- A 61-year-old man has been brought to the emergency department intubated and ventilated. Examination reveals a large frontal haematoma and a single dilated, but reactive, pupil. His abnormal observations are a blood pressure of 180/100 mmHg, heart rate of 45 bpm and temperature of 35.5°C. An arterial blood gas shows Pao₂ 13 kPa, Paco₂ of 6.9 kPa and blood glucose 8 mmol/L.
Which of the following parameters should be your priority when attempting to acutely improve this patient’s cerebral perfusion?
A Temperature
B Paco₂
C Blood pressure
D Pao₂
E Blood glucose
B
- B Paco₂
This patient is showing signs of raised intracranial pressure (ICP) from an, as yet,
undiagnosed cause. The dilated pupil infers imminent risk of coning. The priority is
to reduce ICP and optimise cerebral perfusion to prevent secondary ischaemia.
Ordinarily, cerebral blood flow (CBF) is autoregulated across a range of cerebral
perfusion pressure (CPP) (Figure 9.1). This mechanism is uncoupled in the event of
traumatic brain injury (TBI).
- You are anaesthetising a 78-year-old man for a right upper lobectomy and lymphadenectomy for adenocarcinoma via video assisted thoracoscopic surgical approach (VATS). He is a long-term smoker, has chronic obstructive pulmonary disease (COPD) and takes aspirin 75 mg o.d. His FEV1 is 1.5 L. Despite your best efforts, you fail to site a thoracic epidural.
Which of the following would be the most appropriate technique to optimise this gentleman’s perioperative analgesia?
A Single shot paravertebral injection at T6
B Ask the surgeon to site a paravertebral catheter
C Run a remifentanil infusion perioperatively and leave the patient intubated
overnight
D Ask the surgeon to site an intrapleural catheter
E Perform intercostal blocks at T5–8
B
- B Ask the surgeon to site a paravertebral catheter
The aims of analgesia in this scenario are:
• To use a technique that covers the wide surgical field: The camera is inserted at
approximately T8 in the mid clavicular line, with ports between T9 +/– T5. Further
pain may be felt from any trauma to the parietal pleura adjacent to the right
upper lobe
• To allow thoracotomy and rib resection if required: The rate of conversion to
open thoracotomy is around 10%, and the need for a lymphadenectomy, which
may be technically difficult, may increase this conversion rate further
• To provide effective intra- and postoperative analgesia: The patient has
significant respiratory disease and effective analgesia will allow extubation,
spontaneous ventilation and coughing. Prompt extubation reduces the risk of
ventilator associated complications in the critical care unit, therefore option C is
not the best choice here
Although thoracic epidural analgesia is seen as the gold standard for this scenario,
injection of local anaesthetic into the paravertebral space aims to block spinal
nerves as they leave the intervertebral foramina; providing unilateral analgesia with
a degree of sympathetic blockade. A single shot injection may give analgesia for
over 20 hours but use of a catheter allows infusion of local anaesthetic in the post
operative period and is the best option of those listed here (option B).
In light of failed attempts to site a thoracic epidural, it may be kinder to perform
further procedures when the patient is asleep; surgically placed catheters during
VATS have been described and it would be worth asking the surgeon whether they
can perform this procedure in the first instance.
Intrapleural local anaesthetic, that is administration of local anaesthetic into the
space between the parietal and visceral pleura, would diffuse around the intercostal
nerves as they travel between the inner and innermost intercostal muscles.
However, disruption of the pleura leads to erratic absorption, potential leakage
into any intercostal drains sited and so less effective analgesia. Systemic absorption
via this route is high so option D is neither the safest nor the most effective of
those given. Intercostal blocks (option E) in general do not have adequate duration
for this scenario and offer inadequate analgesia compared with paravertebral
techniques.
- You are asked to urgently review a 57-year-old man 7 days post left pneumonectomy.
He remained intubated and ventilated for 24 hours post operatively due to intraoperative bleeding and hypothermia. A left sided intercostal drain was removed 24 hours ago. He is now complaining of cough, shortness of breath and chest pain. His oxygen saturations are 89% on 15 L/min oxygen.
On examination there is new subcutaneous emphysema of the chest wall. Heart rate is 60 beats per minute and blood pressure is 80/50 mmHg.
What is the most appropriate next step?
A Urgent chest radiograph (CXR)
B Needle thoracocentesis followed by insertion of 22F intercostal drain
C Immediate insertion of a 12F intercostal drain by the Seldinger technique
D Urgent bronchoscopy
E Urgent CT scan and thoracic surgical opinion
B
- B Needle thoracocentesis followed by insertion of 22F
intercostal drain
The clinical signs are suggestive of a massive air leak, possibly from breakdown
of the bronchial stump. There are signs of cardiovascular impairment (including
paradoxical bradycardia) suggesting impending cardiovascular collapse. The most
likely diagnosis is a bronchopleural fistula leading to tension pneumothorax that
should be decompressed immediately by needle thoracocentesis. Other diagnoses
could include delayed infection and bleeding so it would be prudent to follow
needle decompression with a larger bore (22F) intercostal drain. A smaller 12F
drain inserted via the Seldinger technique may not drain blood/purulent matter
adequately and takes more time to site. Obtaining a chest radiograph often takes
time that may be detrimental in this scenario.
Risk factors for bronchopleural fistulae include increased age, poor wound healing,
pneumonectomy, previous chemo/radiotherapy and prolonged mechanical
ventilation postoperatively.
Although bronchoscopy +/– CT thorax may be needed to make the diagnosis and
assess for any other complications (e.g. empyema) when the patient stabilises, the
priority is restoration of oxygenation and adequate cardiovascular parameters.
- A 3-year-old boy is under general anaesthesia for the removal of a foreign body partially obstructing his right main bronchus via rigid bronchoscopy. He is breathing spontaneously and receiving sevoflurane in air. Foreign body instrumentation is difficult and after prolonged grasping attempts and suctioning,
he becomes bradycardic with a heart rate of 25 beats per minute.
What is the most likely cause of his clinical deterioration?
A Hypoxia
B Depth of anaesthesia
C Hypothermia
D Hypercarbia
E Vasovagal reflex
E
- A Hypoxia
Foreign body aspiration is a dangerous condition most frequently seen in infants
where inadvertent aspiration of objects disrupts the normal airway structure and
function. The classic triad of symptoms consists of paroxysmal coughing, wheezing
and reduced breath sounds on the affected side occurring after a witnessed choking
episode. It is a leading cause of death in 1–3 year olds and its safe management is
challenging to both surgeon and anaesthetist.
