Pre and Post-operative management

Question 1

You are asked to review a 45-year-old man on the surgical ward by the nursing
staff. Checking through the notes, you observe that he is 1 day following an open
anterior resection for rectal carcinoma. He describes severe central abdominal pain associated with dyspnoea. The abdomen is soft but generally tender throughout. His symptoms have occurred despite an epidural that was inserted prior to surgery. What is the most effective form of analgesia in this setting?

A. Four-hourly intramuscular morphine
B. Patient-controlled opiate analgesia (PCA)
C. Intravenous paracetamol
D. Per rectum diclofenac
E. Intravenous oxycodeine hydrochloride

Answer 1

B. Patient-controlled opiate analgesia (PCA).

The ideal analgesia for post operative pain in this kind of surgery would be an epidural, which doesn’t seem to be working. Given that, a PCA is indicated. It has been shown to reduce the risk of basal atelectasis and other respiratory complications. The disadvantage is that it requires a level of co-operation and ability to use the device.

IV oxy (E) and IM morphine (A), are both strong and effective but more suited to management of breakthrough pain rather than background cover. They are preffered in patients who cannot use PCA.

Diclofenac (D) and paracetamol (C) are both simple analgesics which are not enough in this case. In addition the use of PR drugs is strictly avoided in recent low rectal resections.

Question 2

A 64-year-old man undergoes a laparoscopic gastric bypass for obesity. His
baseline blood pressure is 150/80 mmHg. Intraoperatively, there was a small
serosal tear which was sutured laparoscopically. The patient had some bleeding
during the dissection of the lesser omentum, which was controlled with diathermy. The patient did not require intraoperative transfusion. Postoperatively on return to the high dependency unit, the patient is mechanically ventilated and his blood pressure is 80/40 mmHg. His urine output is 15 mL/h. Which of the following is the best means of improving his urine output?

A. Commence an infusion of furosemide
B. A trial of dobutamine
C. O-negative blood transfusion
D. Insert a Swan–Ganz catheter
E. Give a fluid challenge and monitor the clinical response

Answer 2

E. Give a fluid challenge and monitor the clinical response

It is sensible in a post surgical patient that the cause of hypotension should be considered to be hypovolaemia until otherwise proven.

There may be a haemorrhage in this case, possibly in the lesser omentum. In that case the best management step would be to administer a fluid challenge and monitor whilst awaiting blood results.

Inotropes (B) are only used in a well filled patient who cannot maintain a sufficient BP due to cardiac output insufficiency.

A Swan-Ganz catheter (D) (Pulmonary artery catheter) is of little value and is controversial.

Furosemide (A) plays a role in patients who cannot maintain an adequate urine in the context of fluid overload

until you know his fluid status and full blood count, a transfusion (C) would not be indicated

Question 3

A 46-year-old woman re-presents to the emergency department 48 hours
following an ‘uncomplicated’ laparoscopic cholecystectomy and on-table
cholangiogram. She describes a history of progressive, constant, right upper
quadrant pain radiating to the shoulder tip since the surgery. The pain is worse on coughing and moving. On direct questioning she describes a 24-hour history of nausea and vomiting. The abdomen is rigid. Her liver function tests are abnormal as follows: bilirubin 60 mmol/L, alkaline phosphatase 550 IU/L and alanine aminotransferase 220 IU/L. Her international normalized ratio is <1.5. Which single investigation is most likely to be diagnostic?

A. Endoscopic retrograde cholangiopancreatography
B. Computed tomography scan of abdomen and pelvis
C. Erect chest radiograph
D. Amylase or lipase levels
E. Urine Ketostix to detect ketonuria

Answer 3

A. Endoscopic retrograde cholangiopancreatography

The most likely diagnosis here is that there is a biliary leak, possibly due to a slipped Ligclip, a high pressure in the ductal system or a duct of luschka.

Although a CT (B) would be useful in assessing the free air and fluid in the abdomen but only an ERCP (A) would be able to identify the source.

A Chest XR (C) would always show free air in the abdomen after a laproscopic procedure.

