Having just finished some obstetric revision, I have a sneaky suspicion that the new CEMACH 2003-2005 report may feature in next years exam in some form or another. Below is a concise summary, the majority of which relates to anaesthesia:
CEMACH 2003-2005 Summary
Definition
-Confidential Enquiries into Maternal Deaths.
-The longest running "Gold Standard" audit in the world. First Report covered 1952-54
-Triennial report published by DOH looking into all maternal deaths in UK
Causes of death:
-Direct: deaths of women while pregnant or within 42 days of termination of pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not accidental or incidental causes.
-Indirect: deaths resulting from previous existing disease, or disease that developed during pregnancy and which was not due to direct obstetric causes, but which was aggravated by the physiological effects of pregnancy.
Late: deaths occurring between 42 days and one year after the end of pregnancy
Changed title from “Why Mothers Die” to “Saving Mothers’ Lives”.
- All maternal deaths: 14 per 100000 maternities (no statistically significant change).
- Direct maternal mortality: slight rise (not statistically significant).
- Lack of decline of maternal mortality: older patient, obesity, comorbidities, migrants, lifestyle.
Commonest direct causes of maternal death
1) Thromboembolism (again)
=2 )pre-eclampsia/sepsis
4) Amniotic fluid embolism
=5) Haemorrhage/early pregnancy
- Increased numbers of: pre-eclampsia, genital tract sepsis/trauma + inexplicable rise in amniotic fluid embolism.
- Decreased haemorrhage/early pregnancy/ectopic.
- Nil of above: statistically significant.
Commonest indirect cause of maternal death
- Cardiac disease (less healthy diets, smoking, alcohol and the growing epidemic of obesity).
Anaesthetics
- 150 cases reviewed: direct or indirect cause of death also having anaesthetic
Direct anaesthetic deaths:
- 6 deaths – (4.5%) 0.28 per 100000 maternities. Same as previous triennium.
- All but one: Caucasian.
- 4/6: obese (2 were morbidly obese: BMI > 35)
Cases
1) Post-op bronchospasm & resp failure: obese asthmatic lady – failed reintubation during recovery post laparascopic surgery for ectopic pregnancy. Irreversible cardiac arrest.
2) Obese lady, early pregnancy, trainee anaesthetist. High-dose opiate given prior to extubation. In recovery developed respiratory difficulties. Inadequate ventilation, bradycardia, cardiac arrest.
3) Morbidly obese asthmatic lady, elective LSCS, spinal anaesthesia. Post-op agitation and SOB. Fatal cardiac arrest on post-op ward with inadequate resuscitation equipment.
4) Low-dose infusion epidural during labour & forceps delivery. PPH + IVI + syntocinon infusions. Grand mal convulsion + VF arrest – unable to resuscitate. Given 150mls 0.1% bupivacaine IV.
5) Lady with pectus excavatum in mid-pregnancy: â foetal movements, fulminant PET, & HELLP. Hypertensive, hyperreflexic, oliguric, & abnormal LFTs – given labetalol, Mg, & hydralazine. For urgent LSCS: RIJ cannulation unsuccessful but subclavian cannulation successful on the second attempt. Cardiac arrest shortly afterwards – large right haemothorax.
6) Obese woman with longstanding renal problems requiring nephrectomy. Had premature labour and delivery. A few weeks later, she was admitted with fever, loin pain, and ileofemoral venous thrombosis. Planned for drainage of septic focus from remaining kidney under U/S guidance. Pt refused LA and suffered an irreversible cardiac arrest during GA.
Indirect Anaesthetic Deaths
-Further 31 cases where poor perioperative anaesthetic management may have contributed to outcome
- Failure to recognise serious illness
- Poor management of haemorrhage (including syntocinon use): Less than optimum anaesthetic management contributed to many of the 17 maternal deaths from haemorrhage (12 died from PPH).
- Sepsis: Poor anaesthetic management/resuscitation was thought to have contributed to 10 maternal deaths from sepsis (usually failure to appreciate seriousness of maternal condition).
- Pre-eclampsia/eclampsia: 4 women died in relation to poor anaesthetic management (usually related to poor control of systolic blood pressure at time of LSCS/post-operatively)
- Management of obese pregnant women
- Quality of in-house hospital Trust enquiries into serious untoward incidents including maternal deaths: some reports of internal hospital enquiries sent to CEMACH were lacking in insight, improperly conducted, did not include clinicians from relevant specialties, or included clinicians involved directly with the maternal death (potential bias).
Wednesday, December 19, 2007
Tuesday, December 11, 2007
Slowly
Still not firing on all cylinders yet - motivational issues + obstetric nights! Have managed to finish the paediatric syllabus now, so moving onto obstetrics this week. Below is a paediatric crib sheet which I have copied directly onto my PDA as a useful resource:
Paediatric Crib Sheet
Neonate
-1st 44wks postconceptual age
-TV = 7ml/kg
-CO = 200ml/kg/min
-Blood vol = 90ml/kg
Infant
-Up to 12 months
-Weight = (Age in months + 9)/2
-TV = 6-8ml/kg
-Blood vol = 85ml/kg
Child
-1-12 years
-Weight = (Age + 4) x 2
-Blood vol = 80ml/kg
-Mean SBP = 90 + (age x 2)
Fluids
-Maintenance: 4ml/kg/hr for 1st 10kg. 2ml/kg/hr for 2nd 10kg. 1ml/kg/hr for subsequent kgs
-4% dextrose/0.18% saline
-Fluid Bolus: 20ml/kg
Equipment
LMA size
1 (0-5kg)-cuff 2-5mls.
1.5 (5-10kg)-5-7mls.
2 (10-20kg)-7-10mls.
2.5 (20-30kg)-12-14mls.
3 (>30kg)-15-20mls.
-Uncuffed until 8-10yrs
ETT size
>2kg = 2.5mm
2-4kg = 3.0mm
Term neonate = 3.5mm
3 months-1yr = 4.0mm
>2yrs = (Age/4) + 4
ETT length
oral (age/2) + 12
nasal (age/2) + 15
-TV= 10mls/kg
-PCV 18-20cmH2O/RR 16-24
-Min FGF 3L
-Insp press = 18-20cmH2O
-RR = 16-24
Fasting
-Clear fluid 2hrs
-Breast Milk/Formula 4hrs (<12months)
-Solids (& milk) 6hrs
Drugs
-EMLA: 5% lignocaine & 5% prilocaine (45mins)
-Ametop: 4% amethocaine gel (30mins)
-Midazolam 0.1-0.2mg/kg (PO 0.5mg/kg)
-(Flumazenil 5µg/kg incr to 40µg/kg)
-Temazepam 0.5-1mg/kg
-Fentanyl 1-5µg/kg (up to 25µg/kg: cardiac)
-Propofol 2-5mg/kg
-Thiopentone 4-6mg/kg
-(Etomidate 0.3mg/kg (0.1-0.4))
-Ketamine 2mg/kg (5-7mg/kg IM)
-Suxamethonium 2mg/kg
-Atropine 10µg/kg (20µg/kg IM)
-Adrenaline 0.1ml/kg 1:10000 (10µg/kg)
-Atracurium 0.5mg/kg
-Rocuronium 0.6mg/kg
-Vecuronium 0.1mg/kg
-Neo/Glyco 0.02ml/kg
(dilute 1ml w. 4ml saline give 0.1ml/kg).
-Morphine 0.1-0.2mg/kg 4hrly
-Oramorph 0.4mg/kg
(Naloxone 5-10µg/kg)
-Paracetamol 20-30mg/kg loading then 15mg/kg qds
-Diclofenac 1mg/kg tds (max 3mg/kg/day)
-Ibuprofen 5-10mg/kg tds
-Codeine phos 1mg/kg qds
-Cefuroxime 20-30mg/kg tds
-Metronidazole 7.5mg/kg
-Augmentin 25-50mg/kg qds
-Erythromycin 10-25mg/kg
-Cyclizine 1mg/kg
-Dexamethasone 0.15mg/kg
Ondansetron >2yrs 0.1mg/kg
Armitage regime
-0.25% bupivacaine
-Lumbosacral: 0.5ml/kg
-Thoracolumbar: 1ml.kg
-Midthoracic: 1.25ml/kg
Add
-clonidine 1µg/kg,
-diamorphine 30µg/kg,
-PF ketamine 0.5mg/kg,
-PF morphine 50µg/kg
-Wound infiltration 1ml/kg 0.25% bupivacaine
Epidurals
Loading dose:
-0.75ml/kg(lumbar) or 0.5ml/kg(thoracic) of 0.25% bupivacaine
Infusion:
-60ml of 0.125% bupivacaine + 2µg/ml fentanyl
Sunday, December 2, 2007
SAQ
I have tried to group these into topics as best I can:
General SAQ
Summarise the causes, effects and prevention of aspiration pneumonitis.
