pain: Duloxetine + As of 1 April 2019, pregabalin and gabapentin are Class C controlled substances (under the Misuse of Drugs Act 1971) and scheduled under the Misuse of Drugs Regulations 2001 as Schedule 3. Evaluate patients carefully for a history of drug abuse before prescribing and observe patients for development of signs of abuse and dependence (MHRA, Drug Safety Update April 2019). References 1 http://guidance.nice.org.uk/CG173/Guidance/pdt/English 2. Lovich-Sapola J, Smith CE, Brandt CP. Post operative pain control. Surg Clin North Am. 2015 ‘Apr:95(2):301-183. Finnerup N et al. Pharmacotherapy for neuropathic pain in adults: a systematic review and meta-analysis. Lancet Neurol. 2015 Feb;14(2):162-73. a wo avers | ‘Search ‘Search textbook Q Google search on ‘Management of pain’ “Suggest lnk Suggest media Dashboard ROR838 Question 7 of 70 v 5 © ‘23 year old man Is undergoing an open inguinal hernia repair as a daycase procedure and Is being given sevoflurane. What is the best option for maintaining his airway during the procedure? Insertion of endotracheal tube Insertion of nasotracheal tube Insertion of nasopharyngeal airway Use of Guedel airway 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. « Improve 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 + Widely used mask * 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 * Provides optimal control of the airway once cuff inflated tube + May be used for long or short term ventilation * Errors in insertion may resutt in oesophageal intubation (therefore end tidal CO, usually measured) + Paralysis often required * Higher ventilation pressures can be used TIPS Biew = Save my notes Search ‘Search textbook. Q Google search on “Airway management” suggest tink suggest media Dashboard eVounrona n 12 13 14 15 RICCI TRS CIR CCC<) Question 8 of 70 x Bp (>) Which statement is true on enteral feeding? ‘PEG can only be used 12 hours after insertion Amotllity agent is avoided for ITU patients with an Nasogastric tube oS Qo eo @ Itis associated with more hepatic synthetic disruption than use of TPN [ERIE oe ootpssse nape sino = 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/m? + unintentional weight loss of > 10% over 3-6/12 * BMI <20 kg/m? and unintentional weight loss of > 5% over 3-6/12 AT RISK of malnutrition + Eaten nothing or Ittle > § days, who are likely to eat little for a further § 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(Supp! vu:virt -virr2 Bola me = ‘Save my notes Search Search textbook. B Q Google search on “Enteral Feeding” “Suggest tink suggest media Dashboard n 12 13 4 15 16 RES © ACIS Ke Ce 1 RUCGB _—_—___avestion 9 of 70 v 5 © ‘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? Dextran 70 Pentastarch Gelofusin 5% Dextrose He will have sequestration of electrolyte rich fluids in the abdomen and gut lumen. These are best replaced by use of Hart mans solution in the first instance. [1 | | improve Post operative fluid management * Composition of commonly used intravenous fluids mmol"? Na K cl Bicarbonate Lactate Plasma 137-147 45.5 95-105 22-25 : 0.9% Saline 153 - 153 - : Dextrose / saline 30.6 - 30.6 Hartmans 130 4 110 : 28 Post operative fluid management In the UK the GIFTASUP and NICE (CG174 2013) guidelines (see reference below) were devised to try and provide some consensus guidance as to how intravenous fluids should be administered. A decade ago it was a commonly held belief that little harm would occur as a result of excessive administration of normal saline and many oliguric post operative patients received enormous quantities of lV fluids. As a result they developed hyperchloraemic acidosis. With greater understanding of this potential complication, the use of electrolyte balanced solutions (Ringers lactate/ Hartmans) is now favored over normal saline.The other guidance includes: * 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 Ifa 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 NICE guidance CG174. Intravenous fluid therapy in adults. December 2013, British Consensus Guidelines on Intravenous Fluid Therapy for Adult Surgical Patients. GIFTASUP (2009) Save my notes Search Search textbook B Q Google search on Post operative fluid management” + Suggest lnk + Suggest media Dashboard eanena RO 466ws = Ol = " ws Which statement regarding post operative cognitive impairment is true? term) reduces post Pain does not cause delirium Delirium has no impact on length of hospital stay oe Aregional anaesthetic rather than a general anaesthetic is more likely to contribute to e post operative cognitive impairment 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 References Fines DP & Severn A. Anaesthesia and cognitive disturbance in the elderly Continuing Education in Anaesthesia, Critical Care & Pain 2006 6(1):37-40 6 | 9 | improve Postoperative cognitive dysfunction management * * 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 Poco * Increasing age + GA rather than regional + Duration of anaesthesia + Reoperation + Postoperative infection Late POcD + Increasing age + Emboll + Rinchemical disturhances3° Question 11 of 70 v Pe o ‘825 year old man s injured ina road traffic accident. His right tibia is fractured and is managed by fasclotomies and application of an external fixator. Over the next 48 hours his serum creatinine rises and urine is sent for microscopy, muddy brown casts are identified. What Is the most likely underlying diagnosis? Acute interstitial nephritis Glomerulonephritis IgA Nephropathy Thin basement membrane disease This patient Is likely to have had compartment syndrome (tibial fracture + fasciotomies) which may produce myoglobinuria. The presence of worsening renal function, together with muddy brown casts is strongly suggestive of acute tubular necrosis. Acute interstitial nephritis usually arises from drug toxicity and does not usually produce urinary muddy brown casts. Thin basement membrane disease is an autosomal dominant condition that causes persistent microscopic haematuria, but not worsening renal function, | @ | Improve 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 an 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.oC Question 12 of 70 v Pp [>] What is the most appropriate analgesic to administer to a term neonate who is recovering following an inguinal herniotomy? Co-codamal Ibuprofen Carbamazepine Codeine Paracetamol is an effective analgesic in children and pain following herniotomy is relatively minor. Note that