Post Operative Care

yomna92009@yahoo.
com - MRCS Part A - My account
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Question 1 of 67 Question stats Score: 0%
1
A 7.2%
A 44 year old man undergoes a distal gastrectomy for cancer. He is slightly B 65.1%
anaemic and therefore receives a transfusion of 4 units of packed red cells to
C 9.6%
cover both the existing anaemia and associated perioperative blood loss. He is
D 14.5%
noted to develop ECG changes that are not consistent with ischaemia. What is
E 3.6%
the most likely cause?
65.1% of users answered this

question correctly
A. Hyponatraemia
B. Hyperkalaemia
C. Hypercalcaemia
D. Metabolic alkalosis
E. Hypernatraemia
Next question
The transfusion of packed red cells has been shown to increase serum potassium
levels. The risk is higher with large volume transfusions and with old blood.
Blood transfusion reactions
Immune mediated Non immune mediated
Pyrexia Hypocalcaemia
Alloimmunization CCF
Thrombocytopaenia Infections
Transfusion associated lung injury Hyperkalaemia
Graft vs Host disease
Urticaria
Acute or delayed haemolysis
ABO incompatibility
Rhesus incompatibility
Notes:
GVHD: lymphocyte proliferation causing organ failure

Transfusion associated lung injury: neutrophil mediated allergic pulmonary
oedema
ABO and Rhesus incompatibility: causes acute haemolytic transfusion reaction
leading to agglutination and haemolysis
Rate question: Next question
Com m ent on this question
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yomna92009@yahoo.com - MRCS Part A - My account
1
A 59.8%
A 23 year old man is recovering from an appendicectomy. The operation was B 9.8%
complicated by the presence of perforation. He is now recovering on the ward.
C 7.6%
However, his urine output is falling and he has been vomiting. Which of the
D 11%
following intravenous fluids should be initially administered, pending analysis of
E 11.8%
his urea and electrolyte levels?

question correctly
A. Hartmans solution
B. Dextran 70
C. Pentastarch
D. Gelofusin
E. 5% Dextrose
Next question
Theme from January 2011 Exam
He will have sequestration of electrolyte rich fluids in the abdomen and gut lumen.
These are best replaced by use of Hartmans solution in the first instance.
Post operative fluid management
Composition of commonly used intravenous fluids mmol-1
Na K Cl Bicarbonate Lactate
Plasma 137-147 4-5.5 95-105 22-25 -
0.9% Saline 153 - 153 - -
Dextrose / saline 30.6 - 30.6 - -
Hartmans 130 4 110 - 28
A summary of the recommendations for post operative fluid management
Fluids given should be documented clearly and easily available

Assess the patient's fluid status when they leave theatre
If a patient is haemodynamically stable and euvolaemic, aim to restart oral
fluid intake as soon as possible
Review patients whose urinary sodium is < 20
If a patient is oedematous, hypovolaemia if present should be treated first.
This should then be followed by a negative balance of sodium and water,
monitored using urine Na excretion levels.
Solutions such as Dextran 70 should be used in caution in patients with
sepsis as there is a risk of developing acute renal injury.
References
British Consensus Guidelines on Intravenous Fluid Therapy for Adult Surgical
Patients
GIFTASUP (2009)
1
A 17.9%
A 32 year old man presents to the acute surgical unit with acute pancreatitis. He 2
B 8.4%
suddenly becomes dyspnoeic and his saturations are 89% on air. A CXR shows
C 8.1%
bilateral pulmonary infiltrates. His CVP pressure is 16mmHg. What is the most
D 5.4%
likely diagnosis?
E 60.3%
A. Pulmonary oedema 60.3% of users answered this

question correctly
B. Pneumococcal pneumonia
C. Staphylococcal pneumonia
D. Pneumocystis carinii
E. Adult respiratory distress syndrome
Next question
Theme from January 2012 Exam
Acute pancreatitis is known to precipitate ARDS. ARDS is characterised by

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

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

Multi organ failure
Management
Treat the underlying cause

Antibiotics
Negative fluid balance i.e. Diuretics
Mechanical ventilation strategy using low tidal volumes as conventional tidal
volumes may cause lung injury (only treatment found to improve survival
rates)

Question 3 of 66 Question stats Score: 33.3%
1
A 26.4%
Which of the following anaesthetic agents is most likely to induce adrenal 2
B 10.4%
suppression? 3
C 12.1%
D 33.1%
A. Sodium thiopentone E 18%
B. Midazolam
C. Propofol question correctly
D. Etomidate
E. Ketamine
Next question
Etomidate is a recognised cause of adrenal suppression, this has been

associated with increased mortality when used as a sedation agent in the critically
ill.
Anaesthetic agents
The table below summarises some of the more commonly used IV induction
agents
Agent Specific features
Propofol Rapid onset of anaesthesia

Pain on IV injection
Rapidly metabolised with little accumulation of metabolites
Proven anti emetic properties
Moderate myocardial depression
Widely used especially for maintaining sedation on ITU, total IV
anaesthesia and for daycase surgery
Sodium Extremely rapid onset of action making it the agent of choice for rapid
thiopentone sequence of induction
Marked myocardial depression may occur
Metabolites build up quickly
Unsuitable for maintenance infusion
Little analgesic effects
Ketamine May be used for induction of anaesthesia

Has moderate to strong analgesic properties
Produces little myocardial depression making it a suitable agent for
anaesthesia in those who are haemodynamically unstable
May induce state of dissociative anaesthesia resulting in nightmares
Etomidate Has favorable cardiac safety profile with very little haemodynamic
instability
No analgesic properties
Unsuitable for maintaining sedation as prolonged (and even brief) use
may result in adrenal suppression
Post operative vomiting is common
1
A 12.4%
A patient with tachycardia and hypotension is to receive inotropes. Which of the 2
B 26.9%
following conditions are most likely to be treated with inotropes? 3
C 9%
D 46.1% 4
A. Hypovolaemic shock E 5.5%
B. Septic shock
C. Neurogenic shock question correctly
D. Cardiogenic shock
E. None of the above
Next question
Theme from April 2012 Exam

The term septic shock has a precise meaning and refers to refractory systemic
arterial hypotension in spite of fluid resuscitation. Patients will therefore usually
require inotropes. Individuals suffering from neurogenic shock will usually receive
intravenous fluids to achieve a mean arterial pressure of 90mmHg. If this target
cannot be achieved then these patients will receive inotropes. Hypovolaemic
shock requires fluids and the management of cardiogenic shock is multifactorial
and includes inotropes, vasodilators and intra-aortic balloon pumps
Inotropes and cardiovascular receptors
Inotrope Cardiovascular receptor action
Adrenaline -1, -2, -1, -2
Noradrenaline -1,( -2), (-1), (-2)
Dobutamine -1, ( 2)
Dopamine (-1), (-2), (-1), D-1,D-2
Minor receptor effects in brackets
Effects of receptor binding

-1, -2 vasoconstriction
-1 increased cardiac contractility and HR
-2 vasodilatation
D-1 renal and spleen vasodilatation
D-2 inhibits release of noradrenaline
1/3 Question 5-7 of 66 Question stats Score: 28.6%
Average score for registered users: 1
Theme: Feeding options 2

5 61.5%
3
6 53.4%
A. Feeding jejunostomy
7 62.2% 4
B. Percutaneous endoscopic gastrostomy 5-7 1/3
C. Total parenteral nutrition
D. Naso gastric feeding tube
E. Naso jejunal feeding tube
F. Normal oral intake
Please select the most appropriate method of delivering nutrition in each of the
following scenarios. Each option may be used once, more than once or not at all.
5. A 28 year old man is comatose, from head injuries, on the

neurosurgical intensive care unit. He is recovering well and should be
extubated soon.
You answered Normal oral intake
The correct answer is Naso gastric feeding tube