Urgent amylase or lipase levels (D) will be needed to exclude pancreatitis due to cholangiogram but that is unlikey to be the cause for this patient’s peritonism

Question 4

You are called urgently to see a 67-year-old man who is 24 hours following
uncomplicated laparoscopic cholecystectomy. The patient is human
immunodeficiency virus-positive and has a past history of thrombocytopenia and
at pre-assessment his platelet count was 60 x 109/L. He is complaining of chest
pain and breathlessness and his abdomen is noticeably more distended than in the initial postoperative period with significant peri-umbilical tenderness. His
postoperative electrocardiogram shows lateral ischaemia and his current
haemoglobin level is 7.5 g/dL. He is tachycardic and his blood pressure is 115/75
mmHg. The next appropriate step is:

A. Bleep the on-call cardiologist
B. Start treatment dose heparin
C. Start an infusion of glyceryl trinitrate
D. Start blood transfusion
E. Return the patient to operating theatre for re-look laparoscopy

Answer 4

D. Start blood transfusion

This scenaio is likely to represen a bleed or haematoma, potentially at the site of the ports. This blood loss has led to anaemia which is the cause of the angina and dyspnoea.

Of note, atherosclerosis is more common in HIV positive indviduals.

The most appropriate first step here is to correct the blood loss with a transfusion (D)

A cardiology input (A) may be warented at a later stage.

GTN (C) will cause vasodilation and reduce crucial perfusion of tissues

Heparin (B) is a bad option for a potential bleeder

Question 5

The nursing staff ask you to review an erect chest radiograph of a 60-year-old
woman who has undergone open colonic surgery for a pelvic mass 3 days ago. She is comfortable at rest. Her abdomen is distended, with absent bowel sounds. Free air under the hemi-diaphragms is likely to be due to:

A. Perforated peptic ulcer
B. Anastomotic leakage
C. Perforated sigmoid diverticulum
D. A normal finding 4 days post laparotomy
E. A diaphragmatic injury

Answer 5

D. A normal finding 4 days post laparotomy

This is not an uncommon finding after a laprotomy. Free air could also indicate a perforation or an anastomotic leakage.=, however this patient seems to well for these explainations. The absent bowel sounds ould be a result of Ileus due to handling of the bowel.

Question 6

A 22-year-old woman with known Crohn’s disease is about to undergo an
emergency subtotal colectomy with ileostomy. Prior to surgery the patient has been on 30 mg of prednisolone daily for more than 3 months. The best management to prevent an addisonian crisis would be:

A. Additional steroid cover is not required
B. Usual preoperative dose only (30 mg oral prednisolone)
C. 50 mg of hydrocortisone intravenously preoperatively, followed by 50
mg of hydrocortisone intravenously 8 hourly for 72 hours
D. 25 mg of hydrocortisone intravenously preoperatively, then resume
normal steroid dose postoperatively
E. 25 mg of hydrocortisone intravenously preoperatively, followed by 25
mg of hydrocortisone intravenously for 24 hours

Answer 6

C. 50 mg of hydrocortisone intravenously preoperatively, followed by 50
mg of hydrocortisone intravenously 8 hourly for 72 hours

Table 1.1 Pre- and postoperative steroid regimens for different types of surgery

(Preoperative) <10mg daily (Nature of Suggested surgery) Minor (steroid regimen steroid use) No cover required

≥10mg daily - Minor - 25mg intravenous hydrocortisone preoperatively Resume normal steroid use postoperatively

≥10mg daily - Intermediate - 25mg intravenous hydrocortisone preoperatively 25mg intravenous hydrocortisone every 8 hours for 24 hours then resume normal steroid dose

≥10mg daily - Major - 50mg intravenous hydrocortisone preoperatively 50mg intravenous hydrocortisone every 8 hours for 72 hours then resume normal steroid dose

Question 7

You are asked to assist your consultant who is operating on a 43-year-old human
immunodeficiency virus-positive man involved in a road traffic accident. The
following precautions have been shown to decrease risk of HIV transmission, with the exception of:

A. Gowns
B. Double glove with indicator system
C. Protective eye wear
D. Laminar flow ventilation
E. Surgical masks

Answer 7

D. Laminar flow ventilation

Protective eyewear and gowns are important in any procedure likely to generate droplets for reducing contamination with bodily fluids.

Gloves and masks are important in all surgical procedures.