codeine is contra indicated in neonates. The child ts too young to receive ibuprofen Improve Management of pain * World Health Organisation Analgesic Ladder * Initially peripherally acting drugs such as paracetamol or non-steroidal anttinflammatory 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 stil 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. Itis 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 itis 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 thelr 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 Mornhine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 ine ‘+ 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 antr-inflammatory effect * Its 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. Neuropathic 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 * As of 1 April 2019, pregabalin and gabapentin are Class C controlled substances (under the Misuse of Drugs Act 1971) and scheduled under the Misuse of Drugs Regulations 2001 as Schedule 3. Evaluate patients carefully for a history of drug abuse before prescribing and observe patients for development of signs of abuse and dependence (MHRA, Drug Safety Update April 2019). Re 1. http://guidance.nice.org.uk/CG173/Guidance/pat/English 2. Lovich-Sapola J, Smith CE, Brandt CP. Post operative pain control. Surg Clin North Am. 2015 ‘Apr.95(2):301-183. Finnerup N et al, Pharmacotherapy for neuropathic pain in adults: a systematic review and meta-analysis. Lancet Neurol. 2015 Feb;14(2):162-73. ences Tr gy @ © ‘Save my notes ‘Search Search textbook. Q Google search on "Management of pain’ + suggest link + suggest media Dashboard CH 42 ERREE° Question 13 of 70 ¥ Bp >) Which of the following statements relating to the use of human albumin solution is false? ‘When administered in the peri operative period it does not increase the length of stay in hospital compared with crystalloid solutions @ Concentrated solutions may produce diuresis in patients with liver failure e Itmay restore plasma volume in cases of sodium and water overload @ Itmay be associated with risk of acquiring new variant Creutzfeldt Jakob disease i | reps crenans cinemas tne seine = 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. @ | | Improve Post operative fluid management * Composition of commonly used intravenous fluids mmo!” Na kK cl Bicarbonate Lactate Plasma 137147 45.5 95105 (22-25 - 0.9% Saline 153, : 153 - - Dextrose / saline 30.6 : 30.6 - - Hartmans 130 4 110 : 28 Post operative fluid management In the UK the GIFTASUP and NICE (CG174 2013) guidelines (see reference below) were devised to try and provide some consensus guidance as to how intravenous fluids should be administered. A decade ago it was a commonly held belief that little harm would occur as a result of excessive administration of normal saline and many oliguric post operative patients received enormous quantities of lV fluids. As a result they developed hyperchloraemic acidosis. Withgreater understanding of this potential complication, the use of electrolyte balanced solutions (Ringers lactate/ Hartmans) is now favored over normal saline. ‘The other guidance includes: ‘+ Fluids given should be documented clearly and easily available ‘+ Assess the patient's fluld status when they leave theatre + Ifa patient Is haemodynamically stable and euvolaemic, aim to restart oral fluid intake as soon as possible + Review patients whose urinary sodium is < 20, + Ifa 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 @ risk of developing acute renal injury References NICE guidance CG174. Intravenous fluid therapy in adults. December 2013. British Consensus Guidelines on Intravenous Fluid Therapy for Adult Surgical Patients. GIFTASUP (2009) ‘Save my notes Search ‘Search textbook. Go ‘Q Google search on ‘Post operative fluid management” 4 Suggest ink FSuggest media Dashboard lv 2 30 av° Question 14 of 70 v 5 °° ‘A24 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. Which of the following intravenous fluids should be administered? 0.9% sodium chloride 0.45% sodium chloride S% dextrose 10% dextrose Of the solutions given Hartmans is the most suitable. Consideration should also be given to potassium supplementation. Improve Post operative fluid management * Composition of commonly used intravenous fluids mmol" Na K cl Bicarbonate Lactate Plasma 137147 455 95105 22-25 : 0.9% Saline 183 : 153 : : Dextrose / saline 30.6 - 30.6 - s Hartmans 130 4 110 - 28 Post operative fluid management In the UK the GIFTASUP and NICE (C6174 2013) guidelines (see reference below) were devised to try and provide some consensus guidance as to how intravenous fluids should be administered. A decade ago it was a commonly held belief that little harm would occur as a result of excessive administration of normal saline and many oliguric post operative patients received enormous quantities of IV fluids. As a result they developed hyperchloraemic acidosis. With greater understanding of this potential complication, the use of electrolyte balanced solutions (Ringers lactate/ Hart mans) is now favored over normal saline. The other auidance includes:* Fluids given should be documented clearly and easily available + Assess the patient's fluid status when they leave theatre * Ifa patient is haemodynamically stable and euvolaemic, aim to restart oral fluid intake as soon as possible * Review patients whose urinary sodium is < 20, * Ifa 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 NICE guidance C6174. Intravenous fluid therapy in adults. December 2013. British Consensus Guidelines on intravenous Fluid Therapy for Adult Surgical Patients. GIFTASUP (2009) Save my notes ‘Search ih textbook. go Q Google search on “Post operative fluid management” “Suggest ink “Suggest media Dashboard Si ey eas eed na 6464646648(<) Question 15 of 70 x B © 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? Feeding duodenostomy. Liquid diet orally. Soft solids orally. 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. | 9 | improve 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 of 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/m? * unintentional weight loss of > 10% over 3-6/12 ‘= BMI< 20 kg/m? 