7. Day Surgery

Question 1

1. A 76- year- old man requires right upper lobectomy of lung for bronchial carcinoma. He attends preoperative assessment to identify his
   suitability for surgery. His lung function tests reveal a forced expiratory volume in 1 second (FEV1) of 1.3 L. The next most appropriate investigation is:
   A. Cardiopulmonary exercise testing (CPET)
   B. 6- min walk test
   C. Arterial blood gas
   D. Calculation of predicted postoperative lung volumes
   E. Echocardiography

Answer 1

. D

Both the British Thoracic Society (BTS) and American College of Chest Physicians (ACCP) have
produced management algorithms which are similar. The flow chart shown is an amalgamation of
the BTS and ACCP guidelines (see Figure 7.).

The initial screening tool prior to lung surgery is pulmonary function tests. A measured FEV >2
L is required for pneumonectomy and >.5 L for lobectomy. If there is no comorbidity, achieving
the appropriate lung volume is sufficient. When these threshold lung volumes are not met, full
respiratory function testing allows calculation of the predicted postoperative (PPO) FEV and
diffusing capacity of the lungs for carbon monoxide (DLCO). For lobectomy, the simple calculation
uses the number of bronchopulmonary segments removed compared with the total number (9)
in both lungs. In this case a right upper lobe removal carries 3/ 9 segments. If either (or both) the
PPO, FEV, or DLCO is <40%, the patient should then undergo formal CPET. The threshold VO2
max of 5 mL/ kg/ min delineates between high- and medium- risk patients.

Question 2

2. You review a 72- year- old woman in preoperative assessment who is listed for laparoscopic cholecystectomy.
   She is a lifelong heavy smoker but with no significant medical history in her notes.

Pulmonary function tests were ordered because of shortness of breath after one flight of stairs. The volume– time curve reaches a plateau, and expiration lasts at least 6 seconds. Repeated attempts are similar. FEV1 is 40%, forced vital capacity (FVC) is 65% and predicted FEV1/ FVC ratio is 60%. The most
likely diagnosis is:
A. Poor effort
B. Normal
C. Restrictive
D. Obstructive
E. Mixed

Answer 2

2. E
   The FEV/ FVC ratio is low (<70%) indicating obstruction. The FVC is also low indicating restriction.
   The results are valid as the patient has reproduced the same values on repeated blows and is able
   to reach plateau. In a pure restrictive disorder, the FEV and FVC are both reduced to <80% but the
   FEV/ FVC ratio would be >70%

Question 3

3. A 64- year- old man undergoing transurethral resection of prostate (TURP) under spinal anaesthesia. The procedure has been going on for 90 min and the measured blood loss is 600 mL.
   The patient starts to complain of headache and nausea and is becoming a little agitated.
   His SaO2 is 95% on 4 L via a Hudson mask. His blood pressure drops to 84/ 34 mmHg and his heart rate drops to 52 bpm.
   You stop the surgery. What is the most appropriate immediate pharmacological management?
   A. Ephedrine
   B. Fluid bolus
   C. Metaraminol
   D. Furosemide
   E. Hypertonic saline

Answer 3

3. A
   This clinical picture is suggestive of mild to moderate TURP syndrome. The prolonged procedure
   and moderate blood loss, implying a large number of open veins, are risk factors for absorption
   of irrigating fluid.
   The most important initial management is to abandon the surgery and stop
   intravenous fluid administration.
   The syndrome is secondary to excess absorption of irrigating fluid with acute changes in
   intravascular volume and plasma osmolality, as well as the direct effects of glycine if it has
   been used.

Ephedrine would increase the heart rate and blood pressure through its alpha and beta agonist
effects. Metaraminol may worsen the bradycardia.

If the situation progresses the patient may well need airway support and cardiovascular support
with vasopressors. If neurological symptoms deteriorate and seizures occur, the appropriate
treatment would be benzodiazepines and magnesium. Blood should be checked urgently for
sodium, osmolality, and haemoglobin levels.

