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Flashcards in Perioperative Management Deck (64)
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1
Q

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?

	Amitriptylline
	Pregabalin
	Duloxetine
	Morphine
	Diclofenac
A

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

2
Q

Which of the following preparatory regimes should be considered for a 63 year old man with normal renal function who requires a diagnostic colonoscopy to investigate iron deficiency anaemia for which he takes ferrous sulphate?

Stop ferrous sulphate 7 days pre procedure and administration of oral purgatives the day prior to the procedure
Administration of oral purgatives the day prior to the procedure and continue ferrous sulphate
Continue ferrous sulphate and administration of phosphate enemas on the day
Cease ferrous sulphate 7 days pre procedure and administration of phosphate enema 30 minutes pre procedure
No preparation required
A

Stop ferrous sulphate 7 days pre procedure and administration of oral purgatives the day prior to the procedure

Endoscopy requires full bowel preparation. In elderly patients, this can cause electrolyte disturbance and renal compromise and it is important to check the patients urea and electrolytes beforehand. Drugs like ferrous sulphate impair the efficacy of purgatives and give poor endoscopic views as a result and should be stopped beforehand.

3
Q

A 72 year old man with prostate cancer is admitted to urology with urinary retention. He complains of back pain which is not responding to ward analgesia. Imaging shows several lumbar vertebral body metastasis. What is the most appropriate management?

Commence a bisphosphonate
Arrange radiotherapy to the lumbar spine
Surgical resection and reconstruction of the vertebral body
Administration of pregabalin
Chemotherapy
A

Arrange radiotherapy to the lumbar spine

The fact that ward based analgesia has been tried suggests that the patient be considered for palliative radiotherapy. Surgical resection of prostate cancer bony metastatic disease is not generally performed.

4
Q

A 66 year old man is admitted following a collapse whilst waiting for a bus. Clinical examination confirms a ruptured abdominal aortic aneurysm. He is moribund and hypotensive. What is his ASA?

	1
	2
	3
	4
	5
A

5

Patients who are moribund and will not survive without surgery are graded as ASA 5.

5
Q

Which of the agents listed below is associated with the strongest anti emetic properties?

	Sodium thiopentone
	Propofol
	Etomidate
	Ketamine
	Sevoflurane
A

Propofol

Propofol has anti emetic properties which is of considerable advantage in day case anaesthesia.

6
Q

What is the most appropriate method of delivering early post-operative analgesia to a 6 month old child following an orchidopexy?

	TAP block
	Caudal block
	Wound analgesic infusion catheter
	Spinal block
	Epidural block
A

Caudal block

Orchidopexy can be quite uncomfortable immediately following surgery. A caudal block can be a very effective adjunct and provides good analgesia. A spinal block and epidural would be inappropriate. A TAP block may cover the inguinal canal but this is not generally reliable and wound catheters are not used.

7
Q

Of the agents listed below, which is the most appropriate to give a 65 year old man with a locally unresectable gastrointestinal stromal tumour. Biopsies confirm that it is KIT positive.

	Imatinib
	Infliximab
	Trastuzumab
	Bevacizumab
	Cetuximab
A

Imatinib

Imatinib is licensed for treatment of GIST in the United Kingdom for this situation. The guidance from the National Institute of Clinical evidence is that patients be reviewed at 12 weeks after initiating therapy.

8
Q

Which of the following is not directly affected by warfarin?

	Protein C
	Factor II
	Factor VII
	Factor IX
	Factor VIII
A

Factor VIII

Warfarin affects synthesis of factors II, VII, IX, X and protein C.

9
Q

A 70 year old lady has a cerebrovascular accident and has been recovering in hospital for the past 3 weeks. She has been deemed to have an unsafe swallow. What is the best option for long term feeding?

Endoscopically inserted PEG feeding tube
Long term fine bore nasogastric feeding tube
Surgically inserted feeding jejunostomy tube
TPN via a central vein
TPN via a peripheral cannula
A

Endoscopically inserted PEG feeding tube

At 3 weeks, it is unlikely that feeding orally is going to resume and therefore a definitive long term feeding solution is needed. A PEG is favored over a feeding jejunostomy in such circumstances.