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

oesophagectomy for carcinoma.
You answered Normal oral intake
The correct answer is Feeding jejunostomy
Feeding jejunostomy is the standard of care in most centres. Naso

jejunal tubes are preferred by some surgeons. However, if they
become displaced the only alternative then becomes TPN.
7. A 43 year old man is recovering from a laparoscopic low anterior

resection with loop ileostomy.
Normal oral intake
Early feeding in this situation is both safe and will enhance recovery.
Next question
Nutrition options in surgical patients
Oral intake Easiest option

May be supplemented by calorie rich dietary supplements
May contra indicated following certain procedures
Naso gastric Usually administered via fine bore naso gastric feeding tube
feeding Complications relate to aspiration of feed or misplaced tube
May be safe to use in patients with impaired swallow
May be safe to use in patients with impaired swallow
Often contra indicated following head injury due to risks
associated with tube insertion
Naso jejunal Avoids problems of feed pooling in stomach (and risk of

feeding aspiration)
Insertion of feeding tube more technically complicated (easiest
if done intra operatively)
Safe to use following oesophagogastric surgery
Feeding Surgically sited feeding tube

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

endoscopic May not be technically possible in those patients who cannot
gastrostomy undergo successful endoscopy
Risks include aspiration and leakage at the insertion site
Total parenteral The definitive option in those patients in whom enteral feeding
nutrition is contra indicated
Individualised prescribing and monitoring needed
Should be administered via a central vein as it is strongly
phlebitic
Long term use is associated with fatty liver and deranged
LFT's
0/3 Question 8-10 of 66 Question stats Score: 20%
Theme: Anaesthetic agents 2

8 46.6%
3
9 43.9%
A. Etomidate
10 33.5% 4
B. Ketamine 5-7 1/3
C. Propofol 8-10 0 / 3
D. Sodium thiopentone
E. Methohexitone
F. Metaraminol
G. Midazolam
Please select the most appropriate anaesthetic induction agent for the procedure
described. Each option may be used once, more than once or not at all.
8. A 32 year old man is admitted for a trendelenberg procedure for

varicose veins. He is known to have porphyria.
You answered Midazolam
The correct answer is Propofol
This is a daycase procedure for which propofol is ideal. Sodium

thiopentone and etomidate are contraindicated in porphyria.
9. A 77 year old lady with unstable ischaemic heart disease requires

an emergency femoral hernia repair. She is volume depleted and
slightly hypotensive.
The correct answer is Ketamine
Ketamine is not negatively inotropic and will not depress cardiac

output. Propofol and Sodium thiopentone will produce myocardial
depression. Some doctors may also consider etomidate. However, it
may cause adrenal suppression and post operative vomiting- which
she is at high risk of developing.
10. A 22 year old man is brought to theatre for an emergency

apppendicectomy for generalised peritonitis. He is vomiting.
The correct answer is Sodium thiopentone
Most anaesthetists would use sodium thiopentone for a rapid

sequence induction (which this man will need).
Next question
Propofol- Ideal agent for daycase- wears off rapidly, good antiemetic effect.
Sodium thiopentone- Fast onset of action- prone to accumulation. Depresses

cardiac output.
Ketamine- Little haemodynamic instability. Good analgesic properties.
Nightmares and restlessness.
Theme: Surgical analgesia 2

11 45.7%
3
12 30.7%
A. Amitriptylline
13 61.4% 4
B. Pregabalin 5-7 1/3
C. Duloxetine 8-10 0 / 3
D. Paracetamol 11-13 0 / 3
E. Diclofenac
F. Pethidine
G. Morphine
Please select the most appropriate analgesic modality for the scenario given.
Each option may be used once, more than once or not at all.
11. 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.
You answered Pethidine
The correct answer is Pregabalin
This patient has phantom limb pain which is a neuropathic pain.

First line management is with amitriptylline or pregabalin. However
this patient has orthostatic hypotension, which is a side effect of
amitriptylline, therefore pregabalin is the treatment of choice.
12. A 64 year old type 2 diabetic is referred to vascular clinic with

painful foot ulcers. His ABPI is 0.6. On further questioning the
patient reports a burning sensation in both of his feet.
The correct answer is Duloxetine
This NICE guidelines state that duloxetine should be used as a 1st

line agent in diabetic neuropathic pain.
13. A 24 year old man has had a fracture of the tibia after playing
football. He arrives in the emergency room distressed and in severe
pain.
The correct answer is Morphine
This type of injury will require morphine. However, timely fracture

splinting will have a significant analgesic effect.
Next question
Management of pain
World Health Organisation Analgesic Ladder

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

Analgesic Ladder
For management of acute pain

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

Bupivacaine
Analgesia for several hours
Further pain relief can be obtained with repeat injections or by infusions via
a thin catheter
Blockade of plexuses or peripheral nerves will provide selective analgesia
in those parts of the body supplied by the plexus or nerves
Can either be used to provide anaesthesia for the surgery or specifically
for postoperative pain relief
Especially useful where a sympathetic block is needed to improve
postoperative blood supply or where central blockade such as spinal or
epidural blockade is contraindicated.
Spinal anaesthesia
Provides excellent analgesia for surgery in the lower half of the body and pain
relief can last many hours after completion of the operation if long-acting drugs
containing vasoconstrictors are used.
- Side effects of spinal anaesthesia include: hypotension, sensory and motor

block, nausea and urinary retention.
Epidural anaesthesia
An indwelling epidural catheter inserted. This can then be used to provide a
continuous infusion of analgesic agents. It can provide excellent analgesia. They
are still the preferred option following major open abdominal procedures and help
prevent post operative respiratory compromise resulting from pain.
- Disadvantages of epidurals is that they usually confine patients to bed,

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

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

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

- Mild to moderate pain.
Paracetamol
Inhibits prostaglandin synthesis.

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

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

Second line: Amitriptyline AND pregabalin
Third line: refer to pain specialist. Give tramadol in the interim (avoid
morphine)
If diabetic neuropathic pain: Duloxetine
References
1. http://guidance.nice.org.uk/CG96/Guidance/pdf/English
2. Charlton E. The Management of Postoperative Pain . Update in Anaesthesia.
Issue 7 (1997)
1
A 41.3%
A 17 year old man undergoes an elective right hemicolectomy. Post operatively 2
B 12.7%
he receives a total of 6 litres of 0.9% sodium chloride solution, over 24 hours. 3
C 26.2%
Which of the following complications may ensue?
D 8.7% 4
E 11% 5-7 1/3
A. Hyperchloraemiac acidosis. 8-10 0 / 3
B. Hypochloraemic alkalosis question correctly 11-13 0 / 3
C. Hyperchloraemic alkalosis 14
D. Acute renal failure

Next question
Excessive infusions of any intravenous fluid carry the risk of development of

tissue oedema and potentially cardiac failure. Excessive administration of sodium
chloride is a recognised cause of hyperchloraemic acidosis and therefore
Hartmans solution may be preferred where large volumes of fluid are to be
administered.
Plasma 137-147 4-5.5 95-105 22-25 -
0.9% Saline 153 - 153 - -
Hartmans 130 4 110 - 28

References
Patients
GIFTASUP (2009)
1
A 5.7%
A 28 year old man with Crohn's disease has undergone a number of resections. 2
B 23.1%
His BMI is currently 18 and his albumin is 18. He feels well but does have a small 3
C 12.8%
localised perforation of his small bowel. The gastroenterologists are giving
D 47.7% 4
azathioprine. What is the most appropriate advice regarding feeding?
E 10.6% 5-7 1/3
8-10 0 / 3
A. Nil by mouth 47.7% of users answered this
question correctly 11-13 0 / 3
B. Nil by mouth and continuous intra venous fluids until surgery 14
C. Enteral feeding 15
D. Parenteral feeding
E. Nutritional supplements
Next question
This man is malnourished, although he is likely to require surgery it is best for him
to be nutritionally optimised first. As he may have reduced surface area for
absorption and has a localised perforation TPN is likely to be the best feeding
modality.
Parenteral feeding-NICE guidelines
Parenteral nutrition: NICE guidelines summary
Identify patients as malnourished or at risk
Patients identified as being malnourished-
BMI < 18.5 kg/m2

unintentional weight loss of > 10% over 3-6/12
BMI < 20 kg/m2 and unintentional weight loss of > 5% over 3-6/12
AT RISK of malnutrition-
eaten nothing or little > 5 days, who are likely to eat little for a further 5
days
poor absorptive capacity
high nutrient losses
high metabolism
Identify unsafe/inadequate oral intake OR a non functional GI

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

tract/perforation/inaccessible then consider peri operative parenteral feeding.