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 ltt 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(Supp! vuly:vitt -viln2. Bis &- Tr & @ @ Save my notes Search Search textbook Q Google search on “Enteral Feeding” + Suggest ink 4+ Suggest media Dashboard lv 2 av av 5 v ov 7 a x ov wv uy wy° Question 16 of 70 v pn ° A 32 year old man presents to the acute surgical unit with acute pancreatitis. Over the next few days he becomes dyspnoeic and his saturations are 89% on alr. A CXR shows bilateral pulmonary infiltrates, His CVP pressure is 16mmHg. What is the most likely diagnosis? Cardiac failure Pneumococcal pneumonia ‘Staphylococcal pneumonia Pneumocystis carinii Acute pancreatitis is known to precipitate ARDS. ARDS Is characterised by bilateral pulmonary infiltrates and hypoxaemia. Note that pulmonary oedema is excluded by the CVP reading < 18mmHg. oo || improve Adult respiratory distress syndrome * Defined as an acute condition characterized by bilateral pulmonary infiltrates and severe hypoxemia (Pa02/Fi0, ratio < 200) in the absence of evidence for cardiogenic pulmonary ‘oedema (clinically or pulmonary capillary wedge pressure of less than 18 mm Hag). Itis subdivided into two stages. Early stages consist of an exudative phase of injury 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 + Rising ventilatory pressuresManagement Treat the underlying cause Antibiotics (if signs of sepsis) Negative fluid balance Le. Diuretics Recruitment manoeuvres such as prone ventilation, use of positive end expiratory pressure Mechanical ventilation strategy using low tidal volumes, as conventional tidal volumes may cause lung injury (only treatment found to improve survival rates) ne Save my notes Search + + ‘Search textbook. Q Google search on “Adult respiratory distress syndrome” Suggest tn suggest media Dashboard n 12 13 4 C0410 < 610 CCK <<° Question 17 0f 70 ’ e ° Which of the variables listed below Is not considered in the sequential organ failure assessment (SOFA) tool? Bilirubin Mean arterial pressure Platelet count Creatinine Urea Is not one of the variables considered. 99 | improve Severe infections « Sepsis is a multifaceted syndrome which arises as a result of an infective process. Historically, the main focus was on the pro-inflammatory nature of the process, accordingly, 2 of the 4 SIRS criteria were related solely to inflammatory excesses. More modern systems take into account the fact that some of the effects of sepsis are suppressive from an immunological perspective and effects on organ function can be widespread. Sepsis is now defined as life-threatening organ dysfunction caused by a dysregulated host response to infection. This new definition, emphasizes the primacy of the non homeostatic host response to infection, the potential lethality that is considerably in excess of a straightforward infection, and the need for urgent recognition. To help identify and categorise patients the Sequential (Sepsis-Related) Organ Failure ‘Assessment Score (SOFA) Is increasingly used. The score grades abnormality by organ system and accounts for clinical interventions. However, laboratory variables, namely, PaO2, platelet count, creatinine level, and bilirubin level, are needed for full computation. ‘SOFA Score System Scored Score. Score2 Score 3 ‘Score 4 PaQ2 /FIO2 >400 <400 <300 «200 <100 Platelets x10° >150 <150 <100 <50 <20 microlitres: Bilirubin micro 20 20-32 33-101 102-204 >208 Mol/L.Cardiovascular. MAP MAP Dopamine Dopamine 5.1- Dopamine >15 >70mmHg —70mmHg —440 micro mol/L Urine output —->500 >500 >500 <500 <200 mi/day A SOFA score of 2 or more reflects an overall mortality risk of approximately 10% in a general hospital population with suspected infection. Even patients presenting with modest dysfunction can deteriorate further, emphasizing the seriousness of this condition and the need for prompt ‘and appropriate intervention, if not already being instituted. ‘The qSOFA score (also known as quickSOFA) is a bedside prompt that may Identify patients with suspected infection who are at greater risk for a poor outcome outside the intensive care unit (ICU). It uses three criteria, assigning one point for low blood pressure (SBP<100 mmHs), high respiratory rate (>22 breaths per min), or altered mentation (Glasgow coma scale<15). Patients with septic shock can be identified with a clinical construct of sepsis with persisting hypotension requiring vasopressors to maintain MAP 65 mm Hg and having a serum lactate level >2 mmol/L (18mg/dL) despite adequate volume resuscitation. With these criteria, hospital mortality s in excess of 40%. Resuscitation goals + CVP.8-12mmHg + MAP >65mmHg + Urine output >0.5mi/kg per hour * Superior vena cava oxygen saturation >70% + Normal lactate References Singer M, Deutschman C, Seymour C et al. The third international consensus definitions for sepsis and septic shock (Sepsis 3). JAMA 2016; 315(8):801-810.3° Question 18 of 70 v 5 °o ‘A75 year old man is admitted to the intensive care unit following a laparotomy. He has a central line, pulmonary artery catheter and arterial lines inserted. The following results are obtained: Pulmonary artery occlusion pressure Cardiac output Systemic vascular resistance gh tow igh How may these findings be best interpreted? Hypovolaemia Qo Normal Neurogenic shock Septic shock eo Elia j- In cardiogenic shock pulmonary pressures are often high. This is the basis for the use of venodilators in the treatment of pulmonary oedema. [1s [| imorove | ob Pulmonary artery occlusion pressure monitoring * The pulmonary artery occlusion pressure is an indirect measure of left atrial pressure, and thus filing pressure of the left heart. The low resistance within the pulmonary venous system allows this useful measurement to be made. The most accurate trace is made by inflating the balloon at the catheter tip and ‘floating’ it so that it occludes the vessel. If itis not possible to occlude the vessel in this way then the measurement gained will be the pulmonary artery end diastolic pressure Interpretation of PAOP PAOP mmHg ‘Scenario Normal 812 Low <5 Hypovolaemia Low with pulmonary oedema 18 OverloadWhen combined with measurements of systemic vascular resistance and cardiac output itis possible to accurately classify patients. Systemic vascular resistance Derived from aortic pressure, right atrial pressure and cardiac output. ‘SVR=80(mean aortic pressure-mean right atrial pressure)/cardiac output Search ‘Search textbook. ‘Q Google search on “Pulmonary artery occlusion pressure monitoring” “+ Suggest Ink “# Suggest media Dashboard @Vounona " 12 13 14 15 ROESLh264 666404404546 Question 19 of 70 ¥ n © A 56 year old man is on the ward 5 days following a high anterior resection for a carcinoma of the recto sigmoid