What are the indications for performing a tracheostomy? List the complications of tracheostomy
What solutions are available for the restoration of circulating volume in a patient suffering from acute blood loss? Discuss the advantages and disadvantages of each.
What are the causes and management of circulatory collapse at induction of anaesthesia?
Outline the key points in the management of a patient with massive haemorrhage.
Formulate a guideline for the perioperative administration of blood, explaining the reasons for your recommendations.
A General Practitioner has contacted you for advice about a patient who may be susceptible to malignant hyperthermia. Write a letter to the General Practitioner explaining the significance of this condition for the patient and the relatives.
What diagnostic features would lead you to identify malignant hyperthermia during and immediately after anaesthesia of an adolescent presenting for appendicectomy?
What is the pathophysiology of malignant hyperthermia? How would you investigate it?
What factors determine the rate of haemoglobin desaturation during a failed intubation? What can be done to maintain oxygenation in this situation?
How can jugular venous bulb oxygen saturation be measured? What factors cause its value to increase or decrease?
How may coagulation be assessed in the perioperative period?
What is the normal glucocorticoid response to surgery? Outline, with reasons, your perioperative corticosteroid regimens in patients:
a) taking steroids at the time of surgery;
b) who have stopped taking steroids several months previously.
What tests may be done to evaluate the adequacy of pulmonary oxygen transfer? Briefly describe how you would interpret the results.
What nationally based audits in the
List the risk factors for venous thromboembolism and classify the current methods of prevention, with examples
Explain the importance of a high airway pressure alarm system during general anaesthesia.
Outline the methods for prophylaxis of venous thromboembolism in routine surgical practice.
A patient who is HIV sero-positive is scheduled to undergo a laparotomy. Discuss the factors determining the risk of transmission to theatre staff. How can this risk be reduced?
What are the indications for a preoperative chest radiograph?
What do you understand by the term critical incident? Following a critical incident, what information should be recorded? What sequence of events should ensue??
Discuss the risks and benefits associated with intermittent positive pressure ventilation through a laryngeal mask airway.
What are the advantages and limitations of the laryngeal mask airway?
What is evidence-based medicine? How would you apply the process to your clinical practice
List the key clinical features, and commonest causative agents, of severe anaphylaxis occurring during general anaesthesia. Outline its management.
Under what circumstances is myoglobin found in the urine? What are the implications of myoglobinuria and how is it managed?
How may unintended perioperative hypothermia harm patients?
What are the potential causes of delayed resumption of spontaneous ventilation after major intra-abdominal surgery with general anaesthesia? Discuss prevention, diagnosis and management
What are the indications and contraindications for the use of an arterial tourniquet?
What complications may arise from the use of such a tourniquet
What are the anaesthetic problems caused by morbid obesity?
How would you prevent awareness under general anaesthesia?
Under what circumstances should general anaesthesia for elective cases be postponed and why?
What are the causes and management of hypoventilation immediately following anaesthesia?
List the causes and briefly give the management of tachycardia in an adult during general anaesthesia.
What factors do you consider important in selection of day case patients?
How does the presence of aortic stenosis affect the management of anaesthesia?
A houseman informs you that a patient's arterial pressure is raised before surgery; describe your management.
What is the significance of preoperative jaundice?
Surgery
GI
What particular problems may occur during lower abdominal surgery in a patient who suffered a traumatic transection of the spinal cord at C6 four weeks previously? Briefly indicate how you would avoid or prevent the problems you describe.
An 80 year old lady with a sub-capital fractured neck of femur requires surgical fixation. She is found to be in fast atrial fibrillation. What are the important points in the preoperative preparation for anaesthesia in this case?
A patient with a history of obstructive sleep apnoea presents for an elective cholecystectomy. How would you assess the fitness for anaesthesia? What precautions would you take with your anaesthetic management of this patient?
A surgeon is attempting an inguinal herniorrhaphy in a fit obese young man under local anaesthetic infiltration that is proving inadequate and asks for your help. What anaesthetic strategies are available for managing this situation?
A 78 year old male heavy smoker is admitted for laparotomy for his rectal cancer. He is treated with bendrofluazide and atenolol for hypertension (160/90 mmHg on admission). What specific actions would you take to improve the chances of a successful outcome.
VASCULAR
You have been asked to anaesthetise a 60 year old woman for ligation and stripping of varicose veins in one leg. She has a history of ischaemic heart disease. Explain briefly how suitability for her management in a day-case facility is assessed.
An obese 70-year-old man underwent an emergency abdominal aortic aneurysm repair yesterday evening. He is known to be a heavy smoker and is a treated hypertensive. He has been cardiovascularly stable overnight and is responding appropriately. Propofol and morphine infusions are stopped with a view to extubation. Agitation, tachycardia (heart rate 130 bpm) and hypertension develop (250/90 mmHg).
List the factors that could be important in precipitating this response. (40%)
Briefly outline your further management in the ICU of these factors. (60%)
Outline your perioperative management of a patient with a ruptured abdominal aortic aneurysm.
Discuss the principles underlying the anaesthetic management of carotid endarterectomy. What are the risks of carotid endarterectomy? How may the anaesthetist reduce these risks
UROLOGY
A 70 yr old man with chronic obstructive airways disease requires a transurethral resection of the prostate. Outline the advantages and disadvantages of intrathecal block for this patient.
ORTHO
A 20 year old patient, with sickle cell disease, was injured 12 hours ago. He has fractures of the metacarpal bones on his dominant hand. Elective surgical reduction and fixation is planned. Describe your anaesthetic management.
You anaesthetised a sixty-four year old man for removal of a protruding disc C4/5. The patient was found to be quadriplegic in recovery. Discuss the likelihood of this being a consequence of you anaesthetic.
A 70 year old man presents for a total hip replacement. He has no significant past medical history. At the anaesthetic assessment clinic he is noted to have a grade III ejection systolic murmur at the right sternal edge, radiating to his neck.
Describe, with reasons, what investigations should be undertaken on this patient and explain how the results would affect your anaesthetic management.
What are the types of anaesthetic that should be considered for fixation of a compound ankle fracture in a patient who was briefly knocked unconscious at the accident? Outline the advantages and disadvantages of each technique.
What information would you wish to obtain from a patient at your postanaesthetic visit, the day after a total hip replacement?
GYNAE
A sixty-five year old diabetic female is to undergo a total abdominal hysterectomy. She is normally controlled by oral hypoglycaemic drugs. Describe your perioperative management of her blood sugar.
RENAL
What problems are associated with anaesthesia for elective surgery in a patient with dialysis-dependent renal failure?
An otherwise fit patient requires nephrectomy for a large solitary renal tumour.
What surgical factors might influence your conduct of the anaesthetic?
DENTAL
List the likely causes of collapse in the dental chair of a patient undergoing a procedure under local anaesthetic without sedation, with notes on the presenting signs and symptoms. Briefly state what first-aid measures can be undertaken in each case.
What are the risks for patients associated with the administration of general anaesthesia in dental surgery? How may these risks be reduced?
Summarise the perioperative anaesthetic management of a patient who requires plating of his jaw fractured in a fight?
Discuss the principles of the management of a 25 year old patient with Down’s syndrome, who requires multiple dental extractions.
NEURO
What are the pathophysiological insults which exacerbate the primary brain injury following head trauma? How can these effects be prevented or reduced
How would you manage the transfer of a patient to a regional neurosurgical unit for evacuation of an extradural haematoma
A 40-year old man is admitted with an acute head injury. List the indications for intubation, ventilation and referral to a neurosurgical unit.
