Perioperative Management Flashcards
A 72 year old man attends vascular clinic after having an amputation 2 months ago. He is having difficulty sleeping at night due to persistent tingling at the amputation site. He is known to have orthostatic hypotension. What is the most appropriate analgesic modality?
Amitriptylline Pregabalin Duloxetine Morphine Diclofenac
Pregabalin
This patient has phantom limb pain which is a neuropathic pain. First line management is with amitriptylline or pregabalin. However this patient has orthostatic hypotension, which is a side effect of amitriptylline, therefore pregabalin is the treatment of choice
Which of the following preparatory regimes should be considered for a 63 year old man with normal renal function who requires a diagnostic colonoscopy to investigate iron deficiency anaemia for which he takes ferrous sulphate?
Stop ferrous sulphate 7 days pre procedure and administration of oral purgatives the day prior to the procedure Administration of oral purgatives the day prior to the procedure and continue ferrous sulphate Continue ferrous sulphate and administration of phosphate enemas on the day Cease ferrous sulphate 7 days pre procedure and administration of phosphate enema 30 minutes pre procedure No preparation required
Stop ferrous sulphate 7 days pre procedure and administration of oral purgatives the day prior to the procedure
Endoscopy requires full bowel preparation. In elderly patients, this can cause electrolyte disturbance and renal compromise and it is important to check the patients urea and electrolytes beforehand. Drugs like ferrous sulphate impair the efficacy of purgatives and give poor endoscopic views as a result and should be stopped beforehand.
A 72 year old man with prostate cancer is admitted to urology with urinary retention. He complains of back pain which is not responding to ward analgesia. Imaging shows several lumbar vertebral body metastasis. What is the most appropriate management?
Commence a bisphosphonate Arrange radiotherapy to the lumbar spine Surgical resection and reconstruction of the vertebral body Administration of pregabalin Chemotherapy
Arrange radiotherapy to the lumbar spine
The fact that ward based analgesia has been tried suggests that the patient be considered for palliative radiotherapy. Surgical resection of prostate cancer bony metastatic disease is not generally performed.
A 66 year old man is admitted following a collapse whilst waiting for a bus. Clinical examination confirms a ruptured abdominal aortic aneurysm. He is moribund and hypotensive. What is his ASA?
1 2 3 4 5
5
Patients who are moribund and will not survive without surgery are graded as ASA 5.
Which of the agents listed below is associated with the strongest anti emetic properties?
Sodium thiopentone Propofol Etomidate Ketamine Sevoflurane
Propofol
Propofol has anti emetic properties which is of considerable advantage in day case anaesthesia.
What is the most appropriate method of delivering early post-operative analgesia to a 6 month old child following an orchidopexy?
TAP block Caudal block Wound analgesic infusion catheter Spinal block Epidural block
Caudal block
Orchidopexy can be quite uncomfortable immediately following surgery. A caudal block can be a very effective adjunct and provides good analgesia. A spinal block and epidural would be inappropriate. A TAP block may cover the inguinal canal but this is not generally reliable and wound catheters are not used.
Of the agents listed below, which is the most appropriate to give a 65 year old man with a locally unresectable gastrointestinal stromal tumour. Biopsies confirm that it is KIT positive.
Imatinib Infliximab Trastuzumab Bevacizumab Cetuximab
Imatinib
Imatinib is licensed for treatment of GIST in the United Kingdom for this situation. The guidance from the National Institute of Clinical evidence is that patients be reviewed at 12 weeks after initiating therapy.
Which of the following is not directly affected by warfarin?
Protein C Factor II Factor VII Factor IX Factor VIII
Factor VIII
Warfarin affects synthesis of factors II, VII, IX, X and protein C.
A 70 year old lady has a cerebrovascular accident and has been recovering in hospital for the past 3 weeks. She has been deemed to have an unsafe swallow. What is the best option for long term feeding?
Endoscopically inserted PEG feeding tube Long term fine bore nasogastric feeding tube Surgically inserted feeding jejunostomy tube TPN via a central vein TPN via a peripheral cannula
Endoscopically inserted PEG feeding tube
At 3 weeks, it is unlikely that feeding orally is going to resume and therefore a definitive long term feeding solution is needed. A PEG is favored over a feeding jejunostomy in such circumstances.
