Professional Documents
Culture Documents
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?
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.
Pyrexia Hypocalcaemia
Alloimmunization CCF
Thrombocytopaenia Infections
Urticaria
ABO incompatibility
Rhesus incompatibility
Notes:
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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?
Next question
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.
Na K Cl Bicarbonate Lactate
References
British Consensus Guidelines on Intravenous Fluid Therapy for Adult Surgical
Patients
GIFTASUP (2009)
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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%
Next question
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
Management
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%
B. Midazolam
33.1% of users answered this
C. Propofol question correctly
D. Etomidate
E. Ketamine
Next question
Anaesthetic agents
The table below summarises some of the more commonly used IV induction
agents
Agent Specific features
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
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
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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
26.9% of users answered this
C. Neurogenic shock question correctly
D. Cardiogenic shock
E. None of the above
Next question
Dobutamine -1, ( 2)
-2 vasodilatation
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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.
Early feeding in this situation is both safe and will enhance recovery.
Next question
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
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
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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.
Next question
Propofol- Ideal agent for daycase- wears off rapidly, good antiemetic effect.
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.
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.
Next question
Management of pain
Local anaesthetics
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.
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.
- 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
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.
Paracetamol
NSAIDs
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)
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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
41.3% of users answered this
B. Hypochloraemic alkalosis question correctly 11-13 0 / 3
C. Hyperchloraemic alkalosis 14
Next question
Na K Cl Bicarbonate Lactate
References
British Consensus Guidelines on Intravenous Fluid Therapy for Adult Surgical
Patients
GIFTASUP (2009)
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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.
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
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
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
Na + 131 mmol/l
K+ 4.6 mmol/l
Creatinine 78 mol/l
ALT 89 u/l
GT 103 u/l
What is the most likely underlying cause for the abnormalities noted?
Next question
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1
A 39.9%
Which statement regarding post operative cognitive impairment is true? 2
B 16.6%
C 11% 3
14
D. A regional anaesthetic rather than a general anaesthetic is more
likely to contribute to post operative cognitive impairment 15
17
Next question
Definition
Or
Early POCD
Increasing age
GA rather than regional
Duration of anaesthesia
Reoperation
Postoperative infection
Late POCD
Increasing age
Emboli
Biochemical disturbances
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1
A 26.4%
Which statement is false about pethidine? 2
B 28.8%
C 18.1% 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
Local anaesthetics
Spinal anaesthesia
Provides excellent analgesia for surgery in the lower half of the body and pain
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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
40.7% of users answered this
question correctly 11-13 0 / 3
C. Sodium thiopentone
14
D. Ether
15
E. None of the above
16
Next question 17
18
Of the agents mentioned, etomidate has the most favorable cardiac safety profile.
19
Anaesthetic agents
The table below summarises some of the more commonly used IV induction
agents
Agent Specific features
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
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
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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
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.
Next question
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.
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.
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.
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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
60.4% of users answered this
question correctly 11-13 0 / 3
C. Vecuronium
14
D. Pancuronium
15
E. None of the above
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
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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
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)
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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
30. A 48 year old man is due to undergo a laparotomy for small bowel
obstruction.
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
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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
32. A 42 year old woman complains of shooting pains in her left arm
after a mastectomy.
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
34.2% of users answered this
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
Na K Cl Bicarbonate Lactate
References
British Consensus Guidelines on Intravenous Fluid Therapy for Adult Surgical
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
46.3% of users answered this
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
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.
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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
50.8% of users answered this
question correctly 11-13 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
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
36
Vasopressor use is linked to renal failure as they are a marker of haemodynamic
compromise.
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
46.3% of users answered this
B. Patients typically require high ventillatory pressures. question correctly 11-13 0 / 3
18
Next question
19
20-22 1 / 3
Right heart pressure should be normal.
23-25 1 / 3
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
Management
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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.
3. An agent that may be absorbed from multiple bodily sites and causes
histamine release.
It can be absorbed orally and rectally, though few would choose this
route of administration. It is now rarely used.
Next question
Muscle relaxants
A. Hypoalbuminaemia E 34.6%
B. BMI < 17.5 kg/m2 and unintentional weight loss of > 5% over 3-6/12
34.6% of users answered this
C. BMI < 17.5 kg/m2 question correctly
Next question
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E 28.5%
A. Only once bowels have been opened to stool
28.5% of users answered this
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
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:
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
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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.
Next question
Muscle relaxants
B. Adrenal suppression
55.1% of users answered this
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
The table below summarises some of the more commonly used IV induction
agents
Agent Specific features
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
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
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Next question
Neuropathic pain
Examples include:
diabetic neuropathy
post-herpetic neuralgia
trigeminal neuralgia
prolapsed intervertebral disc
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
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Next question
Re-feeding problems
If patient not eaten for > 5 days, aim to re-feed at < 50% energy and protein
levels
Prescription
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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.
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Next question
Surgical strategy
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.
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Next question
Peaked T waves are the first and most common finding in hyperkalaemia.
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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.
Dopamine
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.
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Circulatory support
Impaired tissue oxygenation may occur as a result of circulatory shock. Shock is
considered further under its own topic heading.
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).
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:
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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.
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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
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.
Inflammation
Regeneration
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.
Conditions such as jaundice will impair fibroblast synthetic function and overall
immunity with a detrimental effect in most parts of healing.
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.
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:
Closure
Delayed primary closure is the anatomically precise closure that is delayed for a
few days but before granulation tissue becomes macroscopically evident.
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C. Spinal block 10
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.
23. A 63 year old man with rectal cancer is due to undergo an anterior
resection by laparoscopic approach. He is otherwise well.
Next question
Management of pain
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
The table below summarises some of the more commonly used IV induction
agents
Agent Specific features
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
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
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15-17 1 / 3
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18
19-21 0 / 3
22-24 0 / 3
25
Enteral Feeding
26
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.
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B. Zinc levels 10
40.4% of users answered this
C. Vitamin D question correctly 11
D. Thyroid function 12
E. Bone densitometry 13
14
Next question 15-17 1 / 3
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
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B. Lipid 10
65.4% of users answered this
C. Potassium question correctly 11
D. Glucose 12
E. Magnesium 13
14
Next question 15-17 1 / 3
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.
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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
27
Parenteral nutrition: NICE guidelines summary
28
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
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
Rate question:
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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?
CTPA is the first line investigation for PE according to current BTS guidelines
Clinical probability scores based on risk factors and history and now widely used
to help decide on further investigation/management
D-dimers
V/Q scan
Pulmonary angiography
Rate question:
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