Rakesh 6 Flashcards
1
Q
- A 24-year-old male fell off a horse and sustained a femoral shaft fracture.
The chest X-ray and C-spine were clear. He under went internal fi xation
of the femoral shaft with intramedullary nail, with blood loss of about a
800 mL. Forty-eight hours later the patient is confused. His respiration
is 22/min, blood pressure 80/40 mmHg, oxygen saturation 92 % , and
temperature 39 ° C. On examination there are scattered crepitations
on the chest with widespread petechial rash noted. What would be the
most appropriate next step?
A. Immediately alert the orthopaedic team and send blood for investigation.
B. Transfuse packed red cells and ensure the good circulating blood volume.
C. Treat with anticoagulation for pulmonary embolism.
D. Get a CT head scan as patient had a fall from horse.
E. Transfer the patient to critical care with oxygen for CPAP ventilation and monitoring.
A
E
- Answer: E
Fat embolism is commonly seen in patients with major trauma, especially with long bones.
The clinical feature described in the question suggests there is embolization of fat and
microaggregates of platelets, RBCs, and fi brin in the systemic and pulmonary circulation.
Pulmonary damage may result directly from the emboli (infarction) or by a chemical pneumonitis
and adult respiratory distress syndrome (ARDS).
The diagnosis is based on clinical presentation of symptoms, which usually appear 1–3 days after
injury. Onset is sudden, with presenting symptoms of tachypnea, dyspnoea, and tachycardia.
The most signifi cant feature is the potentially severe respiratory eff ects, which may result in ARDS.
Neurologic symptoms may also be present; initial irritability, confusion, and restlessness may
progress to delirium or coma. Petechiae appear on the trunk and face and in the axillary folds,
conjunctiva and fundi in up to 50 % of patients, which helps in diagnosis. Of these symptoms,
respiratory insuffi ciency, central neurologic impairment, and petechial rash are considered
major diagnostic criteria, and tachycardia, fever, retinal fat emboli, lipiduria, anaemia, and
thrombocytopenia are considered minor diagnostic criteria.
There is no specifi c therapy for fat embolism syndrome; prevention, early diagnosis, and adequate
symptomatic treatment are of paramount importance. Supportive care includes maintenance of
adequate oxygenation and ventilation, stable haemodynamics, blood products as clinically indicated,
hydration, prophylaxis of deep venous thrombosis and stress-related gastrointestinal bleeding,
and nutrition. The goals of pharmacotherapy are to reduce morbidity and prevent complications.
Supportive care is the mainstay of therapy for clinically apparent cases of fat embolism syndrome.
Mortality is estimated to be 5–15 % overall, but most patients will recover fully.
As the patient had no head or chest injury the most appropriate next step would be to transfer the
patient to critical care. This will ensure adequate monitoring along with the supportive treatment.
2
Q
- A 28-year-old woman is admitted to the labour ward following prolonged
rupture of membrane at 38 weeks of gestation. She is very distressed
by labour pains, and is requesting an epidural. On examination she is
6-cm dilated, with temperature of 38.8 ° C, heart rate of 140/min, and
blood pressure of 110/60. She was given paracetamol 1 g orally and 1.2
g of coamoxiclav intravenously. What is the most appropriate course of
action?
A. Explain the procedure and provide epidural.
B. It is safe to put the epidural in as she has had antibiotic cover.
C. Epidural analgesia is contraindicated in this case.
D. Wait for an hour so the antibiotics may work and then insert the epidural.
E. Give some fl uids fi rst and then insert the epidural.
A
A
- Answer: C
Signs of infection are contraindications to central neuraxial block.
Relative contraindications are:
aortic stenosis/mitral stenosis (profound hypotension — sympathetic block)
previous back surgery (technical diffi culty)
neurological disease (medicolegal)
systemic sepsis (increased incidence of epidural abscess, meningitis).
3
Q
- An 84-year-old woman is admitted with fracture of neck of femur,
which she sustained after a fall at her nursing home. She has a history
of dementia and ischaemic heart disease and had a coronary bypass 10
years ago. She is on the trauma list for surgical fi xation of her hip. In the
preoperative visit the anaesthetist noticed that there is an active ‘do not
attempt resuscitation’ form. Regarding the DNAR which of the following
statements is correct?