junction. Over the past 12 hours, he has developed increasing lower abdominal, pain, a fever of 37.8°C and fast atrial fibrillation. Of the investigations listed below, which is likely to be the most useful? ‘Abdominal X-ray ‘Abdominal ultrasound scan Echocardiogram Measurement of cardiac enzymes in the blood New AF following a colonic resection is most likely to represent an anastomotic leak and this will be best seen on CT scanning of | @ | Improve Complications following colorectal surgery * Bleeding Resections of the colon and rectum can result in immediate complications such as bleeding. The ‘two main sites for this are the spleen which can be injured when the splenic flexure of the colon Is mobilized and the pre sacral veins in the pelvis that can be injured in resections of the rectum. Other causes of bleeding include slipped ties. Where bleeding is suspected, the correct course of action is to resuscitate the patient and arrange a return to theatre. Infection Wound infections are not uncommon following colonic resections, this is particularly true in the emergency setting when there may be extensive contamination of the wound by virtue of the Underlying disease process. In all cases of bowel resection, itis important to administer broad spectrum intravenous antibiotics before starting the case, if the case Is a long one, additional doses of antibiotics may be needed intra operatively. Post operatively, wound infections may manifest as cellulitis or wound collections. These will Usually respond to measures such as draining the collections on the ward and administration of antibiotics, Where the patient is more unwell, there is usually concern about intra abdominal infection, in such cases, cross sectional imaging with CT scanning with contrast is commonly performed. ‘Anastomotic leak Any bowel anastomosis can leak, sometimes as a result of technical failings, at other times, its patient factors such as background disease that contribute. As a general rule, rectal resections carry the highest risk of anastomotic leak. Indeed, low anterior resections are routinelydefunctioned with loop ileostomy to mitigate the clinically effects of a leak. Left sided colonic resections carry a higher risk of anastomotic leak than right sided resections. The reason for this is that an ileocolic anastomosis (or indeed any small bowel anastomosis) has a very low risk of leak (provided the small bowel is otherwise healthy). Where a leak is suspected (new AF and raised inflammatory markers 5 days post resection), the correct course of action is to arrange cross sectional imaging with a CT scan. Ifa leak Is confirmed and the patient septic, then they should go back to theatre, the anastomosis taken down and the bowel ends exteriorized. Gl © [ Save my notes Search Search textbook. Q Google search on "Complications following colorectal surgery" “+ Suggest ink ‘+ Suggest media Dashboard RS 2446484446668e Question 20 of 70 ¥ 5 So ‘A 45 year old man is admitted to the intensive care unit following a laparotomy. He has a central line, pulmonary artery catheter and arterial lines inserted. The following results are obtained: ‘Pulmonary artery occlusion pressure Cardiac output Systemic vascular resistance Low tow High What is the most likely interpretation of this? Normal Cardiogenic shock Septic shock @ Fluid overload I e Cardiac output is lowered in hypovolaemia due to decreased preload. a |e Improve | Pulmonary artery occlusion pressure monitoring * ‘The pulmonary artery occlusion pressure is an indirect measure of left atrial pressure, and thus filing pressure of the left heart. The low resistance within the pulmonary venous system allows this useful measurement to be made. The most accurate trace is made by inflating the balloon at the catheter tip and 'floating'it so that it occludes the vessel. If it is not possible to occlude the vessel in this way then the measurement gained will be the pulmonary artery end diastolic. pressure, Interpretation of PAOP PAOP mmHg Scenario Normal 812 Low <5 Hypovolaemia Low with pulmonary oedema <6 ARDS High >18 Overload When combined with measurements of systemic vascular resistance and cardiac output it is possible to accurately classify patients.Systemic vascular resistance Derived from aortic pressure, right atrial pressure and cardiac output. ‘SVR=80(mean aortic pressure-mean right atrial pressure)/cardiac output ‘Save my notes ‘Search Search textbook Q Google search on "Pulmonary artery occlusion pressure monitoring’ + Suggest ink Suggest media Dashboard eYanesuona " 12 8 14 15 16 W7 18 6 Si AR er OIC 4) Cre) ete Re eee8 Question 21 of 70 ¥ B °o Which statement js false about pethidine? Itis thirty times more lipid soluble than morphine Pethidine has a toxic metabolite (norpethidine) which is cleared by the kidney Pethidine is metabolized by the liver Can be given intramuscularly Ithas a different structure. Its much more lipid soluble than morphine. It produces less biliary tract spasm than morphine | @ | Improve 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 opiolds 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. Its 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 itis 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 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, vorniting, 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 fe 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 antt-inflammatory effect * It ls 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. Neuropathic 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 + As of 1 April 2019, pregabalin and gabapentin are Class C controlled substances (under the Misuse of Drugs Act 1971) and scheduled under the Misuse of Drugs Regulations 2001 as Schedule 3. Evaluate patients carefully for a history of drug abuse before prescribing and observe patients for development of signs of abuse and dependence (MHRA, Drug Safety Update April 2019), References 1. http://guidance.nice.org.uk/CG173/Guidance/pdt/English 2. Lovich-Sapola J, Smith CE, Brandt CP. Post operative pain control. Surg Clin North Am. 2015 ‘Apr,95(2):301-183. Finnerup N et al. Pharmacotherapy for neuropathic pain in adults: a systematic review and meta-analysis. Lancet Neurol. 2015 Feb;14(2):162-73. Boe Save my notes Search ‘Search textbook. Q Google search on “Management of pain® “Suggest link Suggest media Dashboard warannon CRBRER CERES a6° Question 22 of 70, v bp °o You are the cardiothoracic surgical registrar reviewing a patient referred for an aortic valve teplacement. 