Laminar airflow (D) has no evidence of risk reduction in HIV contraction

Question 8

You are called to the ward to review a 72-year-old man who is pyrexial at 38.0 °C, 8 hours following an anterior resection for rectal adenocarcinoma without
defunctioning stoma. He is asymptomatic and pain-free with an epidural. A
urinary catheter inserted in theatre is draining concentrated urine. He has a history of chronic airways disease controlled with inhalers. He has no respiratory distress but both lung bases sound quiet. The most likely explanation for the patient’s pyrexia is:

A. Epidural abscess
B. Systemic response to surgical trauma
C. Basal atelectasis
D. Infective exacerbation of chronic airways disease
E. Urinary sepsis

Answer 8

B. Systemic response to surgical trauma

This patient is only 8 hours post surgery, the only possible answer is that this is a systemic inflammatory response to the trauma of surgery. The only other potential cause for this rapid pyrexia would be a pre-existing infection or a contaminated blood transfusion.

The patient is at risk of atelectasis (C) but you would expect to see that at the 24-48hr mark.

Infective exacerbation of airways disease (D) would take longer still (3-7 days) and may well be due to atelectasis.

The urinary catheter (E) was only inserted 8 hours ago, so unlikely

Similarly the epidural (A) hasn’t been in long enough to form an abcess

Question 9

You are called to see the same patient (COPD patient followig an anterior resection for adenocarcinoma) 7 days postoperatively as he has become
unwell and pyrexial with a temperature of 39.0 °C. The patient has generalized
abdominal discomfort. The abdomen is tender with generalized guarding and
rebound. The chest is clear to auscultation. The patient’s catheter and epidural were removed 2 days ago. The most likely explanation for the patient’s pyrexia is:

A. Deep vein thrombosis
B. Infective exacerbation of chronic airways disease
C. Pulmonary embolus
D. Anastomotic leakage
E. Pre-existing chest infection

Answer 9

D. Anastomotic leakage

Here the patient is 7 days following an anterior resection with a defunctioning stoma, with these signs of generalised peritonism an anastomotic leak is the most likely explaination.

a DVT/PE (A)(C) and an excacerbation of COPD are potential complications in this patient ut neither explains the abdominal pain and peritonism.

Question 10

A 62-year-old man is admitted to the emergency department with abdominal pain. The patient has past history of ischaemic heart disease and atrial fibrillation.
Computed tomography scan features are highly suggestive of ischaemic bowel. The patient’s blood gases are as follows:
• pH = 7.25
• paO2 = 10
• paCO2 = 2.8
• HCO3 = 18
• Base excess = –8
Which of the following best describes the patient’s acid–base status?

A. Metabolic acidosis
B. Metabolic acidosis with respiratory compensation
C. Respiratory acidosis with metabolic compensation
D. Metabolic acidosis with inadequate respiratory compensation
E. Cannot be sure without a serum lactate level.

Answer 10

D. Metabolic acidosis with inadequate respiratory compensation

• The patient is acidotic
• His CO2 is low, as he is acidotic we know this is a compensatory effect, not the origional issue.
• he is still acidotic despite the respiratory compensation

therefore (C) is the correct answer, this is likely a result of increasing lactate due to ischaemic bowel. the serum lactate (E) may help diagnosis the cause of the acidosis but isn’t needed to identify the process.

Question 11

You are called urgently to see an 80-year-old man who is 6 days following open anterior resection for rectal carcinoma with defunctioning stoma. The patient reported seeing a gush of pink fluid from the central laparotomy wound. You notice that the small bowel is eviscerating from the wound. Following initial resuscitation, the next best step is to:

A. Cover the small bowel with a sterile saline-soaked gauze

B. Call for senior help

C. Administer intravenous cefuroxime 1.5 g

D. Return the patient to theatre for deep-tension abdominal wall closure

E. Apply vacuum-assisted closure therapy

Answer 11

A. Cover the small bowel with a sterile saline-soaked gauze

although you would get senior help, give antibiotic cover, and return the patient to theatre the most immediate step here is to protect the bowel from the outside world (A).

VAC dressing (E) is used for wound dehiscence but not in the prescence of bowel evisceration.

Question 12

The surgical registrar is about to obtain informed consent from a 16-year-old boy for an open appendicectomy. Which of the following statements regarding consent in minors is most correct?