Diuretics are only recommended if there is acute pulmonary oedema as furosemide can worsen
hyponatraemia.

Hypertonic saline is only indicated if there is severe hyponatraemia.

Question 4

4. A 48- year- old lady has a mastectomy with a latissimus dorsi reconstruction under general anaesthesia.
   She has a history of well controlled asthma only. What is be the best strategy to preserve flap perfusion in the perioperative period?

A. Active warming to maintain normothermia
B. Using isoflurane as the volatile anaesthetic agent
C. Maintain urine output >2 mL/ kg with diuretics
D. Haemodilution to a haematocrit of 20%
E. Phenlyephrine infusion to maintain a MAP >80 mmHg

Answer 4

4. A
   Normothermia should be maintained with active warming before the start of induction of anaesthesia.

Hypothermia causes vasoconstriction and increases plasma viscosity, which decrease microcirculatory flow.

Isoflurane may offer an advantage because it causes some vasodilatation and causes minimal cardiac
depression but this is of less importance than good temperature control and optimal fluid balance.

Aiming for a urine output of 1– 2 mL/ kg is appropriate but is best achieved with goal directed fluid
management rather than diuretics as volume depletion can compromise the free flap.

Isovolaemic haemodilution to achieve a haematocrit of 30– 35% (0.3– 0.35) improves flow by
decreasing plasma viscosity.
Larger reductions than this risk oxygen delivery with no further advantage in flow.

Vasoconstrictors such as noradrenaline (norepinephrine) should be avoided

Question 5

5. A 79- year- old patient presents for a total knee replacement. The patient has a history of stable angina and chronic obstructive pulmonary
   disease. You review the patient preoperatively. Which of the following is a specific indicator of frailty?
   A. Body mass index (BMI) <25
   B. Female gender
   C. Anaemia
   D. Unintentional weight loss
   E. High pain score

Answer 5

5. D
   All the other options may also be present in someone with frailty, but only unintentional weight loss
   is scored on both the frailty phenotype model and the frailty index scale.
   Most frailty definitions include reduced muscle strength, unintentional weight loss, tiredness and
   fatigue, and low physical activity with slow walking. These factors are scored to indicate a frailty
   phenotype.
   The Edmonton Frail Scale assesses nine criteria to give a score: mood, cognition, general health,
   functional status, social support, nutrition especially history of weight loss, medication use,
   continence, and functional performance. This can be performed preoperatively at the bedside.
   Many factors increase the risk of frailty including female sex, multiple comorbidities, low socioeconomic
   class, depression, disability, cognitive decline, and polypharmacy. Frailty increases
   postoperative complications and the length of hospital stay. It can also affect the discharge
   destination of the patient.

Question 6

6. A 76- year- old man attends the preoperative clinic prior to elective removal of ingrown toenail under general anaesthetic.
   He has no significant past medical history, takes no mediation, and has good functional status. His BMI is 28. What are the most appropriate
   preoperative investigations?
   A. Full blood count (FBC), urea and electrolytes (U&E), and electrocardiogram (ECG)
   B. FBC and U&E
   C. U&E only
   D. ECG only
   E. No investigations required

Answer 6

6. E
   NICE guidance: NG45— Routine preoperative tests for elective surgery (http:// nice.org.uk/
   guidance/ ng45). This guideline covers routine preoperative tests for people aged over 6 who
   are having elective surgery. It prompts assessment of the patient’s comorbidity versus the
   severity of surgery planned. It aims to reduce unnecessary testing by advising which tests to offer
   people before minor, intermediate, and major or complex surgery, taking into account specific
   comorbidities (cardiovascular, renal, and respiratory conditions, and diabetes and obesity). There
   is a general trend to try and reduce the volume of preoperative investigations with an emphasis
   on individual assessment. This patient has an ASA class of  and is having minor (or severity grade
   ) surgery. While the age is increased, guidance suggests that this in isolation does not necessitate
   testing. Patients with significant comorbidity requiring intermediate/ major surgery will have basic
   tests routinely performed.
   The AAGBI Safety Guideline. Preoperative Assessment and Patient Preparation, the Role of the
   Anaesthetist (200) https:// www.aagbi.org/ sites/ default/ files/ preop200.pdf is an older guideline
   which suggests patients >80 years should have ECG but also recognizes the suggestion that patients
   of any age with no major comorbidities (ASA physical status  or 2) presenting for day surgery may
   not need any preoperative investigations.