The gold standard for managing foreign body aspiration in children is removal via
rigid bronchoscopy under general anaesthesia. The instrument most commonly
used in children is the Storz ventilating bronchoscope which consists of a metal
tube and a removable optical scope (Hopkins rod). During instrumentation, the
optical scope is within the lumen of the bronchoscope and provides excellent
visualisation of the airway. The scope however significantly reduces the lumen
of the bronchoscope available for ventilation and should only be used for short
periods. Hypoventilation is a real possibility especially if the patient is spontaneously
ventilating.
Bradycardias during bronchoscopy are uncommon and should be assumed to be
secondary to hypoxia until proven otherwise. Hypoxia can occur if the scope is
placed in a bronchus or if instrumentation triggers bronchospasm. Furthermore,
when excessive suctioning is performed, there may be atelectasis and a reduction
in the inspired oxygen concentration. Also, a feared complication which can cause
hypoxia acutely is dislodgement of the foreign body into the trachea creating
complete obstruction of the airway.
In order to reduce the risk of foreign body dislodgement whilst allowing
spontaneous ventilation, anaesthesia needs to be deep enough to minimise
coughing and moving without paralysis. Excessive anaesthesia to achieve this can
trigger bradycardias, but it is not the most likely cause in the above scenario. The
arrhythmia occurred after prolonged instrumentation which would have restricted
the spontaneous ventilation and elevated the boy to a lighter plane of anaesthesia.
Children are commonly affected by inhaled foreign bodies and it is important for the
anaesthetist to also be aware of the challenges of paediatric anaesthesia. Children
are at more risk of becoming hypothermic during anaesthesia which if severe, can
cause arrhythmias. The patient’s core temperature in the above case however is
highly unlikely to be sufficiently low to produce this response.
Bradycardias during bronchoscopy are uncommon and should be assumed to be
secondary to hypoxia until proven otherwise. Hypoxia can occur if the scope is
placed in a bronchus or if instrumentation triggers bronchospasm. Furthermore,
when excessive suctioning is performed, there may be atelectasis and a reduction
in the inspired oxygen concentration. Also, a feared complication which can cause
hypoxia acutely is dislodgement of the foreign body into the trachea creating
complete obstruction of the airway.
- A 48-year-old woman has had an arthroscopic rotator cuff repair. She has received a general anaesthetic, a supraglottic airway was inserted and had an interscalene block. Her surgery finished at midday.
Which of the following is most likely to prevent her from being discharged on the day of surgery?
A Lives in a rural location 30 minutes by car to the nearest hospital
B Has an adult relative to act as carer at home only until 20.00
C Hasn’t yet passed urine
D Is taking a public taxi home with an adult relative
E Has residual upper arm weakness
B
- B Has an adult relative to act as carer at home only until
20.00
In the ‘ten high impact changes’ document published by the NHS Modernisation
Agency it is outlined that day surgery, rather than inpatient surgery, should be
treated as the norm for all elective surgery. Locally agreed protocols exist in most
day case units for selection and exclusion criteria. These fall broadly into medical,
surgical and social considerations (Table 9.1).
Medical
Preoperative assessment of a
patient’s health status should
be made to determine eligibility
rather than use of arbitrary limits,
e.g. BMI, ASA, age
Chronic stable disease may be
better treated as day case
Surgical
Procedure should not pose any
serious complications, e.g. risk of
haemorrhage and cardiovascular
instability
Oral medications and local
anaesthetic techniques should
be sufficient to manage post
operative symptoms
Procedure should not prevent
resumption of oral intake within
a few hours
Patients should be able to
mobilise but full mobilisation is
not always required
Social
Patients must understand
procedure, postoperative
care and be able to consent
to day surgery
A responsible adult should
escort the patient home and
be present for the first 24
hours postoperatively
Domestic circumstances
should be appropriate for
postoperative care
- A 78-year-old man is listed for a transurethral resection of his prostate (TURP) under spinal anaesthesia. He has moderate to severe chronic obstructive pulmonary disease (COPD) with ongoing steroid use, ischaemic heart disease, and had a coronary stent inserted 15 months ago.
He normally takes aspirin and clopidogrel, but has not been taking the latter for “a few weeks”.
He has also recently started taking rivaroxaban 10 mg at night for an irregular heart rate.
What is the safest way to proceed?
A Ensuring 18 hours after the last dose of rivaroxaban, give a spinal, and then start a heparin infusion postoperatively
B Give a spinal now and use treatment dose low molecular weight heparin
(LMWH) from 2 hours postoperatively
C Wait until 24 hours after the last dose of rivaroxaban, then proceed with a spinal, and give the next dose immediately postoperatively
D Ensure 12 hours after the last dose of rivaroxaban, and give prophylactic LMWH 6 hours postoperatively
E Discuss with the patient the increased risks of central neuraxial blockade and
proceed under general anaesthesia
D
- A Ensuring 18 hours after the last dose of rivaroxaban, give a
spinal, and then start a heparin infusion postoperatively
Vast numbers of patients present for surgery on antiplatelet drugs. The perioperative
management of these medications commonly falls to anaesthetists to coordinate,
and there is a significant overlap also in the assessment of cardiac risk for noncardiac
surgery. A solid understanding of these issues will help in preparation for
both the written and viva elements of the Final FRCA.
Aspirin and clopidogrel
Aspirin is an irreversible inhibitor of platelet cyclooxygenase (COX), and thus normal
platelet function relies on new platelet manufacture, which takes approximately 7
days. Aspirin is not contraindicated in central neuraxial blockade (CNB), as the risk of
haematoma is not elevated.
Conversely, clopidogrel is associated with haematoma formation in case reports. It
is a thienopyridine adenosine diphosphate (ADP) blocker, and published advice is to
avoid for at least 7 days prior to CNB. Prasugrel, a more potent thienopyridine, should
be avoided for 7–10 days and not restarted until 6 hours after block or catheter
removal, where clopidogrel can be given just afterwards.
Tirofiban/abciximab
These two are glycoprotein IIb/IIIa blockers, in the case of abciximab this is via
binding of a monoclonal antibody. Tirofiban is the shorter acting of the two, and
CNB can be attempted after 8 hours, whereas antibody persistence means a duration
of 24–48 hours is needed for abciximab.
