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.