1
A 16.4%
A 51 year old man is shot in the abdomen and sustains a significant intra 2
B 10.8%
abdominal injury. A laparotomy, bowel resection and end colostomy are 3
C 9.6%
performed. An associated vascular injury necessitates a 6 unit blood transfusion.
D 50% 4
He has a prolonged recovery and is paralysed and ventilated for 2 weeks on
E 13.2% 5-7 1/3
intensive care. He receives total parenteral nutrition and is eventually weaned
from the ventilator and transferred to the ward. On reviewing his routine blood 8-10 0 / 3
50% of users answered this
tests the following results are noted: question correctly 11-13 0 / 3
14
Full blood count
15
Hb 11.3 g/dl
16
Platelets 267 x 10 9 /l
WBC 10.1 x10 9 /l
Urea and electrolytes
Na + 131 mmol/l
K+ 4.6 mmol/l
Urea 2.3 mmol/l
Creatinine 78 mol/l
Liver function tests

Bilirubin 25 mol/l
ALP 445 u/l
ALT 89 u/l
GT 103 u/l
What is the most likely underlying cause for the abnormalities noted?
A. Delayed type blood transfusion reaction

B. Bile leak
C. Anastomotic leak
D. Total parenteral nutrition
E. Gallstones
Next question
TPN is known to result in derangement of liver function tests. Although,

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

Bags contain combinations of glucose, lipids and essential electrolytes, the
exact composition is determined by the patients nutritional requirements.
Although it may be infused peripherally, this may result in thrombophlebitis.
Longer term infusions should be administered into a central vein
(preferably via a PICC line).
Complications are related to sepsis, re-feeding syndromes and hepatic
dysfunction.
1
A 39.9%
Which statement regarding post operative cognitive impairment is true? 2
B 16.6%
C 11% 3
A. Use of Benzodiazepines preoperatively reduces long-term post D 15.4% 4

operative cognitive dysfunction E 17.1% 5-7 1/3
B. Pain does not cause delirium 8-10 0 / 3
C. Delirium has no impact on length of hospital stay question correctly 11-13 0 / 3
14
D. A regional anaesthetic rather than a general anaesthetic is more
likely to contribute to post operative cognitive impairment 15
E. Visual hallucinations are not a feature of delirium 16
17
Next question
Anaesthetic technique and Post operative cognitive impairment (POCD):

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

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

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

following surgery
Early POCD
Increasing age
GA rather than regional
Duration of anaesthesia
Reoperation
Postoperative infection
Late POCD
Increasing age
Emboli
Biochemical disturbances
1
A 26.4%
Which statement is false about pethidine? 2
B 28.8%
C 18.1% 3
A. Has approximately 10% efficacy of morphine D 14.1% 4
B. Structurally similar to morphine E 12.5% 5-7 1/3

8-10 0 / 3
C. Pethidine has a toxic metabolite (norpethidine) which is cleared by 28.8% of users answered this
the kidney question correctly 11-13 0 / 3
14
D. Pethidine is metabolized by the liver
15
E. Can be given intramuscularly
16
Next question 17
18
It has a different structure.
Management of pain

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
1
A 23%
Which of the following anaesthetic agents least likely to be associated with 2
B 40.7%
depression of myocardial contractility? 3
C 17.5%
D 9.7% 4
A. Propofol E 9.1% 5-7 1/3
B. Etomidate 8-10 0 / 3
C. Sodium thiopentone
14
D. Ether
15
16
Next question 17
18
Of the agents mentioned, etomidate has the most favorable cardiac safety profile.
19
Anaesthetic agents
agents


instability
Theme: Intravenous fluids 2

20 37.6%
3
21 56.7%
A. Dextran 40
22 71% 4
B. Human albumin solution 4.5% 5-7 1/3
C. Dextran 70 8-10 0 / 3
D. Dextrose 4%/ Saline 0.19% 11-13 0 / 3
E. Dextrose 5% 14
F. Hartmans solution 15
G. Dextrose 10% 16
H. Gelofusin 17
18
Please select the most appropriate intravenous fluid for the scenario given. Each
19
option may be used once, more than once or not at all.
20-22 1 / 3
20. A 45 year old lady with cirrhosis of the liver is recovering following
an emergency para umbilical hernia repair. She has been slow to
resume oral intake and has been receiving regular boluses of
normal saline for oliguria
You answered Gelofusin
The correct answer is Human albumin solution 4.5%
In patients who are hypoalbuminaemic the use of albumin solution

may help promote a diuresis and manage fluid overload.
21. A 23 year old lady is severely unwell with pyelonephritis. She is

hypotensive and clinically has septic shock.
Gelofusin
In this situation gelofusin will remain in the circulation for a long time.
Starches are not a popular choice in sepsis as they have been
shown to be an independent risk factor for the development of renal
failure.
22. A 24 year old man is recovering from a right hemicolectomy for

Crohns disease. He is oliguric and dehydrated owing to a high
output ileostomy. His electrolytes are normal.
You answered Gelofusin
The correct answer is Hartmans solution
Of the solutions given Hartmans is the most suitable. Consideration

should also be given to potassium supplementation.
Next question
Starches increase risk of renal failure when used in septic shock.

Theme: Intravenous access 2

23 24%
3
24 79.5%
A. 14 G peripheral cannula
25 62.6% 4
B. Intraosseous infusion 5-7 1/3
C. Triple lumen central line (internal jugular route) 8-10 0 / 3
D. Triple lumen central line (femoral vein route) 11-13 0 / 3
E. Swann Ganz Catheter 14
F. Swann Ganz Introducer (7G) 15
G. 22 G peripheral cannula 16
H. Hickman line 17
18
Please select the most appropriate modality of intravenous access for the
19
scenario given. Each option may be used once, more than once or not at all.
20-22 1 / 3
23-25 1 / 3
23. A 45 year old man with liver cirrhosis is admitted with a brisk upper
GI bleed. Multiple infusions are required and he is peripherally shut
down.
You answered Hickman line
The correct answer is Triple lumen central line (femoral vein

route)
A central line is the most sensible option. He is highly likely to be

coagulopathic and a femoral insertion route is safest in these
circumstances.
Multiple infusions and absence of peripheral veins are the
compelling indications for central access in this case.
24. A 3 year old is injured in a road traffic accident and is hypotensive

and tachycardic due to a suspected splenic injury, she is
peripherally shut down.
You answered Hickman line
The correct answer is Intraosseous infusion
Intraosseous infusions are the preferred route in this situation as

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

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

the proximal tibia and provides access to the marrow cavity and circulatory
system. Although traditionally preferred in paediatric practice they may be used in
adults and a wide range of fluids can be infused using these devices.
1
A 13.7%
Which of the following muscle relaxants will tend to incite neuromuscular 2
B 60.4%
excitability following administration? 3
C 9.1%
D 8.7% 4
A. Atracurium E 8.1% 5-7 1/3
B. Suxamethonium 8-10 0 / 3
C. Vecuronium
14
D. Pancuronium
15
16
Next question 17
18
Suxamethonium may induce generalised muscular contractions following
19
administration. This may raise serum potassium levels.
20-22 1 / 3
23-25 1 / 3
Muscle relaxants
26
Suxamethonium Depolarising neuromuscular blocker