A. DNAR form should be respected and the patient should not come to theatre.
B. DNAR form should be respected and in the event of arrest in theatre CPR should not be
undertaken.
C. DNAR should be cancelled as the patient needs surgery.
D. DNAR should be reviewed before anaesthesia and surgery.
E. DNAR form is not valid as the reason for admission is a fracture.
A
d
- Answer: D
A review of the DNAR decision by the anaesthetist and surgeon with the patient, proxy decision
maker, other doctor in charge of the patient’s care, and relatives or carers, if indicated, is essential
before proceeding with surgery and anaesthesia. Surgery can proceed despite the presence of a
DNAR decision if it is in the patient’s best interests at that time.
Medical conditions that may require anaesthesia for operative interventions in a patient with a
DNAR decision include:
provision of a support device (e.g. a feeding tube)
urgent surgery for a condition unrelated to the underlying chronic problem (e.g. acute
appendicitis)
urgent surgery for a condition related to the underlying chronic problem but not believed to
be a terminal event (e.g. bowel obstruction)
procedure to decrease pains (e.g. repair of fractured neck of femur)
procedure to provide vascular access.
4
Q
- A 45 -year-old , 85 - kg male is retrieved from a house fi re. He has
sustained 40 % burn s with no other injury and is haemodynamic ally stable .
Which of the following is the correct fl uid requirement in the fi rst 8 h?
A. 800 m L colloid and 3500 m L crystalloid.
B. 5000 m L crystalloi d.
C. 6800 m L crystalloi d.
D. 13 600 m L crystalloi d.
E. 5000 mL colloid
A
C
- Answer: C
A burns patient who has sustained burns over more than 25 % of total body surface area (TBSA)
produces a marked systemic infl ammatory response accompanied by an increase in capillary
permeability and generalized oedema. These patients require fl uids for both resuscitation and
maintenance. Hartmann’s solution is the preferred resuscitation fl uid. Various formulae have been
suggested to calculate the fl uid requirements in these patients. A modifi ed Parklands formula is one
of most commonly used.
Modifi ed Parklands formula
4 mL/kg/ % total body surface area/24 h
The total volume of Hartmann’s solution for the fi rst 24 h = 4 mL × 85 × 40 = 13 600 mL. Half the
volume is administered in the fi rst 8 h, the rest is delivered over the next 16 h. (Hartmann’s solution
× bodyweight [kg] × % burn.).
Maintenance fl uids are required in addition to the calculated resuscitation fl uid. These calculated
values are merely an estimate, while the precise volumes required will be guided by urine output
( > 0.5–1.0 mL/kg) and cardiovascular response.
Mount Vernon formula
The Mount Vernon formula is also used for resuscitation in burns patients:
0.5 × weight in kg × % TBSA (mL) of 4.5 % human albumin in each six periods over 36 h.
5
Q
- A 36-year-old male patient suff ering from primary hyperaldoesteronism
is scheduled for laparoscopic cholecystectomy. His routine investigation
would show:
A. High sodium, low potassium, and low hydrogen ions.
B. High sodium, low potassium, and high hydrogen ions.
C. Low sodium, low potassium, and high hydrogen ions.
D. Low sodium, high potassium, and high hydrogen ions.
E. Low sodium, high potassium, and low hydrogen ions.
A
B
- Answer: A
Hyperaldoesteronism is a condition in which excessive aldosterone is secreted by the adrenal gland.
This is featured where there are low potassium levels in blood. Clinical features are hypertension,
hypokelemia, and alkalosis . Aldosterone is a steroid hormone (mineralocorticoid family) produced
by the outer-section (zona glomerulosa) of the adrenal cortex in the adrenal gland, and acts on the
distal tubules and collecting ducts of the nephron, the functioning unit of the kidney, to cause the
conservation of sodium, secretion of potassium, increased water retention, and increased blood
pressure. The overall eff ect of aldosterone is to increase reabsorption of ions and water in the kidney.