10
Q

A 56 year old lady with idiopathic thrombocytopenic purpura has a platelet count of 50. She is due to undergo a splenectomy. What is the optimal timing of a platelet transfusion in this case?

	24 hours pre-operatively
	2 hours pre-operatively
	Whilst making the skin incision
	After ligation of the splenic artery
	On removal of the spleen
A

After ligation of the splenic artery

ITP causes splenic sequestration of platelets. Therefore a platelet transfusion should be carefully timed. Too soon and it will be ineffective. Too late and unnecessary bleeding will occur. The optimal time is after the splenic artery has been ligated.

11
Q

Which of the following would be a sensible volume for maintenance intravenous fluids in a 3 day old term neonate?

	50ml/ kg/ hour
	50ml/ kg/ day
	100ml/kg/hour
	100ml/kg/day
	200ml/kg/day
A

100ml/kg/day

From birth to day 1: 50-60 ml/kg/day.
Day 2: 70-80 ml/kg/day.
Day 3: 80-100 ml/kg/day.
Day 4: 100-120 ml/kg/day.
Days 5-8: 120-150 ml/kg/day.
12
Q

A 67 year old female undergoes an oesophagogastrectomy for carcinoma of the distal oesophagus. She complains of chest pain. The following day there is brisk bubbling into the chest drain when suction is applied. What is the most likely cause?

	Anastomotic leak
	Air leak from lung
	Chyle leak
	Bile leak
	Cutaneous wound breakdown
A

Air leak from lung

Damage to the lung substance may produce an air leak. Air leaks will manifest themselves as a persistent pneumothorax that fails to settle despite chest drainage. When suction is applied to the chest drainage system, active and persistent bubbling may be seen. Although an anastomotic leak may produce a small pneumothorax, a large volume air leak is more indicative of lung injury

13
Q

A 19 year old man has a skin lesion excised from his back. He is reviewed clinically at 4 months post procedure and the surgeon notes that the scar has begun to contract. Which of the following facilitates this process?

	Myofibroblasts
	Neutrophils
	Granuloma formation
	Macrophages
	Fibroblasts
A

Myofibroblasts

As wounds mature the fibroblast population differentiates into myofibroblasts (usually 6 weeks and beyond), these have a contractile phenotype and therefore help in contracting the wound. Immature fibroblasts, though able to adhere to the ECM, do not have this ability.

14
Q

Which of the following blood products can be administered to a non ABO matched recipient?

	Whole blood
	Platelets
	Packed red cells
	Stem cells
	Irradiated whole blood
A

Platelets

In the UK, platelets either come from pooling of the platelet component from four units of whole donated blood, called random donor platelets, or by plasmapharesis from a single donor. The platelets are suspended in 200-300 ml of plasma and may be stored for up to 4 days in the transfusion laboratory where they are continually agitated at 22oC to preserve function

15
Q

Which of the following would be the optimal fluid management option for a 45 year old man due to undergo an elective right hemicolectomy?

Remain "nil by mouth" for at least 6 hours pre-operatively and avoid intra venous fluids
Remain "nil by mouth" for at least 6 hours pre-operatively and receive supplementary intravenous 5% dextrose to replace lost calories
Allow him free access to oral fluids only until 30 minutes prior to surgery
Administer a carbohydrate based loading drink 3 hours pre operatively, and avoid intravenous fluids
Administer a carbohydrate based loading drink 6 hours pre-operatively and administer 5% dextrose saline thereafter
A

Administer a carbohydrate based loading drink 3 hours pre operatively, and avoid intravenous fluids

Patients for elective surgery should not have solids for 6 hours pre-operatively. However, clear fluids may be given up to 2 hours pre-operatively.

16
Q

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

	Cortisol
	Atrial natriuretic hormone
	Vasopressin
	Insulin
	Glucagon
A

Vasopressin

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

17
Q

A 48 year old lady is being prepared for a Whipples procedure. A right sided subclavian line is inserted and then anaesthesia is induced. Following intubation the patient becomes progressively hypoxic and haemodynamically unstable. What is the most likely underlying explanation?

