Post operative Management Flashcards
Which of the following conditions is most likely to be associated with these arterial blood gas sample results: pH 7.48 pO2 10.1 HCO3 30 pCO2 4.5 Cl- 96mEq
Respiratory alkalosis Metabolic acidosis with normal anion gap Metabolic alkalosis Metabolic acidosis with increased anion gap Type 2 respiratory failure
Metabolic alkalosis
These arterial blood gas results are classically seen in situations where there is metabolic alkalosis such as may occur following prolonged vomiting.
A 22 year old lady is admitted to the intensive care unit following a laparotomy. She has a central line, pulmonary artery catheter and arterial lines inserted. The following results are obtained:
Pulmonary artery occlusion pressure Low
Cardiac output High
Systemic vascular resistance Low
How may these findings be best interpreted?
Hypovolaemia Septic shock Normal Fluid overload Cardiogenic shock
Septic shock
Decreased SVR is a major feature of sepsis. A hyperdynamic circulation is often present. This is the reason for the use of vasoconstrictors.
Which of the drugs listed below confers the greatest risk of malignant hyperthermia?
Decamethonium halides Suxamethonium Benzquinonium Gallamine Vecuronium
Suxamethonium
Suxamethonium may cause malignant hyperthermia and 1 in 2800 will have abnormal cholinesterase enzyme and prolonged clinical effect.
Which of the agents listed below is a phosphodiesterase inhibitor?
Milrinone Metaraminol Dopamine Dobutamine Adrenaline
Milrinone
A 56 year old man is on the ward 5 days following a high anterior resection for a carcinoma of the recto sigmoid junction. Over the past 12 hours, he has developed increasing lower abdominal pain, a fever of 37.8oC and fast atrial fibrillation. Of the investigations listed below, which is likely to be the most useful?
Abdominal X-ray Abdominal ultrasound scan Abdominal CT scan Echocardiogram Measurement of cardiac enzymes in the blood
Abdominal CT scan
New AF following a colonic resection is most likely to represent an anastomotic leak and this will be best seen on CT scanning.
A 28 year old lady with known von Willebrands disease is bleeding following the excision of a sebaceous cyst. Administration of which of the following agents is most likely to be beneficial?
Desmopressin Factor IX concentrate Factor VII concentrate Factor X concentrate Vasopressin
Desmopressin
Desmopressin is useful in managing the bleeding from the commonest type of vWD. Vasopressin is less likely to be disease specific and at most would have a vasoconstrictor approach which is likely to be of brief duration.
A 6 week old preterm neonate is due to have surgery for an inguinal hernia. Which of the following fluids should be administered whilst they are nil by mouth?
10% dextrose 50% dextrose 5% dextrose 25% dextrose Hartmanns solution
10% dextrose
Neonates are at considerable risk of hypoglycaemia following surgery and should receive 10% dextrose.
A 53 year old man has an arterial blood gas sample taken and the following results are obtained, he is breathing room air.
pH 7.49
pO2 8.5
HCO3 22
pCO2 2.4
Cl- <10meq
Which of the conditions listed below is most likely to account for these findings?
Respiratory alkalosis Type 2 respiratory failure Metabolic acidosis with increased anion gap Metabolic alkalosis Metabolic acidosis with normal anion gap
Respiratory alkalosis
The hyperventilation results in decreased carbon dioxide levels, causing a respiratory alkalosis (non compensated).
A 44 year old man undergoes a distal gastrectomy for cancer. He is slightly anaemic and therefore receives a transfusion of 4 units of packed red cells to cover both the existing anaemia and associated perioperative blood loss. He is noted to develop ECG changes that are not consistent with ischaemia. What is the most likely cause?
Hyponatraemia Hyperkalaemia Hypercalcaemia Metabolic alkalosis Hypernatraemia
Hyperkalaemia
The transfusion of packed red cells has been shown to increase serum potassium levels. The risk is higher with large volume transfusions and with old blood.