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

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

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

Onset of action approximately 2-3 minutes
Duration of action up to 2 hours
Effects may be partially reversed with drugs such as neostigmine
1
A 55.4%
Which of the following is a not a diagnostic criteria for brain death? 2
B 7.5%
C 8.7% 3
A. No response to sound D 12.5% 4
B. No corneal reflex E 15.9% 5-7 1/3

8-10 0 / 3
C. Absent oculo-vestibular reflexes 55.4% of users answered this
D. No response to supraorbital pressure
14
E. No cough reflex to bronchial stimulation
15
16
Next question
17
18
19
Brain death
20-22 1 / 3
23-25 1 / 3
Criteria for brain death
26
Fixed pupils which do not respond to sharp changes in the intensity of 27
incident light
No corneal reflex
Absent oculo-vestibular reflexes - no eye movements following the slow
injection of at least 50ml of ice-cold water into each ear in turn (the caloric
test)
No response to supraorbital pressure
No cough reflex to bronchial stimulation or gagging response to pharyngeal
stimulation
No observed respiratory effort in response to disconnection of the
ventilator for long enough (typically 5 minutes) to ensure elevation of the
arterial partial pressure of carbon dioxide to at least 6.0 kPa (6.5 kPa in
patients with chronic carbon dioxide retention). Adequate oxygenation is
ensured by pre-oxygenation and diffusion oxygenation during the
disconnection (so the brain stem respiratory centre is not challenged by the
ultimate, anoxic, drive stimulus)
The test should be undertaken by two appropriately experienced doctors on two

separate occasions.
Theme: Airway management 2

28 67.5%
3
29 75%
A. Cricothyroidotomy
30 87.6% 4
B. Laryngeal mask 5-7 1/3
C. Endotracheal intubation 8-10 0 / 3
D. Tracheostomy 11-13 0 / 3
E. Oropharyngeal airway 14
15
Please select the most appropriate method of airway access for the scenario 16
given. Each option may be used once, more than once or not at all.
17
18
19
28. A 63 year old man has been on the intensive care unit for a week
with adult respiratory distress syndrome complicating acute 20-22 1 / 3
pancreatitis. He has required ventilation and is still being 23-25 1 / 3
mechanically ventilated.
26
27
You answered Oropharyngeal airway
28-30 0 / 3
The correct answer is Tracheostomy
Tracheostomy is often used to facilitate long term weaning. The

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

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

anaesthesia and recovery. Muscle paralysis is not required and this
would an ideal case for laryngeal mask airway.
30. A 48 year old man is due to undergo a laparotomy for small bowel
obstruction.
The correct answer is Endotracheal intubation
Patients who are due to undergo laparotomies for bowel obstruction

have either been vomiting or at high risk of regurgitation of gastric
contents on induction of anaesthesia. A rapid sequence induction
with cricothyroid pressure applied to occlude the oesophagus is
performed. A cuffed endotracheal tube is then inserted. Once
correct placement of the ET tube is confirmed the cricothyroid
pressure can be removed.
Next question
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 result in oesophageal intubation (therefore
end tidal CO2 usually measured)
Paralysis often required
Higher ventilation pressures can be used
Theme: Management of pain 2

31 63.3%
3
32 54.4%
A. Paracetamol
33 79.8% 4
B. Non steroidal anti inflammatory drugs 5-7 1/3
C. Fentanyl patch 8-10 0 / 3
D. Carbamazepine 11-13 0 / 3
E. Pregabalin 14
F. Duloxetine 15
G. Radiotherapy 16
H. Chemotherapy 17
I. Spinal block 18
19
For each scenario please select the most appropriate analgesic modality. Each 20-22 1 / 3
option may be used once, more than once or not at all. 23-25 1 / 3
26
27
31. A 52 year old man with prostate cancer is admitted to urology with
28-30 0 / 3
urinary retention. He complains of back pain which is not responding
to ward analgesia. A lumbar xray confirms lumbar spine metastases. 31-33 0 / 3
You answered Spinal block
The correct answer is Radiotherapy
This patient needs radiotherapy for pain relief. Bisphosphonates

may also be effective.
32. A 42 year old woman complains of shooting pains in her left arm
after a mastectomy.
The correct answer is Pregabalin
Pregabalin is the 1st line treatment described in the NICE

guidelines.
33. A 2 year old boy is recovering following an uncomplicated

appendicectomy.
The correct answer is Paracetamol
Paracetamol is an extremely effective analgesic in children.
Next question
Management of pain

1
A 20.8%
Which of the following statements relating to the use of human albumin solution is 2
B 13.8%
false? 3
C 17.6%
D 13.7% 4
A. When administered in the peri operative period it does not increase E 34.2% 5-7 1/3
the length of stay compared with crystalloid solutions 8-10 0 / 3
B. Concentrated solutions may produce diuresis in patients with liver question correctly 11-13 0 / 3
failure 14
C. It may restore plasma volume in cases of sodium and water overload
15
D. It may be associated with risk of acquiring new variant Creutzfeld-
16
Jacob disease
17
E. Hepatitis C remains a concern when large volumes are infused
18
Next question 19
20-22 1 / 3
Human albumin solution went out of vogue following the Cochrane review in 2004 23-25 1 / 3
that showed it increased mortality. This view has been challenged and 26
subsequent studies have confirmed it to be safe for use. Viruses are inactivated
27
during the preparation process. However, theoretical risks regarding new varient
28-30 0 / 3
CJD still exist. Outcomes in the peri operative setting are similar whether colloid,
31-33 0 / 3
crystalloid or albumin are used.
34
Plasma 137-147 4-5.5 95-105 22-25 -
0.9% Saline 153 - 153 - -
Hartmans 130 4 110 - 28

References
Patients
GIFTASUP (2009)

1
A 46.3%
Which statement is true when prescribing nutritional support? 2
B 16.7%
C 20.8% 3
A. For severely ill patients aim to give < 50% energy needs in the first D 9.8% 4
24-48 hours E 6.3% 5-7 1/3
B. For patients at risk of refeeding syndrome, they should be given 35 8-10 0 / 3
kcal/kg/day initially 11-13 0 / 3
question correctly
C. For severely ill patients aim to give the full energy needs in the first 14
24-48 hours
15
D. Patients on diuretics are unlikely to need thiamine
16
E. Patients on chemotherapy are unlikely to need thiamine
17
18
Next question
19
Diuretics and chemotherapy increase the risk of refeeding syndrome. 20-22 1 / 3

23-25 1 / 3
Nutrition prescriptions 26
27
National institute of clinical excellence (NICE) guidelines
28-30 0 / 3
31-33 0 / 3
For people not severely ill and not at risk of refeeding syndrome aim to
34
give
35
25-35 kcal/kg/day (lower if BMI > 25)
0.8-1.5g protein /kg/day
30-35 ml fluid/kg/day
Adequate electrolytes, minerals, vitamins
Severely ill patients aim to give < 50% of the energy and protein levels over
the first 24-48h.
For people at high risk of refeeding syndrome:
Start at up to 10 kcal/kg/day increasing to full needs over 4-7 days

Start immediately before and during feeding: oral thiamine 200-300mg/day,
vitamin B co strong 1 tds and supplements
Give K+ (2-4 mmol/kg/day), phosphate (0.3-0.6 mmol/kg/day), magnesium
(0.2-0.4 mmol/kg/day)
1
A 19.6%
A 78 year old man presents with a ruptured aortic aneurysm. This is repaired but 2
B 6.3%
the operation is difficult as it has a juxtarenal location. A supra renal cross clamp 3
C 14.3%
is applied. Post operatively he is found to be oliguric and acute renal failure is
D 50.8% 4
suspected. Which of the following statements relating to acute post-operative
E 9% 5-7 1/3
renal failure are untrue?
8-10 0 / 3
A. Intravenous dopamine does not prevent acute renal failure.
14
B. It is more common after emergency surgery.
15
C. Use of excessive amounts of intravenous fluids may lead to falsely
16
normal serum creatinine measurements.
17
D. Vasopressor drugs have a strong renoprotective effect
18
E. It is minimised by normalisation of haemodynamic status.
19
Next question 20-22 1 / 3

23-25 1 / 3
26
Key points : Renal injury and acute renal failure: RIFLE Classification.
27
R=Risk (Serum Creatinine x1.5)
28-30 0 / 3
I=Injury (Serum Creatinine x 2)
31-33 0 / 3
F=Failure (Serum Creatinine x3)
L=Loss (Loss of renal function >4weeks) 34
E=End stage kidney disease 35
36
Vasopressor use is linked to renal failure as they are a marker of haemodynamic
compromise.
Acute Renal Failure
Final pathway is tubular cell death.