	Drug allergy
	Simple pneumothorax
	Tension pneumothorax
	Halothane toxicity
	Haemothorax
A

Tension pneumothorax

Central lines (and particularly subclavian lines) are risk factors for the development of pneumothorax. In the context of positive pressure ventilation a tension pneumothorax is a strong possibility and would be associated with haemodynamic instability.

18
Q

A 30 year old male is admitted electively for a right inguinal hernia repair under local anaesthesia. He is otherwise well but his grandfather died from a pulmonary embolism. What is the most appropriate form of thromboprophylaxis?

Administration of low dose low molecular weight heparin for 2 weeks
Administration of high dose low molecular weight heparin for 2 weeks
No prophylaxis
Low dose low molecular weight heparin and pneumatic compression stockings
High dose low molecular weight heparin and pneumatic compression stockings
A

No prophylaxis

Inguinal hernia repairs under local anaesthetic have a short operative time and patients are usually ambulant immediately afterwards. His family history is unlikely to be significant and he is at very low risk.

19
Q

What is the most appropriate analgesic modality for a 52 year old male undergoing an open elective resection of the splenic flexure colonic cancer?

	TAP block
	Local anaesthetic wound infiltration
	Spinal block
	Epidural anaesthetic
	Rectal diclofenac
A

Epidural anaesthetic

An open resection of a splenic flexure cancer will require a long midline incision and carries the potential for respiratory compromise. This is best countered with a well placed epidural. An alternative would be rectus sheath catheter infiltration of local anaesthetic and PCA.

20
Q

What is the most appropriate analgesic to administer to a term neonate who is recovering following an inguinal herniotomy?

	Co-codamol
	Paracetamol
	Ibuprofen
	Carbamazepine
	Codeine
A

Paracetamol

Paracetamol is an effective analgesic in children and pain following herniotomy is relatively minor. Note that codeine is contra indicated in neonates. The child is too young to receive ibuprofen.

21
Q

Which statement relating to the peri operative management of patients with diabetes mellitus is false?

They should be placed first on the operating list
An intravenous sliding scale should be used in all cases
Potassium supplementation is likely to be required in diabetics on a sliding scale
Electrolyte abnormalities are more common after major visceral resections
Blood glucose monitoring is required during general anaesthesia
A

An intravenous sliding scale should be used in all cases

This is not the case and some type 2 diabetics may be managed using a watch and wait policy with regular blood glucose monitoring. The cellular shifts of potassium with sliding scales may cause problems with electrolyte management which should be anticipated.

22
Q

An 80 year old lady is investigated in the pre operative clinic and found to have severe aortic stenosis. What, if any, is the main peri operative concern?

	They cannot adjust their heart rate
	They may have ventricular hypertrophy
	The patient cannot increase their cardiac output
	They are more prone to arrhythmias
	There is no concern
A

The patient cannot increase their cardiac output

Patients with aortic stenosis are a major perioperative concern. They may have ventricular hypertrophy and this can result in relative myocardial ischaemia and increase the risk of arrhymias. However, the main concern is that they cannot increase their cardiac output particularly if vasodilation occurs.

23
Q

A 63 year old lady is undergoing colonoscopy with midazolam sedation. Her respiratory rate slows and she becomes hypoxic and the decision is made to reverse her sedation. What is the most appropriate agent to administer?

	Flumazenil
	Doxapram
	Naloxone
	Procyclidine
	Etomidate
A

Flumazenil

Flumazenil antagonises the effects of benzodiazepines by competition at GABA binding sites. Since many benzodiazepines have longer half lives than flumazenil patients still require close monitoring after receiving the drug. Whilst doxapram would increase the respiratory rate, it is not an agent for reversal of midazolam.

24
Q

A 23 year old man with a 4cm lipoma on his flank is due to have this removed as a daycase. He is otherwise well. What is his ASA?

	2
	3
	1
	5
	4
A

1

Absence of co-morbidities and small procedure with no systemic compromise will equate to an ASA score of 1.

25
Q

A 3 year old is involved in trauma and is haemodynamically unstable. Initial attempts at intravenous access are proving unsuccessful. What is the best course of action?