Which of the following muscle relaxants will tend to incite neuromuscular excitability following administration?
Atracurium Suxamethonium Vecuronium Pancuronium None of the above
Suxamethonium
Suxamethonium may induce generalised muscular contractions following administration. This may raise serum potassium levels.
Which of the variables listed below is not considered in the sequential organ failure assessment (SOFA) tool?
Bilirubin Urea Mean arterial pressure Platelet count Creatinine
Urea
Urea is not one of the variables considered.
A 23 year old man is recovering from an appendicectomy. The operation was complicated by the presence of perforation. He is now recovering on the ward. However, his urine output is falling and he has been vomiting. Which of the following intravenous fluids should be initially administered, pending analysis of his urea and electrolyte levels?
Hartmans solution Dextran 70 Pentastarch Gelofusin 5% Dextrose
Hartmans solution
He will have sequestration of electrolyte rich fluids in the abdomen and gut lumen. These are best replaced by use of Hartmans solution in the first instance.
A 73 year old man develops disseminated intravascular coagulation following an abdominal aortic aneurysm repair. He receives an infusion of cryoprecipitate. What is the major constituent of this infusion?
Factor VIII Factor IX Protein C Protein S Factor V
Factor VIII
A 32 year old man presents to the acute surgical unit with acute pancreatitis. Over the next few days he becomes dyspnoeic and his saturations are 89% on air. A CXR shows bilateral pulmonary infiltrates. His CVP pressure is 16mmHg. What is the most likely diagnosis?
Cardiac failure Pneumococcal pneumonia Staphylococcal pneumonia Pneumocystis carinii Adult respiratory distress syndrome
Adult respiratory distress syndrome
Acute pancreatitis is known to precipitate ARDS. ARDS is characterised by bilateral pulmonary infiltrates and hypoxaemia. Note that pulmonary oedema is excluded by the CVP reading < 18mmHg.
Which of the anaesthetic agents below is most likely to induce adrenal suppression?
Sodium thiopentone Midazolam Propofol Etomidate Ketamine
Etomidate
Etomidate is a recognised cause of adrenal suppression, this has been associated with increased mortality when used as a sedation agent in the critically ill.
A 63 year old man is commenced on an infusion of packed red cells following a total hip replacement. Which of the following adverse events is most likely?
ABO mismatching Immune mediated intolerance of rhesus incompatible blood Pyrexia Jaundice Graft versus host disease
Pyrexia
Mild pyrexia during blood transfusion is the most common event and commonly occurs during transfusion.
A 45 year old man is admitted to the intensive care unit following a laparotomy. He has a central line, pulmonary artery catheter and arterial lines inserted. The following results are obtained:
Pulmonary artery occlusion pressure Cardiac output Systemic vascular resistance
Low Low High
What is the most likely interpretation of this?
Normal Cardiogenic shock Septic shock Fluid overload Hypovolaemia
Hypovolaemia
Cardiac output is lowered in hypovolaemia due to decreased preload.
A 32 year male with leukaemia attends the day unit for a blood transfusion. Five days after the transfusion he attends the Emergency Department with a temperature of 38.5, erythroderma and desquamation. What is the most likely explanation?
Graft versus host disease Acute haemolytic transfusion reaction Delayed haemolytic transfusion reaction Transfusion associated lung injury Neutrophilic febrile reaction
Graft versus host disease
This is associated with transfusion of unirradiated blood in immunosuppressed patients. Transfusion associated GVHD can occur 4-30 days after a transfusion and follows a sub acute pathway. Patients may also have diarrhoea and abnormal liver function tests. Management involves steroid therapy.
A 63 year old man has been on the intensive care unit for a week with adult respiratory distress syndrome complicating acute pancreatitis. He has required ventilation and is still being mechanically ventilated. What is the best option for maintenance of his airway?
