Anaesthesia and peri-operative care incorrects

Question 1

patient with new onset atrial fiibrillation following right hemicolectomy

feculent material present in abdominal drain

most likely diagnosis?
investigation?

Answer 1

anastomotic leak

CT with luminal contrast

Question 2

most likely cause for patients stats falling following intubation?

Answer 2

esophageal intubation

Question 3

patients with diabetes should be first on the list for surgery

Question 4

complications of perioperative hypothermia? (temp <36!!)

Answer 4

prolonged/ excessive bleeding!!!
prolonged recovery from anaesthesia
impaired wound healing
increased risk of infection

Question 5

when a surgery is undertaken which has a low chance of transfusion all you need is group and save, you dont need cross match

Question 6

name aneasthetics that can cause malignant hyperthermia

management?

Answer 6

isoflurane, desflurane, sevoflurane

(volatile liquid anaesthetics)

suxamethonium
halothane

manage = dantrolene

Question 7

name an anesthetic that is useful in trauma as it doesnt cause a drop in BP

Answer 7

ketamine

Question 8

nitrous oxide should be avoided in patients with what emergency presentation?

Answer 8

pneumothorax

Question 9

when can metformin be continued as normal in a patient with diabetes undergoing surgery?

Answer 9

one meal will be missed during the surgery, and the patient’s eGFR is above 60 mL/min/1.73m

Question 10

after indduction with anesthesia and intubation, a low oxygen saturation, absent air entry in both lung bases, and distended abdomen suggests what?

Answer 10

esophageal intubation

Question 11

patient presenting after tonic clonic siezure. groans and localises to pain but does not open eyes. sats 95%

next step in management?

Answer 11

oropharyngeal airway - as patient has reduced consciousness

airway protection comes before 02 and possibly CT head

Question 12

causes of post-operative fever?

Answer 12

Day 1-2: ‘Wind’ - Pneumonia, aspiration, pulmonary embolism
Day 3-5: ‘Water’ - Urinary tract infection (especially if the patient was catheterised)
Day 5-7: ‘Wound’ - Infection at the surgical site or abscess formation
Day 5+: ‘Walking’ - Deep vein thrombosis or pulmonary embolism
Any time: Drugs, transfusion reactions, sepsis, line contamination.

Question 13

patient. 12 hours after the operation her epidural fell out, leaving her in significant pain. following morning, shortness of breath and fever 38

most likely cause of fever?

Answer 13

penumonia

pain -> shallow breathing -> atelectasis and respiratory tract infections

Question 14

which neuromuscular blocker is contraindicated in surgery for a patient with hyperkalemia?

Answer 14

suxamethonium/ succinylcholine

Question 15

which anaesthetic is best used in a patient with a history of post-op nausea and vomiting

Answer 15

propofol

Question 16

what is the potential complication of excessive administration of NaCl post op

Answer 16

hyperchloraemic ACIDOSIS

and therefore Hartmans solution may be preferred where large volumes of fluid are to be administered.

Question 17

first line emergency access if cannulation fails?

Answer 17

intraosseus access

Question 18

food can be consumed up till x hours before surgery

fluids can be consumed up till x hours before surgery

Answer 18

6

2

Question 19

rapid sequence induction and what else helps reduce risk of aspiration during induction?

Answer 19

administration of antacid

Question 20

acute onset of breathlessness, LAPCHOLY 10 days ago.
normal temp and other obs.

minimal tenderness over right hypochondrium.

most likely diagnosis?

Answer 20

pulmonary embolism!!!!

findings dont support a subphrenic abscess or pneumonia!

Question 21

patient intubated but it was difficult

most useful test to check placement?

Answer 21

capnography - helps rule out esophageal intubation

Question 22

management of sulfonylurueas specifically eg gliclazide, when a patient has a surgery on the day?

Answer 22

omit the drug

except the patient has BD dose and surgery is in the morning -> can give afternoon dose

Question 23

A 23-year-old man is undergoing an inguinal hernia repair as a daycase procedure and is being given sevoflurane.

What is the most appropriate method for airway access?

Answer 23

This procedure will be associated with requirement for swift onset of anaesthesia and recovery. Muscle paralysis is not required and this would an ideal case for laryngeal mask airway.!!

• note laryngeal mask has poor control against reflex of gastric contents

Question 24

A 48-year-old man is due to undergo a laparotomy for small bowel obstruction.
What is the most appropriate method for airway access?

Answer 24

endotracheal intubation

Question 25

how would obstructive fibrinous tracheal psuedomembrane present as a complication of intubation?

Answer 25

it involves the formation of a physical barrier in the airway due to inflammation tissue. This ‘pseudomembrane’ would cause upper airway obstruction signs

upper airway noises (e.g. stridor), difficulty breathing around 3 days post-extubation and respiratory distress signs (increased work of breathing, low sats and high respiratory rate).

Endoscopy is the investigation of choice

Question 26

how would tracheomalacia present as a complication of intubation?

Answer 26

block the airway, depending on the degree of deformity, resulting in respiratory symptoms like decreased vital capacity and upper airway sounds like stridor.

