13- Pre operative MSQs Only

Question 1

1 of 64

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?

Answer 1

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.

Question 2

2 of 64

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?

Answer 2

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.

Question 3

3 of 64

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?

Answer 3

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.

Question 4

4 of 64

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

Answer 4

They should be placed first on the operating list
An intravenous sliding scale should be used in all cases(Right)
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
……………………………………………….
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.

Question 5

5 of 64’

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?

Answer 5

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.

Question 6

6 of 64

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?

Answer 6

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.

Question 7

7 of 64

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

Answer 7

100ml/kg/day

Calculate routine maintenance IV fluid rates for children and young people using the HollidaySegar formula (100 ml/kg/day for the first 10 kg of weight, 50 ml/kg/day for the next 10 kg and 20 ml/kg/day for the weight over 20 kg).
Be aware that over a 24hour period, males rarely need more than 2500 ml and females rarely need more than 2000 ml of fluids.

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.

Question 8

8 of 64

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?

Answer 8

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.

Question 9

9 of 64

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

Answer 9

Propofol

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

Question 10

10 of 64

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?

Answer 10

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.

Question 11

11 of 64

Which of the following is not directly affected by warfarin?

Answer 11

Protein C
Factor II
Factor VII
Factor IX
Factor VIII(Right)
………………………………………….
Warfarin affects synthesis of factors II, VII, IX, X and protein C.

Question 12

12 of 64

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

Answer 12

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.

Question 13

13 of 64

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?

Answer 13

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.

Question 14

14 of 64

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?

Answer 14

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.

Question 15

15 of 64

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?

Answer 15

Patient controlled analgesic infusion

Question 16

16 of 64

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?

Answer 16

TURP syndrome

Complications of Transurethral Resection: TURP
T ur syndrome
U rethral stricture/UTI
R etrograde ejaculation
P erforation of the prostate

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.

Question 17

17 of 64

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?

Answer 17

Gentamicin

Ototoxicity is a recognised adverse reaction with the aminoglycoside antibiotics.

Question 18

18 of 64

Which of the following drugs is not positively inotropic?

Answer 18

Dopamine
Glucagon
Theophylline
Sodium thiopentone ( Right)
Dobutamine
…………………………………………………..
Inotropes are a class of drugs that increase the force or cardiac contractility. This may improve cardiac output. Increased blood pressure may have direct beneficial effects for the heart in that it improves myocardial perfusion pressure. Dopamine and dobutamine are both commonly used inotropes, they should be administered via a central line and in a monitored setting. Glucagon and theophylline are also positive inotropes (although not commonly used for this purpose). In contrast sodium thiopentone causes marked myocardial depression.

Question 19

19 of 64

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?

Answer 19

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.

Question 20

20 of 64

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

Answer 20

Single phosphate enema 30 minutes pre procedure

For a limited endoscopy a simple enema will suffice.

Question 21

21 of 64

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?

Answer 21

0.9% sodium chloride with 40mmol potassium chloride per litre

The potassium will decline further if this deficiency is not addressed. Remember that potassium is predominantly an intracellular cation. U+E’s measure the serum potassium which is relatively buffered by the intra cellular stores. Therefore a fall in serum potassium represents a very real intracellular deficiency. This requires supplementary potassium to correct the defect.

Question 22

22 of 64

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?

Answer 22

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.

Question 23

23 of 64

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?

Answer 23

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, re read the options if you got the answer wrong.

Question 23

24 of 64

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?

Answer 23

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.

Question 24

25 of 64

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

Answer 24

Accelerated idioventricular rhythm
Current treatment with flecainide
3rd degree heart block without pacemaker
Severe sino atrial block
Protein C deficiency(Right)
……………………………………………………………………
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.

Question 25

27 of 64

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?

Answer 25

Pregabalin

Pregabalin is generally the first line agent for neuropathic pain.

Question 26

26 of 64

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?

Answer 26

Intravenous 0.9% sodium chloride

The immediate treatment of hypercalcaemia involves intravenous fluid resuscitation. This may be complemented with the use of bisphosphonates and sometimes diuretics. However, fluids are administered first and because this question asks what the most appropriate initial treatment is, intravenous fluids are the most appropriate answer. Normal saline is usually preferred for this over dextrose containing solutions.

Question 27

28 of 64

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?

Answer 27

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. Oral diet is not permitted following a resection until the anastamosis has had time to heal.

Question 28

29 of 64

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?

Answer 28

Ileus (Right)
Atelectasis
Anastomotic leak
Wound infection
Urinary tract infection
……………………………………………..
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, as open extended right hemicolectomies will necessitate a long midline incision. Anastomotic leaks are less common after right sided colonic surgery and the timeframe for it is rather short (but are possible). Both wound infections and UTI’s ,may complicate major abdominal surgery at any stage. We remind you to check the wording of the question, it asks for the “least likely” cause of pyrexia.

Question 29

30 of 64

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?