Aldosterone tends to promote Na + and water retention, and lower plasma K + concentration.
Hence excessive aldoesterone secretion leads to excessive renal absorption of sodium in exchange
for potassium and increased secretion of hydrogen ions in the collecting duct.
6
Q
- A 45-year-old man is undergoing laparoscopic cholecystectomy. Following
induction in the anaesthetic room he was transferred to the operating table
in theatre and the monitor shows heart rate is 150/min. His peak airway
pressure is rising. The patient looks fl ushed and has a feeble pulse. Which
of the following would be the most appropriate action in this situation?
A. Call for help and check the ventilator.
B. Call for help and give a bolus of 50 mcg of adrenaline IV.
C. Call for help and give a bolus of 50 mcg of adrenaline IM.
D. Call for help and give a bolus of 1 mg of adrenaline IM.
E. Call for help and give a bolus of 10 mg chlorphenamine and 200 mg hydrocortisone IV.
A
B
- Answer: B
This is a case of anaphylaxis, an acute emergency situation. Anaphylaxis is an IgE-mediated type
B hypersensitivity reaction to an antigen, resulting in histamine and serotonin release from mast
cells and basophils. The common clinical presentation is cardiovascular collapse, erythema,
bronchospasm, oedema, and rash.
Immediate management steps are as follows: - Use the ABC approach (airway, breathing and circulation). Team working enables several
tasks to be accomplished simultaneously. - Remove all potential causative agents (including IV colloids, latex, and chlorhexidine) and
maintain anaesthesia, if necessary, with an inhalational agent. - Call for help and note the time.
- Maintain the airway and administer oxygen 100 % . Intubate the trachea if necessary and
ventilate the lungs with oxygen. - Elevate the patient’s legs if there is hypotension.
- If appropriate, start cardiopulmonary resuscitation immediately according to the Advanced
Life Support Guidelines . - Administer adrenaline intravenously. An initial dose of 50 mcg (0.5 mL of 1: 10 000 solution)
is appropriate (adult dose). Several doses may be required if there is severe hypotension or
bronchospasm. - If several doses of adrenaline are required, consider starting an intravenous infusion of
adrenaline (adrenaline has a short half-life).
7
Q
- A 75-year-old woman had a total abdominal hysterectomy for cervical
cancer, under general anaesthesia and epidural for pain relief. She is on
long-term clopidogrel, which was stopped 7 days before elective surgery.
The routine preoperative blood investigations revealed a normal clotting
screen. Plasma urea and creatinine were raised, at 9.2 mmol L − 1 and
112 μmol L − 1 respectively. Post-operatively, epidural infusion was 10 mL/h
of 0.125 % bupivacaine. Eight hours postoperatively she has a dense motor
block of her right leg. The most appropriate action would be to:
A. Remove the epidural catheter and do an MRI.
B. Stop the epidural and refer her to the neurologist.
C. Book an urgent MRI and refer to neurosurgeon.
D. Stop the epidural infusion and reassess the neurology in 2 h.
E. Change the epidural infusion bag for another of lower concentration.
A
D
- Answer: D
The development of a spinal haematoma is a rare but potentially devastating complication of
central neuraxial blockade. Monitoring of sensory and motor block is essential for the early
detection of potentially serious complications. The Bromage scale is an accepted tool for the
measurement of motor block. An increasing degree of motor weakness usually implies excessive
epidural drug administration. However, it can indicate very serious complications including dural
penetration of the catheter or the development of an epidural haematoma or abscess. Therefore,
it is essential that protocols are in place to manage the scenario of excessive motor block. As a
working rule of thumb, some recovery should be seen within 4 h and if this is not seen, further
assessment and investigation to exclude major complications is required. Examples of suitable
algorithms and specifi c advice on protocols for this situation are given in the report on the audit of
major complications of central neuraxial block performed by the Royal College of Anaesthetists.