Question 7

7. You anaesthetize a 44- year- old lady for electroconvulsive therapy (ECT).
   What is the most common adverse effect following electroconvulsive
   therapy?
   A. Postoperative cognitive dysfunction
   B. Myocardial ischaemia
   C. Severe myalgia
   D. Fractured bone
   E. Cardiac arrhythmia

Answer 7

7. A
   Disorientation, impaired attention, and memory problems are frequent post- ictally and short- term
   memory impairment lasting several weeks occurs in more than 50% of patients.

ECT causes activation of the autonomic nervous system. Initially there is a short parasympathetic
discharge associated with bradycardia and hypotension.
A more prominent sympathetic response
follows with increased BP, heart rate, and myocardial oxygen consumption. This may be associated
occasionally with cardiac arrhythmias and myocardial ischaemia and infarction particularly if there is
pre- existing disease.

Historically during unmodified fits (i.e. without a GA) there was a high incidence of fractures and
dislocations but these are now rare

Myalgia either from seizure activity or succinylcholine can occur but symptoms are usually mild.

Question 8

8. You anaesthetize a 34- year- old lady for a hysteroscopy. She has no significant past medical history and does not smoke. What is the most
   accurate predicted risk of her suffering postoperative nausea and vomiting (PONV)?
   A. 0%
   B. 20%
   C. 40%
   D. 60%
   E. 80%

Answer 8

8. C

There are two simplified PONV scores for adults— the Koivurata et al. and the Apfel et al. scores.
Both would count female gender and non- smoking status as risk factors giving a predicted incidence
of approximately 40%.
In the Apfel score when 0, , 2, 3, or 4 factors are present, the risk of PONV is 0%, 20%, 40%,
60%, and 80% respectively. The four risk factors in the Apfel scoring system are female gender, nonsmoking
status, history of PONV or motion sickness, and postoperative use of opioids in the Apfel
scoring system.
The Koivurata system gives a score of  for the five risk factors of female gender, non- smoking status,
history of PONV, history of motion sickness, and duration of surgery >60 min. If 0, , 2, 3, 4, or 5
risk factors are present the incidence of PONV is 7%, 8%, 42%, 54%, 74%, and 87% respectively.

Question 9

9. A man with type 2 diabetes presents for varicose vein surgery on your morning list. He has taken his metformin and half his usual morning
   dose of long- acting insulin. His capillary blood glucose (CBG) level has been checked and is 18 mmol/ L. What is the next step in this patient’s
   management?
   A. Start a variable rate insulin infusion and proceed
   B. Cancel his operation
   C. Check his urine for ketones
   D. Give him 0. units/ kg insulin and proceed
   E. Give him the other half of his morning long- acting insulin dose and proceed

Answer 9

9. C
   It is important to maintain good glycaemic control aiming for a CBG level of 6– 0 mmol/ L in
   diabetic patients. Studies have shown that a high preoperative and perioperative glucose and
   HbAc levels are associated with poor surgical outcomes in both the elective and emergency
   situations. There is increased risk of postoperative respiratory, urinary tract, and surgical site
   infections, and increased risk of myocardial infarction and acute kidney injury.
   If the glucose level exceeds 2 mmol/ L it is important to rule out diabetic ketoacidosis (DKA)
   which is a medical emergency. If DKA is not present you should treat the hyperglycaemia with
   insulin as a bolus initially but if blood glucose remains difficult to control with a variable rate
   infusion. Once blood glucose has normalized surgery could proceed

Question 10

10. A 21- year- old woman presents for diagnostic laparoscopy as a day case. She takes no regular medication and is a non- smoker. She has no significant past medical history. She has never had a general anaesthetic and has no significant family history of illness.
    Her BMI is 30. What is the single best management plan for this case?