A. Parental consent must be sought prior to obtaining patient consent

B. If the child refuses treatment, the parent’s consent is required

C. The registrar must determine if the child is competent to obtain informed consent

D. A court order is required

E. None of the above

Answer 12

C. The registrar must determine if the child is competent to obtain informed consent

salient points here;

Age of consent is 18, but a child aged 16-18 can consent to a treatment if the medical professional establishes they can understand the choice being presented.

No-one cn consent on behalf of another person, so (A) and (B) are illogical answers

If a child under 18 refuses treatment then a court order may be needed if the treatment is to go ahead.

Question 13

A 72-year-old woman is about to undergo an elective total hip replacement for osteoarthritis. She has a history of hypertension and type 2 diabetes mellitus but no ischaemic heart disease or peripheral vascular disease. Which of the following is the most appropriate thromboembolic prophylaxis?

A. Intermittent pneumatic calf compression

B. Calf-length thromboembolic deterrent elastic stockings and early ambulation

C. Full-dose unfractionated heparin to increase the activated partial thromboplastin time to two times control

D. Insertion of an inferior vena cava filter

E. Subcutaneous low-molecular-weight heparin

Answer 13

E. Subcutaneous low-molecular-weight heparin

Although a patient with these risk factors (DM and HTN) would best require a combined approach to VTE prophylaxis the question needs you to identify the single most effective preventative method here.

According to published data, following hip surgery elasticized stockings alone reduce risk of VTE by 23 per cent, intermittent compression stockings reduce the incidence by 63 per cent and LMWH alone reduces the risk by 70 per cent.

Unfractionated Heparin (C) is just as effective as LMWH but is more difficult from a practical perspective, making (E) the best option.

Question 14

A 22-year-old man (O blood group) sustained a splenic injury in a road traffic accident. He is undergoing a transfusion of 4 units prior to surgery. You are asked to review the patient 10 minutes into the transfusion as he has become unwell and agitated. He has pyrexia (39.5 °C) with associated tachycardia (120 beats/min) and hypotension (80/50 mmHg). Which of the following is the most likely cause?

A. Non-haemolytic febrile transfusion reaction

B. Transfusion-related acute lung injury

C. Bacterial contamination

D. Air embolus

E. Haemolytic transfusion reaction (ABO incompatibility)

Answer 14

E. Haemolytic transfusion reaction (ABO incompatibility)

A patient becoming this profoundly unwell within minutes of a transfusion should make you think of an ABO incompatibility issue. This is more of a risk in O group patients as they will react to both A and B group blood. Conversely someone with group AB is a universal recipient.

the non-haemolytic reactions (A) tend to occur after 30 minutes or more and the patient is generally well.

Bacterial contamination is a possibiltty (C) but is likely than ABO incompatibility

TRALI (B) and air embolus (D) are less likely given the symptoms here.

Question 15

You are called to the ward to see an agitated 68-year-old man who is 3 days following radical prostatectomy. He is wandering aimlessly around the ward convinced that he is the Duke of Wellington. His Mini-Mental Test score is 4/10. His latest observations reveal pyrexia of 37.6 °C, pulse 100 beats/min, blood pressure 146/88 mmHg and respiratory rate 20 breaths/min. You note that the urinary catheter bag contents are cloudy. Which is the most likely explanation for the patient’s confusion?

A. Preoperative dementia

B. Delirium secondary to chest infection

C. Delirium secondary to reactionary haemorrhage

D. Delirium secondary to urinary tract sepsis

E. Stroke

Answer 15

D. Delirium secondary to urinary tract sepsis

An acute confusion is common in an elderly patient in the post-operative period, it should be suspected in any acute confusion or change in conciousness. To label this as a pre-existing dementia (A) would be inappropriate.

The most likely cause in this case is a urinary infection as there has been a urological procedure and the urine is cloudy.

This is not the presentation of a stroke (E)

Question 16

A 49-year-old woman weighing 65 kg is 5 days following gastrectomy for gastric carcinoma. Her observations are as follows: • Temperature = 39.0 °C • Pulse = 110 beats/min • Blood pressure = 90/50 mmHg • Urine output = 10 mL/h • Respiratory rate = 30 breaths/min Which of the following best describes this patient’s pathophysiological status?