____________________________________________
Dabigatran/rivaroxaban
Dabigatran is an oral thrombin inhibitor only licensed for venous thromboembolism
(VTE) prophylaxis after surgery. CNB should not be established in patients already
on this drug, as it is contraindicated by the manufacturer. It can be started 6 hours
after the risk period. Rivaroxaban is a direct oral inhibitor of factor Xa. It is becoming
more common as the list of approved indications increases. Previously only for
postoperative VTE prophylaxis, it is now being used in AF and in Europe as an
adjunct to aspirin and clopidogrel in acute coronary syndromes. CNB should be
12–18 hours post-dose, and the drug should only be given 6 hours after a block or
catheter removal.
- A 64-year-old man undergoes hip surgery under general anaesthesia. He is positive pressure ventilated through a size 5 laryngeal mask airway and anaesthesia is maintained with nitrous oxide and sevoflurane. In recovery, he complains of
paraesthesia over the right anterior aspect of his tongue. There is no dysphagia or
dysarthria and tongue appearance and movements are normal.
What is the most likely cause of his neurological signs in recovery?
A Hypoglossal nerve injury
B Lingual nerve injury
C Recurrent laryngeal nerve injury
D Inferior alveolar nerve injury
E Venous drainage obstruction
A
- B Lingual nerve injury
The laryngeal mask airway (LMA) is a versatile supraglottic airway device which
consists of a tube connected to an inflatable cuff which surrounds a mask designed
to seal off the laryngeal inlet from the gastrointestinal tract. However, it is not a
definitive airway and vigilance against aspiration is advised particularly when used
in conjunction with positive pressure ventilation. Another recognised complication
associated with laryngeal mask airway ventilation is pressure neurapraxia to
anatomically vulnerable nerves within the pharynx or oral cavity.
A neurapraxia refers to a localised and transient conduction block along a nerve
without any anatomical interruption, which in the above case is likely to be caused
by pressure from the cuff. Predisposing factors include the use of nitrous oxide, cuff
over-inflation, using an undersized laryngeal mask airway, the lateral position and a
difficult insertion.
The lingual nerve is a branch from the mandibular division of the trigeminal
nerve and supplies sensory innervation to the anterior 2/3 of the tongue. It also
carries sensory taste fibres from the anterior tongue to the facial nerve via the
chorda tympani. Damage to the lingual nerve characteristically produces a loss of
sensation and taste confined to one side of the anterior tongue without any motor
dysfunction. Although rare, lingual nerve neurapraxia is a recognised complication
- A patient with an acute subarachnoid haemorrhage is undergoing coil embolisation of the aneurysm in the interventional neuroradiology suite.
Anaesthesia is induced with alfentanil, propofol and rocuronium. Maintenance of anaesthesia is with sevoflurane and remifentanil infusion. Shortly after intubation
the observations are as follows:
• Blood pressure: 220/110 mmHg
• Heart rate: 90 beats per minute
• Spo2 98%
• ETCO2 4.9 kPa
• End-tidal sevoflurane 1.9%
What is the most appropriate initial management?
A Alert radiologist
B Increase depth of anaesthesia
C Increase minute ventilation
D Give mannitol 1 g/kg
E Start intravenous esmolol infusion
E
- A Alert radiologist
General anaesthesia is often used for aneurysm coiling as it allows control over
parameters to provide optimal cerebral perfusion pressure (CPP), and provides an
immobile patient. These procedures are carried out often in a site remote from the
theatre complex and can be long.
A sudden rise in blood pressure should alert the anaesthetist to the possibility of
aneurysm rupture, which has an intraoperative incidence of 2–19%. Rupture can
occur spontaneously, during induction, or as a result of guidewire, microcatheter
or coil placement. The priority during induction of anaesthesia is to avoid a
hyperdynamic response to laryngoscopy, whilst maintaining adequate cerebral
perfusion pressure. The pressor response can be attenuated using co-induction with
short acting opiates and beta-blockers and confirming adequacy of muscle paralysis
prior to intubation.
Signs of rupture and bleeding under anaesthesia may be subtle and the
radiologist should be immediately alerted of any sudden haemodynamic
changes. Depending on the stage of procedure and degree of bleeding, coiling
may continue, but transfer to theatre may be required for ventriculostomy
or rescue craniotomy and clipping, so assistance should be sought early. The
other options in this question are appropriate actions but should follow after
communication of the changes to the radiologist in case of rupture. Interventions
can then be made to control arterial pressure by deepening anaesthesia or using
beta-blockers and if necessary to control intracranial pressure by head elevation,
maintaining Paco₂ to 4.5–5.0 kPa, administering mannitol or reversing any heparin
administered with protamine.
Other complications that can occur during these procedures are thromboembolic or
iatrogenic occlusion of a vessel, vasospasm, contrast reactions, and displacement of
lines and tubes by movement of the image intensifier.
- A 10 kg child with no comorbidities is scheduled for an elective umbilical hernia repair as a day case. Which of the following would be the best regime of injectate for caudal epidural analgesia?
A 10 mL of 0.25% levobupivacaine with 10 μg fentanyl
B 10 mL of 0.25% levobupivacaine
C 10 mL of 0.25% plain bupivacaine with 300 μg diamorphine
D 10 mL of 0.25% levobupivacaine with 25 μg clonidine
E 10 mL of 0.25% bupivacaine
A
- B 10 mL of 0.25% levobupivacaine
Caudal epidural analgesia is the commonest regional technique used in children. It
is suitable for all infraumbilical surgery, including hypospadias repair, circumcision
and inguinal or umbilical hernia repair. It provides a reliable block between T10 and
S5 in children less than 20 kg. The combination of minimal side effects and excellent
analgesia make it suitable for day case surgery.
Since motor block is poorly tolerated in awake children, local anaesthetic choice
prioritises weakest motor block and the long lasting analgesic effects possible.
Although bupivacaine meets these criteria, levobupivacaine and ropivacaine are the
drug of choice in paediatric practice. They produce a differential block by preserving
the motor function with the same analgesic effect. They also have less cardiac and
central nervous system toxicity.
The volume of caudally injected local anaesthetic determines the spread of the block
and must be adapted to the procedure. Doses described by Armitage are the most
frequently used regimen in current paediatric practice:
Sacro-lumbar block: 0.5 mL/kg, 0.25% bupivacaine or levobupivacaine
Upper abdominal block: 1 mL/kg, 0.25% bupivacaine or levobupivacaine
Mid-thoracic block: 1.25 mL/kg, 0.25% bupivacaine or levobupivacaine
- A 65-year-old man for elective thoracotomy and pulmonary lobectomy is to have a thoracic epidural for perioperative analgesia.