Renal medulla is a relatively hypoxic environment making it susceptible to
renal tubular hypoxia.
Renovascular autoregulation maintains renal blood flow across a range of
arterial pressures.
Estimates of GFR are best indices of level of renal function. Useful clinical
estimates can be obtained by considering serum creatinine, age, race,
gender and body size. eGFR calculations such as the Cockcroft and Gault
equation are less reliable in populations with high GFR's.
Nephrotoxic stimuli such as aminoglycosides and radiological contrast
media induce apoptosis. Myoglobinuria and haemolysis result in necrosis.
Overlap exists and proinflammatory cytokines play and important role in
potentiating ongoing damage.
Post-operative renal failure is more likely to occur in patients who are
elderly, have peripheral vascular disease, high BMI, have COPD, receive
vasopressors, are on nephrotoxic medication or undergo emergency
surgery.
Avoiding hypotension will reduce risk of renal tubular damage.
There is no evidence that administration of ACE inhibitors or dopamine
reduces the incidence of post-operative renal failure.

1
A 16.8%
A 45 year old man develops acute respiratory distress syndrome during an attack 2
B 15.5%
of severe acute pancreatitis. Which of the following is not a feature of adult 3
C 46.3%
respiratory distress syndrome?
D 6.3% 4
E 15.1% 5-7 1/3
A. It usually consists of type I respiratory failure. 8-10 0 / 3
B. Patients typically require high ventillatory pressures. question correctly 11-13 0 / 3
C. A Swann Ganz Catheter would typically have a reading in excess of 14

18mmHg. 15
D. It may complicate acute pancreatitis. 16
E. It may heal with fibrosis. 17
18
Next question
19
20-22 1 / 3
Right heart pressure should be normal.
23-25 1 / 3
Adult respiratory distress syndrome 26
27
Defined as an acute condition characterized by bilateral pulmonary infiltrates and 28-30 0 / 3
severe hypoxemia (PaO2/FiO2 ratio < 200) in the absence of evidence for 31-33 0 / 3
cardiogenic pulmonary oedema (clinically or pulmonary capillary wedge pressure 34
of less than 18 mm Hg).
35
In is subdivided into two stages. Early stages consist of an exudative phase of
inury with associated oedema. The later stage is one of repair and consists of 36
fibroproliferative changes. Subsequent scarring may result in poor lung function. 37
Causes
Sepsis
Direct lung injury
Trauma
Acute pancreatitis
Long bone fracture or multiple fractures (through fat embolism)
Head injury (causes sympathetic nervous stimulation which leads to acute
pulmonary hypertension)
Clinical features
Acute dyspnoea and hypoxaemia hours/days after event

Multi organ failure
Management
Treat the underlying cause

Antibiotics
Negative fluid balance i.e. Diuretics
Mechanical ventilation strategy using low tidal volumes as conventional tidal
volumes may cause lung injury (only treatment found to improve survival
rates)

1-3 0/3
Average score for registered users:
Theme: Muscle relaxants
1 49.1%
2 70.3%
A. Gallamine
3 31.6%
B. Benzquinonium
C. Tubocurarine
D. Vecuronium
E. Pancuronium
F. Suxamethonium
G. Decamethonium halides
Please select the most appropriate neuromuscular blocking drugs for the
procedure described. Each option may be used once, more than once or not at
all.
1. A 56 year old man is undergoing a distal gastrectomy and just as the

surgeon begins to close the deep abdominal muscle layer the patient
develops marked respiratory efforts and closure cannot continue.
You answered Decamethonium halides
The correct answer is Suxamethonium
Suxamethonium has a rapid onset with short duration of action. As

this is the final stage of the procedure only brief muscle relaxation is
needed.
2. An agent that is associated with a risk of malignant hyperthermia.
Suxamethonium may cause malignant hyperthermia and 1 in 2800 will

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

relaxants

1-3 0/3
A 9.3%
4
Which of the following fulfills the criteria for malnutrition based on the NICE B 34.6%
guidelines?
C 14.6%
D 6.8%
A. Hypoalbuminaemia E 34.6%
B. BMI < 17.5 kg/m2 and unintentional weight loss of > 5% over 3-6/12
C. BMI < 17.5 kg/m2 question correctly
D. Reduced skin turgor

E. Unintentional weight loss of > 10% over 3- 6 months
Next question
Nutrition Screening-NICE guidelines
NICE Screening for malnutrition: A summary
To be performed by an appropriate professional.

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

BMI < 18.5 kg/m2
Unintentional weight loss of > 10% over 3-6/12
NB BMI= weight (kg)/height (m)
Considered in people identified as being AT RISK of malnutrition:

Eaten nothing or little > 5 days, who are likely to eat little for a further 5
days
Poor absorptive capacity
High nutrient losses
High metabolism
NB if considering feed withdrawal refer to GMC guidance 'withholding and

withdrawing life prolonging treatment'.

1-3 0/3
A 11.2%
4
A 52 year old man is recovering following an elective right hemicolectomy for B 37.5%
carcinoma of the caecum. His surgery is uncomplicated, when should oral intake 5
C 13.9%
resume?
D 8.8%
E 28.5%
A. Only once bowels have been opened to stool
B. Only once the patient has passed flatus question correctly
C. Between 24 and 48 hours of surgery
D. More than 48 hours after surgery
E. Within 24 hours of surgery
Next question
As part of the enhanced recovery principles oral intake in this setting should
resume soon after surgery. Administration of liquid and even light diet does not
increase the risk of anastomotic leak.
Oral Nutrition
Oral nutrition: a summary of NICE guidelines
Identify patients who are or at risk of being malnourished (see below for
definitions)
Check for dysphagia
If safe swallow, provide food and fluid in adequate quantity and quality
Give a balanced diet
Offer multivitamins and minerals
Surgical patients:
If malnourished and safe swallow and post op caesarean, gynaecological or

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

AT RISK of malnutrition:
days
high metabolism

1-3 0/3
4
Theme: Muscle relaxants
6 42.5%
5
7 50%
A. Atracurium 6-8 0/3
8 71.1%
B. Suxamethonium
C. Pancuronium
D. Vecuronium
E. Curare
Please select the muscle relaxant that applies to the scenario or description
supplied. Each option may be used once, more than once or not at all.
6. An agent that is degraded by hydrolysis and may produce histamine

release.
You answered Vecuronium
The correct answer is Atracurium
Atracurium is degraded by a process of ester hydrolysis. This uses

non specific plasma esterases.
7. An agent which should be avoided in a 23 year old man with burn

and bilateral tibial fractures are being trapped in a car accident for 2
hours.
Suxamethonium may induce hyperkalaemia as it induces generalised

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

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

relaxants
and lack of acetylcholinesterase

1-3 0/3
A 11%
4
Which of the following is a recognised feature of ketamine when used as an B 11.7%
anaesthetic agent? 5
C 12.7%
6-8 0/3
D 55.1%
9
A. Malignant hyperpyrexia E 9.5%
B. Adrenal suppression
C. Myocardial depression question correctly
D. Dissociative anaesthesia
E. Marked respiratory depression
Next question
Unlike most anaesthetic agents ketamine does not cause myocardial or marked
respiratory depression. It is not associated with the adrenal suppression that may
occur with etomidate. It is however, associated with a state of dissociative
anaesthesia which patients may find distressing.
Anaesthetic agents
agents


instability

1-3 0/3
A 62.6%
4
A 73 year old man undergoes a right below knee amputation for end stage B 8.7%
peripheral vascular disease. He is reviewed in the clinic 8 weeks post operatively 5
C 9.1%
and complains of a persistent, burning discomfort over his amputation site stump. 6-8 0/3
D 5.6%
On examination his wound has healed and proximal pulses have a biphasic signal
9
E 14%
on doppler ultrasound. What is the post appropriate management?
10
question correctly
A. Commence amitryptyline
B. Commence fentanyl patch
C. Arrange duplex scan
D. Arrange MRI scan of the stump
E. Commence carbamazepine
Next question
This patient has neuropathic pain. Amitryptyline is the treatment of choice.