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 Fev 14 fhe ATL FEV/FVE 82% What is the most likely explanation? Asthma eo Bronchiectasis, o oe Chronic obstructive pulmonary disease Laryngeal malignancy eo ‘These results show a restrictive picture, which may result from a number of conditions including kyphoscoliosis. The other answers cause an obstructive picture, We note that most people have chosen COPD as the answer. In COPD the FEV1/FVC would show an obstructive picture with the FEV1/FVC value being low (approximately less than 70%). In restrictive conditions the FEV1/FVC is normal or increased (greater than 70%). With the FEV1/FVC being over 70% the most likely answer is kyphoscoliosis. | | Improve 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 Restrictive lung disease FEV1 - significantly reduced FEV1-reducedFVC - reduced or normal FVC - significantly reduced FEV1% (FEV1/FVC) - reduced (less than FEV1% (FEV1/FVC) - normal or increased (over approx. 70%) approx. 70%) Asthma Pulmonary fibrosis, copD Asbestosis Bronchiectasis Sarcoidosis. Bronchioltis obliterans ‘Acute respiratory distress syndrome Infant respiratory distress syndrome kyphoscoliosis, Neuromuscular disorders If you would lke to read more about pulmonary function tests, here is a link that may be useful: Interpreting pulmonary function tests: Recognize the pattern, and the diagnosis will follow http://www.ccjm.org/content/70/10/866 full. pdf ‘Save my notes Search Semen taboo 5 Q Google search on “Pulmonary function tests" + Suggest link + suggest media Dashboard Yourona Cee SS(¢) Question 23 of 70 ¥ Bb >) Which of the anaesthetic agents listed below is associated with hepatotoxicity? Sevoflurane @ Propofol oe Ketamine eo Desflurane Qe Halothane is largely of historical interest and that is because of its hepatotoxicity. Improve 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 ita suitable agent for anaesthesia in those who are hemodynamically 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 Bis w& Tr g @ © Save my notes Search ‘Search textbook ‘Q Google search on “Anaesthetic agents" + Suggest ink + Suggest media Dashboard Vv 2 av av 5 ov 6v 7 ao ov wv uy wy By “uv° Question 24 of 70 v Bp ° Which of the following anaesthetic agents is least likely to be associated with depression of myocardial contractility? Propofol Sodium thiopentone Ether None of the above Of the agents mentioned, etomidate has the most favorable cardiac safety profile. || improve | 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 n> Bie #& Save my notes Search Search textbook | so | Q Google search on “Anaesthetic agents” Suggest ink Suggest media Dashboard evanrone " 12 13 4 ANC Cee Cc ceBs auestion250f70 ° ‘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 xray is normal. Following treatment with low-molecular weight heparin, what is the most appropriate initial lung imaging investigation to perform? Pulmonary angiography Echocardiogram MRI thorax Ventilation-perfusion scan CTPA \Is the first line investigation for PE according to current BTS guidelines Current UK NICE guidance supports CTPA as first line investigation now. Pulmonary angiography Is of course the ‘gold standard’ but this is not what the question asks for Improve Pulmonary embolism: investigation * UK 2020 NICE guidance endorses CTPA is most cases of suspected 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 .cray 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wa scan ‘+ sensitivity = 98%; specificity = 40% - high negative predictive value, Le. if normal virtually excludes PE + other causes of mismatch in V/Q include old pulmonary embolisms, AV malformations, vascultis, previous radiotherapy + COPD gives matched defects CTPA ‘+ peripheral emboll affecting subsegmental arteries may be missed Pulmonary angiography ‘= the gold standard ‘+ significant complication rate compared to other investigations Save my notes Search Search textbook B Q Google search on "Pulmonary embolism: investigation” Suggest nk “Suggest media Dashboard pNousona RRA°o Question 26 of 70 ¥ B ° ‘A22 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. On arrival in the recovery area; the patient develops a tachycardia of 120 bpm and a temperature of 40 °C. He has generalised muscular rigidity. What is the most likely diagnosis? ‘Acute dystonic reaction eo Pelvic abscess @e Epilepsy oe ‘Serotonin syndrome eo ‘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, [4 |e | improve | rt Malignant hyperthermia * Overview + Condition seen following administration of anaesthetic agents (rate of 1 in 15,000) + Characterised by hyperpyrexia and muscle rigidity + Cause by excessive release of Ca from the sarcoplasmic reticulum of skeletal muscle + Associated with defects in a gene on chromosome 19 encoding the ryanodine receptor, Which controls Ca”* 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 Ca release from the sarcoplasmic reticulum No ion > ‘Save my notes Search Search textbook. Q Google search on “Malignant hyperthermia’ + Suggest nk “+ Suggest media Dashboard eYoneona u 12 13 4 18 16 7 18 19 6 re ieee Cee Cie Cone Ce3° Question 27 of 70 v B © Which of the following agents is most likely to be helpful in controlling refractory hypotension in a 23 year old female with severe pyelonephritis? Adrenaline Dobutamine Dopamine Milrinone Since the main issue here is vasodilation, a vasoconstrictor is most likely to be helpful. [a | improve | 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. Itis 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 filing 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 6-8mmtig). 