Which of the following is the best approach for epidural insertion?
A A midline mid-thoracic epidural under general anaesthesia
B A paramedian mid-thoracic epidural under light sedation or awake
C A paramedian lower-thoracic epidural under general anaesthesia
D A midline upper lumbar epidural under light sedation or awake
E A midline mid-thoracic epidural under light sedation or awake
B
- B A paramedian mid-thoracic epidural under light
sedation or awake
Thoracic epidural analgesia is commonly used in cardiothoracic surgery for
providing sympatholysis and pain relief during and after operations. The main
objective is to allow cardiothoracic pain-free patients to breath adequately, cough
and cooperate with chest physiotherapy.
A good anatomical knowledge is essential for successful epidural block. The spinous
processes of cervical, thoracic and lumbar vertebrae have different alignment. They
are posteriorly directed and relatively straight at the cervical, lower thoracic and
lumbar levels. However, they are caudally inclined in the high- and mid-thoracic
regions. The highest degree of angulation is at T3–T7, making the paramedian
approach easier at this level.
- An 84-year-old ASA 3 woman is listed for multilevel facet joint injections and a caudal epidural by the orthopaedic surgeons. The patient will need to lie in the
prone position. Comorbidities include moderate chronic obstructive pulmonary disease (COPD), angina, hypertension and chronic lower back pain. Alongside all her cardiovascular medications she takes regular co-dydramol and amitriptyline
for her pain.
The safest anaesthetic technique for this procedure is:
A 0.25–0.5 mg/kg intravenous ketamine
B Local anaesthesia only with no sedation
C Infusion of remifentanil at 0.25 mg/kg/min
D Target controlled infusion of propofol at a 1 mg/mL
E 0.5 μg/kg fentanyl followed after several minutes by small doses of intravenous midazolam titrated to effect
B
- E 0.5 μg/kg fentanyl followed after several minutes by
small doses of intravenous midazolam titrated to effect
Sedation is required in a myriad of clinical settings and across many specialties.
Complications arise not uncommonly and not just from the inappropriate use
of agents, but from the inadequate skills and training of operators, poor patient
assessment, and lack of or failure to use appropriate levels of monitoring. Despite
the fact that anaesthetists have the detailed knowledge and skills required to give
sedation safely, few had received any formal training in sedation per se. Thus, since
August 2010, the curriculum for anaesthetic training now includes sections on
sedation.
The key here is that the procedure (and also the positioning) itself is uncomfortable,
even with local anaesthesia infiltration. The patient also takes an opioid in the
community, and has established chronic back pain. Thus analgesia is essential.
Ketamine would provide sedation and analgesia, but the sympathomimetic effects
may be best avoided in the setting of her angina, the severity of which is not stated.
Remifentanil, despite being a nearly ideal short-acting opioid, carries the significant
risk of respiratory suppression. Thus the best combination is fentanyl, followed later
by small aliquots of midazolam.
- A 62-year-old non-diabetic woman presents to the intensive care unit with severe
urosepsis.
Which of the following glucose levels would be the most appropriate to target?
A > 4 mmol/L
B 4–6 mmol/L
C 6–8 mmol/L
D < 10 mmol/L
E < 15 mmol/L
C
- D < 10 mmol/L
Whilst poor glycaemic control is associated with worse morbidity and mortality, the
optimal glucose level remains controversial. Early trials suggested benefit from tight
glycaemic control (4–6 mmol/L), however recent evidence suggest that there is no
additional benefit and in fact, may cause possible harm.
Leuven I was a single centre trial of surgical intensive care unit patients comparing
intensive (tight) to conventional glucose control. The results suggested a 34%
decrease in mortality with tight glucose control, with additional reductions in the
occurrence of sepsis, acute renal failure and critical illness polyneuropathy. However
these results were not concurred in a subsequent trial (Leuven II) by the same
author in medical intensive care patients. The uncertainty lead to a large multicentre
randomised control trial (Normoglycemia in Intensive Care Evaluation-Survival
Using Glucose Algorithm Regulation; NICE SUGAR) in 2009. 6,000 patients were
randomised to tight (4.5–6 mmol/L) or conventional glucose control (< 10 mmol/L).
The results of NICE SUGAR suggested an increase in mortality (27.5% vs 24.9%) and
a significant increase in hypoglycemic events (6.8% vs 0.5%) in the tight versus the
conventional glucose control groups. The trial evidence was incorporated into the
‘2010 International recommendations for glucose control in the adult non-diabetic
critically ill’:
• < 10 mmol/L strongly suggested
• severe hypoglycemia is defined as < 2.2 mmol/L
• glucose levels should be sampled from arterial rather than capillary or venous
blood, using laboratory or blood gas analysers rather than point of care anaylsers
- A 19-year-old male motorcyclist is admitted following a high speed road traffic accident. The retrieval team report he has clinical evidence of bilateral flail segments and a significant neurological injury. He is intubated and sedated by the retrieval service with intermittent doses of ketamine, propofol and rocuronium and arrives to the intensive care unit. He has been haemodynamically stable with moderate and escalating ventilator requirements.
The most appropriate sedation regime for this patient on the intensive care unit would be:
A Propofol and fentanyl
B Clonidine and fentanyl
C Midazolam and fentanyl
D Ketamine and fentanyl
E Fentanyl alone
A
- A Propofol and fentanyl
Sedation protocols are diverse and consideration of the purpose of sedation, patient
characteristics and the pharmacology of the sedative agents should guide the
decision. The purpose of sedation is to allow a reduction in patients’ awareness and
their response to external stimuli. Under-sedation results in hypercatabolism and
increased sympathetic activity, which can have detrimental effects, for example
myocardial ischaemia. However, oversedation is problematic resulting in increased
mechanical ventilation days, respiratory and cardiovascular depression, delayed
neurological recovery and impairs muscular rehabilitation. It is important that
sedation is titrated to the individual patient’s requirement; scoring systems such as
the Richmond Agitation Sedation Scale (RASS) aid this.