OTHER
What factors contribute to intravenous drug errors in anaesthetic practice? (40%)
What strategies are available to reduce the incidence of such errors? (60%)
What are the presenting clinical features of infective endocarditis? (40%)
What are the principles that guide the use of antibiotics as prophylaxis against this condition during surgery? (60%)
What is the physiological basis of preoxygenation for anaesthesia? (40%)
Describe a method of preoxygenation and how you would assess its adequacy. (35%)
What are the advantages and disadvantages of preoxygenating a fit adult? (25%)
What perioperative measures can be taken to minimize non-autologous red cell transfusion in a patient undergoing elective surgery
Which patients are at increased risk of infection related to an epidural catheter? (30%)
What symptoms and signs suggest the development of an epidural abscess? (30%)
What investigations would be definitive in initiating further management? (20%)
What should this be? (20%)
List the predisposing factors for aspiration of gastric contents during general anaesthesia. How can the risk of this complication be minimised? How should it be treated?
What are the anaesthetic considerations in a patient with autonomic neuropathy?
Discuss the perioperative management of the blood pressure of a patient undergoing removal of a phaeochromocytoma.
A 60 year old smoker requires non-laser surgery to the vocal cords. Outline the various anaesthetic techniques available, listing advantages and disadvantages of each.
What would make you suspect that a patient had sustained an air embolus during an anaesthetic? How should this situation be managed?
What procedures are associated with venous gas embolism? How can it be detected?
What are the effects of a large venous gas embolus? Describe its management.
List the dangers to the eye of general anaesthesia for elective intraocular operations. How are these prevented?
Outline the problems involved in anaesthetising an intravenous heroin abuser needing urgent surgery for incision of perianal abscess
What are the principles of pain relief after surgery in a drug abuser dependent on opioids?
What are the problems of monitoring anaesthetised patients in the magnetic resonance imaging unit?
What hazards does a patient encounter as a result of being placed in the lithotomy position for surgery? What additional hazards are introduced by then tilting the operating table head-down? Indicate briefly how you attempt to prevent these hazards
Outline the possible complications of anaesthesia with a patient in the prone position.
What are the factors contributing to unplanned awareness during general anaesthesia?
Elderly
Outline the effects of old age upon morbidity and mortality in anaesthesia.
You are asked to anaesthetise an 87 year old lady for diathermy of her bladder tumour on a day case basis. What are the potential problems of this case and how would you manage them?
What factors contribute to postoperative cognitive deficits in elderly surgical patients? How may these risks be minimised?
What are the advantages and disadvantages of day case anaesthesia in patients aged more than 80 years?
What are the important organisational (40%) and clinical (60%) factors which govern the anaesthetic management of patients over 80 years of age
Difficult airway
An adult patient is known to be severely difficult to intubate. Describe a technique of fibreoptic intubation for this case
List the bedside tests available to predict a difficult intubation. Comment on their usefulness.
What is the role of the laryngeal mask airway in the management of difficult intubation?
ITU
Outline your management of an adult patient brought into the A & E department in status asthmaticus.
A 62 year old man is admitted to the high dependency unit following a laparotomy to relieve a large bowel obstruction. He has a urinary catheter in situ. Two hours later, he has only passed 25 ml of urine. List, with reasons, the likely causes. What is going to be your initial plan of management?
What measurements and derived values can be made from pulmonary artery catheters used in the intensive care unit? Suggest a clinical application for each one.
A patient on the intensive care unit has a mean arterial pressure of 130 mmHg. What drugs might be useful for reducing this to a safe level and what is the mechanism of action of each
List the factors associated with central venous catheter infections and suggest methods to limit such infections
How would you determine the mixed venous oxygen content in the intensive care patient? What is the usefulness of this measurement?
Describe the immediate resuscitation of a patient admitted to A&E following a fall from a 20 ft ladder.
A 27 year old man is admitted with a fracture of the cervical spine at C5/6. There are no other injuries. Describe the management of this patient in the first 48 hours after injury.
List the radiological investigations that are available to help exclude an unstable cervical spine injury in an unconscious, ventilated adult with multiple severe injuries. (25%)
What are the limitations of each technique? (75%)
Describe the criteria and tests for brain stem death. Briefly indicate the neurological basis for each test
Discuss the causes of muscle weakness in a critically ill patient. How would you investigate them
Discuss the ventilatory management of an adult with ARDS. What pathophysiological processes are involved in patients who develop acute respiratory distress syndrome?
A patient is mechanically ventilated for acute lung injury in the ICU. Explain what practical steps you would take to turn the patient from the supine to the prone position. (70%)
List three common acute complications of the prone position. (30%)
A comatose, ventilated patient who has a head injury has an intracranial pressure of 35 mmHg. His CT scan excludes a surgically reversible cause. What immediate steps would you take to assess and treat the patient
You are asked to see a 45 year old man in the Emergency Department who has suffered 30% burns. What factors in the history would suggest that he has suffered a significant inhalational injury? (25%)
What symptoms, signs and results of laboratory tests would confirm your suspicions? (75%)
Describe the diagnosis and immediate assessment of a patient with smoke inhalation injury.
What is disseminated intravascular coagulation. Discuss its management in the critically ill patient.
What are the limitations and risks of intra-arterial pressure monitoring in the critically ill? How may these be minimised
How is ventilator-associated pneumonia (VAP) diagnosed? (20%)
Explain the physical (50%), positional (15%) and pharmacological (15%) strategies that have been
advocated for its prevention?
Discuss methods of applying non-invasive ventilation. What are its uses and benefits?
What is ventilator-induced lung injury? Explain the relative importance of volutrauma and barotrauma. What is the practical importance of ventilator induced lung injury?
Define transfusion related acute lung injury (TRALI). Discuss its pathogenesis, presentation, management and outcome
Describe your technique for insertion of a chest drain.
What forms of ventilatory support are used for patients undergoing mechanical ventilation?
What methods of sedation of patients undergoing mechanical ventilation are available in the intensive care unit (ICU)?
What factors affect the ablility to wean patients from mechanical ventilation?
Describe the criteria and methods to wean such patients from mechanical support.
Discuss the management of a patient admitted to the ICU with: acute severe asthma; severe burns; septicaemia; Guillain Barre.
Discuss the differential diagnosis of stridor in a 3-year-old child.
What information can be measured or derived from a successfully placed multilumen PA catheter?
Describe the alternatives to donor blood transfusion.
Statistics
The plasma concentrations of a drug have been measured in 20 normal patients and in 20 patients with renal failure. What simple statistical tests exist to determine whether these 2 sets of observations differ at the 5% level? What assumptions are inherent in each test which you describe?
What is meta-analysis? Outline the methodology. How are the results usually presented
Acute Pain
What are the advantages and disadvantages of intravenous patient controlled analgesia for postoperative pain control?
What are the advantages and disadvantages of the different ways by which opioids may be administered for postoperative pain?
What methods are available for therapeutic nerve blockade? Explain the mechanism of action for each method
A 60 year old man presents for a hemicolectomy. How may choice of pain management influence recovery from surgery?
Describe the methods of pain relief for total abdominal hysterectomy.
What safety features should be incorporated into a patient controlled analgesia (PCA) system and what is the purpose of each? What instructions would you give to the nursing staff, having set up the PCA?
A 70 year old man is to undergo an above knee amputation. What can be done to relieve any pain he may experience thereafter
What safety features should be incorporated into an intravenous patient controlled analgesia (PCA) system and what is the purpose of each? What instructions would you give the nursing staff, having set up the PCA?
How would you provide optimal pain relief for a 60 year old man undergoing shoulder replacement
What aims and strategies are emphasised in a "Pain Management Programme
Outline the nerve pathways involved in the transmission and perception of a painful stimulus from the foot.
List the indications and contraindications for Transcutaneous Electrical Nerve Stimulation (TENS)? What does the patient need to know when using a TENS machine ?
Describe two assessment tools used for the measurement of acute pain in adults. (30%)
Describe the McGill pain questionnaire used to assess chronic pain. (20%)
Include the strengths and weaknesses of each of the above. (30%)
Why do assessment tools used in acute and chronic pain differ? (20%)
Write short notes on paracetamol.
Chronic Pain
A 60-year old man is referred to you with reflex sympathetic dystrophy following an injury at the elbow 6 months earlier. Outline the treatment.
List, with examples, the causes of neurogenic pain. What symptoms are produced? What treatments are available?
What are the principles of cancer pain management
Describe the features and management of phantom limb pain
A patient presents to the pain clinic with low back pain. List the indicators (‘red flags’) that would alert you to the possibility of serious pathology? In their absence, what is the early management of simple mechanical low back pain?