A 56 year old lady with idiopathic thrombocytopenic purpura has a platelet count of 50. She is due to undergo a splenectomy. What is the optimal timing of a platelet transfusion in this case?
24 hours pre-operatively 2 hours pre-operatively Whilst making the skin incision After ligation of the splenic artery On removal of the spleen
After ligation of the splenic artery
ITP causes splenic sequestration of platelets. Therefore a platelet transfusion should be carefully timed. Too soon and it will be ineffective. Too late and unnecessary bleeding will occur. The optimal time is after the splenic artery has been ligated.
Which of the following would be a sensible volume for maintenance intravenous fluids in a 3 day old term neonate?
50ml/ kg/ hour 50ml/ kg/ day 100ml/kg/hour 100ml/kg/day 200ml/kg/day
100ml/kg/day
From birth to day 1: 50-60 ml/kg/day. Day 2: 70-80 ml/kg/day. Day 3: 80-100 ml/kg/day. Day 4: 100-120 ml/kg/day. Days 5-8: 120-150 ml/kg/day.
A 67 year old female undergoes an oesophagogastrectomy for carcinoma of the distal oesophagus. She complains of chest pain. The following day there is brisk bubbling into the chest drain when suction is applied. What is the most likely cause?
Anastomotic leak Air leak from lung Chyle leak Bile leak Cutaneous wound breakdown
Air leak from lung
Damage to the lung substance may produce an air leak. Air leaks will manifest themselves as a persistent pneumothorax that fails to settle despite chest drainage. When suction is applied to the chest drainage system, active and persistent bubbling may be seen. Although an anastomotic leak may produce a small pneumothorax, a large volume air leak is more indicative of lung injury
A 19 year old man has a skin lesion excised from his back. He is reviewed clinically at 4 months post procedure and the surgeon notes that the scar has begun to contract. Which of the following facilitates this process?
Myofibroblasts Neutrophils Granuloma formation Macrophages Fibroblasts
Myofibroblasts
As wounds mature the fibroblast population differentiates into myofibroblasts (usually 6 weeks and beyond), these have a contractile phenotype and therefore help in contracting the wound. Immature fibroblasts, though able to adhere to the ECM, do not have this ability.
Which of the following blood products can be administered to a non ABO matched recipient?
Whole blood Platelets Packed red cells Stem cells Irradiated whole blood
Platelets
In the UK, platelets either come from pooling of the platelet component from four units of whole donated blood, called random donor platelets, or by plasmapharesis from a single donor. The platelets are suspended in 200-300 ml of plasma and may be stored for up to 4 days in the transfusion laboratory where they are continually agitated at 22oC to preserve function
Which of the following would be the optimal fluid management option for a 45 year old man due to undergo an elective right hemicolectomy?
Remain "nil by mouth" for at least 6 hours pre-operatively and avoid intra venous fluids Remain "nil by mouth" for at least 6 hours pre-operatively and receive supplementary intravenous 5% dextrose to replace lost calories Allow him free access to oral fluids only until 30 minutes prior to surgery Administer a carbohydrate based loading drink 3 hours pre operatively, and avoid intravenous fluids Administer a carbohydrate based loading drink 6 hours pre-operatively and administer 5% dextrose saline thereafter
Administer a carbohydrate based loading drink 3 hours pre operatively, and avoid intravenous fluids
Patients for elective surgery should not have solids for 6 hours pre-operatively. However, clear fluids may be given up to 2 hours pre-operatively.
A 63 year old man undergoes a laparotomy and small bowel resection. Twelve hours post operatively he is noted to have a decreased urine output. Which of the hormones listed below is most likely to be responsible?
Cortisol Atrial natriuretic hormone Vasopressin Insulin Glucagon
Vasopressin
Vasopressin is released in increased quantities following most operative procedures and will tend to cause water retention. For this reason, excessive administration of intravenous fluids in an attempt to force a diuresis may cause fluid overload in post operative patients.
A 48 year old lady is being prepared for a Whipples procedure. A right sided subclavian line is inserted and then anaesthesia is induced. Following intubation the patient becomes progressively hypoxic and haemodynamically unstable. What is the most likely underlying explanation?