Question 27

A 58-year-old man is seen in the neurosurgery ward coughing and choking after meals, bringing up yellow and brown sputum.

He has been recovering from a traumatic brain injury, for which he needed to be intubated for 2 months.

Upon examination, there are mild crackles in the right middle zone.

Answer 27

trancheosophageal fistula!! -> has now caused aspiration penumonia

Question 28

first line management of an anastamotic leak?

Answer 28

call consultant and take patient to theatre immediately -> surgical emergency

Question 29

how long should COCP/HRT be stopped before surgery?

Answer 29

4 weeks prior

Question 30

best intravenous access for patient on long term chemo with poor peripheral veins

Answer 30

hickman line

Question 31

what size peripheral cannula is used short term in hemodynamically stable patient?

Answer 31

20G

Question 32

patient that is peripherally shut down following a road traffic accident. best intravenous access?

Answer 32

intraosseus infusion

Question 33

what do illeus bloods show post surgery?

Answer 33

fluid and electrolyte loss -> nausea and distended abdomen is later

Question 34

treatment for local anesthetic toxicity

Answer 34

20% IV lipid emulsion

Question 35

Metformin
sulfonylureas
DPP IV inhibitors (-gliptins)
GLP-1 analogues (-tides)
SGLT-2 inhibitors (-flozins)
Once daily insulins (e.g. Lantus, Levemir)
Twice daily Biphasic or ultra-long acting insulins

how are these drugs managed in surgery?

when would a variable rate intravenous insulin infusion be required?

Answer 35

Metformin - if taken once or twice a day, take as normal!! If taken three times per day, omit lunchtime dose

sulfonylureas - If taken once daily in the morning - omit the dose that
day.If taken twice daily - omit the morning dose that day. omit both doses of afternoon surgery

DPP IV inhibitors (-gliptins) - take as normal
GLP-1 analogues (-tides) - take as normal
SGLT-2 inhibitors (-flozins) - omit

Once daily insulins (long acting insulins)!! (e.g. Lantus, Levemir) - reduce dose by 20%!!!

Twice daily Biphasic!! or ultra-long acting insulins - half morning dose, leave evening dose

VRII REQUIRED if:
if more than one meal is to be missed!!
patients with poor glycaemic control!!
risk of renal injury (e.g. low eGFR, contrast being used)!!

Question 36

post operative wound cleansing what do you use?

Answer 36

sterile saline for wound cleansing up to 48 hours after surgery.

Advise patients that they may shower safely 48 hours after surgery.

Question 37

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.

Answer 37

air leak

Question 38

A 20-year-old man has a protracted stay on ITU following a difficult appendicectomy for perforated appendicitis with pelvic and sub phrenic abscesses. He has now deteriorated further and developed deranged liver function tests.

Answer 38

portal vein thrombosis!!
intra-abdominal sepsis -> coagulopathy -> portal vein thrombosis.

Question 39

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.

Answer 39

chyle leak -> damage to lymphatic duct

Question 40

what are some clear fluids that can be taken up to 2 hours before surgery?

Answer 40

water, fruit juice without pulp, coffee or tea without milk and ice lollies

Question 41

lidocaine mechanism of action?

Answer 41

blockage of sodium channels

Question 42

name and describe causes of post-operative fever

Answer 42

Early causes of post-op pyrexia (0-5 days) include:
Blood transfusion
Cellulitis
Urinary tract infection
Physiological systemic inflammatory reaction (usually within a day! following the operation)
Pulmonary atelectasis - this if often listed but the evidence base to support this link is limited

Late causes (>5 days!) include:
Venous thromboembolism
Pneumonia
Wound infection!! - if abdomen = soft abdomen, no abdominal pain but tender to touch, discharge
Anastomotic leak - abdominal pain, abdominal distension,

Question 43

muscle relaxant of choice for rapid sequence intubation?

Answer 43

Suxamethonium

Question 44

comatose/patients with head injury should be fed with NG tube unless there is a base of skull fracture

what is the feeding option for A 43-year-old man recovering from a laparoscopic low anterior resection with loop ileostomy.

Answer 44

normal oral intake

Question 45

You are an FY1 doctor. You have been called to attend an unconscious 65-year-old woman on the floor of a ward. When assessing her airway it looks clear, but you can hear snoring. The snoring stops when you do a head tilt, chin lift and jaw thrust. On auscultation, her chest is clear with good bilateral air flow and her trachea is central. Her peripheral capillary refill is more than 2 seconds. Her oxygen saturation is 96% on 4L of oxygen, her pulse is weak and regular at 105/min, her respiratory rate is 16/min, her blood pressure is 98/54 mmHg, and her temperature is 36.6 ºC.

What is the most appropriate immediate management?

Answer 45

insert an oropharyngeal tube - used to prevent airway obstruction caused by poor pharyngeal muscle tone

Question 46

name a medication that can slow the rate of healing of a fracture

Answer 46

NSAIDs

Question 47

65-year-old male undergoes a Hartmann’s procedure for a sigmoid cancer. On day 2 post-op, nurses are concerned as his colostomy has not passed any wind or stool yet and he is complaining of increasing bloatedness. You review the patient and witness him vomit profusely.

what is this common post-operative complication? how would you manage it?