Insert a femoral venous central line
Insert a right internal jugular central line
Insert an intra osseous infusion system
Insert a 14 G cannula into the antecubital fossa
Insert a Broviac line
A

Insert an intra osseous infusion system

Gaining venous access in small children is challenging at the best of times and when they are shut down its nearly impossible. Intraosseous infusions are best in this setting. Broviac lines are long term IV access systems with narrow lumens and would be unsuitable

26
Q

A 52 year old male presents with tearing central chest pain. On examination, he has an aortic regurgitation murmur. An ECG shows ST elevation in leads II, III and aVF. What is the likely explanation?

	Distal aortic dissection
	Anterior myocardial infarct
	Inferior myocardial infarct
	Proximal aortic dissection
	Pulmonary embolism
A

Proximal aortic dissection

An inferior myocardial infarction and AR murmur should raise suspicions of an ascending aorta dissection rather than an inferior myocardial infarction alone. Also the history is more suggestive of a dissection. Other features may include pericardial effusion, carotid dissection and absent subclavian pulse.

27
Q

A 63 year old man undergoes an Ivor - Lewis oesophagogastrectomy for carcinoma of the distal oesophagus. The following day a pale opalescent liquid is noted to be draining from the right chest drain. What is the most likely explanation?

	Lung injury
	Chyle leak
	Anastomotic leak
	Infection
	Seroma
A

Chyle leak

Damage to the lymphatic duct may occur during this procedure and some surgeons administer a lipid rich material immediately prior to surgery to facilitate its identification in the event of iatrogenic damage.

28
Q

Which of the following statements relating to pre-operative fluid management is false?

5% dextrose should be given cautiously in the elderly
Patients undergoing elective colonic resections may continue to drink water up to 2 hours prior to surgery
Normal saline increases the risk of hyperchloraemic acidosis
A 70kg man will need approximately 100mmol of sodium daily
Carbohydrate rich beverages and loading drinks can cause ileus therefore should be avoided
A

Carbohydrate rich beverages and loading drinks can cause ileus therefore should be avoided

Carbohydrate loading is one of the enhanced recovery principles.

29
Q

A 48 year old lady has a metallic heart valve and requires a paraumbilical hernia repair. Perioperatively she is receiving intra venous unfractionated heparin. To perform the surgery safely a normal coagulation state is required. Which of the following strategies is routine standard practice?

Administration of 10 mg of vitamin K the night prior to surgery and stopping the heparin infusion 6 hours pre operatively
Stopping the heparin infusion 6 hours pre operatively
Stop the heparin infusion on induction of anaesthesia
Stopping the heparin infusion 6 hours pre operatively and administration of intravenous protamine sulphate on commencing the operation
None of the above
A

Stopping the heparin infusion 6 hours pre operatively

Patients with metallic heart valves will generally stop unfractionated heparin 6 hours pre operatively. Unfractionated heparin is generally cleared from the circulation within 2 hours so this will allow plenty of time and is the method of choice in the elective setting. Protamine sulphate will reverse heparin but is associated with risks of anaphylaxis and is thus not generally used unless immediate reversal of anticoagulation is needed, e.g. coming off bypass

30
Q

A 22 year old man presents with a peri anal abscess, which is managed by incision and drainage. The perineal wound measures 3cm by 3cm. Which of the following is best management option?

Primary closure with interrupted mattress sutures
Delayed primary closure with interrupted mattress sutures
Allow the wound to heal by secondary intention
Insert a seton through the cavity into the rectum to allow a mature fistula track to develop
Perform a V-Y flap 2 weeks later
A

Allow the wound to heal by secondary intention

Peri anal abscess are typically managed by secondary intention healing. Any attempt at early closure is at best futile and at worst dangerous. Insertion of a seton may be considered by an experienced colorectal surgeon, and only if the tract is clearly identifiable with minimal probing. There is seldom a need for flaps, ongoing discharge usually indicates a fistula (managed separately

31
Q

A surgeon is considering using lignocaine to provide local anaesthesia for a minor surgical procedure. Which of the following may attenuate its action?