Drug allergy Simple pneumothorax Tension pneumothorax Halothane toxicity Haemothorax
Tension pneumothorax
Central lines (and particularly subclavian lines) are risk factors for the development of pneumothorax. In the context of positive pressure ventilation a tension pneumothorax is a strong possibility and would be associated with haemodynamic instability.
A 30 year old male is admitted electively for a right inguinal hernia repair under local anaesthesia. He is otherwise well but his grandfather died from a pulmonary embolism. What is the most appropriate form of thromboprophylaxis?
Administration of low dose low molecular weight heparin for 2 weeks Administration of high dose low molecular weight heparin for 2 weeks No prophylaxis Low dose low molecular weight heparin and pneumatic compression stockings High dose low molecular weight heparin and pneumatic compression stockings
No prophylaxis
Inguinal hernia repairs under local anaesthetic have a short operative time and patients are usually ambulant immediately afterwards. His family history is unlikely to be significant and he is at very low risk.
What is the most appropriate analgesic modality for a 52 year old male undergoing an open elective resection of the splenic flexure colonic cancer?
TAP block Local anaesthetic wound infiltration Spinal block Epidural anaesthetic Rectal diclofenac
Epidural anaesthetic
An open resection of a splenic flexure cancer will require a long midline incision and carries the potential for respiratory compromise. This is best countered with a well placed epidural. An alternative would be rectus sheath catheter infiltration of local anaesthetic and PCA.
What is the most appropriate analgesic to administer to a term neonate who is recovering following an inguinal herniotomy?
Co-codamol Paracetamol Ibuprofen Carbamazepine Codeine
Paracetamol
Paracetamol is an effective analgesic in children and pain following herniotomy is relatively minor. Note that codeine is contra indicated in neonates. The child is too young to receive ibuprofen.
Which statement relating to the peri operative management of patients with diabetes mellitus is false?
They should be placed first on the operating list An intravenous sliding scale should be used in all cases Potassium supplementation is likely to be required in diabetics on a sliding scale Electrolyte abnormalities are more common after major visceral resections Blood glucose monitoring is required during general anaesthesia
An intravenous sliding scale should be used in all cases
This is not the case and some type 2 diabetics may be managed using a watch and wait policy with regular blood glucose monitoring. The cellular shifts of potassium with sliding scales may cause problems with electrolyte management which should be anticipated.
An 80 year old lady is investigated in the pre operative clinic and found to have severe aortic stenosis. What, if any, is the main peri operative concern?
They cannot adjust their heart rate They may have ventricular hypertrophy The patient cannot increase their cardiac output They are more prone to arrhythmias There is no concern
The patient cannot increase their cardiac output
Patients with aortic stenosis are a major perioperative concern. They may have ventricular hypertrophy and this can result in relative myocardial ischaemia and increase the risk of arrhymias. However, the main concern is that they cannot increase their cardiac output particularly if vasodilation occurs.
A 63 year old lady is undergoing colonoscopy with midazolam sedation. Her respiratory rate slows and she becomes hypoxic and the decision is made to reverse her sedation. What is the most appropriate agent to administer?
Flumazenil Doxapram Naloxone Procyclidine Etomidate
Flumazenil
Flumazenil antagonises the effects of benzodiazepines by competition at GABA binding sites. Since many benzodiazepines have longer half lives than flumazenil patients still require close monitoring after receiving the drug. Whilst doxapram would increase the respiratory rate, it is not an agent for reversal of midazolam.
A 23 year old man with a 4cm lipoma on his flank is due to have this removed as a daycase. He is otherwise well. What is his ASA?
2 3 1 5 4
1
Absence of co-morbidities and small procedure with no systemic compromise will equate to an ASA score of 1.
A 3 year old is involved in trauma and is haemodynamically unstable. Initial attempts at intravenous access are proving unsuccessful. What is the best course of action?
Insert a femoral venous central line Insert a right internal jugular central line Insert an intra osseous infusion system Insert a 14 G cannula into the antecubital fossa Insert a Broviac line
Insert an intra osseous infusion system
Gaining venous access in small children is challenging at the best of times and when they are shut down its nearly impossible. Intraosseous infusions are best in this setting. Broviac lines are long term IV access systems with narrow lumens and would be unsuitable