Nasotracheal tube Endotracheal tube Tracheostomy Guedel airway Laryngeal mask
Tracheostomy
Tracheostomy is often used to facilitate long term weaning. The percutaneous devices are popular. These involve a seldinger type insertion of the tube. A second operator inserts a bronchoscope to ensure the device is not advanced through the posterior wall of the trachea. Complications include damage to adjacent structures and bleeding (contra indication in coagulopathy).
A patient with tachycardia and hypotension is to receive vasopressors. Which of the following conditions are most likely to be treated with vasopressors?
Hypovolaemic shock Septic shock Neurogenic shock Cardiogenic shock None of the above
Septic shock
The term septic shock has a precise meaning and refers to refractory systemic arterial hypotension in spite of fluid resuscitation. Patients will therefore usually require vasopressors.
A 24 year old man is recovering from a right hemicolectomy for Crohns disease. He is oliguric and dehydrated owing to a high output ileostomy. His electrolytes are normal. Which of the following intravenous fluids should be administered?
0.9% sodium chloride Hartmanns solution 0.45% sodium chloride 5% dextrose 10% dextrose
Hartmanns solution
Of the solutions given Hartmans is the most suitable. Consideration should also be given to potassium supplementation.
Infusion with which of the following blood products is most likely to result in an urticarial reaction?
Packed red cells Fresh frozen plasma Platelets Cryoprecipitate Factor VIII concentrate
Fresh frozen plasma
Pyrexia is the most common adverse event in transfusing packed red cells
Urticaria is the most common adverse event following infusion of FFP
Which of the arterial blood gas analyses would most likely be seen in a patient with a high output ureterosigmoidostomy?
pH 7.64, pO2 10.0 kPa pCO2 2.8 kPa, HCO3 20 pH 7.25, pO2 8.9, pCO2 3.2, HCO3 10 pH 7.20, pO2 6.2, pCO2 8.2, HCO3 27 pH 7.60, pO2 8.2, pCO2 5.8, HCO3 40 pH 7.45, pO2 7.2, pCO2 2.5, HCO3 24
pH 7.25, pO2 8.9, pCO2 3.2, HCO3 10
There is acidosis. To compensate the patient will attempt to raise the pH level in the blood by hyperventilating, hence the low CO2 level .
A 54-year-old man is admitted for an elective hip replacement. Three days post operatively you suspect he has had a pulmonary embolism. He has no past medical history of note. Blood pressure is 120/80 mmHg with a pulse of 90/min. The chest x-ray is normal. Following treatment with low-molecular weight heparin, what is the most appropriate initial lung imaging investigation to perform?
Pulmonary angiography Echocardiogram MRI thorax Ventilation-perfusion scan Computed tomographic pulmonary angiography
Computed tomographic pulmonary angiography
CTPA is the first line investigation for PE according to current BTS guidelines
Which of the intravenous fluid combinations listed below should be considered for replacement of losses from a high output ileostomy in a 2 year old?
0.9% saline with added potassium Hartmanns solution 10% dextrose with added potassium 0.45% saline with added potassium 2.7% saline with added potassium
0.9% saline with added potassium
In children with ongoing losses, these should be replaced with 0.9% sodium chloride with added potassium.
Which of the agents listed below can be administered via the peripheral route in the non cardiac arrest setting?
Milrinone Noradrenaline Adrenaline Metaraminol Dobutamine
Metaraminol
As a general rule, inotropes and vasopressors can only be administered via a central vein. Metaraminol is an exception to this as it can be administered via a peripheral line.
Administration of neostigmine to a patient who has received a non depolarizing muscle relaxant is most likely to result in which of the following?
Prolongation of muscle relaxation Tachycardia Hypertension Bradycardia Decreased gut peristalsis
Bradycardia
Neostigmine can cause bradycardia and atropine is often administered concomitantly to counter this effect.
Which of the following agents is most likely to be helpful in controlling refractory hypotension in a 23 year old female with severe pyelonephritis?
Noradrenaline Adrenaline Dobutamine Dopamine Milrinone
Noradrenaline
Since the main issue here is vasodilation, a vasoconstrictor is most likely to be helpful.