A. Laryngeal mask airway (LMA), spontaneous breathing, fentanyl, cyclizine, 500 mL of
Hartmann’s solution
B. Endotracheal tube (ETT), intermittent positive pressure ventilation (IPPV), morphine,
ondansetron, 250 mL gelofusine bolus
C. LMA, IPPV, IV paracetamol, metoclopramide, 500 mL Hartmann’s solution
D. ETT, IPPV, IV oxycodone, dexamethasone, ,000 L Hartmann’s solution
E. ETT, IPPV, morphine, cyclizine, ,000 mL sodium chloride 0.9% solution

Answer 10

0. D
Rationale: Answers ordered in: Airway/ Ventilation/ Analgesia/ Antiemesis/ Fluids
In terms of airway control, obese, pneumoperitoneum, Trendelenburg tilt, possible lithotomy all
point to definitive airway in the hands of ST3/ 4 trainee (NAP 4). Therefore A and C excluded.
Young, female, non- smoker for day case, therefore PONV prophylaxis and adequate analgesia
paramount.
B and E both have morphine, cyclizine has sedative side effects, 250 mL Gelofusine is a resuscitation
fluid prescription, not replacement.

Question 11

11. A 42- year- old woman presents for elective laparoscopic cholecystectomy for biliary colic. She has diet- controlled diabetes mellitus. Her tympanic temperature is 35.7°C preoperatively. What perioperative warming strategy is indicated?
    A. Place foil hat and warmed blankets on patient before transfer to anaesthetic room
    B. Intraoperative forced air warming blanket
    C. Intraoperative forced air warming blanket and warmed IV fluids
    D. Preoperative forced air warming blanket continued intraoperatively
    E. Intraoperative warmed IV fluids

Answer 11

11. D
    This is an elective procedure and her temperature is less than 36.0°C, hence preoperative active
    warming is recommended until temperature exceeds 36.0°C.
    Forced air warming is indicated intraoperatively because having hypothermia preoperatively and a
    total anaesthetized time likely to be greater than 30 min are both independent indications and also

meets criteria equating to ‘high risk’ of intraoperative hypothermia (high risk is having at least two
factors from the following list: ASA II- V, hypothermia preoperatively, combined GA and RA, at risk
of cardiovascular complications and having intermediate or major level surgery).
Warmed IV fluids are not specifically recommended unless over 500 mL has been infused.
Passive measures such as foil hats and warmed blankets will only prevent further heat loss and will
not correct existing hypothermia.

Question 12

12. A 52- year- old woman with chronic liver disease is listed for mastectomy for carcinoma. You see her preoperatively to discuss her risks. Which of
    the following variables carries the greatest operative risk?

A. Grade 2 encephalopathy
B. Poorly controlled ascites
C. Serum bilirubin of 20 mg/ dL
D. Serum albumin of 32 g/ L
E. Prothrombin time of 29 seconds

Answer 12

12. B
    Using the Pugh modification of Child’s criteria points are given for increasing abnormality of
    encephalopathy, ascites, serum bilirubin, serum albumin, and prothrombin time. The greater the
    abnormality, the greater the score. These are added together to predict operative mortality risk.