An epidural abscess or haematoma can cause severe, permanent neurological damage and must
be detected and treated as soon as possible. This diagnosis must be considered if excessive motor
block does not resolve rapidly after stopping the epidural infusion. A clear protocol should be in
place describing the actions required in this situation, including informing senior anaesthetic staff
and immediate availability of suitable imaging and surgical expertise
8
Q
- A 50-year-old man is on your elective list for inguinal hernia repair under
general anaesthesia. He had successful cardiac transplant 6 years ago
with no problems, and has good exercise tolerance. The ECG showed
right bundle branch block, with a rate of 90/min. At anaesthetic induction
it would be essential to:
A. Ensure adequate preload is maintained.
B. Avoid nephrotoxic drugs.
C. Perioperative β -block the patient to avoid risk of ischemia.
D. Be aware that in the case of bradycardia, atropine would not work.
E. Be aware that epinephrine will increase the contractility and chronotropy.
A
D
- Answer: A
The transplant heart has no autonomic innervations; the resting heart rate is typically 90–100 bpm
due to the loss of vagal tone. Normal autonomic system responses are lost (beat-to-beat variation
in heart rate, response to Valsalva manoeuvre/carotid sinus massage). Contractility of the heart is
close to normal. The transplanted heart should be viewed as permanently denervated. This results
in poor tolerance of acute hypovolaemia. An adequate preload must be maintained in a patient
with a transplanted heart, as there is a lack of rapid homeostatic adjustments in the heart. Hence
wide varation in vascular resistance can produce wide swings in blood pressure, which can be
troublesome during anaesthesia.
If pharmacological manipulation is required then direct-acting agents should be used: atropine
has no eff ect on the denervated heart, the eff ect of ephedrine is reduced and unpredictable, and
hydralazine and phenylephrine produce no refl ex tachy- or bradycardia in response to their primary
action. Adrenaline, noradrenaline, isoprenaline, and β - and α -blockers act as expected.
9
Q
- A 40-year-old man with myotonic dystrophy is admitted for
tonsillectomy to treat his sleep apnoea symptoms. He has no
cardiovascular or pulmonary issues, his lung function is normal, and
he suff ers from type II diabetes, which is well controlled. The best
anaesthetic management for this patient would be:
A. Patient should be intubated using depolarizing neuromuscular blocking agents.
B. Patient should be intubated using non-depolarizing neuromuscular blocking agents.
C. Neuromuscular relaxant should be avoided if possible.
D. Avoid hypothermia, shivering, and mechanical and electrical stimulation.
E. Tight control of blood sugar.
A
B
- Answer: D
Myotonic dystrophy is an autosomal dominant disorder, with an incidence of 2.4–5.5 cases per
100 000 in the UK. The locus for myotonic dystrophy is on chromosome 19. Findings include
myotonia (incomplete muscle relaxation, especially the inability to ‘let go’ after a hand grip),
muscle wasting, cardiac abnormalities (conduction defects, cardiomyopathy, structural deformities),
respiratory abnormalities (restrictive lung disease and obstructive sleep apnoea), endocrine
dysfunction, and intellectual impairment.
Anaesthetic considerations
Factors that may precipitate myotonias must be avoided where possible. These include
hypothermia, shivering, and mechanical and electrical stimulation. There may be increased
sensitivity to sedatives and analgesics due to the respiratory involvement and therefore these agents
should be used judiciously. Depolarizing neuromuscular blocking agents may induce generalized
muscular contractures and are therefore not recommended. Non-depolarizing neuromuscular
blocking agents are not associated with myotonias, but the use of anti-cholinesterase drugs may
precipitate contractures due to the increased sensitivity to acetylcholine. Glucose metabolism may
be aff ected as part of the disease, and therefore levels should be monitored perioperatively. Bulbar
muscle weakness may result in aspiration. Conduction defects may require access to pacemaker
equipment.
10
Q
- A 20-year-old woman is listed for an elective femoral hernia repair.
Currently she suff ers from indigestion, and 7 months ago she was admitted
to critical care with Guillain–Barré syndrome. At the pre-operative visit
she is very anxious and would prefer general anaesthesia for the operation.
What would be the appropriate method to manage this case?