In this example, the patient has been involved in a high speed injury and sustained
a neurological injury and a severe thoracic injury. While the extent of his injuries
are ascertained it is sensible to keep him sedated. Clearly in this patient, who has
escalating ventilator requirements, potentially life threatening injuries such as a
pneumothorax need to be excluded. However, the extent of his neurological injury
will need to be assessed at the earliest opportunity, necessitating an early sedation
hold.
- A 26-year-old woman who is 32/40 pregnant had a witnessed collapse whilst shopping. She received bystander cardiopulmonary resuscitation (CPR) and advanced life support (ALS) by the paramedics for one hour prior to transfer to a
teaching hospital.
In hospital, a Caesarean section was performed immediately. ALS continued for a further 45 minutes without return of spontaneous circulation and a profound metabolic acidosis developed.
What now is the most appropriate management option?
A Terminate life support and organise a team debrief
B Administer thrombolysis and continue ALS
C Continue ALS until the intensive care consultant arrives
D Commence extra-corporeal membrane oxygenation (ECMO)
E Administer 10–20 mL of 8.4% sodium bicarbonate
A
- D Commence extra-corporeal membrane oxygenation
(ECMO)
This scenario is based on a real case and this patient and her child both survived to
discharge neurologically intact.
ECMO uses technology refined from cardiopulmonary bypass circuits used for cardiac
surgery. As the technology advances and with the opportunity to gain experience in
its use (the H1N1 swine-flu epidemic of 2009) the complication rates have decreased.
The CESAR trial evaluated the benefits of ECMO in adult respiratory distress syndrome
(ARDS) and demonstrated that patients transferred to a centre offering ECMO had a
better outcome (less death or severe disability at 6 months) than those treated at the
original hospital with conventional therapy. However, treatment at the ECMO centre
did not always involve ECMO and the improvement in outcome was not shown when
comparing ECMO verses conventional ventilation at the ECMO centre.
An ECMO circuit can be set up in three ways:
• Venoarterial ECMO: blood is pumped from the venous to the arterial side
allowing gas exchange and haemodynamic support
• Venovenous: blood is removed from the venous side and then pumped back into
it facilitating gas exchange only
• Arteriovenous: arterial pressure moves the blood from the arterial side to the
venous side and facilitates gas exchange. No mechanical pump is required.
The large-bore cannulae are placed surgically or with a percutaneous approach
under ultrasound or X-ray guidance. The circuit is more effective at carbon dioxide
removal than oxygenation due to differences in solubility between the two gases.
Anticoagulation is required as the circuit activates the coagulation cascade
Complications include:
• Haemorrhagic complications (50% of patients):
–– 50% of these due to the cannulation, especially at the arterial site
–– Intracranial bleeding (5%)
–– Bleeding may occur in any organ
• Thrombosis in the circuit can:
–– Affect the function of the pump or the oxygenator
–– Cause stroke
–– Result in leg ischaemia
• Infective complications can be related to the invasive lines or primary pathology
• Technical complications include:
–– ECMO circuit failure or breakage
–– Cannula displacement
–– Mechanical pump failure
Returning to the scenario, this young woman who has had continuous CPR and has
not responded to support measures should be considered for ECMO if it is available.
To ensure the best outcome, oxygenated blood flow to the brain should be restored
as early as possible. Pregnancy is an absolute contra indication to thrombolysis as
is having a major operation within 14 days. After a rushed emergency department
cesarean section with a low cardiac output state (and therefore difficulty identifying
bleeding points) thrombolysis would have a high complication rate may only be
considered if no alternative was available.
- A 76-year-old woman has had an upper gastrointestinal bleed and presented with an acute kidney injury. After resuscitation and an oesophago-duedenoscopy she
is admitted to the intensive care unit for renal replacement therapy. The nurse requests that you prescribe the particulars of renal haemofiltration including the anticoagulation.
The most appropriate choice is:
A Unfractionated heparin loading dose followed by a pre-filter infusion
B No anti-coagulation
C Prostacyclin infusion
D Sodium citrate pre-filter infusion
E Increasing the fraction of replacement fluid added before the filter
D
- C Prostacyclin infusion
One third of critically ill adults develop an acute kidney injury and 5% of these will
require renal replacement therapy. This question highlights some of the complexities
of managing a patient on renal replacement therapy.
The indications for renal replacement therapy include:
• Fluid balance management
• Hyperkalaemia (potassium over 6.5 mmol/L)
• Metabolic acidosis (pH < 7.1)
• Raised urea (> 30 mmol/L) or symptomatic ureamia
• Severe sepsis to remove inflammatory mediators
• Removal of water-soluble, low protein-bound drugs, e.g. some antibiotics to
increase dose administered.
The different types of renal replacement therapy are:
• Haemo-(ultra)filtration: venous blood is pumped into an extra-corporeal
circuit which creates a hydrostatic pressure gradient across a semi-permeable
membrane. Plasma (ultrafiltrate) and molecules of less than 50,000 Daltons are
forced across by convection. The plasma is replaced by fluid either before or after
the filter to maintain volume and haematocrit
• Haemodialysis: venous blood is pumped into a dialyser in which blood is
separated by a semi-permeable membrane from a countercurrent flow of dialysis
solution. Solute moves along its concentration gradient from blood to dialysis
solution (e.g. urea) or from solution to blood (e.g. bicarbonate) by diffusion
• Haemodiafiltration: this is a combination of the two.
The methods can be applied intermittently or continuously, with continuous
methods (filtration or dialysis) being preferred on the intensive care unit due to
cardiovascular stability.
Anticoagulation is required as all extra-corporeal circuits activate the clotting cascade.
Clot that forms within the catheter causes an access pressure alarm, whereas clot
that forms in the filter will cause a trans-membrane alarm. The latter will reduce the
efficiency of the filter and if it clots of completely then blood within the circuit is lost.
Non-pharmacological methods to prevent clot formation include:
• Ensure adequate driving pressure (venous pressure)
• Ensure adequate flow rates through the vascular-catheter (vascath):
–– Correct site choice (femoral preferred over right internal jugular which is in turn
preferred over left internal jugular veins)
–– Good insertion technique
–– Catheter position and care
• Adding replacement fluid before the filter (pre-dilution) lowers the haematocrit and
reduces the chance of filter clot but reduces the efficacy of the filtration process
If the patient has a coagulopathy (INR > 2, APTT > 60 seconds) no anti-coagulation is
required, however most patients require pharmacological treatment to prolong the
life of the filter.