Which arterial blood gas sample best represents widespread mesenteric infarction?
pH 7.64, pO2 10.0 kPa pCO2 2.8 kPa, HCO3 20 pH 7.25, pO2 8.9, pCO2 3.2, HCO3 10 pH 7.20, pO2 6.2, pCO2 8.2, HCO3 27 pH 7.60, pO2 8.2, pCO2 5.8, HCO3 40 pH 7.45, pO2 7.2, pCO2 2.5, HCO3 24
pH 7.25, pO2 8.9, pCO2 3.2, HCO3 10
This is usually associated with acidosis, hyperventillation and reduction in bicarbonate.
A 17 year old man undergoes an elective right hemicolectomy. Post operatively he receives a total of 6 litres of 0.9% sodium chloride solution, over 24 hours. Which of the following complications may ensue?
Hyperchloraemic acidosis Hypochloraemic alkalosis Hyperchloraemic alkalosis Acute renal failure None of the above
Hyperchloraemic acidosis
Excessive infusions of any intravenous fluid carry the risk of development of tissue oedema and potentially cardiac failure. Excessive administration of sodium chloride is a recognised cause of hyperchloraemic acidosis and therefore Hartmans solution may be preferred where large volumes of fluid are to be administered.
A 28 year old man with Crohn’s disease has undergone a number of resections. His BMI is currently 18 and his albumin is 18. He feels well but does have a small localised perforation of his small bowel. The gastroenterologists are giving azathioprine. What is the most appropriate advice regarding feeding?
Nil by mouth Nil by mouth and continuous intra venous fluids until surgery Enteral feeding Parenteral feeding Nutritional supplements
Parenteral feeding
This man is malnourished, although he is likely to require surgery it is best for him to be nutritionally optimised first. As he may have reduced surface area for absorption and has a localised perforation TPN is likely to be the best feeding modality.
A 51 year old man is shot in the abdomen and sustains a significant intra abdominal injury. A laparotomy, bowel resection and end colostomy are performed. An associated vascular injury necessitates a 6 unit blood transfusion. He has a prolonged recovery and is paralysed and ventilated for 2 weeks on intensive care. He receives total parenteral nutrition and is eventually weaned from the ventilator and transferred to the ward. On reviewing his routine blood tests the following results are noted:
Full blood count
Hb 11.3 g/dl
Platelets 267 x 109/l
WBC 10.1 x109/l
Urea and electrolytes Na+ 131 mmol/l K+ 4.6 mmol/l Urea 2.3 mmol/l Creatinine 78 µmol/l
Liver function tests Bilirubin 25 µmol/l ALP 445 u/l ALT 89 u/l γGT 103 u/l
What is the most likely underlying cause for the abnormalities noted?
Delayed type blood transfusion reaction Bile leak Anastomotic leak Total parenteral nutrition Gallstones
Total parenteral nutrition
TPN is known to result in derangement of liver function tests. Although, cholestasis may result from TPN, it would be very unusual for gallstones to form and result in the picture above. Blood transfusion reactions typically present earlier and with changes in the haemoglobin and although they may cause hepatitis this is rare nowadays.
Which statement regarding post operative cognitive impairment is true?
Use of Benzodiazepines preoperatively reduces long-term post operative cognitive dysfunction Pain does not cause delirium Delirium has no impact on length of hospital stay A regional anaesthetic rather than a general anaesthetic is more likely to contribute to post operative cognitive impairment Visual hallucinations are not a feature of delirium
Use of Benzodiazepines preoperatively reduces long-term post operative cognitive dysfunction
Anaesthetic technique and Post operative cognitive impairment (POCD):
Use of benzodiazepines preoperatively reduces long-term POCD (9.9% vs. 5%)
Do not stop drugs for cognitive function
Regional techniques reduce POCD in first week, but no difference at 3 months
A 75 year old man is admitted to the intensive care unit following a laparotomy. He has a central line, pulmonary artery catheter and arterial lines inserted. The following results are obtained:
Pulmonary artery occlusion pressure High
Cardiac output Low
Systemic vascular resistance High
How may these findings be best interpreted?