A. Regional anaesthesia with sedation.
B. General anaesthesia using rapid sequence induction with suxamethonium.
C. General anaesthesia with modifi ed rapid sequence induction using rocuronium.
D. General anaesthesia should be avoided for the next 6 months.
E. General anaesthesia with laryngeal mask airway.
A
C
- Answer: C
Guillain–Barré syndrome is an immune-mediated polyneuropathy that often follows a viral or
bacterial illness within the preceding 4 weeks. The weakness typically ascends from the legs and is
symmetrical. Sensory and autoimmune dysfunction can also occur. Ascending weakness can lead
to respiratory compromise, requiring prolonged ventilatory support and bulbar dysfunction.
The use of depolarizing neuromuscular blocking agents should be avoided even following a long
period after recovering from the neurological defi cit, as the risk of hyperkalaemic cardiac arrest
after depolarizing neuromuscular blocking agents may persist. There may be increased sensitivity
to non-depolarizing neuromuscular blocking agents.
11
Q
- A 58-year-old diabetic patient on insulin is referred to the chronic pain
clinic. He complains of severe burning sensations and pain in his foot.
His quality of life is very poor and simple analgesia such as paracetamol,
NSAIDs, and opioids have been unsuccessful. The fi rst line of treatment
would be:
A. Pregabalin.
B. Amitriptyline.
C. Ketamine.
D. Methadone.
E. Duloxetine.
A
A
- Answer: E
The most common symptoms of diabetic neuropathy include pain, burning, tingling, or numbness in
the toes or feet, and extreme sensitivity to light touch. The pain may be worst at rest and improve
with activity, such as walking. Some people initially have intensely painful feet while others have few
or no symptoms.
The fi rst line pharmacological management for diabetic neuropathic pain according to the NICE guideline is duloxetine.
Class of drug: antidepressant — serotonin/norepinephrine reuptake inhibition.
Mode of action: 5-HT/NE reuptake inhibition.
Indications: fi rst-line treatment of diabetic neuropathy.
Contraindications: hepatic impairment, renal impairment (avoid if GFR < 30 mL/min),
pregnancy, breast feeding.
12
Q
- A 29-year-old, on long-term opioids for chronic pain, undergoes
exploration of a wound under general anaesthesia. Intra-operatively,
intravenous paracetamol, diclofenac, and morphine was administered
for pain. In recovery, the patient complains of severe pain. His heart rate
is 120/min and blood pressure is 160/85 mmHg. Which of the following
would be the most appropriate for management of his pain?
A. Intravenous bolus of 10 mg of morphine.
B. This patient will be tolerant to opioid analgesia — increasing his opioid load in the
perioperative period can lead to addiction and should be avoided.
C. A standard patient-controlled morphine analgesia.
D. A loading dose of 10 mg morphine followed by morphine infusion in the recovery.
E. A loading dose of fentanyl 100 mcg followed by patient-controlled fentanyl analgesia
regime with a shorter lock-out and possibly with a higher bolus dose.
A
D
- Answer: E
The fi nding of increased postoperative pain and postoperative opioid consumption in a patient
receiving a high rather than low intraoperative opioid dose indicates the possibility of opioidinduced
hyperalgesia. Management of postoperative analgesia in patients with opioid dependency
is challenging — fi rstly to diff erentiate addiction from dependence and avoid opioid withdrawal
symptoms, and secondly to achieve adequate pain management, as tolerance to the eff ect of
postoperative opioids must also be considered. Fear of pain can induce requests for increased
opioids, which can be mistaken for addiction. Non-opioid analgesic drugs (e.g. non-steroidal antiinfl
ammatory drugs, paracetamol, and clonidine) and appropriate regional techniques will have the
eff ect of reducing requirements: an ‘opioid-sparing eff ect’.
This patient will require her baseline preoperative opioid dose and a provision made for ‘as required’
dosing for breakthrough pain. In this scenario, a short-acting opioid patient-controlled analgesia
regime with a shorter lock-out and/or a higher bolus dose is more appropriate to her needs.
The opioid-induced hyperalgesia occurs when opioid drugs prescribed for pain relief may
paradoxically make the patient more sensitive to painful stimuli.