	Hyperkalaemia
	Administration with adrenaline
	Administration with bupivicaine
	Administration with sodium bicarbonate
	Use in tissues which are infected
A

Use in tissues which are infected

Most anaesthetic agents are amine bases that become ionised due to the relative alkalinity of tissues. In active infection there may acidosis of the tissues and therefore local anasthetics may be less effective. Some surgeons mix sodium bicarbonate as it is reported to reduce the pain experienced by patients during administration.

32
Q

Which of the following statements relating to use of total parenteral nutrition is untrue?

It may cause steatosis and derangement of liver function tests
Administration via a central line or PICC line is preferable to peripheral administration
It is highly irritant to vessel walls
It should be administered when a patient has an albumin less than15
Administration of TPN for periods of less than 1 week is unlikely to produce noticable benefits
A

It should be administered when a patient has an albumin less than15

Albumin is a poor indicator of overall nutrition and the decision to start TPN should not be based on this parameter alone. Patients should ideally be fed enterally where possible and if this is likely to occur within 5-7 days then starting TPN is unlikely to confer benefit.

33
Q

A 32 year old man requires venous access for chemotherapy for acute myeloid leukaemia. What is the best option?

	Groshong line
	Internal jugular central line (triple lumen)
	14 G cannula in the dorsum of the hand
	18 G cannula in the non dominant hand
	Sub cuticular catheter
A

Groshong line

Groshong lines and Hickman lines are similar and knowledge of these systems is needed because surgeons are often called upon to either insert or remove them. Chemotherapy for AML requires long term therapy and multiple blood tests therefore an indwelling device is preferable.

34
Q

Which of the following statements relating to use of tourniquets in surgery is false?

The use of an esmarch bandage tourniquet to exsanguinate the limb reduces the incidence of neuropraxia.
Excessive inflation pressures are amongst the commonest causes of nerve injury related to tourniquet use.
Tourniquet deflation causes a fall in CVP.
Children require lower inflation pressures than adults.
In patients developing neuropraxia related to tourniquets the radial nerve is most frequently affected.
A

The use of an esmarch bandage tourniquet to exsanguinate the limb reduces the incidence of neuropraxia.

The use of esmarch bandage tourniquet increases the risk of nerve injury as it increases pressure in the limb. Limb elevation is safer.

35
Q

In relation to patients with type 1 diabetes mellitus undergoing surgery, which of the following statements is untrue?

They should not receive oral carbohydrate loading drinks as part of enhanced recovery programmes
When a variable rate insulin infusion is required 0.45% sodium chloride and 5% dextrose with either 0.15% or 0.3% potassium are the fluids of choice
Hourly intraoperative blood glucose measurements are required
Insulin infusions are only required in patients who will miss more than two meals or who are nil by mouth for greater than 12 hours
Blood glucose levels persistently greater than 12 should initiate a change in therapy
A

Insulin infusions are only required in patients who will miss more than two meals or who are nil by mouth for greater than 12 hours

Type 1 diabetics who take insulin should have this continued through the perioperative period.
Fluid guidelines in diabetics differ and are not well covered in NPSA fluid guidelines.

36
Q

A 55 year old man with no co-morbidity is due to undergo a Milligan Morgan haemorrhoidectomy, what is the most appropriate method of delivering immediate post operative analgesia?

	Pudendal nerve block
	Caudal block
	Rectal NSAIDS
	IV fentanyl
	Paracetamol
A

Pudendal nerve block

Following excisional haemorrhoidectomy, severe pain is not unusual, a well placed caudal anaesthetic will counter this. A pudendal nerve block is an alternative but is less effective than a caudal.

37
Q

A 72 year old man is recovering from an inguinal hernia repair when he suffers from an extensive CVA. He is managed on the rehabilitation unit. However, he is still not able to feed safely and repeated swallowing assessments have shown that he tends to aspirate. Which of the following is the best option for long term feeding?

	PEG tube feeding
	Feeding jejunostomy
	Total parenteral nutrition
	Long term naso gastric tube feeding
	Withold feeding and palliate
A

PEG tube feeding

A PEG tube is the best long term option although they are associated with a significant degree of morbidity. A feeding jejunostomy would require a general anaesthetic. TPN is not a good option. Long term naso gastric feeding is usually unsatisfactory.