Carbamazepine is mainly used for trigeminal neuralgia.
Neuropathic pain
Neuropathic pain may be defined as pain which arises following damage or

disruption of the nervous system. It is often difficult to treat and responds poorly
to standard analgesia.
Examples include:
diabetic neuropathy
post-herpetic neuralgia
trigeminal neuralgia
prolapsed intervertebral disc
NICE issued guidance in 2010 on the management of neuropathic pain:
first-line treatment*: oral amitriptyline or pregabalin

if satisfactory pain reduction is obtained with amitriptyline but the person
cannot tolerate the adverse effects, consider oral imipramine or
nortriptyline as an alternative
second-line treatment: if first-line treatment was with amitriptyline, switch to
or combine with pregabalin. If first-line treatment was with pregabalin, switch
to or
combine with amitriptyline
other options: pain management clinic, tramadol (not other strong opioids),
topical lidocaine for localised pain if patients unable to take oral medication
*please note that for some specific conditions the guidance may vary. For
example carbamazepine is used first-line for trigeminal neuralgia, duloxetine for
diabetic neuropathy

1-3 0/3
A 44.5%
4
A homeless 42 year old male had an emergency inguinal hernia repair 24h B 27%
previously. He has a BMI of 15. His electrolytes are normal. What is the best initial 5
C 11.8%
feeding regime? 6-8 0/3
D 5.8%
9
E 11%
A. Give 10 kcal/kg/day initially, oral thiamine 200-300mg/day, vitamin B 10
co strong1 tds and supplements. 44.5% of users answered this
question correctly 11
B. Give 35 kcal/kg/day initially, oral thiamine 200-300mg/day, vitamin B
co strong 1 tds and supplements.
C. No change to diet needed
D. Oral thiamine 200-300mg/day, vitamin B co strong1 tds and
supplements.
E. Give 35 kcal/kg/day initially
Next question
This patient is at high risk of refeeding syndrome.
Nutrition - Refeeding syndrome
Re-feeding problems
If patient not eaten for > 5 days, aim to re-feed at < 50% energy and protein
levels
High risk for refeeding problems

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

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

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

Start immediately before and during feeding: oral thiamine 200-300mg/day,
vitamin B co strong 1 tds and supplements
Give K+ (2-4 mmol/kg/day), phosphate (0.3-0.6 mmol/kg/day), magnesium
(0.2-0.4 mmol/kg/day)

1-3 0/3
A 19.7%
4
A 48 year old man is recovering on the high dependency unit following a long and B 58.5%
complex laparotomy. His preoperative medication includes an ACE inhibitor for 5
C 3.8%
blood pressure control. For the past two hours he has been oliguric with a urine 6-8 0/3
D 7.8%
output of 10ml/hr-1. What the most appropriate course of action? 9
E 10.1%
10
A. Stop the ACE inhibitor question correctly 11
B. Administer a fluid challenge 12
C. Start an infusion of nor adrenaline

D. Administer intravenous frusemide
E. Insert a Swann-Ganz Catheter
Next question
Hypovolaemia is the most likely cause for oliguria and a fluid challenge is the most
appropriate action. Blind administration of inotropes to hypovolaemic patients is
unwise, with the possible exception of cardiac patients.
Hypovolaemia and the surgical patient
Hypovolaemia often represents the end point of multiple pathological processes. It

may be divided into the following categories; overt compensated hypovolaemia,
covert compensated hypovolaemia and decompensated hypovolaemia. Of these
three categories the covert compensated subtype of hypovolaemia remains the
commonest and is accounted for by the fact that class I shock will often produce
no overtly discernible clinical signs. This is due, in most cases, to a degree of
splanchnic autotransfusion. The most useful diagnostic test for detection of covert
compensated hypovolaemia remains urinanalysis. This often shows increased
urinary osmolality and decreased sodium concentration.
In overt compensated hypovolaemia the blood pressure is maintained although

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

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

fluid challenge such as the rapid infusion of 250ml of crystalloid will often serve as
both a diagnostic and resuscitative measure. In the event that this fails to produce
the desired response the patient will need to be re-evaluated clinically. More fluid
may be needed. However, it is important not to overlook mechanical ureteric
obstruction in the anuric, normotensive patient.

1-3 0/3
A 13%
4
A 52 year old man undergoes a laparotomy for perforated bowel after a B 16.4%
colonoscopy. 2 days after surgery the nursing staff report there is pink, serous 5
C 48.9%
fluid discharging from the wound. What is the next most appropriate management 6-8 0/3
D 8.2%
step?
9
E 13.5%
10
A. IV antibiotics for wound infection 48.9% of users answered this
B. No further management
12
C. Examine the wound for separation of the rectus fascia
13
D. Insert a drain into the wound
E. CT abdomen
Next question
The seepage of pink serosanguineous fluid through a closed abdominal wound is

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

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

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

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

Determine the most appropriate strategy for managing the wound
Options
Resuturing This may be an option if the wound edges are healthy and there is enough
of the tissue for sufficient coverage. Deep tension sutures are traditionally used for
wound this purpose.
Application This is a clear dressing with removable front. Particularly suitable when some
of a wound granulation tissue is present over the viscera or where there is a high output
manager bowel fistula present in the dehisced wound.
Application This is a clear plastic bag that is cut and sutured to the wound edges and is
of a only a temporary measure to be adopted when the wound cannot be closed
'Bogota and will necessitate a return to theatre for definitive management.
bag'
Application These can be safely used BUT ONLY if the correct layer is interposed between
of a VAC the suction device and the bowel. Failure to adhere to this absolute rule will
dressing almost invariably result in the development of multiple bowel fistulae and
system create an extremely difficult management problem.