Question 13

13. A 56- year- old man presents for emergency repair of obstructed inguinal hernia.
    His BMI is 45 and he is being treated for hypertension. His wife reports that he snores loudly and routinely falls asleep while watching television. The best perioperative management plan is:

A. Proceed with general anaesthesia and ventilate for 12 hours postoperatively on ITU
B. Proceed under spinal anaesthesia with intrathecal morphine and no systemic sedation
C. Proceed with general anaesthesia, avoid opioids, and monitor on HDU postoperatively
D. Proceed with general anaesthesia, titrate opioids carefully, and monitor on ITU postoperatively
E. Proceed under field block

Answer 13

E3. D
Using the STOP- BANG score, the patient scores over 5 therefore is at high risk of having
obstructive sleep apnoea (OSA) and episodes of postoperative desaturation and hypoxaemia
following the emergency procedure.

Spinal anaesthesia is not usually a good option in the obstructed patient, and the incidence of
respiratory complications in OSA from intrathecal opioids is largely unknown, and thus poses a risk
to the patient.

The cumulative sedative nature of anaesthesia and analgesics should be minimized and therefore it
would not be optimal to electively ventilate the patient.

Field block will be inadequate for this emergency case. It is likely that some opioid will be
required for the procedure and also to help maintain a steady blood pressure during intubation
and extubation. OSA is made worse by general anaesthesia as well as opioid analgesics so while
monitoring on HDU may be adequate, monitoring saturation on ITU postoperatively is ideal, in
case advanced airway and ventilation support becomes necessary.

Question 14

4. A 65- year- old patient presents to preoperative assessment for elective total knee replacement. He has no other past medical history. He is
brought to your attention as his BP is 172/ 105. His resting ECG and renal function are normal. The most appropriate course of action is:

A. Proceed to surgery
B. Proceed to surgery, inform GP
C. Postpone surgery, request ambulatory BP monitor
D. Postpone surgery, recommend immediate treatment by GP
E. Postpone surgery until BP is below 40/ 90

Answer 14

`4. B
Preoperative assessment clinics should measure the blood pressures of patients who present
without documentation of primary care blood pressures. If the blood pressure is raised above
180 mmHg systolic or 110 mmHg diastolic, the patient should return to their general practice for
primary care assessment and management of their blood pressure.

If the blood pressure is above
140 mmHg systolic or 90 mmHg diastolic, but below 180 mmHg systolic and below 110 mmHg
diastolic, the GP should be informed, but elective surgery should not be postponed according to
AAGBI/ British Hypertensive Society guidance.

Question 15

15. A 75- year- old man presents for trans- urethral resection of prostate (TURP) for suspicion of cancer. He is on ticagrelor since having a cardiac
    stent inserted six months ago. He requests regional anaesthesia as he experienced significant postoperative nausea and vomiting after his last
    general anaesthetic. What is the best course of action?

A. Recommend proceeding with general anaesthesia
B. Stop ticagrelor five days before surgery, proceed with spinal anaesthesia
C. Stop ticagrelor five days before surgery, bridge with IV heparin, proceed with general anaesthesia
D. Stop ticagrelor, wait 36 hours from last dose and proceed with spinal anaesthesia
E. Proceed with spinal anaesthesia

Answer 15

15. B
    Ticagrelor is a platelet
    adenosine diphosphate (ADP) P2Y12 receptor inhibitor.

Its antiplatelet effect can be removed by stopping the drug and waiting.
Ticagrelor is a longer acting drug with a half life
of 18 hours and it is recommended waiting five days from the last dose before performing spinal
anaesthesia.

Bridging with heparin is not necessary in this case as antiplatelet therapy can be safely
discontinued at six months with bare metal stents. The stents with have epithelialized by this time
and the risk of thrombosis is no longer increased.

Question 16

16. A 41- year- old woman requires drainage of Bartholin’s cyst. She was diagnosed with multiple sclerosis (MS) one year ago following an episode
    of unilateral visual loss. She takes Tecfidera (dimethyl fumarate) twice daily and is currently asymptomatic.

