Anaesthetics and peri-op

Question 1

where in the spine is epidural analgesia given in c-section

Answer 1

below L2

L3/4 or L4/5

Question 2

how do you calculate fluid deficit

Answer 2

IV fluids given- output of urine

all of this over the same time period e.g. 24 hours

Question 3

ASA grade 1

Answer 3

defined as normal healthy patients, who are non-smokers and with no/minimal alcohol intake.

Question 4

ASA grade 2

Answer 4

defined as patients with mild systemic disease e.g. well controlled diabetes or hypertension, current smoker, obesity (BMI 30-40), and mild lung disease.

Question 5

ASA grade 3

Answer 5

defined as patients with severe systemic disease e.g. poorly controlled diabetes or hypertension, COPD, morbid obesity (BMI >40), history of ACS/stroke/TIA >3 months ago.

Question 6

ASA grade 4

Answer 6

defined as patients with severe systemic disease that is a constant threat to life e.g. MI/stroke/TIA within 3 months, severe valve dysfunction, severe reduction in ejection fraction, sepsis.

Question 7

ASA grade 5

Answer 7

defined as moribund patients not expected to survive the operation e.g. ruptured abdominal aortic aneurysm, massive bleed, intracranial haemorrhage with mass effect.

Question 8

ASA grade 6

Answer 8

defined as a patient declared brain-dead whose organs are being removed for donation.

Question 9

what is first line for acute alcohol withdrawal

Answer 9

lorazepam

works quicker than chlordiazepoxide

Question 10

most likely cause of post op pyrexia within 24 hours

Answer 10

physiological SIRS

Question 11

which GA is particularly useful for patients with a high risk of post-operative vomiting

Answer 11

propofol

Question 12

when should nitrous oxide be avoided

Answer 12

in pneumothorax,

increases pressure in gas filled cavities, in this case leading to tension pneumothorax

Question 13

in terms of blood products, what should be done if transfusion is unlikely to be needed

Answer 13

just group and save

Question 14

in terms of blood products, what should be done if transfusion is likely to be needed

Answer 14

cross match 2 units

Question 15

in terms of blood products, what should be done if transfusion is definitely needed

Answer 15

cross match 4-6 units

Question 16

which induction agents are problematic in myasthenia gravis patients?

Answer 16

non-depolarising agents e.g. rocuronium

work by antagonism of nicotinic acetylcholine receptors in the motor end plate, producing paralysis by their blockade.The myasthenic patient has fewer available nicotinic receptors due to autoimmune-mediated destruction, meaning that they are more sensitive to non-depolarising blockade.

Question 17

benefit of nasogastric jejunal feeding

Answer 17

Avoids problems of feed pooling in stomach (and risk of aspiration)

Safe to use following oesophagogastric surgery

Question 18

adverse effects of volatile liquid anaesthetics
(isoflurane, desflurane, sevoflurane)

Answer 18

• Myocardial depression
• Malignant hyperthermia
• Halothane (not commonly used now) is hepatotoxic

Question 19

which IV anaesthetic causes adrenal suppression

Answer 19

ethomidate

Question 20

which IV anaesthetic causes laryngospasm

Answer 20

thiopental

Question 21

requirement for CT head within the hour

Answer 21

GCS < 13 on initial assessment
GCS < 15 at 2 hours post-injury
suspected open or depressed skull fracture
any sign of basal skull fracture (haemotympanum, ‘panda’ eyes, cerebrospinal fluid leakage from the ear or nose, Battle’s sign).
post-traumatic seizure.
focal neurological deficit.
more than 1 episode of vomiting

Question 22

early causes of post-op pyrexia (0-5 days)[5]

Answer 22

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

Question 23

late causes of post-op pyrexia (>5 days)

Answer 23

Venous thromboembolism
Pneumonia
Wound infection
Anastomotic leak

Question 24

causes of post op fever

Answer 24

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

Question 25

surgery requiring a long fasting period of more than one missed meal or whose diabetes is poorly controlled require what

Answer 25

variable rate insulin infusion

Question 26

example of hepatotoxic agent

Answer 26

halothane

Question 27

anaesthetic with antiemetic properties

Answer 27

propofol

Question 28

which anti diabetic drugs can be used on the day of the surgery [2]

Answer 28

gliptins and GLP analogues

Question 29

signs of wound dehiscence

Answer 29

bowel protruding
wound rupture

urgent senior review

Question 30

why should hypotonic saline be avoided in children

Answer 30

risk of hyponatraemic encephalopathy

Question 31

how long before surgery can patients have fluids

Answer 31

2 hours before

drinking clear fluids before the operation can help reduce headaches, nausea and vomiting afterwards

Question 32

bowel prep for colonoscopy

Answer 32

no food for 24 hours before exam
have laxatives day before

Question 33

agent with strongest analgesic effect

Answer 33

ketamine

Question 34

which agents can cause myocardial depression

Answer 34

propofol and sodium thiopentone

Question 35

which agent may cause pain on IV injection

Answer 35

propofol

Question 36

MoA of lidocaine

Answer 36

blockage of sodium channels