Therefore, in this patient who has been resuscitated (which in the context of a
gastrointestinal bleed means the coagulation has been normalised), the safest
option in this case would be prostacyclin infused into the filter, which will result in
minimal systemic anti-coagulation and may be reversed by terminating the infusion.
Heparin given into the circuit still causes systemic anticoagulation and increases the
bleeding risk.
- A 65-year-old man is recovering on the high dependency unit after an emergency laparotomy for small bowel perforation for which he received an effective epidural. His background includes treated hypertension, a smoker of 20 cigarettes per day and mild depression. Overnight he becomes very agitated
and confused and attempts to remove his invasive lines and monitoring.
Examination, review of his blood science investigations and blood gas results are all unremarkable.
What is the most appropriate course of treatment?
A Reassure the patient regarding his situation
B Call his wife to hospital to help calm him down
C Prescribe vitamin replacement therapy and benzodiazepine sedation
D Prescribe haloperidol
E Commence sedation with clonidine
D
- D Prescribe haloperidol
Delirium in critically ill patients is common, with 60–80% of patients being affected.
It is characterised by an acute change in cognition and disturbance of consciousness
and may follow a fluctuating course. There is an increased length of ventilation,
intensive care stay, hospital stay, risk of infection, risk of long-term cognitive
impairment and mortality. There is a much higher rate of adverse incidents such as
self-extubation and removal of catheters and lines.
The different types of delirium are:
• Hyperactive delirium (5–22%), which is the case described above, and includes
agitation, hallucinations and aggression
• Hypoactive delirium is more common, presenting with inattention and decreased
situational awareness, but may be peaceful and compliant so is often not diagnosed
• Mixed delirium is a fluctuation between the two extremes above
The risk factors for developing delirium are show in Table 9.2.
There are two different delirium assessment methods in the intensive care unit to be
aware of for the exam, both of which are described in detail in the references below:
• Intensive Care Delirium Screening Checklist (ICDSC): Patients are scored for
alertness from waking, and then their attention, orientation, agitation or
retardation, hallucinations, speech and mood and sleep cycle is scored daily. A
score of 4 or more has a sensitivity of 99% but a low specificity of 64%
• Confusion Assessment Method in the intensive care unit (CAM-ICU): This is
designed for ventilated patients and has a high sensitivity and specificity.
Following a level of consciousness assessment (Richmond agitation sedation scale
is commonly used), attention, organised thinking and ability to follow instructions
is assessed
Preventative management includes ensuring a correct and adequate sleep pattern,
constant information and reassurance regarding their situation and as consistent
as possible attendants (family members are the best). The management of delirium
is multi-factorial, and includes exclusion of reversible organic causes as described
above, which requires an examination and review of relevant investigations.
Pharmacological management can be considered in an escalating fashion:
• Haloperidol 2.5 mg intravenously, doubling the dose every 30 minutes until
settled followed by a regular regime. Side-effects include prolongation of the QT
interval and an extra-pyramidal movement disorders
• Olanzapine 5 mg orally or intramuscularly may be considered as an alternative
• Quetiapine, an atypical antipsychotic is being used increasingly as an alternative
to haloperidol, has equal efficacy and safety, without extra-pyramidal side effects
• Dexmedetomidine, an α2 adrenoceptor agonist, similar to clonidine, has also been
used in ventilated patients with delirium and is as effective as haloperidol. A bolus
of 0.1 mg/kg followed by 0.2-0.7 mg/kg/hour may be used.
It is worth noting that other sedation methods including opioids and
benzodiazepines may contribute to delirium, although benzodiazepines do have a
role in alcohol withdrawal.
The question describes a patient in danger of harming himself in the immediateterm,
and therefore the preventative measures are likely to be unhelpful. There is
no firm evidence of alcohol consumption excess and it is too early in the patients
clinical course to blame this on alcohol withdrawal, therefore benzodiazepine
treatment may exacerbate his condition. The first line treatment is haloperidol,
followed by other measures if unsuccessful.
Table 9.2 Risk factors associated with developing delirium in critically ill patients
Patient Age
Substance abuse (alcohol, smoking, illicit drugs)
Hypertension
Depression
Existing cognitive deficiency
Sensory loss (deafness or blindness)
Clinical conditions Metabolic and electrolyte disturbances (particularly hyponatraemia)
Sepsis
Hypoxia or hypercapnia
Hypotension
Ischaemic myocardial event
Disturbances in blood glucose control
Postoperative pain, urinary retention, constipation
Iatrogenic Sedation or analgesic medication
Day-night cycle disruption
Immobilization
- A 26-year-old woman who is 3 days post-partum has returned to the labour ward complaining of an ongoing headache. She delivered vaginally after having a
lumbar epidural for labour. On the first day postpartum she had complained of a frontal headache that worsened with coughing and had been diagnosed with a post-dural puncture headache (PDPH). At home, she has been taking simple analgesia and drinking plenty of water for the past 2 days but the headache is
persisting.
What is the next best line of management in this situation?
A Encourage her to drink coffee and 3 L of water per day
B Encourage her to drink coffee and prescribe sumatriptan
C Admit her overnight for intravenous fluid therapy, regular analgesia and
further assessment
D Offer her an epidural blood patch
E Offer her an epidural blood patch and perform routine blood cultures at the
same time
D
- D Offer her an epidural blood patch
Post dural puncture headache (PDPH) is a well-known complication of central
neuraxial blockade. In epidural anaesthesia, dural puncture is not always obvious at
the time of the procedure, as the Tuohy needle may nick the dura, but not enough
to cause a frank CSF spill. Patients with PDPH usually present within 72 hours of the
incident with the typical low-pressure headache – worse on standing, coughing,
straining and better on lying supine. The headache is usually frontal or occipital and
may be associated with symptoms such as neck stiffness, photophobia, nausea or
tinnitus. Gutsche’s test may be positive – pressing over the liver with the patient at
45o relieves the headache.
When assessing a patient with suspected PDPH it is important to take a full history
and complete a full neurological examination in order to try to rule out more sinister
differential diagnosis such as meningitis, cortical vein thrombosis, cerebral infarction
and subarachnoid haemorrhage. Other causes such as tension headache, migraine
and sinusitis should also be considered, which a thorough history will help with.
Management can be conservative with hydration, paracetamol and non-steroidal
anti-inflammatory drugs. Bed rest is also encouraged, but this can be impractical
for a nursing mother. Caffeine causes cerebral vasoconstriction and so may provide
some relief of the headache, although concrete evidence of benefit is lacking.