Answer 29

Suxamethonium(Right)
Atracurium
Vecuronium
Pancuronium
Propofol
…………………………………….
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.

Question 29

31 of 64

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?

Answer 29

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.

Question 30

32 of 64

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?

Answer 30

4

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

Question 31

33 of 64

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

Answer 31

Pupillary dilation
Dry mouth
Urinary retention
Bradycardia (Right)
Decreased salivation
………………………………………………….
Since it inhibits vagal tone, the use of atropine will typically result in an increased heart rate.

Question 32

34 of 64

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?

Answer 32

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.

Question 33

35 of 64

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

Answer 33

None (Right)
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
…………………………………………………………………………..
In paediatric surgical practice, the use of heparin type agents is rare. This is because, even with abdominal surgery, children are ambulant soon after surgery and DVT’s vanishingly rare in this population.

Question 34

36 of 64

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

Answer 34

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.

Question 35

38 of 64

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?

Answer 35

Reduced stroke volume

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

Question 36

37 of 64

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

Answer 36

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. (Right)
……………………………………………………
Beta blockers should not be stopped acutely prior to surgery as there may be a rebound effect associated with increased complications.
Brain natriuretic peptide is a neurohormone synthesized in the cardiac ventricles.
Levels have been used to assess prognosis in heart failure and acute coronary syndromes. Preoperative elevated brain natriuretic peptide levels identify patients undergoing non cardiac surgery at high risk of cardiac mortality and all cause mortality.
All patients with peripheral vascular disease should take statins prior to vascular surgery as studies have shown a 50% risk reduction and a reduction in perioperative cardiac events.

Question 37

39 of 64

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?

Answer 37

Anaphylaxis
……………………………………….
Dextran 40 and 70 have higher incidence of anaphylaxis than either gelatins or starches.

Dextrans are branched polysaccharide molecules. Dextran 40 and 70 are available.
The higher molecular weight dextran 70 may persist for up to 8 hours. They inhibit platelet aggregation and leucocyte plugging in the microcirculation. Thereby improving flow through the microcirculation, primarily of use in sepsis.
Unlike many other intravenous fluids Dextrans are a recognised cause of anaphylaxis.

Question 38

40 of 64

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?

Answer 38

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.

Question 39

41 of 64

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?

Answer 39

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.

Question 40

42 of 64

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?

Answer 40

Caudal 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.

Question 41

43 of 64

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

Answer 41

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. (Right)

Blood glucose levels persistently greater than 12 should initiate a change in therapy.
…………………………………………………………………….
Insulin should not be stopped in patients with type 1 diabetes and omission of more than one meal will usually require a variable rate insulin infusion

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.

Question 41

44 of 64

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

Answer 41

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

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

Question 41

45 of 64

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

Answer 41

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.

Question 42

48 of 64

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?

Answer 42

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).

Question 42

46 of 64

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

Answer 42

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.
………………………………………………………………………
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.

Question 43

47 of 64

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

Answer 43

Use in tissues which are infected
………………………………………………………..
Local anaesthetics are relatively ineffective when used in infected tissues.

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.

Question 43

50 of 64

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?

Answer 43

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.

Question 44

49 of 64

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

Answer 44

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 (Right)
…………………………………………………….
Carbohydrate loading is one of the enhanced recovery principles.

Question 45

51 of 64

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?

Answer 45

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.

Question 46

52 of 64

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?

Answer 46

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.

Question 47

53 of 64

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?

Answer 47

1

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

Question 48

54 of 64

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

Answer 48

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.

Question 49

55 of 64

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

Answer 49

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.

Question 49

57 of 64

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?

Answer 49

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.

Question 49

56 of 64

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?

Answer 49

Administration of low dose low molecular weight heparin for 2 weeks.
Administration of high dose low molecular weight heparin for 2 weeks.
No prophylaxis. (Right)
Low dose low molecular weight heparin and pneumatic compression stockings.
High dose low molecular weight heparin and pneumatic compression stockings.
……………………………………………
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.

Question 50

58 of 64

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?

Answer 50

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.

Question 50

59 of 64

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

Answer 50

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. Enhanced recovery programmes are now the standard of care in many countries around the world and involve administration of carbohydrate loading drinks.
The routine administration of 5% dextrose in the scenarios given above would convey little in the way of benefit and increase the risks of electrolyte derangement post operatively.

Question 51

60 of 64

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

Answer 51

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 22 C to preserve function. One adult platelet pool raises the normal platelet count by 30,000 to 60,000 platelets litre. ABO identical or compatible platelets are preferred but not necessary in adults; but rhesus compatibility is required in recipients who are children and women of childbearing age to prevent haemolytic disease of the newborn.

Question 52

61 of 64

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.

Answer 52

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.

Question 53

62 of 64

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?

Answer 53

5

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

Question 54

63 of 64

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?

Answer 54

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.

Question 55

64 of 64

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?

Answer 55

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.