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: Agent Mode of action Effect Noradrenaline aagonist \Vasopressor action, minimal effect on cardiac output Adrenaline and Breceptor —_ Increases cardiac output and peripheral vascular agonist resistance Dopamine B1 agonist Increases contractility and rate Dobutamine 81 and BZ agonist _Increases cardiac output and decreases SVR Milrinone Phosphodiesterase Elevation of cAMP levels improves muscular Inhibitor contractility, short halflife and acts as vasodilator Tr gy @ © ‘Save my notes Search Search textbook, Q Google search on ‘Circulatory support ofthe critically ill” ‘+ Suggest nk “+ Suggest media Dashboard°e Question 28 of 70, v B © ‘A 23 year old man with a dom lipoma on his flank is due to have this removed as a daycase. He is otherwise well. What is his ASA? 2 e 3 Qo 5 eo 4 Absence of comorbidities and small procedure with no systemic compromise will equate to an ASA score of 1. | | Improve Ne American Society of anesthesiologists physical status scoring system (ASA) * ASA Description grade 1 No organic physiological, blochemical or psychiatric disturbance. The surgical pathology is localised and has not invoked systemic disturbance 2 Mild or moderate systemic disruption caused elther by the surgical disease process or though underlying pre-existing disease 3 Severe systemic disruption caused elther 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 a @ @ww Muestion <7 ori = » wy Use of which of the following muscle relaxants is least likely to result in histamine release? Tubocurarine Doxacurium Mivacurium, Drugs in the tetrahydroisoquinoline such as atracurium cause histamine release. ‘Vecuronium and suxamethonium do not do this. [4 [9 | improve | Muscle relaxants ‘Suxamethonium + ‘Atracurium . Vecuronium, . Depolarising neuromuscular blocker Inhibits action of acetylcholine at the neuromuscular junction Degraded by plasma cholinesterase and acetylcholinesterase (affected by lack of 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, delayed recovery 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 Non depolarising neuromuscular blocking drug Duration of action approximately 30 - 40 minutes Degraded by liver and kidney and effects prolonged in organ dysfunction Effects mav be reversed by neostiamine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 Bie &- Tr By @ @ ‘Save my notes Search Search textbook. Q Google search on “Muscle relaxants” Suggest ink suggest meaia Dashboard n 12 18 14 15 REO RR CC SCO OCS)° Question 30 of 70 v Bp © ‘A 66 year old man is admitted following a collapse whilst waiting for bus. Clinical examination confirms a ruptured abdominal aortic aneurysm. He is moribund and hypotensive. What Is his ASA? 1 oe 2 eo 3 oe 4 @o _— XZ ie” ° Patients who are moribund and will not survive without surgery are graded as ASA 5. [4 [| tmorove | 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°e Question 31 of 70 x Be >) ‘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? Itusually consists of type | respiratory failure. Patients typically require high ventillatory pressures. | s>vemncan cane nous pestyveareaig ness or Tammie Itmay complicate acute pancreatitis. [BBB we ero Right heart pressure should be normal. wo | | Improve Adult respiratory distress syndrome * Defined as an acute condition characterized by bilateral pulmonary infiltrates and severe hypoxemia (Pa02/Fi0 ratio < 200) in the absence of evidence for cardiogenic pulmonary ‘oedema (clinically or pulmonary capillary wedge pressure of less than 18 mm Hg) Itis subdivided into two stages. Early stages consist of an exudative phase of injury 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 ‘= Rising ventilatory pressures Management + Treat the underlying cause ‘+ Antibiotics (if signs of sepsis)+ Negative fluid balance i.e. Diuretics + Recruitment manoeuvres such as prone ventilation, use of positive end expiratory pressure + Mechanical ventilation strategy using low tidal volumes, as conventional tidal volumes may cause lung injury (only treatment found to improve survival rates) Be Search ‘Search textbook. ‘Q Google search on “Adit respiratory distress syndrome” Suggest ink Fsuggest media Dashboard eBVouseon un 2 13 4 15 16 v7 18 19 3 CRO CCR CCK CCC?° Question 32 of 70 v p © ‘A73 year old man develops disseminated intravascular coagulation following an abdominal aortic aneurysm repair. He receives an infusion of cryoprecipitate. What is the major constituent of this infusion? Factor IX Protein c Protein S Factor V we | | improve Cryoprecipitate * Blood product made from plasma * Usually transfused as 6 unit pool * Indications include massive haemorrhage and uncontrolled bleeding due to haemophilia Composi Agent Quantity Factor Vill 10010 Fibrinogen. 250mg von Willebrand factor Variable Factor Xill Variable38 Question 33 of 70 ’ 5 oO ‘A.48 year old man is due to undergo a laparotomy for small bowel obstruction. What is the best option for maintaining his airway? Insertion of uncuffed endotracheal tube Insertion of laryngeal mask Insertion of nasopharyngeal alrway Percutaneous tracheostomy Uncuffed endotracheal tubes are used in small children to reduce the risk of tracheal injury. 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 cricothyrold pressure can be removed %@ | Improve 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 alrway Laryngeal + Widely used mask + 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 Provides optimal control of the airway once cuff inflated tube 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 iP Ble@g®-=s Tr By Gl © Save my notes Search Search textbook B Q Google search on “Ainvay management” “+ Suggest Ink + Suggest media Dashboard tv 2 av av 5 v ov 7 ax ov wv nv3° Question 34 of 70 v 6 © ‘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 10mW/hr”. What the most appropriate immediate course of action? Stop the ACE inhibitor @ === Start an infusion of nor adrenaline e Administer intravenous frusemide Insert a Swann-Ganz Catheter oe 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. * Improve 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 hypovolemia the blood pressure is maintained although other haemodynamic parameters may be affected. This correlates to class Il shock. In most cases assessment can be determined clinically, Where underlying cardiopulmonary 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 vicious circle. ‘The treatment of hypovolaemia is with intravenous fluids. In the first instance a fluid challenge‘such as the rapid infusion of 250mI of crystalloid will often serve as both a diagnostic and resuscitative measure. In the event that this falls 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. a wo Save my notes ‘Search Search textbook {Q Google search on “Hypovolaemia and the surgical patient” Suggest ink Suggest media Dashboard Nannon n 12 13 4 15 16 7 18 10 CREB ERE EERE KEECEKEeo Question 35 of 70 v R © Which of the following does not need monitoring during home parenteral nutritional support? Folate levels Qo Zinc levels Vitamin D Qe | @ Bone densitometry || @ | improve 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 Dally 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 @ | save my notes