38
Q

A 57 year old man is coming off the cardiac bypass circuit following a successful coronary artery bypass procedure. Which drug should be administered to normalise the patients clotting prior to decannulation and chest closure?

	Intravenous vitamin K
	Protamine sulphate
	Aprotinin
	Fresh frozen plasma
	None of the above
A

Protamine sulphate

Since cardiac bypass circuits are thrombogenic large doses of intravenous heparin are administered. This is reversed with protamine sulphate. FFP may be effective but would carry a significant risk of fluid overload.

39
Q

A 34 year old man is suffering from septic shock and receives an infusion of Dextran 70. Which of the following complications may potentially ensue?

	Anaphylaxis
	Vomiting
	Acute hepatic failure
	Digital necrosis
	Deep vein thrombosis
A

Anaphylaxis

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.

40
Q

A 70 year old man with a past history of angina undergoes an uncomplicated operation, for a hydrocele. Postoperatively he is found to be hypotensive, tachycardic, and has a raised jugular venous pressure. What is the most likely explanation for the hypotension?

	Reduced stroke volume
	Reduced parasympathetic tone
	Reduced preload
	Reduced sympathetic tone
	Reduced afterload
A

Reduced stroke volume

It is likely that this patient has cardiac failure with impaired contractility.

41
Q

In relation to operating in the elderly which statement is false?

A 30 minute increment in operation length is associated with increase in mortality in patients over the age of 80
Hypoalbuminaemia is associated with increased mortality
Statins given preoperatively reduce perioperative cardiac events
Elevated brain (or B-type) natriuretic peptide (BNP) levels before undergoing non cardiac surgery is associated with high risk of cardiac mortality and all cause mortality
Beta blockers should be stopped acutely prior to surgery due to risk of perioperative hypotension
A

Beta blockers should be stopped acutely prior to surgery due to risk of perioperative hypotension

Beta blockers should not be stopped acutely prior to surgery as there may be a rebound effect associated with increased complications.

42
Q

Which of the following intravenous fluid solutions has the greatest chloride content?

	Dextrose / saline
	Normal saline
	Hartmanns solution
	Ringers lactate
	5% dextrose
A

Normal saline

Normal saline has the highest chloride content and excessive administration of normal saline is a recognised risk factor for the development of hyperchloraemic metabolic acidosis

43
Q

A 5 year old boy undergoes a closure of a loop colostomy. What thromboprophylaxis should be used?

None
Daily low dose low molecular weight heparin for 2 weeks
Daily low dose low molecular weight heparin until discharged
Unfractionated heparin and compression stockings
Oral dabigatran for 4 weeks
A

None

In paediatric surgical practice, the use of heparin type agents is rare.

44
Q

A 43 year old lady with a metallic heart valve has just undergone an elective paraumbilical hernia repair. In view of her metallic valve, she is given unfractionated heparin perioperatively. How should the therapeutic efficacy be monitored, assuming her renal function is normal?

	Therapeutic monitoring is not required
	Measurement of APTT
	Measurement of INR
	Measurement of Prothromin time
	None of the above
A

Measurement of APTT

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

45
Q

A patient receives atropine as pre medication prior to a laparotomy. Which of the following is least likely to occur?

	Pupillary dilation
	Dry mouth
	Urinary retention
	Bradycardia
	Decreased salivation
A

Bradycardia

Since it inhibits vagal tone, the use of atropine will typically result in an increased heart rate.

46
Q

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
	1
	3
	4
	2
A

4

Severe systemic disease of this nature is a constant threat to life. Especially as he also has evidence of cardiac failure.

47
Q

A 53 year old alcoholic male presents with acute pancreatitis. He is clinically dehydrated. His blood results show normal renal function and electrolytes. Which of the intravenous fluids below should be prescribed?

	0.9% sodium chloride and 40mmol KCl
	5% dextrose
	Hartmanns solution
	10% dextrose and 20mmol KCl
	5% dextrose and 40 mmol KCl
A

Hartmanns solution

This patient needs fluid replacement due to large third space losses. Hartmann’s solution is recommended. N. Saline would put this patient at risk of hyperchloraemic acidosis.