A. Sepsis

B. Septic shock

C. Systemic inflammatory response syndrome

D. Multiple organ dysfunction syndrome

E. None of the above

Answer 16

C. Systemic inflammatory response syndrome

SIRS is defined as two or more of the following;

• temperature >38 °C or <36 °C
• heart rate >90 beats/min
• tachypnoea (respiratory rate >20 breaths/min) or hyperventilation (paCO2 <4.25 kPa)
• white blood cell count >12 x 109/L or <4 x 109/L or the presence of more than 10 per cent immature neutrophils.

We dont know the white cell count but otherwise this is a full house of signs, without a confirmed source of infection this cannot be diagnosed as sepsis/septic shock.

Multi organ dysfuntion is charecterised by a failure to maintain homeostasis, it has a different assesment criteria.

Question 17

A 62-year-old man is about to undergo an elective abdominoperineal resection for a low rectal carcinoma. He usually takes 5 mg warfarin per day for atrial fibrillation. His most recent international normalized ratio (INR) is 2.9. Which of the following is the best preoperative strategy?

A. Admit the patient 1 day prior to surgery to stop warfarin and check the INR

B. Admit the patient 3–5 days prior to surgery to stop the warfarin and check the INR <1.5

C. Admit the patient 3–5 days prior to surgery to stop the warfarin, check the INR <1.5 and start aspirin

D. Admit the patient 3–5 days prior to surgery to stop the warfarin and check the INR <1.5 and start heparin infusion

E. Admit the patient 1 day prior to surgery to stop warfarin and check the INR <1.5 and start low-molecular-weight heparin

Answer 17

B. Admit the patient 3–5 days prior to surgery to stop the warfarin and check the INR <1.5

The major procedure this patient is about to undergo represents a risk of bleeding. The indication for the Warfarin here is AF, which is not the most substantial risk, as such there is no need for any aspirin or heparin. it would be best to bring the patient in for 3-5 days and ensure the INR was <1.5 on the day prior to surgery.

If the indication for the warfarin was something more risky, such as reccurent VTE or metalic heart valves then conversion to heparin injections/infusions would be advisable.

Question 18

A patient on warfarin for multiple deep vein thromboses is about to undergo an emergency laparotomy for a perforated sigmoid colon. Which of the following is the best preoperative strategy?

A. Discontinue warfarin therapy, administer vitamin K (2–3 mg) and check the international normalized ratio (INR) every 6–8 hours preoperatively

B. Discontinue warfarin therapy and check the INR every 6–8 hours preoperatively

C. Continue warfarin therapy as prescribed

D. Discontinue warfarin therapy, administer vitamin K (2–3 mg), check the INR every 6–8 hours preoperatively, request fresh frozen plasma to cover the procedure

E. None of the above as the surgery should be postponed

Answer 18

D. Discontinue warfarin therapy, administer vitamin K (2–3 mg), check the INR every 6–8 hours preoperatively, request fresh frozen plasma to cover the procedure

The significant and emergency nature of this abdominal pathology precludes any delay to the procedure (A), (B), (D) and (E). What is needed is a reversal of warfarin’s effect, which is achieved with vitamin K (D). The FFP may also be needed if intra-operative bleeding becomes an issue, advice from Haematology should be sought.

Question 19

A 34-year-old man is about to undergo a left hemicolectomy for colorectal carcinoma. He is an insulin-dependent diabetic. The most appropriate perioperative management is:

A. Preoperatively commence 0.9 per cent normal saline (3 L in 3 hours), along with 20 units of intramuscular Actrapid insulin with 6 units per hour thereafter along with potassium supplementation

B. Preoperatively start 50 units of insulin in 500 mL of normal saline and continue through to postoperative period, then restart normal subcutaneous insulin when the patient is eating and drinking normally

C. Start intravenous infusion of 5 or 10 per cent dextrose (500 mL bags) over 4–6 hours and add insulin and potassium chloride to each bag, titrated to blood glucose and potassium levels

D. Continue usual subcutaneous insulin until and including the day of surgery. Place first on the list and monitor blood glucose preoperatively, intraoperatively and in recovery

E. None of the above

Answer 19

C. Start intravenous infusion of 5 or 10 per cent dextrose (500 mL bags) over 4–6 hours and add insulin and potassium chloride to each bag, titrated to blood glucose and potassium levels

insulin dependent diabetics undergoing major procedures should continue with their normal insulin regime until they become nil by mouth. Two operative regimes are generally used, the PIG (potassium, insulin, glucose) as per option (C). or 50 units of insulin in 50ml of saline run alongside fluids with potassium, option (B) is similar to this regime but excludes the potassium.