Write short notes on TENS ... neurolytic agents ... cryoanalgesia.
What are the indications for a coeliac plexus block. Describe one approach and the complications of this technique.
Anatomy/Nerve Blockade
Make a simple drawing, with labels, to show the trachea, main and segmental bronchi.
Make a simple diagram, labelled to show the anatomical structures associated with the right internal jugular vein (including its important relationships). List the complications of cannulation of this vessel, mentioning how each may be avoided. Where should the tip of a left internal jugular line lie and why ? What anatomical abnormalities of this vein can make cannulation hazardous or impossible? Outline the risks associated with cannulation of this vessel and how they can be minimised for hip surgery.
Draw a labelled diagram of the anatomy of the anterior aspect of the wrist. How may this knowledge be used in anaesthetic practice?
Outline your technique for percutaneous tracheostomy, with particular reference to the anatomy involved. List the possible complications of this procedure
Draw a diagram of the lumbar plexus.
Outline the anatomical basis of a ‘3 in 1’ block. Explain why the block may fail to provide reliable analgesia
Describe the anatomy of the inguinal canal and describe a technique for local anaesthesia for herniorrhaphy (excluding extradural/spinal blockade).
Describe the arterial blood supply to the spinal cord. How may it be compromised?
Describe two adjoining mid-lumbar vertebrae. Include the joints, their nerve supply and the ligaments
Describe how you would carry out an axillary brachial plexus block
Draw a labelled diagram of the anatomical relations of the stellate ganglion. How is it blocked and what are the possible complications?
Describe the anatomy of the coeliac plexus. What are the indications for its therapeutic blockade?
Describe the anatomy of the nerves involved for neural conduction blockade at the ankle. Femoral nerve root value. Relation ship of those nerve to the ankle Ankle block performance. Maximum dose. Calculation. Complication
What are the indications for a popliteal fossa block? (10%)
List the nerves that are affected and describe their cutaneous innervation. (35%)
What responses would you get on stimulating these nerves? (25%)
Briefly describe one technique for performing this block. (30%)
List the nerves which supply the eye and its muscles. Briefly describe the relevant function of each nerve. (40%). What specific considerations would you take into account when providing general anaesthesia for adult vitreo-retinal surgery? (60%)
Intercostal nerve. Draw a typical intercostal nerve with its branches What do the branches supply? Do any branches cross over the midline to supply the other side? Draw a cross section of a rib with the intercostals muscles and neurovascular bundle. How are the muscles arranged? What are the indications to block the intercostals nerve? Where would you do it? And how? What are the complications?
How do you prevent LA toxicity? What is it specifically you are worried about? Are there any drugs that can be used to minimize this risk?
Why do you get a pneumothorax? How can you prevent it?
Describe the place of local analgesic nerve blocks during anaesthesia for cholecystectomy.
Describe the anatomy of the caudal space. What are the indications for analgesia administered by this route?
Describe the anatomy of the diaphragm. Which factors in anaesthetic practice affect its function?
Describe the anatomy of the first rib. Outline the technique for subclavian vein catheterisation.
Describe the anatomy of the 9th intercostal nerve. What complications may arise following intercostal nerve block?
Describe the prevention and treatment of the main complications of extradural analgesia using local analgesia.
.
Obsetrics
Outline your management of a fit primagravida who suffers inadvertent dural puncture with a 16 gauge Tuohy needle during attempted epidural for pain relief in the first stage of labour (cervix 4 cm dilated). Outline the possible reasons for the reduction, over the last decade, of maternal mortality associated with anaesthesia
List the pathophysiological and clinical features of HELLP syndrome. What are the diagnostic laboratory findings and the priorities in management?
Write short notes, with reasons, on your anaesthetic management of emergency Caesarean section for cord prolapse in a fit 21 year old primagravida
What are the advantages of retaining motor power in a woman having an epidural for a normal labour? How can this be achieved and what would you check before allowing the woman to get out of bed?
What is the differential diagnosis of persistent headache in the puerperium of a woman who has undergone a regional anaesthetic technique? Describe the distinguishing clinical features of each cause
What is an appropriate intervertebral space at which to insert a spinal needle to administer a subarachnoid anaesthetic for a Caesarean section? Give your reasons and describe how you would locate the space
When obtaining consent for an epidural for a primigravida in labour, what complications do you mention? Quote their incidence if known. What can be done to reduce the likelihood of these problems
List the three commonest causes of direct maternal deaths in the
What potential problems and risks do you consider when planning the anaesthetic management of the delivery of twins
What advice, for and against, would you give a primagravida who is asking if she might eat and drink during her labour? Give reasons.
Define primary postpartum haemorrhage (10%)
List the pharmacological agents that may be used postpartum to reduce uterine atony and any precautions with their use. (50%)
Outline the management of a significant primary postpartum haemorrhage. (40%)
Outline the possible reasons for the reduction, over the last decade, of maternal mortality associated with anaesthesia
List the indications and contraindications for Transcutaneous Electrical Nerve Stimulation (TENS)? What does the patient need to know when using a TENS machine
Which patients are at increased risk of infection related to an epidural catheter? (30%)
What symptoms and signs suggest the development of an epidural abscess? (30%)
What investigations would be definitive in initiating further management? (20%)
What should this be? (20%)
Cardiac
What is your choice of anaesthesia for pericardectomy in constrictive pericarditis? Give reasons for your choice.
The first patient on your operating theatre list tomorrow morning has an implanted (permanent) cardiac pacemaker. List, with reasons, the relevant factors in your preoperative assessment.
What are the postoperative problems in the first 24 hours after coronary artery bypass graft? How are they prevented
List, with reasons, the factors which affect the incidence of perioperative myocardial infarction
What are the principles of adult cardio-pulmonary bypass? What are the common complications of this procedure?
How do you confirm that a double-lumen endobronchial tube has been placed correctly? Outline the possible complications associated with the use of this equipment.
Classify the types of heart block. Outline appropriate treatment in the intraoperative period
A patient who has undergone a heart transplant requires non-cardiac surgery. What problems may this present for the anaesthetist?
What are the possible deleterious consequences of cardiopulmonary bypass when used in coronary artery surgery? How may these be reduced?
A patient with aortic stenosis presents for non-cardiac surgery. What are the clinical features of aortic stenosis and how would preoperative investigations influence your perioperative management?
What are the risks and benefits of thoracic epidural anaesthesia/analgesia for coronary artery surgery?
Outline the pathology of acute coronary syndromes. What pharmacological treatments are available for patients with an acute coronary syndrome
Describe the preoperative assessment and preparation specific to an adult patient who requires a thoraco-abdominal oesophagectomy. Describe your anaesthetic plan for this operation
List the causes of perioperative atrial fibrillation. What are the dangers of acute onset atrial fibrillation? How would you manage acute atrial fibrillation in the postoperative period?
A patient on the ICU, who had cardiac surgery completed 3 hours ago, is still intubated.
What clinical features might suggest the development of acute cardiac tamponade? (55%)
How might you confirm the diagnosis? (5%)
Outline your management of acute cardiac tamponade? (40%)
Paediatrics
What are the choices for postoperative analgesia for a child aged 4 years presenting for repair of an inguinal hernia as a day case? State briefly the advantages and disadvantages of each method.
Describe your procedure for cardiac life support in a child aged five years.
Outline the anaesthetic management of a 2 year old child who is scheduled for therapeutic bronchoscopy following inhalation of a foreign body 2 days ago. The child does not exhibit any signs of upper airway obstruction
What is the anaesthetic management of pyloric stenosis in a 6 week old child?
Describe your procedure for cardiac life support of a child aged 5 years
A ten week old male infant weighing 3.5 kg is scheduled for inguinal hernia repair. He was delivered prematurely at thirty-four weeks. List the risk factors and state how these can be minimised.
Outline the early management of a one year old child with 25% burns caused by scalding
A ten week old male infant weighing 3.5 kg is scheduled for inguinal hernia repair. He was delivered prematurely at thirty-four weeks. List the risk factors and state how these can be minimised
A 4 year old child who has been knocked unconscious by a blow from a cricket bat arrives at a paediatric neurosurgical centre. After initial appropriate management, a CT scan shows an extradural haematoma. There are no other injuries. Discuss the subsequent management.
You are called to the A and E department to review a 4 year old child who requires intubation. She has a clinical diagnosis of meningococcal sepsis. She has reduced consciousness and a petechial rash. Describe your immediate management.