1-3 0/3
A 7.8%
4
A 63 year old man undergoes a subtotal colectomy and iatrogenic injury to both B 9.2%
ureters is sustained. He develops renal failure and his serum potassium is found 5
C 7.8%
to be elevated at 6.9 mmol/L. An ECG is performed, what is the most likely 6-8 0/3
D 70.7%
finding?
9
E 4.4%
10
A. Increased PR interval 70.7% of users answered this
B. Prominent U waves
12
C. Narrow QRS complexes
13
D. Peaked T waves
14
E. Low ST segments
Next question
Peaked T waves are the first and most common finding in hyperkalaemia.
ECG features in hyperkalaemia
Peaking of T waves (occurs first)

Loss of P waves
Broad QRS complexes
Ventricullar fibrillation

1-3 0/3
4
Theme: Use of vasoactive drugs
15 39.6%
5
16 52.4%
A. Dopexamine 6-8 0/3
17 68.3%
B. Dobutamine 9
C. Noradrenaline 10
D. Adrenaline 11
E. Milrinone 12
F. Dopamine 13
14
Please select the most appropriate inotrope for the scenario given. Each option
15-17 1 / 3
may be used once, more than once or not at all.
15. An inotrope with mixed vaso dilating and vaso constricting

properties.
Dopamine
Dilating in the case of renal circulating and constricting in other

areas. Overall increases cardiac output. Concept of renal dose
dopamine is out of date.
16. An inotrope that is a phosphodiesterase inhibitor.
You answered Dopamine
The correct answer is Milrinone
Milrinone works by increasing intracellular cAMP concentration.
17. An inotrope that would be useful in a 23 year old female with sepsis
secondary to pyelonephritis. She has an increased cardiac output
and decreased systemic vascular resistance.
You answered Dopamine
The correct answer is Noradrenaline
Theme from September 2011 Exam
In a setting of septic shock with normal or high cardiac output and

decreased SVR, a peripherally acting vasoconstrictor such as
noradrenaline would be the primary choice.
Next question
Circulatory support of the critically ill
Circulatory support
Impaired tissue oxygenation may occur as a result of circulatory shock. Shock is
considered further under its own topic heading.
Patients requiring circulatory support require haemodynamic monitoring. At its

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

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

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

agonist.
Adrenaline-Acts on both and receptors thereby increasing cardiac
output and increasing systemic vascular resistance.
Dopamine- Acts as a 1 agonist and increases contractility and rate. Renal
dose dopamine is an obsolete concept.
Dobutamine- Has both 1 and 2 effects and will increase cardiac output
and cause decrease in systemic vascular resistance.
Milrinone- Phosphodiesterase inhibitor with a positive inotropic effect. It has
a short half-life (1-2 hours) and may precipitate arrhythmias. Vasopressors
often co-administered as it is a vasodilator.

1-3 0/3
A 32.9%
4
A 56 year old man with chronic schizophrenia undergoes a cholecystectomy. He B 20.4%
receives metoclopramide for post operative nausea. Twenty minutes later he 5
C 16.4%
becomes agitated and develops marked oculogyric crises and oromandibular 6-8 0/3
D 24.7%
dystonia. Which of the following drugs may best alleviate his symptoms?
9
E 5.7%
10
A. Procyclidine 32.9% of users answered this
B. Lorazepam
12
C. Chlorpromazine
13
D. Haloperidol
14
E. Sulpiride
15-17 1 / 3
18
Next question
This man has developed an acute dystonic reaction. Administration of further anti
dopaminergic drugs will worsen the situation. Procyclidine will help to reverse the
event. This is most likely to have occurred because the patient is on long term
anti psychotics and has then received metoclopramide.
Acute dystonic reaction
The anti dopaminergic drugs (such as antipsychotics) may result in

extrapyramidal side effects. These may range from mild parkinsonian symptoms
such as resting tremor and bradykinesia. Through to acute dystonic reactions
which are characterised by abnormal and involuntary facial and bodily
movements, such as spasmodic torticollis, oculogyric crisis and oromandibular
dystonia.
Chronic cases are generally only encountered in psychiatric units. In surgical

practice the administration of the anti dopaminergic drug metoclopramide may be
sufficient to precipitate an attack.
Treatment may be required if symptoms are sufficiently troublesome; benzhexol

and procyclidine are two drugs which may be used.

1-3 0/3
4
Theme: Wound management
19 43.5%
5
20 27.5%
A. VAC Device 6-8 0/3
21 45.3%
B. Packing with alginate ribbon 9
C. Packing with ribbon gauze 10
D. Application of silver nitrate 11
E. Application of potassium permangenate 12
F. Use of iodine soaked gauze 13
G. Gauze soaked in proflavin 14
15-17 1 / 3
For each wound please select the most appropriate management option. Each 18
option may be used once, more than once, or not at all.
19-21 0 / 3
19. A 56 year old man has a superficial dehisence of a midline

sternotomy wound following an aortic valve replacement.
You answered Use of iodine soaked gauze
The correct answer is VAC Device
Provided the sternum is stable a VAC device should promote

granulation and healing. It is not indicated where the sternum has
come apart.
20. A 23 year old man has an incision and drainage of an axillary

abscess, there is no residual surrounding tissue infection.
You answered Gauze soaked in proflavin
The correct answer is Packing with alginate ribbon
Use of gauze is inappropriate and will be painful to redress.
21. A 72 year old man has discharge from a healed abdomino-perineal

resection wound. On examination it has almost completely healed
but there is prominent granulation tissue at the apex of the wound.
There is no evidence of an underlying collection and he is otherwise
well.
You answered Gauze soaked in proflavin
The correct answer is Application of silver nitrate
Silver nitrate will cauterise the exuberant granulation tissue and

promote healing.
Next question
Wound healing
Surgical wounds are either incisional or excisional and either clean, clean
contaminated or dirty. Although the stages of wound healing are broadly similar
their contributions will vary according to the wound type.
The main stages of wound healing include:

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

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

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

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

may distort this process. It is obvious that one of the key events is the
establishing well vascularised tissue. At a local level angiogenesis occurs, but if
arterial inflow and venous return are compromised then healing may be impaired,
or simply nor occur at all. The results of vascular compromise are all too evidence
in those with peripheral vascular disease or those poorly constructed bowel
anastomoses.
Conditions such as jaundice will impair fibroblast synthetic function and overall
immunity with a detrimental effect in most parts of healing.
Problems with scars:
Hypertrophic scars
Excessive amounts of collagen within a scar. Nodules may be present
histologically containing randomly arranged fibrils within and parallel fibres on the
surface. The tissue itself is confined to the extent of the wound itself and is
usually the result of a full thickness dermal injury. They may go on to develop
contractures.
Image of hypertrophic scarring. Note that it remains confined to the boundaries of

the original wound:
Image sourced from Wikipedia
Keloid scars
Excessive amounts of collagen within a scar. Typically a keloid scar will pass
beyond the boundaries of the original injury. They do not contain nodules and
may occur following even trivial injury. They do not regress over time and may
recur following removal.
Image of a keloid scar. Note the extension beyond the boundaries of the original
incision:
Image sourced from Wikipedia
Drugs which impair wound healing:
Non steroidal anti inflammatory drugs

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

after granulation tissue has formed.

1-3 0/3
4
Theme: Surgical analgesia
22 48.4%
5
23 25%
A. TAP block 6-8 0/3
24 25.7%
B. Epidural anaesthatic 9
C. Spinal block 10
D. Patient controlled analgesia 11
E. Paracetamol and diclofenac 12
F. Pethidine as required 13
G. Regular nefopam 14
15-17 1 / 3
Please select the most appropriate analgesic modality for the scenario given. 18
Each option may be used once, more than once or not at all.
19-21 0 / 3
22-24 0 / 3
22. A 63 year old man with carcinoma of the splenic flexure undergoes
an extended right hemicolectomy through a midline excision. He
suffers from COPD.
You answered Regular nefopam
The correct answer is Epidural anaesthatic
This man is at high risk of atelectasis, hypoventilation can be

avoided by minimising post operative pain through an epidural. A
spinal block is short acting, therefore not appropriate.
23. A 63 year old man with rectal cancer is due to undergo an anterior
resection by laparoscopic approach. He is otherwise well.
You answered Patient controlled analgesia
The correct answer is TAP block
This is a localised infiltration of the abdominal wall with long acting

local anaesthetic. This will provide optimal analgesia for the more
limited pain that may occur with a laparoscopic procedure.
24. A 52 year old man undergoes an appendicectomy through a lower