Question 20

A 55-year-old man is about to undergo a diagnostic knee arthroscopy as a day case. He has type 2 diabetes mellitus for which he takes metformin 850 mg/day. The most appropriate perioperative management is:

A. Start intravenous infusion of 5 per cent or 10 per cent dextrose (500 mL bags) over 4–6 hours and add insulin and potassium chloride to each bag, titrated to blood glucose and potassium levels

B. Continue oral hypoglycaemic agents until and including the day of surgery

C. Provided that blood glucose <10 mmol/L, continue oral hypoglycaemic agents until day of surgery, then omit morning dose, restart oral hypoglycaemics with first meal

D. Provided that blood glucose <10 mmol/L, preoperatively start 50 units of insulin in 50 mL of normal saline and continue through to postoperative period, then restart oral hypoglycaemics with first meal

E. None of the above as management depends on HbA1c levels

Answer 20

C. Provided that blood glucose <10 mmol/L, continue oral hypoglycaemic agents until day of surgery, then omit morning dose, restart oral hypoglycaemics with first meal

Type 2 diabetics undergoing a minor or intermediate procedure should continue thier oral hypoglycaemic agents until the day of surgery, omit the morning dose and then continue when back on food.

If they are poorly controlled (>10mmol/L) or undergoing major surgery then one of the insulin dependent regimes should be used (PIG or insulin sliding scale)

HbA1c is a marker of long term control and so useless in this case

Question 21

A 17-year-old Caucasian woman who underwent a laparotomy 2 weeks ago for a perforated appendix develops a swinging fever, dry cough, and pain in the tip of her right shoulder. Her latest observations are as follows: • Temperature = 38.9 °C • Blood pressure = 120/76 mmHg • Pulse rate = 110 beats/min • Respiratory rate = 20 breaths/min Examination shows tenderness over the lower lateral ribcage. Abdominal and rectal examinations are normal. The white blood cell count is 18 000 x 109/L. Which one of the following is the best diagnostic test for this patient?

A. Erect chest radiograph

B. Abdominal radiograph

C. Abdominal ultrasound

D. Abdominal CT scan

E. Gastrografin follow-through

Answer 21

D. Abdominal CT scan

The clinical picture here points towards a subphrenic colection or abcess which is not uncommon 15-20 days after a laparotomy for a perforated viscus.

The shoulder tip pain and swinging fever point towards a diaphragmatic irritation and guide the diagnosis.

The radiograph (A) would show non-specific signs but would not be diagnostic.

The follow through and plain abdo film would exclude other pathology but wouldn’t diagnose a sub-phrenic abcess.

a CT scan would be the only test to identify the pathology and its location and aid radiological aspiration and drainage.

Question 22

A 45-year-old African Caribbean man is approximately 5 days following right femoropopliteal bypass for superficial femoral artery atherosclerosis. The nursing staff have asked you to see the patient, who is complaining of increasing pain over the right groin wound. The patient has a low-grade pyrexia of 37.6 °C. On examination the wound is erythematous, hot and tender on palpation. There is no obvious collection, abscess or crepitation. The right leg is mildly swollen and the calf is soft. All peripheral pulses are palpable. The most likely diagnosis is:

A. Cellulitis secondary to Staphylococcus epidermidis infection

B. Deep vein thrombosis

C. Cellulitis secondary to Streptococcus pyogenes infection

D. Lymphoedema secondary to filariasis

E. Occlusion secondary to graft thrombosis

Answer 22

C. Cellulitis secondary to Streptococcus pyogenes infection

In an immunocompetent patient the most likely causative organisms for cellulitus are Staph Aureus or Strp Pyogenes. Staph Epidermis is a comensual and only becomes an issue in the immunocompromised.

A low grade pyrexia with a leg sweling should make you think to exclude a DVT but it is not the likeliest pathology here.

Filariasis is a bit of a wild card given its tropical distrubution.