Answer 47

Ileus (post-operative) - abdominal pain, vomiting and bloating post surgery.

anastomotic leak may present similarly but will have pyrexia rather than normal obs (it is a cause of post op fever), and possibly sepsis.

raised wcc and crp common after surgery so cant use to distinguish

NG decompression
nil by mouth
check and replace electrolytes

Question 48

key side effect of etomidate when used for rapid sequence induction?

Answer 48

adrenal suppression

Question 49

you need to learn ASA classification

Question 50

what anaesthetic should be avoided in a patient with a pneumothorax?

Answer 50

Nitorus oxide -> May diffuse into gas-filled body compartments → increase in pressure

Question 51

Name an anaesthetic/induction agent that has moderate to strong analgesic properties and thus can be used in emergency settings eg amputation

Answer 51

ketamine - also good in these settings as doesnt cause a drop in BP

(the common IV induction agents = propofol, sodium thiopentone, ketamine, etomidate)

Question 52

name an anaesthetic muscle relaxant that is contraindicated in penetrating eye injury and in acute angle glaucoma

Answer 52

suxamethonium - increases intraocular pressure

Question 53

A 27-year-old patient involved in a car crash is treated in the intensive care unit. The patient has a difficult airway and has had several traumatic intubations during his ICU stay and now has a persistent air leak in the ventilator circuit. He is developing recurrent hospital-acquired pneumonia.

On examination, crackles and dullness to percussion are heard at the lung bases. Breath sounds are present throughout the lung fields.

most likely reason for patients recurrent pneumonia?

Answer 53

tracheo-esophageal fistula

atelectasis or pneumothorax = decreased breath sounds

Question 54

when are laxatives required before colonoscopy?

Answer 54

day before the exam

Question 55

Patients over the age of 65 may need an ECG before major surgery.
Patients with renal disease may need a full blood count and an ECG depending on their ASA grade even before intermediate surgery.
Patients with hypertension do not need any specific investigations pre-operation.
Patients with diabetes may need an ECG before intermediate surgery.

CXR are NOT recommended routinely before surgery

Question 56

a fractured femur and chest pain following a car crash. Her past medical history includes poorly controlled asthma. She is admitted for surgical repair and her pain relief includes general anesthesia, nitrous oxide, and an epidural. You notice she is becoming more breathless and is complaining of chest pain. Her observations are respiratory rate 30/min, BP 70/50mmHg, heart rate 150/min, and temperature 37ºC. On examination, her left chest is hyper-resonant.

What is the likely cause of her deterioration?

Answer 56

nitrous oxide!!!

the patient has a pneumothorax - evidenced by hyperresonant chest

Question 57

when is VTE prophylaxis started for patients? give an example of one

Answer 57

6 hours post surgery

deltaparin sodium (a LMWH)

can also give ted stockings

Question 58

You are the surgical F1 on call and are bleeped to go and review Mr Jones, a 62-year-old who underwent a right sided total hip replacement 6 hours previously. He has type 2 diabetes mellitus but is otherwise healthy. The nursing staff are concerned as his catheter output has steadily declined and has been 40ml over the last two hours. He has also been drowsy since returning to the ward. The urine is very concentrated but is draining slowly.

Answer 58

500ml 0.9% saline -> symptoms due to hypovolemia rom intraoperative blood loss or dehydration

Question 59

head injury, unconscious, next step to ensure airway is protected?

Answer 59

jaw thrust maneuvre!!!

preferred over head tilt and chin lift if there is a concern about cervical spinal injury

Question 60

halothane is hepatotoxic and should be avoided in patients with hepatic dysfunction

Question 61

name and describe the 3 stages in the WHO surgery safety checklist

Answer 61

1) Before the induction of anaesthesia (sign in)
2) Before the incision of the skin (time out)
3) Before the patient leaves the operating room (sign out)

Question 62

in patients taking prednisolone, what do you need to do before surgery?

Answer 62

supplement with hydrocortisone

Question 63

first step in management of wound dehiscence with protruding bowel?

Answer 63

call for senior help - surgical emergency

Question 64

rapid sequence induction is used in patients with life threatening injuries

RSI involves an induction agent (to lead to unresponsiveness) and a neuromuscular agent (to allow muscular relaxation and insertion of an airway device).

what is the nueromuscular agent of choice?

Answer 64

a depolarizing neuromuscular blocking drug

suxamethonium is first line

Question 65

When is igel used for airways?

Answer 65

In cardiac arrests as they are easier to place then tracheal tubes

Question 66

64 Yo woman scheduled fo have arthroscopy of knee. T2DM. Takes metformin 500mg twice daily. And gliclazide 80mg each morning. Operation first thing in morning. Most appropriate plan for managing diabetes meds? (Ukmla bank q)

Answer 66

Omit gliclazide and continue metformin