Outline, with reasons, your perioperative management of an otherwise healthy 4 year old admitted for tonsillectomy
You are asked to anaesthetise a 5-year-old child (weight 20 kg) for an emergency appendicectomy. Describe in detail the induction of anaesthesia with special reference to:-
Fluid management (20%)
The airway (50%)
Drug management, including doses (30%)
A one day old term neonate has arrived at your regional paediatric intensive care unit. A congenital diaphragmatic hernia has been diagnosed. The baby is already intubated and receiving artificial ventilation. Outline, with reasons the principles of preoperative management.
Describe the anaesthetic management of a penetrating eye injury in a screaming 5 year old child.
Physics
List, with a brief statement on the effectiveness of each one, the means available for detecting awareness during anaesthesia.
How does a rotameter flowmeter work? Describe its advantages and limitations
Describe in detail how you would accurately measure a patient’s peak expiratory flow rate. What factors may give rise to erroneous readings
What are the physical principles of the capnograph? Discuss the applications of capnography in anaesthetic practice Define capnography. Draw and label a normal capnograph trace. Why is capnography useful during general anaesthesia? Give examples of abnormal traces and their causes. How may it be calibrated?
List, with a brief statement on the effectiveness of each one, the methods described for detecting awareness during anaesthesia
Outline the methods of estimation of arterial pCO2 and their limitations
Describe the features of the anaesthetic machine which are intended to prevent the delivery of a hypoxic mixture to the patient.
Describe the circle system for anaesthesia.
Describe the principles involved in pulse oximetry. What are its limitations in clinical practice What are the sources of error in a pulse oximeter?
Define pressure. List the methods available for measuring systemic arterial blood pressure. Outline the principles involved in one of the methods listed.
What information can be obtained from measuring central venous pressure?
What arrangements are required for an adult head injured patient during transfer to a neurosurgical unit?
Physiology
What immunological consequences may result from homologous blood transfusion?
Draw the following diagrams (with values): A spirometer trace showing normal lung volumes, FEV1/FVC graphs and flow-volume loops. How are these altered by the following diseases: asthma, emphysema, pulmonary fibrosis, chest wall restriction and respiratory muscle disease1
Draw clotting cascade.What is the role of the platelets? What is the importance of tissue factor?
Fibrinolytic system
Your patient in recovery has a high CO2. What are its implications? Will it cause hypoxia? How? Can you write and explain the alveolar gas equation. What happens according to the equation if the patient is hypercarbic? What is R? What is its value? Is it constant? What does it depend on? List the common causes of increased CO2 Draw a curve relating alveolar ventilation to PACO2 Can you equate alveolar CO2 to arterial CO2? What is the rationale? Can you equate alveolar O2 to arterial O2? What is the rationale? What is A-a difference? When does this gap widen? What is a shunt? Give me some examples.
What is pulmonary surfactant? Discuss its production in the lung, mechanism of action and function. What would be the effect of insufficient pulmonary surfactant?
Define contractility. Outline the methods available to the clinician to assess myocardial contractility in the perioperative period.
Write brief notes on the physiological responses that constitute the stress response to surgery.
What is meant by 'oxygen flux'? What factors affect it and what therapeutic measures increase it?
What are the adverse effects of intermittent positive pressure ventilation? How would you minimise them?
Describe the endocrine and metabolic responses to major surgery. How does anaesthesia affect them?
What is physiological dead space? What factors affect it?
What mechanisms are involved in anaphylactic reactions? How would you manage a patient showing signs of such a reaction?
How does the physiology of children aged 1 year differ from that of adults?
What factors affect cerebral blood flow? Briefly state their importance in relation to anaesthesia within 12 hours of head injury.
Describe the physiological effects of hypercarbia.
Describe the conducting system of the heart. How may abnormalities of cardiac conduction be revealed by the electrocardiogram?
What are the causes and effects of hypothermia?
Pharmacology
How would you manage a case of accidental intra-arterial injection of thiopentone in the upper limb?
What are the disadvantages of nitrous oxide in clinical practice
Outline the clinical features and management of bupivacaine toxicity
You are asked to investigate the effectiveness of a new anti-emetic agent. Briefly outline the priniciples which should guide the design of such a study.
What are the main point that you would include in a patient information leaflet that you would submit to support an application to your local ethics committee to study a new non-depolarising muscle relaxant?
What are the therapeutic uses of magnesium and how does it work?
Draw a nephron with its blood supply. Where and how do the following exert their effects: loop diuretics, thiazide diuretics and aldosterone antagonists?
Write a guideline for reducing and treating postoperative nausea and vomiting.
Discuss the reasons for and against the use of nitrous oxide in anaesthetic practice.
What is the mode of action of epidural opioids? Discuss the relative merits of epidural fentanyl and morphine.
List the patterns of peripheral nerve stimulation that may be used to monitor non-depolarising neuromuscular blockade during anaesthesia. How is each used in clinical practice?
What are the functions of cyclo-oxygenase (COX) enzymes? How are the side-effects of non-steroidal anti-inflammatory drugs related to inhibition of these enzymes?
Describe how and why a vaporiser delivering desflurane is different from one delivering isoflurane
Relate the clinical use of thiopentone and propofol to their pharmacological properties
Outline the pharmacology and clinical use of low molecular weight heparins for prophylaxis against deep vein thrombosis
List the classes, with an example of each, of a) anticoagulants (20%) and b) antiplatelet drugs (20%) in current clinical practice.
How would you minimise the incidence of bleeding and haematoma formation associated with epidural anaesthesia in patients taking each of these drugs? (60%)
What are the endocrine causes of secondary hypertension? (25%)
What is the pharmacological management of each of these endocrine conditions? (35%)
State the mechanism of action of each drug. (40%)
Benzodiazepine action how do they act. GABA recetor. Midazolam: Effects/ Side effects/Uses
Continuous infusion
Context sensitive half life define
Describe the synthesis of 5 hydroxy tryptamine Where is it present? What are its functions? How is it metabolized? What is carcinoid? Where is it found? Small intestine. Which part of small intestine? How does a carcinoid present? Why don’t u get carcinoid syndrome when the tumor is localized to the gut? When do you get carcinoid syndrome and why? What is LSD? What is its relationship to serotonin? Do you know any 5 HT receptors? How many subtypes are there? Are there any drugs you know which act at these receptors? List them. What are their uses?
Compare the electrolyte content and osmolality of 0.9% sodium chloride (normal saline) and compound sodium lactate solution (Hartmann’s). (40%)
Why might compound sodium lactate solution be a better crystalloid replacement fluid than 0.9% sodium chloride? (40%)
Explain the effects of a large infusion of 0.9% sodium chloride on acid-base balance and electrolytes. (20%)
What are the adverse affects of oxygen therapy?
Describe the desirable and undesirable effects of nitrous oxide.
What properties do you consider ideal for a neuromuscular blocking agent?
Compare the cardiovascular effects of desflurane, sevoflurane and isoflurane.
Discuss the mechanism of action and use of spinal opioids.
What are the effects of an overdose of tricyclic antidepressant drugs?
Compare and contrast gelatin-based plasma substitutes and Hartmann's solution.
Long Cases
Again difficult to classify but useful to have as one document for printing:
A 75-year-old female presents for elective fixation of C3 and C5. She has a history of rheumatoid arthritis. Over the past 6 months she has complained of weakness in the right leg and both hands.
Drugs
Diclofenac and prednisolone.
Observations and examination
Blood pressure: 190/80 mmHg
Heart rate: 84/min
Lung function test: Reduced FRC and FEV1 to about 45% predicted. She also has a restrictive picture
Full blood count: Mild anaemia and elevated mean cell volume
Arterial blood gases: Mild respiratory alkalosis; nothing significant
Urea and electrolytes: Elevated urea; no other derangements
Chest X-ray: Hyperinflated, right basal consolidation, trachea deviated to the right side
Questions
1. Summarise the case.
2. What are the anaesthetic considerations in rheumatoid arthritis?
3. Give a detailed analysis of investigations, especially the chest X-ray.
4. What would be your anaesthetic management?
5. What drugs would you give the patient?
6. Discuss your airway management, giving detailed discussion of asleep fibreoptic intubation.
7. Discuss the positioning considerations.
8. What blood pressure would you be happy with intraoperatively?
9. Describe your fluid management for this patient.
10. How would you extubate this patient? What postoperative respiratory support should be given?
11. Discuss high-dependency unit/intensive care unit care.
A male in his 60s presents with a strangulated hernia for urgent surgery. He has known atrial fibrillation (AF) and hypertension. He has not been taking his medication. His ECG shows fast AF (150 bpm), with ischaemic changes. There are mild signs of heart failure on the chest X-ray. He is asymptomatic.