Graft thrombosis is a later complication and would likely lead to non-palpable pulses

Question 23

A 74-year-old Caucasian man with obstructive jaundice secondary to gallstones is about to undergo urgent laparoscopic cholecystectomy and bile duct exploration following failed endoscopic retrograde cholangiopancreatography. His latest blood tests are as follows: • Bilirubin = 180 • Alkaline phosphatase = 700 IU/L • Alanine aminotransferase = 250 IU/L • White cell count = 18 x 109/L • Urea = 9.0 mmol/L • Creatinine = 180 mmol/L Which one of the following is the best statement regarding perioperative management considerations?

A. Rehydration should be approached with caution to prevent the risk of hepatorenal syndrome

B. The patient is at increased risk of bleeding to reduced absorption of clotting factors II, VII, IX and X

C. There is a lower risk of infection so prophylactic antibiotics are not necessary

D. Analgesics are less effective so doses of opiates should be increased

E. Surgery should not be performed in a jaundiced patient

Answer 23

B. The patient is at increased risk of bleeding to reduced absorption of clotting factors II, VII, IX and X

Hepatorenal syndrome is a serious condition characterised by acute renal failure on a background of liver cirrhosis. It is made more likely by dehydration, so (A) is incorrect for a couple of reasons.

Jaundiced patients have a higher risk of infection (C) which is one reason why surgery isn’t the first management step, but here the ERCP has failed so (E) is incorrect.

Liver metabolism of opiates is reduced so thier effects may be prolonged in a jaundiced patient so (D) is not correct.

(B) is indeed correct

Question 24

A 62-year-old man is awaiting an elective femoropopliteal bypass for peripheral vascular disease. He is a smoker of 60 pack years and is being treated for hypertension and hypercholesterolaemia with ramipril 5 mg each morning and simvastatin 10 mg orally at night. Three weeks ago he was admitted following an ST elevation myocardial infarction. His current blood pressure is 170/110 mmHg. Which of the following best describes the preoperative strategy?

A. Preoperative control of blood pressure with nifedipine is mandatory

B. Preoperative unfractionated heparin should be started, with 4-hourly monitoring of the patient’s activated partial thromboplastin time

C. Intensive chest physiotherapy three times a day is vital postoperatively

D. A preoperative echocardiogram is required

E. None of the above, as the surgery should be deferred for 6 months

Answer 24

E. None of the above, as the surgery should be deferred for 6 months

Risk of postoperative reinfarction after a previous myocardial infarction is:

• 0–3 months = 35 per cent
• 3–6 months = 15 per cent
• >6 months = 4 per cent

In this case surgery is elective for non-critical iscaemia, so the decision to delay surgery is more straightforward (E).

(A) is not the right approach as it would be better to manage this patient with BP control in the community setting rather than calcium channel blockers.

(B) unfractionated heparin would be advisable in critical ischaemia

(C) would be unesscecery, and routine chest physio should suffice

(D) is normal for pre-op assessment

Question 25

A 37-year-old man is admitted with abdominal pain and treated for pancreatitis; 48 hours following his admission you are asked to assess the patient as he has become increasingly confused and aggressive. Observations are not possible but you note he appears to be breathing hard, he is tremulous and has pruritus. Choose an appropriate management strategy:

A. Septic screen; urine dip, chest radiograph and blood cultures

B. Chlordiazepoxide 20 mg intravenously, four times daily for 1 week

C. Haloperidol 2 mg intramuscularly and confine to side room

D. Lorazepam infusion

E. Oral chlordiazepoxide-reducing regimen with 48 hours intravenous thiamine

Answer 25

E. Oral chlordiazepoxide-reducing regimen with 48 hours intravenous thiamine

This patient is showing classic signs of alcohol withdrawal, alcohol also being one of the causes of acute pancreatitis. The DT’s tend to occur 24-72hrs after the session of drinking, it presents with tachycardia, hypotension, then confusion, tremor, seizure, coma and death. There are commonly psychotic hallucinations that are extremely unpleasant.

These patients must be started on a weaning regime of benzodiazepines, oral chlordiazepoxide being preferred. IM Diazepam, or lorazepam is the next choice. A septic screen would also be appropriate, but the withdrawal needs treating first. The thiamine is used as there is evidence that it can reduce the incidence of Wernicke’s encephalopathy.