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

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


1-3 0/3
A 22%
4
Which of the following anaesthetic agents has the strongest analgesic effect? B 49%
5
C 12.7%
6-8 0/3
A. Sodium thiopentone D 10.8%
9
B. Ketamine E 5.5%
10
C. Midazolam 49% of users answered this
D. Etomidate
12
13
Next question 14
15-17 1 / 3
Ketamine has a moderate to strong analgesic effect. It may be used for 18
emergency procedures outside the hospital environment to induce anaesthesia 19-21 0 / 3
for procedures such as emergency amputation. 22-24 0 / 3
25
Anaesthetic agents
agents



instability

1-3 0/3
A 13.4%
4
Which statement is true on enteral feeding? B 8.9%
5
C 26.4%
6-8 0/3
A. A PEG can be used 12h after insertion D 36.5%
9
B. A motility agent is avoided for ITU patients with an Nasogastric tube E 14.9%
10
C. A regime of 24h continuous feeding is recommended for ITU 26.4% of users answered this
patients question correctly 11
D. A long-term gastrostomy is recommended if feeding is likely to be > 12

8 weeks
13
E. Enteral feeding is not possible in upper GI dysfunction
14
15-17 1 / 3
Next question
18
19-21 0 / 3
22-24 0 / 3
25
Enteral Feeding
26
Identify patients as malnourished or at risk (see below)

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

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

AT RISK of malnutrition
Eaten nothing or little > 5 days, who are likely to eat little for a further 5
days
Poor absorptive capacity
High nutrient losses
High metabolism
Reference
Stroud M et al. Guidelines for enteral feeding in adult hospital patients. Gut 2003;
52(Suppl VII):vii1 - vii12.


1-3 0/3
A 12.2%
4
Which of the following does not need monitoring during home parenteral B 12.4%
nutritional support? 5
C 11.3%
6-8 0/3
D 40.4%
9
A. Folate levels E 23.7%
B. Zinc levels 10
C. Vitamin D question correctly 11
D. Thyroid function 12
E. Bone densitometry 13
14
18
19-21 0 / 3
22-24 0 / 3
Nutrition Monitoring-NICE guidelines 25
26
Weight: daily if fluid balance concerns, otherwise weekly reducing to 27
monthly
BMI: at start of feeding and then monthly
If weight cannot be obtained: monthly mid arm circumference or triceps skin
fold thickness
Daily electrolytes until levels stable. Then once or twice a week.
Weekly glucose, phosphate, magnesium, LFTs, Ca, albumin, FBC, MCV
levels if stable
2-4 weekly Zn, Folate, B12 and Cu levels if stable

3-6 monthly iron and ferritin levels, manganese (if on home parenteral
regime)
6 monthly vitamin D
Bone densitometry initially on starting home parenteral nutrition then every
2 years

1-3 0/3
A 65.4%
4
Which of the following is not typically included in total parenteral nutritional B 10.7%
solutions? 5
C 8.7%
6-8 0/3
D 6.6%
9
A. Fibre E 8.5%
B. Lipid 10
C. Potassium question correctly 11
D. Glucose 12
E. Magnesium 13
14
18
There is no indication for inclusion of fibre in solutions of TPN, nor would it be 19-21 0 / 3
safe to do so. 22-24 0 / 3
25
Total parenteral nutrition
26
27
Commonly used in nutritionally compromised surgical patients
28
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.

1-3 0/3
A 60.5%
4
A 28 year old man with poorly controlled Crohns disease is nutritionally B 7.2%
compromised. The decision is made to start TPN, via which of the following routes 5
C 9.7%
should it be best administered? 6-8 0/3
D 6.6%
9
E 16.1%
A. Internal jugular vein via a central venous catheter 10
B. Internal carotid artery question correctly 11
C. Cephalic vein via peripheral cannula 12
D. Basilic vein via peripheral cannula 13

E. Common femoral vein via a central venous catheter 14
15-17 1 / 3
18
Since TPN solutions are irritant to veins they are best administered via a central
19-21 0 / 3
line. The femoral route has a higher incidence of line associated sepsis and is
22-24 0 / 3
thus best avoided in this setting.
25
Parenteral feeding-NICE guidelines 26
27
Parenteral nutrition: NICE guidelines summary
28
Identify patients as malnourished or at risk 29
Patients identified as being malnourished-
BMI < 18.5 kg/m2

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

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

tract/perforation/inaccessible then consider peri operative parenteral feeding.
Rate question:
1
A 10.1%
A 54-year-old man is admitted for an elective hip replacement. Three days post B 6.4%
operatively you suspect he has had a pulmonary embolism. He has no past
C 7.1%
medical history of note. Blood pressure is 120/80 mmHg with a pulse of 90/min.
D 27.9%
The chest x-ray is normal. Following treatment with low-molecular weight heparin,
E 48.6%
what is the most appropriate initial lung imaging investigation to perform?

question correctly
A. Pulmonary angiography
B. Echocardiogram
C. MRI thorax
D. Ventilation-perfusion scan
E. Computed tomographic pulmonary angiography
CTPA is the first line investigation for PE according to current BTS guidelines
This is a difficult question to answer as both computed tomographic pulmonary

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

management of patients with suspected pulmonary embolism (PE)
Key points from the guidelines include:
computed tomographic pulmonary angiography (CTPA) is now the

recommended initial lung-imaging modality for non-massive PE.
Advantages compared to V/Q scans include speed, easier to perform out-
of-hours, a reduced need for further imaging and the possibility of
providing an alternative diagnosis if PE is excluded
if the CTPA is negative then patients do not need further investigations or
treatment for PE
ventilation-perfusion scanning may be used initially if appropriate facilities
exist, the chest x-ray is normal, and there is no significant symptomatic
concurrent cardiopulmonary disease
{Some other points}
Clinical probability scores based on risk factors and history and now widely used
to help decide on further investigation/management
D-dimers
sensitivity = 95-98%, but poor specificity
V/Q scan
sensitivity = 98%; specificity = 40% - high negative predictive value, i.e. if

normal virtually excludes PE
other causes of mismatch in V/Q include old pulmonary embolisms, AV
malformations, vasculitis, previous radiotherapy
COPD gives matched defects
CTPA
peripheral emboli affecting subsegmental arteries may be missed
Pulmonary angiography
the gold standard

significant complication rate compared to other investigations
Rate question:

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yomna92009@yahoo.

com - MRCS Part A - My account

Reference ranges End and review

Question 1 of 67 Question stats Score: 0%

65.1% of users answered this

Blood transfusion reactions

Immune mediated Non immune mediated

Transfusion associated lung injury Hyperkalaemia

Graft vs Host disease

Acute or delayed haemolysis

GVHD: lymphocyte proliferation causing organ failure

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Question 1 of 66 Question stats Score: 0%

59.8% of users answered this

Theme from January 2011 Exam

Post operative fluid management

Composition of commonly used intravenous fluids mmol-1

Plasma 137-147 4-5.5 95-105 22-25 -

0.9% Saline 153 - 153 - -

Dextrose / saline 30.6 - 30.6 - -

Hartmans 130 4 110 - 28

A summary of the recommendations for post operative fluid management

Fluids given should be documented clearly and easily available

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Question 2 of 66 Question stats Score: 50%

A. Pulmonary oedema 60.3% of users answered this

Theme from January 2012 Exam

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

Adult respiratory distress syndrome

Defined as an acute condition characterized by bilateral pulmonary infiltrates and

Acute dyspnoea and hypoxaemia hours/days after event

Treat the underlying cause

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Question 3 of 66 Question stats Score: 33.3%

A. Sodium thiopentone E 18%

Etomidate is a recognised cause of adrenal suppression, this has been

Propofol Rapid onset of anaesthesia

Ketamine May be used for induction of anaesthesia

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Question 4 of 66 Question stats Score: 25%

Theme from April 2012 Exam

Inotropes and cardiovascular receptors

Inotrope Cardiovascular receptor action

Adrenaline -1, -2, -1, -2

Noradrenaline -1,( -2), (-1), (-2)

Dopamine (-1), (-2), (-1), D-1,D-2

Minor receptor effects in brackets

Effects of receptor binding

-1 increased cardiac contractility and HR

D-1 renal and spleen vasodilatation

D-2 inhibits release of noradrenaline

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1/3 Question 5-7 of 66 Question stats Score: 28.6%