Tolerance is defi ned as a reduced eff ect for an equivalent dose or the requirement of increased
doses to attain the same eff ect. It can occur with strong opioids such as morphine and oxycodone
within 1–2 weeks, so in this case a larger dose of opioid will be required to achieve adequate
analgesia. Tolerance, however, also develops to some of the side eff ects of opioids, making patients
less likely to suff er from respiratory depression, itching, and nausea than opioid-naive patients, but
careful monitoring is still required.
13
Q
- Pregabalin and gabapentin has been used for multimodal postoperative
pain management of acute pain. On which of the following sites does the
drug act?
A. N-methyl-daspartate receptor.
B. Aminobutyric acid receptor.
C. α -2- δ subunit of calcium channel.
D. Inhibits prostaglandins.
E. α -2 channel.
A
C
- Answer: C
Gabapentin (1–[aminomethyl] cyclohexane-acetic acid) is an antiepileptic drug. Recently it has been
used in acute pain. There is considerable overlap in their pathophysiology of acute pain. Allodynia
and hyperalgesia are cardinal signs and symptoms of neuropathic pain but they are also often
present after trauma and surgery. Sensitization of neurones in the dorsal horns, a mechanism in
neuropathic pain, has been demonstrated in acute pain models. The persistence of this mechanism
may be responsible for the increasingly recognized problem of chronic pain after surgery.
Gabapentin has a high binding affi nity for the α 2 δ subunit of the presynaptic voltage-gated calcium
channels, which inhibits calcium infl ux and subsequent release of excitatory neurotransmitters in the
pain pathways. It reduces the membrane voltage-gated calcium currents (VGCC channels) in dorsal
horn ganglion neurons. It has high affi nity for the subunit of the pre-synaptic VGCC channels, which
inhibits calcium infl ux and subsequent release of excitatory neurotransmitters by sensory neurons.
It increases serotonin concentrations in the brain. Gabapentin does not aff ect nociceptive
thresholds but has a selective eff ect on the nociceptive process involving central sensitization.
As well as a direct analgesic eff ect, gabapentin may prevent and/or reverse opioid tolerance
14
Q
- A 65-year-old male patient had an emergency laprotomy. He was doing
well postoperatively, but 24 h postoperatively he is agitated, confused,
and vomiting. The surgical registrar has reviewed the patient and there
were no surgical issues. The heart rate is 120/min, respiratory rate is
20/min, blood pressure is 180/100 mmHg, and his chest is clear. He has
received 5 % dextrose to meet his fl uid requirements and PCA morphine
for pain control. What is the most likely cause?
A. Stroke.
B. Chest infection.
C. Morphine side eff ect.
D. Hyponatremia.
E. Withdrawal syndrome.
A
D
- Answer: D
Hyponatremia is defi ned as a serum sodium concentration of <135 mmol/L. Iatrogenic
hyponatremia is not uncommon and usually results from the administration of inappropriately
hypotonic fl uids, often in the postoperative period when ADH levels are raised as part of the stress
response. Symptoms and signs of hyponatremia are:
moderate: lethargy, nausea, vomiting, anorexia, thirst, irritability, headache and muscle
weakness/cramps
severe: hyporefl exia, drowsiness and confusion, seizures, coma and death.
15
Q
- A 30-year-old woman with spina bifi da is 34 weeks pregnant. Her MRI
showed no tethering of the spinal cord and there are no neurological
issues. Her pregnancy has been normal, with no problems. She is very
anxious about the pain relief during labour and would like to know the
best option. Which of the following would be best management?
A. TENS machine.
B. Pethidine intramuscular.
C. Epidural.
D. Entonox.
E. Combine spinal epidural
A
C
- Answer: E
Combined spinal–epidural is the best option when inserted above the level of the lesion and will
cover the lower segments as well.
Spina bifi da occulta is part of a spectrum of congenital abnormalities resulting from failed closure of
the neural tube. The incidence, ranging from 10–25 % of the population, is decreasing due to folate
supplementation. Magnetic resonance imaging is mandatory to exclude the presence of a tethered
spinal cord, after which it is acceptable to perform regional anaesthesia at a level not aff ected by the