Sumatriptan is a serotonin receptor agonist used for the treatment of migraine,
which again lacks evidence of benefit in PDPH.
This patient has already tried conservative therapies for the past 2 days and the fact
that she has returned to the labour ward suggests that she is not coping. Although
intravenous fluids may help, it is not the best line of management to take next, as an
epidural blood patch (EBP) has the best chance of curing her symptoms. The patient
should be offered an EBP with all the risks and benefits explained. Blood cultures
were at one point taken routinely at the time of an EBP, but this has fallen out of
favour in many units since patients are usually apyrexial and cultures come back
negative. In fact, if a patient was pyrexial, this should deter the performance of an
EBP and prompt further investigation of another cause for the headache
- A 21-year-old woman in antenatal clinic is due to have an elective Caesarean section for breech presentation within the next two weeks. She is concerned
about having a spinal anaesthetic as she has been diagnosed with gestational thrombocytopenia. You review her blood results and her platelet count has been
low but steady.
Which of the following blood results would prevent this lady from having a spinal?
A Platelet count < 50 × 109/L
B Activated partial thromboplastin (APTT) time of 30 seconds
C Platelet count < 100 × 109/L
D Platelet count < 70 × 109/L
E Prothrombin time (PT) of 12 seconds
A
- A Platelet count <50 x 109/L
The risk of developing a spinal or epidural haematoma as a result of central neuraxial
blockade increases in the presence of abnormal coagulation. In the obstetric
population, there may be a number of reasons for abnormal coagulation, including
pre-eclampsia, disseminated intravascular coagulation (DIC) and gestational
thrombocytopenia. If there is any reason to suspect a clotting problem in a patient
who may need central neuraxial blockade, a full blood count and clotting screen
should be checked.
- A 15 kg, 3-year-old girl was brought to the emergency department with a history of choking on a piece of apple 6 hours previously. She appears comfortable and not in
respiratory distress. Her chest sounds clear on auscultation but a chest X-ray shows a right lung that is more inflated and radiolucent compared to the left, particularly on the expiration film.
Suspecting the child has inhaled the piece of apple, the ENT team want to perform an urgent examination under anaesthesia (EUA) with a rigid bronchoscopy and removal of foreign body.
The most appropriate anaesthetic plan for this case is:
A Perform a rapid sequence induction and intubate to secure the airway
B Routine intravenous induction with muscle relaxant. Intubate and ventilate
until rigid bronchoscopy
C Routine intravenous induction with muscle relaxant. Insert a supraglottic
airway device for ventilation until rigid bronchoscopy
D Routine intravenous induction without muscle relaxant. Facemask ventilation until rigid bronchoscopy
E Inhalational anaesthetic induction and maintenance with sevoflurane, without
muscle relaxant. Maintain spontaneous respiration throughout the case
E
- E Inhalational anaesthetic induction and maintenance
with sevoflurane, without muscle relaxant. Maintain
spontaneous respiration throughout the case
Presentation of inhaled foreign body can vary from asymptomatic, to partial
obstruction with coughing, wheezing, stridor and dyspnoea, to complete
obstruction of the upper airway with hypoxia and cardiac arrest. Most foreign bodies
are radiolucent and the chest X-ray will often be normal. Therefore, a positive history
and clinical signs of aspiration alone may be enough evidence for endoscopy. A
chest X-ray in inspiration and expiration may aid location of the foreign body and
show any atelectasis, pneumonia, or air trapping.
Whatever anaesthetic technique is used, spontaneous respiration is best preserved,
although inhalation induction may be prolonged in the presence of hypoventilation.
Sevoflurane in 100% oxygen and topical anaesthesia to the airway is the technique
of choice. Care must be taken to maintain spontaneous breathing or gentle assisted
ventilation as positive pressure may drive the foreign body distally.
- An 18-month old boy is scheduled for an inguinal hernia repair as a day case. His mother reports that he developed an anxiety to needles since a hospital admission for pneumonia 5 months previously, and has not had his MMR vaccination. His
mother requests a gas induction and asks if he could receive his MMR vaccination while under general anaesthesia.
The best course of action is:
A Administer the MMR vaccination after induction of anaesthesia
B Ask the surgical team to administer the MMR vaccination whilst under general anaesthesia
C Ask the paediatric team to administer the MMR vaccination postoperatively prior to discharge
D Arrange for the GP to administer the MMR vaccination 4 weeks postoperatively
E Cancel the surgery until the child has had his MMR vaccination
D
- D Arrange for the GP to administer the MMR vaccination
4 weeks postoperatively
The Association of Paediatric Anaesthetists of Great Britain and Ireland (APAGBI)
published a guideline on the subject of vaccination around the time of anaesthesia
and surgery. One of the questions addressed was: should vaccines be given
opportunistically during anaesthetic procedures? The APAGBI concluded that
in general, vaccination should not be administered during anaesthesia, in order
that paracetamol or other anti-inflammatory agents can be used freely as part
of the anaesthetic technique and post-surgical care. This is due to concerns that
paracetamol and non-steroidal anti-inflammatory drugs reduce the efficacy and
antibody responses to vaccines.
If indicated, vaccination may be given when the child has recovered, but before
discharge. However, in the case of this infant with an inguinal hernia repair,
paracetamol and other anti-inflammatory drugs are useful for post operative
analgesia, so vaccination is best delayed for at least 72 hours. As this clinical scenario
refers to a day-case operation, the most appropriate course of action is to arrange for
the GP to administer the vaccination after a suitable interval postoperatively.
- A 58-year-old woman is listed for an elective hysterectomy. She states that she has a morphine allergy which made her eyes and lip swell in the past.
Which of the following analgesics would be unsafe in this patient?
A Pethidine
B Tramadol
C Buprenorphine
D Methadone
E Fentanyl
C
- C Buprenorphine
True morphine allergy is rare, but when it does occur patients can safely be
prescribed alternate opioids as long as they are structurally different.
Structural classes:
• Diphenylheptanes: methadone
• Phenanthrenes: morphine, codeine, buprenorphine, oxycodone
• Phenylpiperidines: fentanyl, remifentanil, pethidine
Tramadol is a cyclohexanol derivative and is structurally different to morphine.
Methadone shows no cross-tolerance with other opioids and can be used safely in a
true morphine allergy.