Questions
1. Discuss his preoperative optimisation.
2. Discuss his anaesthetic management.
You see a 70-year-old man 4 days after he has undergone abdominal aortic aneurysm repair. His past medical history includes a transient ischaemic attack, non-insulin-dependent diabetes mellitus, hypertension and shortness of breath on exertion. A chest X-ray shows pulmonary oedema, cardiomegaly and right lower lobe collapse with tracheal deviation. An ECG shows new atrial fibrillation (AF) with ischaemia.
1. Discuss AF management in the intensive care unit.
2. What are the possible causes of AF?
3. What other ways do you know to identify AF?
4. What drugs would you administer?
A 70-year-old male presents 4 days postoperatively, following elective abdominal aortic aneurysm repair, now in the intensive care unit with respiratory distress.
Past history:
Ischaemic heart disease
NIDDM
Osteoarthritis, with limited exercise tolerance
Hypertension
Peripheral vascular disease
Drugs:
NSAIDs
Amlodipine
prn glyceryl trinitrate
Examinations:
ECG: two ECGs presented; the first showed normal sinus rhythm, the second showed fast atrial fibrillation.
Chest X-ray: diffuse haziness, increased at right base.
Blood results:
Urea: 14 mmol/L
Creatinine: 170 µmol/L
Arterial blood gases:
PaO2 11 kPa
PaCO2 6.5 kPa
Bicarbonate: normal
Questions:
1. Why is this patient in respiratory distress?
2. What are the causes of raised hemidiaphragm?
3. What is your interpretation of the arterial blood gas results?
4. Discuss the ECG results, comparing the two ECGs.
5. What are the causes of atrial fibrillation?
6. How would you manage atrial fibrillation:
a) if blood pressure is stable?
b) if blood pressure is unstable?
7. How would you manage his respiratory distress?
8. What are the causes of renal dysfunction?
9. Discuss your perioperative management of the patient if he was on your list.
10. Would he benefit from preoptimisation?
You are presented with a 70-year-old man 4 days postoperatively after an abdominal aortic aneurysm repair. He has a complicated past medical history, which is as follows:
- Hypertension 1991
- Transient ischaemic attack (TIA) 1997
- Type 2 diabetes 1998
- Shortness of breath on exertion (SOBOE) 2000
He has presented to A+E with sudden onset shortness of breath. You, as the ITU registrar, are called down to assess him. His chest X-ray has shown pulmonary oedema, cardiomegaly and right lower lobe collapse with tracheal deviation. His ECG has shown atrial fibrillation (AF) with myocardial ischaemia.
QUESTIONS
1. Please talk in depth about the management of AF in intensive care.
2. Which drugs would you use to treat his AF?
3. What are the causes of AF?
4. How would you identify the causes in this situation?
5. How would you manage this case?
36y male with neurofibromatosis presents with convulsions he also had right sided homonymous hemianopia for last few weeks. He is a smoker and alcoholic. O/E consious, appropriate, no focal neurology other than the eye sight. PR 56/min BP 140/90mmHg.ECG- Right axis deviation, Up slurring of ST in V4&V5.CXR-RUL collapse consolidation and a well circumscribed mass in the midzone. FBC Unremarkable except MCV89 BioChem Unremarkable except high ALP. CT posterior cranial fossa tumour looks malignant. Neurosurgeons want to do a craniotomy
Questions
1.Summarise
2. Planned/ Emergency
3.Differential diagnosis Lung mets/ Nerofibromatosis
4.what is the % of Nerofibromatosis becoming malignant
5.What is R/homonymous hemianopia
6.Alcohol intake what is the recommendation
How much is a unit of alcohol
7.ECG description
8.CXR description
9.Why MCV high/ Causes of high MCV
10.Why ALP high in this Pt normal billirubin
11.What other investigation you need
12. Will you proceed with the case
13. Principal of neurosurgery
14.What is the position for this surgery
Middle aged
1. summary
2.how would you proceed
3.how would cardiologist treat (diuretics)
4. how would you manage GA?
34 year old female presents for an elective thyroidectomy. 3 yrs ago she presented with palpitations, heat intolerance and anxiety. She was diagnosed as
Summarise the case
What are the common indications for thyroidectomy? – hyperthyroid with failed medical management, goiter and malignancy
What are the features of
Why do they get eye signs? Will it get corrected after thyroidectomy?
Why do they get heat intolerance?
What is lid lag?
What do you think about blood results? What is the reason for raised WCC with neutrophilia? You have screened her for infection and the screen is negative. What else would you think of?
Tell about the ECG
Tell me about the thyroid function tests? What is TSH? Why is it raised? Where is secreted from? How is its secretion controlled?
What do you think about the thyroid scintigram? What do they use in this test? What are hot and cold spots? How do they appear in a normal person, in a person with hyperthyroidism and a person with malignancy?
What is radio iodine? How does it help in
What more information do you want about this patient before proceeding to surgery?
Why do you refer these patients to the ENT surgeon? Tell me about vocal cord palsies.
Would you anaesthetize this patient now? Are you sure you want to postpone this lady who has been admitted 48 hrs previously? She is already on 60 mg /day of carbimazole? How else could you control her thyrotoxicosis?
What physical factors would affect your anaesthetic management? (Obesity, hoarseness, dyspnoea on supine, dysphagia)
She had her surgery and is in recovery and she develops resp distress. What are the causes?
How will you manage a wound hematoma?
What is carpopedal spasm? Why does it occur post thyroidectomy?
A 68 year old gentleman presents for elective abdominal aortic aneurysm surgery. Hypertensive for the past 10 years. History of angina - past 2 years. On enalapril, frusemide isosorbide. Had chest pain 2 months ago. No evidence of myocardial infarction on investigation.
On examination
BP - 160/90 mmHg
Jugular venous pressure not raised
Rales on auscultation, both bases
Liver just palpable below the right costal margin
Investigations: Positive findings
White cell count = 12,000/ml
Creatinine - 170 micromol/L
Potassium - 3.2 mmol/L
ECG - T wave inversion v3 - v6, avF
X-Ray chest - mild cardiomegaly
QUESTIONS
Summarise the case.
Do you think his blood pressure is adequately controlled?
What is enalapril/how does it act/what are its side-effects?
What do you think his chest pain was due to (give a differential diagnosis)?
What are the implications if the chest pain had been due to myocardial infarction?
What do you think about his potassium level/why is it low/do you think it is acute/will you correct it before surgery/how will you correct it/what happens if you do not correct it?
Will you be happy to go ahead with the anaesthetic?
What further investigations will you do/why?
How will an echocardiogram help?
Do you think he is in heart failure/does he have a chest infection?
Differential diagnosis for hepatomegaly
What do you find in his ECG?
Did you determine the axis of the heart?
Is there any evidence of MI in the past?
What are the findings on the chest X-ray/how do you say the film is PA view/how did you determine that there is cardiomegaly/how do you measure CT ratio?
What will be your anaesthetic management
Why did you choose to do an epidural
Will you be concerned about something (heparin) that you will be giving intraoperatively?
What are the benefits (of the epidural)?
What will you give in your epidural?
What monitoring will you undertake and why?
59 year old man for transurethral resection of the prostate
Ex-smoker, 20 cigarettes/day
Had 'shadow on lung' 2 years ago
Treated with radiotherapy and drugs - no further information available
Now coughing up blood
Diabetic
Drugs - glibenclamide 5 mg daily
On examination:
1.75 m
72 kg
Pulse: 80/min
BP: 150/90 mmHg
Respiratory rate: 20/min
Chest:
- trachea deviated to right
- bronchial breathing and reduced breath sounds heard in the right upper chest
Abdomen:
- 10 cm bladder palapable
Investigations:
Hb | 16.0 g/dl |
WBC | 7.1 x 109/L |
Platelets | 271 x 109/L |
MCV | normal |
Differential | normal |
Na | 135 mEq/L |
K | 3.5 mEq/L |
Urea | 14.6 mmol/L |
Creatinine | 237 umol/L |
Glucose | 11 mmol/L |
CXR | No cardiomegaly Trachea deviated to right Right upper zone shadowing and loss of volume on right |
Lung function tests:
Predicted | Measured | |
FEV1 | 3.06 L | 1.62 L |
FVC | 4.18 L | 3.18 L |
FEV1/FVC | 69% | 51% |
PEFR | 533 L/min | 250 L/min |
QUESTIONS
- Summarise the problems.