She is fasted, has a BMI of 28, and
no reflux. The best anaesthetic technique to use for this case is:
A. General anaesthesia (GA) LMA spontaneous ventilation (SV)
B. GA ETT IPPV with depolarizing muscle relaxant
C. GA ETT IPPV with non- depolarizing muscle relaxant
D. Caudal block
E. Low spinal block

Answer 16

6. A
This is a case of keeping it simple and not overcomplicating matters. General anaesthesia per se
does not precipitate any deterioration or relapse of multiple sclerosis. (However, a major stress
response to extensive surgery may well do.) Induction agents, volatiles, and relaxants are known to
be safe.
With a BMI of 28 the patient is suitable for anaesthetizing using a laryngeal airway (fasted, no reflux)
because it is a very short procedure. She could also be intubated and ventilated with or without
muscle relaxants, paying attention to elapsed time prior to reversal and safe extubation.
Regional anaesthesia is thought to be safe although there may be an increased blood– brain barrier
permeability and sensitivity to CNS toxicity with MS. It is prudent to use the minimum dose
possible of local anaesthetic. Some related hypotension has been considered relatively resistant to
vasopressors.
A low spinal block would be more appropriate than a caudal (density, predictability, ease of siting,
reliability) but would outlast this operation significantly.
Tecfidera (dimethyl fumarate) is one of several disease modifying treatments for MS. It requires no
special precautions to be taken with drugs used in anaesthesia including muscle relaxants.

Question 17

7. A 36- year- old, self- employed joiner is listed for knee arthroscopy in the
day surgery unit. During your anaesthetic preoperative visit he admits
to smoking 20 cigarettes per day and has a chronic cough. He gives a
three- day history of sore throat, croaky voice, and a runny nose. He is particularly keen to have his operation today as has arranged several
work commitments to suit. The best plan is:
A. Proceed with spinal anaesthesia
B. Proceed with general anaesthesia
C. Proceed with femoral and sciatic nerve blocks
D. Proceed with a Hunter’s canal block
E. Postpone until upper respiratory tract symptoms have resolved

Answer 17

7. A
You can proceed with spinal anaesthesia. The risks of proceeding with symptoms of upper
respiratory tract infection versus postponing the procedure at great inconvenience to the patient
must be balanced pragmatically. There are no systemic signs of illness and his symptoms are
all localized ‘above the clavicles’. The risks of general anaesthesia may outweigh the benefit of
proceeding but short effective spinal anaesthesia can be achieved in a day surgery setting. Prilocaine
is often used in this situation.
Femoral and sciatic blocks take some time to perform and develop. Their duration of action is at
least 2 hours and it is not ideal to send a patient home with a numb leg. A Hunter’s canal block
alone will not provide adequate anaesthesia for a knee arthroscopy.

Question 18

8. A 66- year- old male smoker is referred for preoperative (ramped, maximal, symptom- limited on a cycle ergometer) cardiopulmonary
exercise test (CPET) prior to a gastrectomy for malignant disease.
His results are shown below.

Maximum/ peak oxygen uptake (VO2max) 12 mL/ kg/ min
Anaerobic threshold (AT) 9 mL/ kg/ min
Oxygen pulse 9 mL
Ventilatory equivalent for CO2 (VE/ VCO2) at AT 43
What is the best way to proceed in view of these test results?

A. Refer patient to smoking cessation clinic
B. Only proceed if intensive care bed available
C. Advise thoracic epidural analgesia
D. Advise the patient he is in the high- risk category
E. Advise the patient not to proceed with surgery

Answer 18

8. D
CPET testing helps inform perioperative management of individual patients by allocating them to a
high- or low- risk category for postoperative morbidity and mortality.

This patients results place him very clearly into the high risk group; his VO2 max and anaerobic
threshold (AT) are well below the values accepted as inferring low risk (18 mL/ kg/ min and 14 mL/
kg/ min respectively).
Following this risk assessment, the patient and surgeon/ anaesthetist team can put plans in place to
minimize post- operative risks by instituting a variety of appropriate measures.

Such measures may include higher levels of monitoring, particular forms of analgesia and higher level of monitoring in the postoperative period. These specifics are decided on a patient to patient basis and are not mandated by the test results.