Search ‘Search textbooko Question 36 of 70 v B ©} Which of the agents listed below is a phosphodiesterase inhibitor? HT - Metaramino! Dopamine eo Dobutamine oe Adrenaline oe & | F | Improve 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 filing 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: Agent Mode of action Effect Noradrenaline a agonist Vasopressor action, minimal effect on cardiac output Adrenaline Gand receptor _ Increases cardiac output and peripheral vascular agonist resistance Dopamine B1 agonist Increases contractility and rate Dobutamine 81 and B2 agonist _ Increases cardiac output and decreases SVR Millrinone Phosphodiesterase Elevation of cAMP levels improves muscular Inhibitor contractility, short half life and acts as vasodilator Tr By @ © Search Search textbook GB Q Google search on “Circulatory support of the eritically il Suggest ink “Suggest media Dashboard°o Question 37 of 70 v p So ‘473 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 most appropriate management? Commence fentanyl patch Arrange duplex scan ‘Arrange MRI scan of the stump Commence carbamazepine This patient has neuropathic pain. Amitryptyline is the treatment of choice. Carbamazepine Is ‘mainly used for trigeminal neuralgia. wa | @ | improve 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 firstine 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° Question 38 of 70 x 5 oO 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. Which of the following intravenous fluids should be considered? 1.8% saline 10% dextrose with 20mmol KCL. 0.45% sodium chloride In patients who are hypoalbuminaemic the use of albumin solution may help promote a diuresis and manage fluld overload, | | improve Post operative fluid management * Composition of commonly used intravenous fluids mmol Na K rl Bicarbonate Lactate Plasma 137147 45.5 95-105 22-25 : 0.9% Saline 153 : 153, - : Dextrose / saline 30.6 : 30.6 . : Hartmans 130 4 10 - 28 Post operative fluid management In the UK the GIFTASUP and NICE (CG174 2013) guidelines (see reference below) were devised to try and provide some consensus guidance as to how intravenous fluids should be administered. A decade ago It was a commonly held belief that little harm would occur as a result of excessive administration of normal saline and many oliguric post operative patients recelved enormous quantities of IV fluids. As a result they developed hyperchloraemic acidosis. With greater understanding of this potential complication, the use of electrolyte balanced solutions (Ringers lactate/ Hart mans) is now favored over normal saline.‘The other guidance includes: ‘+ Fluids given should be documented clearly and easily available ‘+ Assess the patient's fluid status when they leave theatre ‘+ Ifa patient is haemodynamically stable and euvolaemic, aim to restart oral fluid intake as soon as possible ‘+ Review patients whose urinary sodium is < 20 ‘+ Ifa 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 NICE guidance CG174, Intravenous fluid therapy in adults. December 2013. British Consensus Guidelines on Intravenous Fluid Therapy for Adult Surgical Patients. GIFTASUP (2009) Search Search textbook. Q Google search on"Post operative fluid management” + Suggest ink suggest mesia Dashboard eons ona SA 44443° Question 39 of 70, ¥ B ° ‘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. What is his ASA? 5 eo 1 @ 3 2 | 2 eo Severe systemic disease of this nature is a constant threat to life. Especially as he also has evidence of cardiac failure [4 [9 | torove | American Society of anesthesiologists physical status scoring system (ASA) * ASA Description grade 1 No organic physiological, blochemical 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 Ne[<) Question 40 of 70, v B >) 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, He 1139/4 Platelets 267% 10° wec 101x105) Urea and electrolytes Nat 131 mmol « 46 mmol Urea 23 mmol/l Creatinine 78 yell Liver function tests. Biirubin 25 pmol Alp aasut AT Boul yer tos uit What is the most likely underlying cause for the abnormalities noted? Delayed type blood transfusion reaction Bile leak Anastomotic leak 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, | | Improve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. Next question > Bilas A- Tr iy fm @ iti Tpn Search ‘Search textbook. Q Google search on “Total parenteral nutrition” ‘+ suggest ink suggest mecia Dashboard tv 20 a av 5 v ov 7 a ov wv uy ny°o Question 41 of 70 v 5 >) 34 year old man is suffering from septic shock and receives an infusion of Dextran 70. Which of the following complications may potentially ensue? Vomiting Acute hepatic failure Deep vein thrombosis @ Digital necrosis e eo Dextran 40 and 70 have higher incidence of anaphylaxis than either gelatins or starches. Dextrans are branched polysaccharide molecules. Dextran 40 and 70 are available. The higher molecular weight dextran 70 may persist for up to 8 hours. They inhibit platelet aggregation and leucocyte plugging in the microcirculation. Thereby improving flow through the microcirculation, primarily of use in sepsis. Unlike many other intravenous fluids Dextrans are a recognised cause of anaphylaxis. (2 [= [ms = Post operative fluid management * Composition of commonly used intravenous fluids mmol”? Na K cl Bicarbonate Lactate Plasma 137147 45.5 95-105 22-25 : 0.9% Saline 153 : 153 Dextrose / saline 306 : 30.6 - : Hartmans 130 4 110 - 28 Post operative fluid management Inthe UK the GIFTASUP and NICE (CG174 2013) guidelines (see reference below) were devised to try and provide some consensus guidance as to how intravenous fluids should be administered. A decade ago it was a commonly held belief that little harm would occur as a resultof excessive administration of normal saline and many oliguric post operative patients received enormous quantities of lV fluids. As a result they developed hyperchloraemic acidosis. With greater understanding of this potential complication, the use of electrolyte balanced solutions (Ringers lactate Hartmans) is now favored over normal saline. The other guidance includes: * Fluids given should be documented clearly and easily available * Assess the patient's fluid status when they leave theatre * Ifa patient Is haemodynamically stable and euvolaemic, aim to restart oral fluid intake as soon as possible + Review patients whose urinary sodium is < 20 * Ifa 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 NICE guidance CG174. Intravenous