Hypovolaemia Normal Neurogenic shock Septic shock Cardiogenic shock
Cardiogenic shock
In cardiogenic shock pulmonary pressures are often high. This is the basis for the use of venodilators in the treatment of pulmonary oedema.
Which statement is false about pethidine?
It is thirty times more lipid soluble than morphine Structurally similar to morphine Pethidine has a toxic metabolite (norpethidine) which is cleared by the kidney Pethidine is metabolized by the liver Can be given intramuscularly
Structurally similar to morphine
It has a different structure. It is much more lipid soluble than morphine. It produces less biliary tract spasm than morphine.
Which of the following anaesthetic agents is least likely to be associated with depression of myocardial contractility?
Propofol Etomidate Sodium thiopentone Ether None of the above
Etomidate
Of the agents mentioned, etomidate has the most favorable cardiac safety profile
A 22 year old lady undergoes a total thyroidectomy for Graves disease. 6 hours post operatively she develops respiratory stridor and develops a small haematoma in the neck. What is the most appropriate course of action?
Perform a cricothyroidotomy Re-open the neck wound Perform a percutaneous tracheostomy Reassure the patient and prescribe an anxiolytic Insert a nasopharyngeal airway
Re-open the neck wound
This is true emergency and evacuation and release of pressure must be performed immediately, in this case by removal of skin clips on the ward. Attempts to access the airway surgically will delay this and can result in death.
A 23 year old man is undergoing an open inguinal hernia repair as a daycase procedure and is being given sevoflurane. What is the best option for maintaining his airway during the procedure?
Insertion of endotracheal tube Insertion of nasotracheal tube Insertion of nasopharyngeal airway Insertion of laryngeal mask Use of Guedel airway
Insertion of laryngeal mask
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.
Which of the following is a not a diagnostic criteria for brain death?
No response to sound No corneal reflex Absent oculo-vestibular reflexes No response to supraorbital pressure No cough reflex to bronchial stimulation
No response to sound
You are the cardiothoracic surgical registrar reviewing a patient referred for an aortic valve replacement. The 40-year-old man is being investigated for progressive breathlessness in a previous respiratory clinic. The notes show he has smoked for the past 25 years. Pulmonary function tests reveal the following:
FEV1 1.4 L
FVC 1.7 L
FEV1/FVC 82%
What is the most likely explanation?
Asthma Bronchiectasis Kyphoscoliosis Chronic obstructive pulmonary disease Laryngeal malignancy
Kyphoscoliosis
These results show a restrictive picture, which may result from a number of conditions including kyphoscoliosis. The other answers cause an obstructive picture.
Which of the following muscle relaxants is an agent that is degraded by hydrolysis and may produce histamine release?
Atracurium Panciuronium Curare Suxamethonium Vecuronium
Atracurium
Atracurium is degraded by a process of ester hydrolysis. This uses non specific plasma esterases.
A 78 year old man presents with a ruptured aortic aneurysm. This is repaired but the operation is difficult as it has a juxtarenal location. A supra renal cross clamp is applied. Post operatively he is found to be oliguric and acute renal failure is suspected. Which of the following statements relating to acute post-operative renal failure are untrue?
Intravenous dopamine does not prevent acute renal failure. It is more common after emergency surgery. Use of excessive amounts of intravenous fluids may lead to falsely normal serum creatinine measurements. Vasopressor drugs have a strong renoprotective effect It is minimised by normalisation of haemodynamic status.
Vasopressor drugs have a strong renoprotective effect
Vasopressor use is linked to renal failure as they are a marker of haemodynamic compromise.
Which of the following is most suggestive of malnutrition?