Fentanyl and pethidine are synthetic opioids of the phenylpiperidine class. This
class of opioid has structures different enough that they can be given to a patient
intolerant to the natural or semi-synthetics without fear of cross reactivity. They are
also very different from others in this same class.
Buprenorphine is a semi-synthetic opioid and therefore has some structural
similarities to morphine, suggesting that there maybe some cross reactivity.
- A 64-year-old woman with a history of chronic pain is listed for a shoulder replacement. She normally takes gabapentin 300 mg three times a day, paracetamol 1 g as needed and a buprenorphine patch at 20 μg/hour.
What is the most appropriate postoperative analgesic regimen for this patient?
A. Paracetamol, ibuprofen, gabapentin, MST 25 mg twice daily, Oramorph 10– 20 mg 4-hourly
B. Paracetamol, diclofenac, a morphine PCA 2 mg bolus with 5 minute lockout
C. Paracetamol, ibuprofen, gabapentin, fentanyl PCA with 25 μg bolus with 5 minute lockout
D. Paracetamol, codeine, tramadol and Oramorph 10–20 mg 4-hourly
E. Paracetamol, ibuprofen, gabapentin, Oxynorm 15 mg twice daily
A
- A Paracetamol, ibuprofen, gabapentin, MST 25 mg twice
daily, Oramorph 10–20 mg 4-hourly
The conversion of transdermal buprenorphine to oral morphine is 1:100.
20 μg/hour = 20 x 24 = 480 μg/day
480 μg x 100 = 48,000 μg = 48 mg per day
Therefore option A gives a background dose to cover the patch and then an as
required (PRN) dose which is one-sixth of the daily usage. This is a safe starting point.
B is unsafe with a 2 mg bolus with a short lockout time of 5 minutes as longer
lockout times are advocated with larger bolus doses.
C gives a standard fentanyl bolus protocol and there is no cover for background
requirement of opiate this patient clearly will need.
D is a standard protocol and does not consider the patient’s normal opiate
requirement
E Oxycodone is twice as potent as oral morphine therefore a 15 mg b.d. of a modified
release oxycodone (Oxycontin) would give a sufficient background. However, the
immediate release Oxynorm is not suitable for this purpose.
- A 35-year-old man with a chronic history of intravenous heroin use and schizophrenia presents to the emergency department with a perforated duodenal ulcer.
He is septic, coagulopathic and haemodynamically unstable, so is rushed to theatre for resuscitation and an emergency laparotomy.
What is the most appropriate analgesic regimen to manage his postoperative pain?
A Thoracic epidural with plain bupivacaine
B Intravenous methadone and ketamine infusion
C Oral methadone and intravenous morphine as required
D Intravenous methadone and intravenous morphine as required
E Morphine patient controlled analgesia (PCA) with a background infusion
E
- E Morphine patient controlled analgesia (PCA) with a
background infusion
Anaesthetists have a fundamental role in providing safe and adequate analgesia
for surgical patients, which sometimes includes individuals who are already
taking recreational opioids or have preceding chronic pain issues. The salient
features in the above case include the history of intravenous heroin use (and likely
physiological dependence), the type of surgery (affecting the postoperative route of
administration and absorption), as well as the diagnosis of schizophrenia (affecting
suitable analgesic choices).
The term ‘opioid’ describes all substances active at the opioid receptor, which
includes heroin (diamorphine) and morphine. Chronic opioid use leads to
suppression of the noradrenergic system and a compensatory up-regulation of the
cyclic adenosine monophosphate signalling pathways in the neurons involved in
noradrenaline release. If opioid intake then ceases abruptly, patients will experience
a ‘noradrenergic storm’ of withdrawal, which includes shivering, goose bumps,
anxiety, and lacrimation. Patients presenting for surgery with a chronic history of
heroin use need to be protected against withdrawal, by maintaining adequate
opioid receptor agonist, which is commonly achieved by administering methadone
- A 68-year-old woman with advanced breast cancer and poor intravenous access is suffering from intractable bone pain in her distal right femur. A recent MRI scan has confirmed a solitary metastases in her right femur and ruled out a fracture.
Management is at a palliative stage and she is currently taking paracetamol, ibuprofen and morphine sulphate.
What is the most appropriate next step in controlling her pain?
A Internal fixation of femur
B Bisphosphonates
C Localised external beam radiotherapy
D Radioisotope treatment
E Gabapentin
B
- C Localised external beam radiotherapy
The neurophysiology of cancer pain is complex and can encompass inflammatory,
neuropathic, ischaemic as well as compressive processes from multiple sites. It is
therefore important when assessing cancer pain to not only identify the location and
severity but also recognise the underlying aetiology to help guide management.
Skeletal pain in cancer patients is most commonly associated with bony metastases
and management can be tailored to a solitary site or multi-focal areas depending on
symptoms. In the above scenario, where the pain is localised to a single metastasis
which is refractory to opioids, the most appropriate next step is to apply targeted
radiotherapy. The efficacy of this treatment modality in managing metastatic
bone pain has been confirmed in a Cochrane review and it can be applied in the
palliative setting. The exact mechanism by which radiotherapy provides analgesia
is not known, although a reduction in tumour load and local osteoclast activity is
believed to play a role. The pain relief evolves consistently over 4–6 weeks from the
start of treatment and approximately 80% of patients will have a recorded response.
Symptoms such as nausea and increased stool frequency are recognised side-effects
of treatment, but are more likely to occur when radiotherapy is applied to bony areas
with a significant amount of surrounding bowel (such as the pelvis or lumbar spine).
-
2. Perioperative27
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3. Trauma & Orthopaedics25
-
4. Resuscitation & Transfer25
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5. ENT, Max Fax & Ophthalmology25
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6. Vascular & General25
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7. Day Surgery25
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8. Cardiothoracic42
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9. Neurosurgery40
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10. Paediatrics50
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11. Obstetrics20
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12. ICU60
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13. Chronic Pain20
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14. Mock30
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RCOA prep paper 211
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El-Boghdadly - 130
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El-Boghdadly - 230
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El-Boghdadly - 330
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El-Boghdadly - 430
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El-Boghdadly - 530
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El-Boghdadly - 630
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El-Boghdadly - 730
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El-Boghdadly - 830
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El-Boghdadly - 930
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El-Boghdadly - 1030
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1 RAKESH31
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2 Rakesh31
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3 Rakesh30
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4 Rakesh30
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Rakesh 530
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Rakesh 630
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Rakesh 630
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SBA Important points2