fluid therapy in adults. December 2013. British Consensus Guidelines on intravenous Fluid Therapy for Adult Surgical Patients. GIFTASUP (2009) Save my notes Search ‘Search textbook Q Google search on ‘Post operative fluid management” Suggest nk suggest media Dashboard3° Question 42 of 70 v Bp °} Which of the agents listed below Is associated with the strongest anti emetic properties? Sodium thiopentone Etomidate Ketamine Sevoflurane Propofol has anti emetic properties which is of considerable advantage in day case anaesthesia (=| [oe errs 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 antl 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 Biew [seve my ois] Search Search textbook B Q Google search on “Anaesthetic agents” + suggest ink “suggest media Dashboard W 12 13 14 15 WIRURG 1 OCRIC KU Re Ce3° Question 43 of 70 v Pp Ss Which of the following is not typically included in total parenteral nutritional solutions? Lipid Potassium Glucose Magnesium There is no indication for inclusion of fibre in solutions of TPN, nor would it be safe to do so. we | | Improve 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. Tpn [ save my notes Search Search textbook B Q Google search on "Total parenteral nutrition”° Question 44 of 70 v 5 °o Which of the agents listed below can be administered via the peripheral intra venous route in the non cardiac arrest setting? Milrinone Noradrenaline Adrenaline Dobutamine Metaraminol is an alpha receptor agonist. As a general rule, inotropes and vasopressors can only be administered via a central vein. ‘Metaraminol is an exception to this as it can be administered via a peripheral line. [« *@ | Improve 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 annulate 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 usuelly sited in the superior vena cava via the internal jugular route. The CVP will demonstrate right atrial filing 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: ‘Agent Mode of action Effect Noradrenaline aagonist Vasopressor action, minimal effect on cardiac output Adrenaline and receptor _ Increases cardiac output and peripheral vascular agonist resistance Dopamine 81 agonist Increases contractility and rate Dobutamine 81 and B2 agonist _ Increases cardiac output and decreases SVR Milrinone Phosphodiesterase Elevation of cAMP levels improves muscular Inhibitor contractility, short half life and acts as vasodilator mieu- iii Tr gy @ @ Save my notes Search ‘Search textbook 'Q Google search on “Circulatory support of the critically ill” + Suggest lnk touggest media6 Question 45 of 70, v Bp © ‘A22 year old lady is admitted to the intensive care unit following a laparotomy. She has a central line, pulmonary artery catheter and arterial lines inserted. The following results are obtained: Pulmonary artery occlusion pressure Cardiac output Systemic vascular resistance tow gh Low How may these findings be best interpreted? Hypovolaemia @ Ee e Normal Fluid overload e Cardiogenie shock eo Decreased SVR is a major feature of sepsis. A hyperdynamic circulation is often present. This is the reason for the use of vasoconstrictors, sé | @ | improve Pulmonary artery occlusion pressure monitoring * The pulmonary artery occlusion pressure is an indirect measure of left atrial pressure, and thus filing pressure of the left heart. The low resistance within the pulmonary venous system allows this useful measurement to be made, The most accurate trace Is made by inflating the balloon at the catheter tip and ‘floating’ It so that it occludes the vessel. If itis not possible to occlude the vessel in this way then the measurement gained will be the pulmonary artery end diastolic. pressure. Interpretation of PAOP PAOP mmHg Scenario Normal 812 Low 18 ‘OverloadWhen combined with measurements of systemic vascular resistance and cardiac output itis possible to accurately classify patients. Systemic vascular resistance Derived from aortic pressure, right atrial pressure and cardiac output. SVR=80(mean aortic pressure-mean right atrial pressure)/cardiac output | Save my notes Search Search textbook B Q Google search on "Pulmonary artery occlusion pressure monitoring” + Suggest ink Fsuagest media Dashboard n 12 13 4 RCA < 1C e Ce S <.° Question 46 of 70 v Bp 5) Which of the following agents is least suitable for a 23 year old man with burns and bilateral tibial fractures after being trapped in a car accident for 2 hours? Atracurium Vecuronium Pancuronium Propofol ‘Suxamethonium may induce hyperkalemia as it induces generalised muscular contractions. In patients with likely extensive tissue necrosis this may be sufficient to produce cardiac arrest. wo | 9 | improve Muscle relaxants * Suxamethonium + Depolarising neuromuscular blocker * Inhibits action of acetylcholine at the neuromuscular junction * Degraded by plasma cholinesterase and acetylcholinesterase (affected by lack of 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, delayed recovery 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 Tr 8 @ © [Savery nots Search Search textbook B Q Google search on "Muscle relaxants* Suggest lnk +ouggest media Dashboard iv 2 3 av 5 v 6v 7 8 8 ov wv uv wy BY “uv 15 ® wv°o Question 47 of 70 v B 5 What is the most appropriate management for a 56 year old lady who has shooting pains in her arm following a mastectomy and axillary node clearance? Carbamazepine Oramorph Diclofenac Chemical neurectomy Pregabalin is generally the first line agent for neuropathic pain. «| improve | Management of pain * World Health Organisation Analgesic Ladder * Initially peripherally acting drugs such as paracetamol or non-steroidal ant drugs (NSAIDs) are given. * If pain control is not achieved, the second part of the ladder Is to introduce weak oplold 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. flammatory ‘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. 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. Its 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 itis 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 thelr 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 haif 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 @ 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 antl-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 antiinflammatory 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. Neuropathic pai Natlonal 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 (avold morphine) * If diabetic neuropathic pain: Duloxetine