- Summarise the positive findings on examination.
- Does a BP of 150/90 mmHg bother you?
- Comment on the investigations.
- How would the raised urea and creatinine affect your management? (Give an example)
- What do you think of a blood glucose of 11 mmol/L?
- What does the CXR show and what is the differential diagnosis?
- Do the lung function tests show a restrictive picture?
- What else would you ask for regarding the lung function tests?
- Would you be happy to anaesthetise this patient now?
- What premedication would you prescribe and why?
- What is your management of his diabetes?
- What anaesthetic would you give and why?
- How would you perform spinal anaesthesia?
A 52 year old male presents electively for transurethral resection of the prostate. He has a history of non-insulin-dependent diabetes, and 2–3 months ago underwent chemotherapy and radiotherapy for 'a shadow on the lung'. He has been a life-long smoker, and recently had an episode of haemoptysis. He is currently taking glibenclamide 5 mg once daily.
On examination
– He is of average build
– Respiratory signs: respiratory rate: 18/min; trachea is deviated to the right; bronchial breathing can be heard in the right upper zone
– Cardiovascular signs: pulse: 80 bpm; blood pressure: 130/90 mmHg
– Gastrointestinal signs: palpable enlarged bladder
Investigations
- Haemoglobin 16 g/dl
- White blood cell count: 8 X 106/ml
- Platelets: normal
- Urea 18: mmol/L
- Creatinine 180 µmol/L
- Na+ and K+: normal
- Liver function tests: normal
- Chest X-ray: right upper lobe collapse
- Pulmonary function tests: FEV1 1.9 L; FVC 3.75 L
- FEV/FVC ratio 0.53
1. Present the salient features of this case.
2. Describe the features of prostatic hypertrophy.
3. Describe the features of renal failure.
4. How might carcinoma of the prostate be diagnosed and treated?
5. Why might this patient have right upper lobe collapse?
6. Why might this patient have a raised haemoglobin level and what is the mechanism for this?
7. Describe the relevance of the lung function results.
8. How might this patient's chest condition be optimised prior to surgery?
9. How would you anaesthetise this man?
10. What are the options for controlling a diabetic patient's glucose perioperatively?
11. Describe the types of oral hypoglycaemic agents available.
12. How would you assess a diabetic patient preoperatively?
A 24 year old male, who is a known drug addict, has recently been admitted to medical ward. He was found unconscious at home with a history of ?heroin overdose. His conscious level improved with 200 mcg naloxone and he became agitated, with a
Investigations:
Arterial blood gases post-naloxone on air: | pO2 | 8.0 kPa |
pCO2 | 6.0 kPa | |
pH | 7.2 | |
HCO3- | 20 mmol/L | |
Urea and electrolytes | Na | 131 mEq/L |
K | 7.8 mEq/L | |
13.0 mmol/L | ||
Cr | 331 umol/L | |
CK | 50,000 IU |
ECG Rate 50 bpm sinus (abnormal intermittent p waves) Broad QRS peaked T waves
CXR CVP line in situ. Bilateral diffuse shadowing. R middle lobe collapse. No pneumothorax.
- Summarise the case.
- What may have made him unconscious other than heroin?
- What other drugs may he have taken?
- How would you determine this?
- What does the ECG show?
- Why can't he feel his legs and why is he weak?
- What may the cause of his raised K+ and his renal impairment?
- What is rhabdomyolsis and how does it cause renal failure?
- Why may he have it?
- How would you resuscitate him?
- How would you treat the K+ acutely and subsequently?
- What is the difference between haemofiltration and dialysis?
- How do they work, and which one would you use in this case, given the choice, and why?
A 64 year old man is undergoing right total hip replacement.
- He gives a history of asthma and chest pain.
- He is taking oxitropium bromide.
- He has been hospitalised 3 times for chest pain.
- The last hospitalisation was 6 months ago.
- He has a history of deep vein thrombosis after a previous operation and took Warfarin, which was stopped 3 months ago.
- He also has history of hiatus hernia, diagnosed after oesophagoscopy.
Examination
- He is moderately obese; his weight is 95 kg, his height is 1.65 cm.
- Apart from bilateral basal crepitations and diffuse wheezing, all over both lung fields are normal; first and second heart sounds normal, apex beat is not displaced.
- Blood pressure is 140/90 mmHg.
- Full blood count - NAD
- Lung function test - FEV1 - 65% of predicted value. FEV1/FVC - 50%. PEFR - 70% of predicted value.
- ECG - Bifacicular block. Inverted T waves in Leads 1, AVL, V1 to V4.
- CXR - shows minimal basal effusion. Lungs are not hyperinflated.
1. Summarise the case
2. Interpret the data
3. What further investigation would you carry out?
4. How would you anaesthetise this patient?
5. How would you prevent DVT?
A 62 year old male with significant cardiovascular and respiratory disease presents for right total hip replacement. He has previously been admitted several times with chest pain, which has been relieved by glyceryl trinitrate (GTN), but he continues to smoke 30 cigarettes a day. He is also obese, and has a hiatus hernia, decreased exercise tolerance and a past history of deep vein thrombosis (DVT). On examination, his blood pressure is 140/85 mmHg, and he has bilateral inspiratory crackles.
His ECG showed widened QRS complexes and a normal axis but did not show the classical signs of right bundle branch block.
His chest X-ray showed flattened hemidiaphragms. He had a normal cardiothoracic ratio, and his lung function tests revealed an obstructive picture. The patient’s blood tests were all normal, with a haemoglobin level of 15 g/dl.
1. Summarise the main issues regarding this case.
2. What other investigations would you undertake?
3. Which cardiovascular investigations should be carried out?
4. What can you glean from the patient’s baseline arterial blood gases?
5. Would you refer this patient to a cardiologist?
6. What can you say about the patient’s blood pressure, and how would this affect your treatment?
7. What other information would you need from his lung function tests?
8. What would you be concerned about in the full blood count?
9. What is the mechanism of the development of polycythaemia in such patients?
10. How should this patient be optimised, for example in terms of preventing DVTs?
11. How would you treat the patient’s hiatus hernia?
12. Would you anaesthetise him by general or regional anaesthesia? Why?
13. Discuss the patient’s postoperative care.
A patient presents for a radical nephrectomy for malignancy. He has a history of chronic obstructive pulmonary disease, ischaemic heart disease, a pacemaker and requires haemodialysis.
Investigations
Full blood count, urea and electrolytes, chest X-ray, ECG, echocardiogram, pulmonary function tests
What is the transfer factor? (discussion re: the pulmonary function tests)
How would you assess this patient's volaemic status?
Would you consider an epidural? Discuss the pros vs cons
How would you optimise this patient preoperatively?
A 62 year old male with significant cardiovascular and respiratory disease presents for right total hip replacement. He has previously been admitted several times with chest pain, which has been relieved by glyceryl trinitrate (GTN), but he continues to smoke 30 cigarettes a day. He is also obese, and has a hiatus hernia, decreased exercise tolerance and a past history of deep vein thrombosis (DVT). On examination, his blood pressure is 140/85 mmHg, and he has bilateral inspiratory crackles. His ECG showed widened QRS complexes and a normal axis but did not show the classical signs of right bundle branch block. His chest X-ray showed flattened hemidiaphragms. He had a normal cardiothoracic ratio, and his lung function tests revealed an obstructive picture. The patient’s blood tests were all normal, with a haemoglobin level of 15 g/dl.