Smoking cessation would improve the test results but surgery for malignant disease should not be
unduly postponed for this reason.

Question 19

19. You have a 25- year- old female patient on your elective orthopaedic list, for minor foot surgery. She has a BMI of 24, is ASA 1, fasted, and does
    not have reflux. You plan to use an LMA to maintain the airway.
    At induction you administer fentanyl 100 μg and propofol 200 mg IV.
    You open her mouth to insert the LMA and notice, for the first time, that she has a tongue stud in situ. The best action to take is:
    A. Wake the patient up
    B. Remove the tongue stud and insert the LMA as planned
    C. Leave the tongue stud in place and insert the LMA very carefully
    D. Insert the LMA and then remove the tongue stud
    E. Intubate the patient and then remove the tongue stud

Answer 19

9. A
Waking the patient up is the safest action to take, bearing in mind the case can be rescheduled.
While many would be tempted to leave the tongue stud in place and proceed carefully with the
LMA (answer C), this confers potential risks including bleeding, oedema, and a can’t intubate, can’t
ventilate (CICV) scenario (see the references below).
Intubation requires instrumentation of the tongue and carries risks of its own both at induction and
emergence.
The danger in removing the tongue stud after induction but before insertion of an airway device is
that can fall or be dropped into the airway. Removal of a slippery stud on a mobile tongue whilst
wearing gloves is tricky. Removing the tongue stud with the LMA in situ does not protect the airway
as the seal of the LMA may not cover the entire glottic opening.
There is an additional possibility that if the patient has concealed details of her piercings, there may
be further inaccuracies in her pre- operative assessment.

Question 20

20. A 62- year- old female patient presents to preoperative assessment clinic prior to elective total knee arthroplasty. Her FBC reveals Hb 108 g/
    dL. Mean corpuscular volume (MCV), mean corpuscular haemoglobin
    (MCH), and ferritin are low. The correct management is:
    A. Inform GP, proceed to surgery
    B. Start oral iron and recheck FBC in four weeks
    C. Start oral iron and proceed to surgery
    D. Give IV iron and recheck FBC in two weeks
    E. Give IV iron and proceed to surgery

Answer 20

20. B
    The blood results indicate iron deficiency anaemia. The haemoglobin level should be optimized
    preoperatively to reduce the likelihood of perioperative transfusion. IV iron is not indicated first
    line in elective non- cancer surgery where there is no obvious requirement to rapidly improve the
    preoperative haemoglobin. Response to oral iron should be confirmed before proceeding with
    rechecking of FBC.

Question 21

21. A 53- year- old presents as a day case for scarf osteotomy. You use ultrasound- guided ankle block as your sole technique to allow early mobilization. Which nerve should you block first to establish the block
    quickly and efficiently?
    A. Saphenous nerve
    B. Tibial nerve
    C. Deep peroneal nerve
    D. Superficial peroneal nerve
    E. Sural nerve

Answer 21

2. B
All five nerves, the tibial, deep and superficial peroneal, sural, and saphenous, are blocked in an
ankle block. The tibial nerve should be blocked first because it is the largest and therefore it takes
the longest time for the block to develop.

Question 22

22. A 2- year- old, 80- kg boy is brought in for multiple dental extractionssecondary to caries. He appears calm on pre- assessment but on arrival
    to the anaesthetic room becomes upset and uncooperative.
    His mother tries to calm him down without success and he refuses to have the procedure. The best option to manage this situation is:
    A. Ask the mother to restrain the child and commence anaesthesia
    B. Do the next patient on the list while he calms down and agrees to procedure
    C. Return him to the ward and give him an anxiolytic pre- med
    D. Reschedule with a plan in place for preoperative behavioural strategies
    E. Ask the dental surgeon to persuade him to have the procedure

Answer 22

22. D
    Preoperative anxiety is common in children and young adults and is associated with adverse clinical
    outcomes. A 2- year- old boy of average intelligence can give or withhold consent. Physical restraint
    is not an option for older children. Measures to reduce anxiety include sedative premedication,
    behavioural/ play therapy, and presence of parent in the anaesthetic room. Sedative premedication also
    requires a degree of willing and consent from the child and the present situation may be too fraught
    to explain and deliver this.