48
Q

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?

	Suxamethonium
	Atracurium
	Vecuronium
	Pancuronium
	Propofol
A

Suxamethonium

Suxamethonium may induce hyperkalaemia as it induces generalised muscular contractions. In patients with likely extensive tissue necrosis this may be sufficient to produce cardiac arrest

49
Q

A 63 year old man is recovering following an open extended right hemicolectomy for carcinoma of the colonic splenic flexure. Two days post operatively he develops a persistent pyrexia. What is the least likely cause?

	Ileus
	Atelectasis
	Anastomotic leak
	Wound infection
	Urinary tract infection
A

Ileus

An ileus in itself is seldom a cause of a pyrexia. It may serve as a proxy marker of other complications. In this scenario atelectasis would be the most likely underlying cause

50
Q

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?

	Total parenteral nutrition.
	Feeding jejunostomy.
	Feeding duodenostomy.
	Liquid diet orally.
	Soft solids orally.
A

Feeding jejunostomy.

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

51
Q

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
	Pregabalin
	Oramorph
	Diclofenac
	Chemical neurectomy
A

Pregabalin

Pregabalin is generally the first line agent for neuropathic pain.

52
Q

A 38 year old lady presents with abdominal pain. On investigation, her serum calcium is found to be 3.5mmol/L. What is the most appropriate initial management?

	Intravenous bisphosphonates
	Oral bisphosphonates
	Intravenous calcitonin
	Intravenous 0.9% sodium chloride
	Intravenous frusemide
A

Intravenous 0.9% sodium chloride

The immediate treatment of hypercalcaemia involves intravenous fluid resuscitation.

53
Q

The following are contra indications to the use of lignocaine for local anaesthesia except:

	Accelerated idioventricular rhythm
	Current treatment with flecainide
	3rd degree heart block without pacemaker
	Severe sino atrial block
	Protein C deficiency
A

Protein C deficiency

Lignocaine is widely used as a local anaesthetic. As a class IB antiarrhythmic it should not be used in people with unstable disorders of cardiac rhythm and ideally should not be co-administered with other anti-arhythmics.

54
Q

A 43 year old lady has undergone a total thyroidectomy for multinodular goitre. You are called to see her because of respiratory distress. On examination she has a marked stridor, her wound seems healthy but there is a swelling within the operative site. What is the most likely explanation for this problem?

Bilateral superior laryngeal nerve injury
Hypocalcaemic tetany
Anxiety
Contained haematoma
Unilateral recurrent laryngeal nerve injury
A

Contained haematoma

In this setting a contained haematoma is the most likely cause. This will impair venous return resulting in laryngeal oedema and respiratory compromise

55
Q

An 83 year old man is admitted for an abdomino-perineal excision of the colon and rectum for a distal rectal tumour. His co-mobidities include diabetes. His renal function is normal. What is the best form of thromboprophylaxis?

None
Compression stockings alone for 4 weeks
Daily low dose low molecular weight heparin for 4 weeks
Daily high dose low molecular weight heparin for 4 weeks
Daily administration of high dose unfractionated heparin until discharge
A

Daily low dose low molecular weight heparin for 4 weeks

There is good evidence to support the use of extended thromboprophylaxis after pelvic cancer surgery. Don’t confuse low dose and high dose low molecular weight heparins

56
Q

A 6 year old child requires long term drug therapy to treat a rare genetic disorder. The drug must be given intravenously. Recently, there have been issues with the child pulling at current system of the Hickman line and the parents are requesting an alternative. What is the best option?

	Triple lumen subclavian line
	Portacath device
	Intermittent cannulation as needed
	PICC line
	Broviac line
A

Portacath device

Portacaths are a good choice for children as they only need to be accessed when they are used. Broviacs would pose the same core problems as a Hickman

57
Q

A 45 year old man with previous laparotomy is admitted with adhesional small bowel obstruction. He is managed with prolonged nasogastric drainage. His U+E’s are as follows:
Sodium 129
Potassium 3.4
Urea 8.4
Creatinine 89
Which of the following intravenous fluids should be prescribed?