Hypoalbuminaemia BMI of 22 kg/m2 and unintentional weight loss of > 5% over 3-6 months BMI of 18.5 kg/m2 Reduced skin turgor Unintentional weight loss of > 10% over 3- 6 months in a 60 Kg female who is 1.6m tall
Unintentional weight loss of > 10% over 3- 6 months in a 60 Kg female who is 1.6m tall
An unintentional weight loss of >10% in a three to six month period is highly suggestive of malnutrition. This is particularly true of people with a normal/ low BMI. Hypoalbuminaemia is not, in itself, a reliable marker of nutrition.
A 52 year old man is recovering following an elective right hemicolectomy for carcinoma of the caecum. His surgery is uncomplicated, when should oral intake resume?
Only once bowels have been opened to stool Only once the patient has passed flatus Between 24 and 48 hours of surgery More than 48 hours after surgery Within 24 hours of surgery
Within 24 hours of surgery
As part of the enhanced recovery principles oral intake in this setting should resume soon after surgery. Administration of liquid and even light diet does not increase the risk of anastomotic leak.
With which of the following blood products is iatrogenic septicaemia with a gram positive organism most likely?
Cryoprecipitate Platelets Packed red cells Factor VIII concentrate Factor IX concentrate
Platelets
Platelets are stored at room temperature and must be used soon after collection. This places them at increased risk of culturing gram positive organisms. Iatrogenic infection with gram negative organisms is more likely with packed red cells as these are stored at 4 degrees.
Infections with blood products of this nature are both rare.
Which of the following is a recognised feature of ketamine when used as an anaesthetic agent?
Malignant hyperpyrexia Adrenal suppression Myocardial depression Dissociative anaesthesia Marked respiratory depression
Dissociative anaesthesia
Unlike most anaesthetic agents ketamine does not cause myocardial or marked respiratory depression. It is not associated with the adrenal suppression that may occur with etomidate. It is however, associated with a state of dissociative anaesthesia which patients may find distressing.
A 45 year old lady with cirrhosis of the liver is recovering following an emergency para umbilical hernia repair. She has been slow to resume oral intake and has been receiving regular boluses of normal saline for oliguria. Which of the following intravenous fluids should be considered?
5% dextrose with 20mmol KCL 1.8% saline Human albumin solution 4.5% 10% dextrose with 20mmol KCL 0.45% sodium chloride
Human albumin solution 4.5%
In patients who are hypoalbuminaemic the use of albumin solution may help promote a diuresis and manage fluid overload.
A 73 year old man undergoes a right below knee amputation for end stage peripheral vascular disease. He is reviewed in the clinic 8 weeks post operatively and complains of a persistent, burning discomfort over his amputation site stump. On examination, his wound has healed and proximal pulses have a biphasic signal on doppler ultrasound. What is the most appropriate management?
Commence amitryptyline Commence fentanyl patch Arrange duplex scan Arrange MRI scan of the stump Commence carbamazepine
Commence amitryptyline
This patient has neuropathic pain. Amitryptyline is the treatment of choice. Carbamazepine is mainly used for trigeminal neuralgia.
A homeless 42 year old male had an emergency inguinal hernia repair 24 hours previously. He has a BMI of 15. His electrolytes are normal. What is the best initial feeding regime?
Give 10 kcal/kg/day initially, oral thiamine 200-300mg/day, vitamin B co strong1 tds and supplements. Give 35 kcal/kg/day initially, oral thiamine 200-300mg/day, vitamin B co strong 1 tds and supplements. No change to diet needed Oral thiamine 200-300mg/day, vitamin B co strong1 tds and supplements. Give 35 kcal/kg/day initially
Give 10 kcal/kg/day initially, oral thiamine 200-300mg/day, vitamin B co strong1 tds and supplements.
This patient is at high risk of refeeding syndrome.
A 48 year old man is recovering on the high dependency unit following a long and complex laparotomy. His preoperative medication includes an ACE inhibitor for blood pressure control. For the past two hours he has been oliguric with a urine output of 10ml/hr-1. What the most appropriate immediate course of action?