Behavioural therapy is time consuming and there is no evidence to support
that having a parent in the anaesthetic room does reduce anxiety in a child, though this remains hotly
debated.
Waiting for the patient to calm down is unlikely to be successful and along with persuasion by the
dentist, provides no guarantee of compliance in the anaesthetic room.

Question 23

23. A 38- year- old female patient is assessed for elective laparoscopic cholecystectomy. She has a history of cystic fibrosis. She has had no
    recent chest infections and has chest physiotherapy performed every day by her partner. She can walk over a mile on the flat but her pace is limited. She becomes short of breath and unable to speak when walking
    quickly. The best test of her respiratory capacity is:

A. Compare arterial blood gases and venous blood gases
B. Compare oxygen saturations at rest and on oxygen 2 L/ min
C. A chest X- ray and clinical examination
D. CPET
E. Lung function tests including peak expiratory flow rate (PEFR), FEV, FVC, and spirometry

Answer 23

23. E
    From the question we can ascertain the patient has limited exercise capacity. FEV is an important
    indicator of ability to cough and engage successfully with physiotherapy postoperatively. Lung function
    tests showing a reduction in FEV to < L/ min may indicate the need for postoperative ventilation.
    CPET primarily categorizes patients into high or low risk of postoperative complication

Question 24

24. The use of CPET in preoperative assessment can reliably predict:
    A. If patient has adequate reserve capacity
    B. If invasive monitoring required perioperatively
    C. If needs to be nursed in critical care postoperatively
    D. Mortality rate
    E. Suitability for an enhanced recovery programme

Answer 24

24. A
    CPET testing is an accessible, minimally invasive test of the patient’s exercise capacity. This reflects
    the cardiorespiratory demands that will be made of the body during, and for some time after,
    major surgery. The information can help with planning appropriate perioperative care for individual
    patients.
    Following the exercise test and recovery period, the cardiorespiratory variables measured are
    analysed taking into consideration any significant external factors. The results are provided to
    the referring clinician advising whether the patient is deemed to be at high risk or low risk of
    perioperative morbidity and mortality. It is then the decision of the referring clinician and the
    surgical team how best to manage the patient in view of this result. The CPET results do not
    mandate whether or not surgery should proceed, nor do they advise upon need for intensive care
    or high dependency availability or the best techniques to be used.

Question 25

25. A 76- year- old man requires a trans- urethral resection of the prostate (TURP). His past medical history includes stable angina, hiatus hernia,
    hypertension, and Alzheimer’s disease. His current medication includes aspirin, ramipril, bendroflumethiazide, nicorandil, GTN spray,
    omeprazole, and donezepil. What is the best approach perioperatively regarding his Alzheimer’s disease treatment?

A. Stop his donezepil for two weeks prior to surgery
B. Withhold his donezepil on the morning of surgery
C. Continue his donezepil and avoid suxamethonium
D. Continue his donezepil and avoid non- depolarizing neuromuscular blockers
E. Continue his donezepil and use spinal anaesthesia

Answer 25

25 E
Donezepil is an anti- cholinesterase used in the treatment of dementia. It can potentially prolong
the effect of depolarizing neuromuscular blockers and decrease or reverse the effects of nondepolarizing
neuromuscular blockers. Some guidelines recommend stopping anticholinesterase
agents before elective surgery but donezepil has a long half- life of 70 hours and would require
a washout period of two to three weeks. A prolonged period without this treatment may lead
to an irreversible decline in cognitive function. Therefore, option E offers the best perioperative
anaesthetic option by avoiding a general anaesthetic and potential for drug interaction. It would also
have the beneficial effect of reducing the risk of the patient developing postoperative delirium.