0.4%/0.18% dextrose saline
0.9% Sodium Chloride
0.9% sodium chloride with 40mmol potassium chloride per litre
Hartmanns solution
5% dextrose with 20mmol KCl
A

0.9% sodium chloride with 40mmol potassium chloride per litre

The potassium will decline further if this deficiency is not addressed.

58
Q

A 55 year old man requires a flexible sigmoidoscopy to investigate bright red rectal bleeding. What is the most appropriate preparation?

Single phosphate enema the day prior to the procedure
Single phosphate enema 30 minutes pre procedure
Oral sodium picosulphate the day prior to the procedure
Oral sodium picosulphate 30 minutes prior to the procedure
Rectal lavage with saline 1 hour pre procedure
A

Single phosphate enema 30 minutes pre procedure

For a limited endoscopy a simple enema will suffice.

59
Q

A 58 year old woman presented to the Emergency Department with a large fluctuant swelling the site of a recent insect bite. She is anxious, tachycardic, and pyrexial. An ECG shows atrial fibrillation. She is noted to have a goitre. The swelling at the site of the bite requires surgical drainage. Which of the following classes of drug would be most appropriate as part of her preoperative preparation for surgery?

	Alpha 1 adrenoceptor agonist
	Alpha 2 adrenoceptor agonist
	Alpha adrenoceptor blocker
	Beta adrenoceptor agonist
	Beta adrenoceptor blocker
A

Beta adrenoceptor blocker

The issue here is an interplay between sepsis and thyroid disease. A degree of rate control is required to facilitate anaesthesia and this is best achieved with beta blockade in this particular setting.

60
Q

Which of the following drugs is not positively inotropic?

	Dopamine
	Glucagon
	Theophylline
	Sodium thiopentone
	Dobutamine
A

Sodium thiopentone

Sodium thiopentone causes marked myocardial depression.

61
Q

A 28 year old man undergoes a laparotomy for perforated duodenal ulcer and broad spectrum antibiotics are administered. Post operatively he has hearing impairment. Which of the following agents is the most likely underlying culprit?

	Gentamicin
	Ciprofloxacin
	Metronidazole
	Ampicillin
	Co-trimoxazole
A

Gentamicin

Ototoxicity is a recognised adverse reaction with the aminoglycoside antibiotics.

62
Q

A 62 year old lawyer has a transurethral resection of the prostate which took 1 hour to perform. The ST2 contacts you as the patient has become agitated. He has a HR 105 bpm and his blood pressure is 170/100 mmHg. He is fluid overloaded. His blood results reveal a Na of 120mmol/l. What is the most likely cause?

Over administration of 0.9% Normal Saline
Syndrome of inappropriate antidiuretic hormone secretion
Congestive cardiac failure
TUR syndrome
Acute renal failure
A

TUR syndrome

TUR syndrome occurs when irrigation fluid enters the systemic circulation. The triad of features are:

  1. Hyponatraemia: dilutional
  2. Fluid overload
  3. Glycine toxicity

Management involves fluid restriction and the treatment of the complications associated with the hyponatraemia.

63
Q

A 55 year old man undergoes an appendicectomy through a lower midline laparotomy incision. What is the most appropriate modality for providing post operative analgesia?

	Epidural
	Spinal
	Patient controlled analgesic infusion
	Oral tramadol alone
	Oral NSAID's alone
A

Patient controlled analgesic infusion

64
Q

A 73 year old man is recovering from a stroke but is deemed to have an unsafe swallow. Apart from his CVA his past medical history includes rate controlled atrial fibrillation and a previous oesophagectomy. What is the best option for long term feeding?

	Endoscopically inserted PEG tube
	Surgically inserted PEG tube
	Surgically inserted feeding jejunostomy tube
	TPN via peripheral venous access system
	TPN via a central line
A

Surgically inserted feeding jejunostomy tube

Most patients with a previous CVA can undergo PEG tube insertion. However, an oesophagectomy will preclude this as the stomach will now be intrathoracic.