Stop the ACE inhibitor Administer a fluid challenge Start an infusion of nor adrenaline Administer intravenous frusemide Insert a Swann-Ganz Catheter
Administer a fluid challenge
Hypovolaemia is the most likely cause for oliguria and a fluid challenge is the most appropriate action. Blind administration of inotropes to hypovolaemic patients is unwise, with the possible exception of cardiac patients.
A 50 year old man has an arterial blood gas sample taken and the following results are obtained, he is breathing room air.
pH 7.20
pO2 7.5
HCO3 22
pCO2 8.1
Cl- 10meq
Which of the conditions listed below is most likely to account for these findings?
Type 1 respiratory failure Metabolic alkalosis Metabolic acidosis with normal anion gap Metabolic acidosis with increased anion gap Type 2 respiratory failure
Type 2 respiratory failure
This is a sign of acute type 2 respiratory failure (non compensated). This is the result of carbon dioxide retention.
A 48 year old man is due to undergo a laparotomy for small bowel obstruction. What is the best option for maintaining his airway?
Insertion of cuffed endotracheal tube Insertion of uncuffed endotracheal tube Insertion of laryngeal mask Insertion of nasopharyngeal airway Percutaneous tracheostomy
Insertion of cuffed endotracheal tube
Patients who are due to undergo laparotomies for bowel obstruction have either been vomiting or at high risk of regurgitation of gastric contents on induction of anaesthesia. A rapid sequence induction with cricothyroid pressure applied to occlude the oesophagus is performed. A cuffed endotracheal tube is then inserted. Once correct placement of the ET tube is confirmed the cricothyroid pressure can be removed.
A 45 year old man is involved in a polytrauma and requires a massive transfusion of packed red cells and fresh frozen plasma. Three hours later he develops marked hypoxia and his CVP is noted to be 10mm Hg. A chest x-rays shows bilateral diffuse pulmonary infiltrates. What is the most likely diagnosis?
Pulmonary embolus Myocardial stunning Myocardial infarct Fluid overload Transfusion associated lung injury
Transfusion associated lung injury
Transfusion lung injury may occur after infusion of plasma components. Microvascular damage occurs in the lungs leading to diffuse infiltrates on imaging. Mortality is high.
A 52 year old man undergoes a laparotomy for perforated bowel after a colonoscopy. 2 days after surgery the nursing staff report there is pink, serous fluid discharging from the wound. What is the next most appropriate management step?
IV antibiotics for wound infection No further management Examine the wound for separation of the rectus fascia Insert a drain into the wound CT abdomen
Examine the wound for separation of the rectus fascia
The seepage of pink serosanguineous fluid through a closed abdominal wound is an early sign of abdominal wound dehiscence with possible evisceration. If this occurs, you should remove one or two sutures in the skin and explore the wound manually, using a sterile glove. If there is separation of the rectus fascia, the patient should be taken to the operating room for primary closure.
A 63 year old man undergoes a subtotal colectomy and iatrogenic injury to both ureters is sustained. He develops renal failure and his serum potassium is found to be elevated at 6.9 mmol/L. An ECG is performed, what is the most likely finding?
Increased PR interval Prominent U waves Narrow QRS complexes Peaked T waves Low ST segments
Peaked T waves
Peaked T waves are the first and most common finding in hyperkalaemia.
A 56 year old man with chronic schizophrenia undergoes a cholecystectomy. He receives metoclopramide for post operative nausea. Twenty minutes later he becomes agitated and develops marked oculogyric crises and oromandibular dystonia. Which of the following drugs may best alleviate his symptoms?
Procyclidine Lorazepam Chlorpromazine Haloperidol Sulpiride
Procyclidine
This man has developed an acute dystonic reaction. Administration of further anti dopaminergic drugs will worsen the situation. Procyclidine will help to reverse the event. This is most likely to have occurred because the patient is on long term anti psychotics and has then received metoclopramide.
Which of the following anaesthetic agents has the strongest analgesic effect?
Sodium thiopentone Ketamine Midazolam Etomidate None of the above
Ketamine
Ketamine has a moderate to strong analgesic effect. It may be used for emergency procedures outside the hospital environment to induce anaesthesia for procedures such as emergency amputation.
Which statement is true on enteral feeding?
A PEG can only be used 12 hours after insertion A motility agent is avoided for ITU patients with an Nasogastric tube A regime of 24 hours continuous feeding is recommended for ITU patients It is associated with more hepatic synthetic disruption than use of TPN Enteral feeding is not possible in upper GI dysfunction
A regime of 24 hours continuous feeding is recommended for ITU patients
Which of the following does not need monitoring during home parenteral nutritional support?
Folate levels Zinc levels Vitamin D Thyroid function Bone densitometry
Thyroid function
Which of the following is not typically included in total parenteral nutritional solutions?
Fibre Lipid Potassium Glucose Magnesium
Fibre
There is no indication for inclusion of fibre in solutions of TPN, nor would it be safe to do so.
A 28 year old man with poorly controlled Crohns disease is nutritionally compromised. The decision is made to start TPN, via which of the following routes should it be best administered?
Internal jugular vein via a central venous catheter Internal carotid artery Cephalic vein via peripheral cannula Basilic vein via peripheral cannula Common femoral vein via a central venous catheter
Internal jugular vein via a central venous catheter
Since TPN solutions are irritant to veins they are best administered via a central line. The femoral route has a higher incidence of line associated sepsis and is thus best avoided in this setting.
Which of the following statements relating to the use of human albumin solution is false?
When administered in the peri operative period it does not increase the length of stay in hospital compared with crystalloid solutions Concentrated solutions may produce diuresis in patients with liver failure It may restore plasma volume in cases of sodium and water overload It may be associated with risk of acquiring new variant Creutzfeldt-Jakob disease Hepatitis C remains a concern when large volumes are infused
Hepatitis C remains a concern when large volumes are infused
Human albumin solution went out of vogue following the Cochrane review in 2004 that showed it increased mortality. This view has been challenged and subsequent studies have confirmed it to be safe for use. Viruses are inactivated during the preparation process. However, theoretical risks regarding new varient CJD still exist. Outcomes in the peri operative setting are similar whether colloid, crystalloid or albumin are used.
Use of which of the following muscle relaxants is least likely to result in histamine release?
Atracurium Tubocurarine Doxacurium Mivacurium Suxamethonium
Suxamethonium
Drugs in the tetrahydroisoquinoline such as atracurium cause histamine release. Vecuronium and suxamethonium do not do this.
Which of the anaesthetic agents listed below is associated with hepatotoxicity?
Halothane Sevoflurane Propofol Ketamine Desflurane
Halothane
Halothane is largely of historical interest and that is because of its hepatotoxicity.
A 22 year old fit and well male undergoes an emergency appendicectomy. He is given suxamethonium. An inflamed appendix is removed and the patient is returned to recovery. On arrival in the recovery area; the patient develops a tachycardia of 120 bpm and a temperature of 40 oC. He has generalised muscular rigidity. What is the most likely diagnosis?
Acute dystonic reaction Malignant hyperthermia Pelvic abscess Epilepsy Serotonin syndrome
Malignant hyperthermia
Anaesthetic agents, such as suxamethonium, can cause malignant hyperthermia in patients with a genetic defect
A 45 year old man develops acute respiratory distress syndrome during an attack of severe acute pancreatitis. Which of the following is not a feature of adult respiratory distress syndrome?
It usually consists of type I respiratory failure. Patients typically require high ventillatory pressures. A Swann Ganz Catheter would typically have a reading in excess of 18mmHg. It may complicate acute pancreatitis. It may heal with fibrosis.
A Swann Ganz Catheter would typically have a reading in excess of 18mmHg.
Right heart pressure should be normal.