QUESTIONS
1. Summarise the main issues regarding this case.
2. What other investigations would you undertake?
3. Which cardiovascular investigations should be carried out?
4. What can you glean from the patient’s baseline arterial blood gases?
5. Would you refer this patient to a cardiologist?
6. What can you say about the patient’s blood pressure, and how would this affect your treatment?
7. What other information would you need from his lung function tests?
8. What would you be concerned about in the full blood count?
9. What is the mechanism of the development of polycythaemia in such patients?
10. How should this patient be optimised, for example in terms of preventing DVTs?
11. How would you treat the patient’s hiatus hernia?
12. Would you anaesthetise him, by general or regional anaesthesia? Why?
13. Discuss the patient’s postoperative care.
You are presented with a 7 year old male child with acute painful swelling in the left scrotum, vomiting and torsion of the testes. He has had a cough and been wheezing for 3 days. He had his last meal 4 hours ago. He has been asthmatic for the past 3 years and is currently taking salbutamol and beclomethasone inhalers.
On examination:
The child is found to be very anxious and in pain. He is mildly dehydrated, and weighs 19 kg.
Respiratory signs
– Respiratory rate: 28/min
– Left lower zone: air entry decreased
– Percussion note decreased
– Bilateral rhonchi
– Abdominal examination: scrotum – nothing abnormal detected
Cardiovascular signs
– Heart rate: >120 bpm
– Blood pressure: 110/60 mmHg
– Auscultation: nothing abnormal detected
The result of investigations are as follows:
– Haemoglobin: 10.6 g/dl
– White blood cell count: 14,600/ml
– Neutrophil count: 80 x 106 ml (Normal range 2-7)
– lymphocyte count: 20 x 106 ml (Normal range 1.5-4)
– Packed cell volume: 40%
Other investigations carried out:
– Chest X-Ray
– Urea and electrolytes
– Na+
– K+
– Creatinine
1. Summarise the patient and identify the problems associated with this case.
2 Give the differential diagnosis.
3. Discuss childhood asthma.
4. How do you assess severity of asthma?
5. Comment on investigations.
6. How would you manage this child?
7. How would you anaesthetise this child?
A 68-year-old man has an implanted pacemaker and a past history of angina-like chest pain. He also has chronic obstructive pulmonary disease but maintains that he can climb stairs and has a reasonably active life. He has been smoking 20 cigarettes a day for many years. He is scheduled for an elective right nephrectomy for renal cell carcinoma and has recently undergone haemodialysis. He is on perindopril 20 mg once daily, frusemide 500 mg once daily and aspirin 75 mg twice daily. On examination, he has pitting pedal oedema and is wheezing.
Biochemistry– Na+: 138 mEq/L
– K+: 3.5 mEq/L
– Cl–: 110 mEq/L
– Urea: 30 mmol/L
– Creatinine: 524 µmol/L
– Liver function tests: within normal limits (WNL)
Haematology
– Haemoglobin: 7.5 g/dl
– Haematocrit: 25%
– Platelet count: 227 X 106
– White blood cell count: 5.5 X 106
Pulmonary function tests
– FEV1: 1.8 L
– FEV1/FVC: 55%
– TLCO Within normal limits
– Flow–volume loop: an obstructive pattern loop was provided
Chest X-ray findings
– Implanted pacemaker
– Chronic venovenous haemofiltration (CVVH)
– Right subclavian lines
– Right internal jugular vein central line
– Cardiac/pulmonary fields within normal limits
ECG findings
– Completely paced rhythm 60/min
– Left axis deviation
– Wide QRS complexes >3 mm
– ST elevation with tall T waves in V2-V5
1. Summarise the case
2. What physiological system should be discussed here?
3. The surgeon wants to operate immediately for fear of metastasis if postponed – would you anaesthetise? If not, why not? When would you deem it appropriate to operate? What more information do you require?
4. Discuss the results of all of the investigations above
5. What would be your anaesthetic plan?
An 81-year-old woman presents to the Accident & Emergency Department following a fall, in which she sustained a supracondylar fracture of the right humerus. She is breathless, with a respiratory rate of 20 breaths per min, a blood pressure of 110/70 mmHg, and is in pain. She underwent local excision and radiotherapy for a mass in the right breast a few years previously. She is hypertensive and hypothyroid, and is currently on atenolol 50 mg and thyroxine 100 mcg. Investigations show the following results:
Weight: 50 kg
Height: 1.50 m
Chest X-ray: right pleural effusion
ECG: Sinus rhythm, with borderline left ventricular hypertrophy
Haemoglobin: 9.9 g/dl
White blood cells: 10.3 ? 106/ml
Na+ 131 (135–145) mEq/L
urea 7.5 mmol/l (3.5–6.5)
BM 7.5 random
Questions
1) Summarise the patient’s condition.
2) Why is she breathless?
3) Present her chest X-ray
4) Describe the ECG findings.
5) Would you drain the effusion?
6) How would you drain the effusion?, describe your technique.
7) Why is the patient anaemic?
8) What do the biochemical values tell you?
9) How would you proceed from here? Would you carry out any further investigations?
10) What are the risks associated with regional anaesthesia (interscalene)?
11) Would you give this patient a general anaesthetic?
12) What r the features of hypothyroidism?
13) How would you treat a thyroid coma?
A 60-year-old woman presents for multiple dental extractions. She underwent an open mitral valvotomy 40 years ago. She is currently on warfarin, digoxin and frumil. She also has a history of shortness of breath on exertion and is short of breath when lying flat. On examination, her observations are normal and her chest is clear. She has a normal body mass index. A diastolic murmur is detected. Her blood results, urea and electrolytes, and full blood count are all normal, and her international normalised ratio is 2.5. Her ECG shows atrial fibrillation (rate controlled). Her chest X-ray shows cardiomegaly, an enlarged left atrium and evidence of pulmonary oedema.
1. Discuss the patient’s blood results and investigations.
2. Discuss any evidence of mitral dysfunction.
3. Discuss the pathophysiology of mitral valve disease.
4. Discuss how you would assess cardiovascular status.
5. What further investigations would you perform?
6. Discuss antibody prophylaxis.
7. Discuss preoperative optimisation in this patient.
8. Discuss how you would correct this patient’s abnormal coagulation.
9. How would you assess the patient’s airway?
10. Discuss the conduct of anaesthesia.
11. Discuss how you would extubate the patient (bearing in mind her shortness of breath when lying flat, and implications for airway safety).
A 79-year-old female presents with lower abdominal pain, nausea and vomiting of 24 hours’ standing. She is admitted onto a ward and treated with analgesics and fluids, but the pain is still present. She underwent hemithyroidectomy 2 years ago and now, on examination, a large goitre is found with inspiratory stridor, although the patient is not in acute distress. The surgeon wants to take her to theatre to see if there is a large bowel obstruction.
Medication: thyroxine and aspirin
Observations/examination
Temperature: high
Pulse: 95 bpm
Blood pressure: 140/85 mmHg
Respiratory rate: 24 breaths/minute
Pulmonary artery: massive distension
Investigations
Haemoglobin: 15.2 g/dl
White blood cell count: 18.2 x 109/L
MCV: below normal
Amylase: <200>
1. Summarise the case.
2. What is the differential diagnosis for lower abdominal pain?
3. What fluids might this woman have received on the ward? What are the normal fluid requirements?
4. What are third space losses?
5. What is the composition of Hartmans solution and saline?
6. What are the disadvantages of using excessive saline?
7. Clinically, how can you judge that she is adequately resuscitated?
8. Would you carry out CO monitoring? Can you do this in an awake patient?
9. What blood investigations would you perform?
10. Is her haemoglobin elevated because of dehydration or is it pathological?
11. From the investigations, do you think she is adequately hydrated?
12. What can you tell from her ECG?
13. What can you tell from her chest X-ray?
14. What is the cause of mediastinal widening in this case?
15 What further investigations would you like to carry out?
16. What would be your general anaesthetic plan?
17. Would you use inhalational or intravenous induction?
18. What are the advantage and disadvantages for each?
19. For maintenance of anaesthesia, would you use total intravenous anaesthesia or inhalational anaesthesia?
20. What are the advantages and disadvantages for each?
21. What invasive and non-invasive monitoring would you perform?
22. What pain relief would you administer?
23. Would you give the patient an epidural?
A 74-year-old lady presents for an elective cataract surgery but refuses a local anaesthetic technique.
Past history
Myocardial infarction 6 years ago
Mastectomy >6 years ago
She was admitted last year with a mottled and painful white upper limb, which got better towards the evening, required admission.
She is now breathless on exertion.
Drugs
Frumil: Frusemide 40 mg/Amiloride
Digoxin: 125mcg
Warfarin: 8mg
Weight 51 kg
Blood results
Haemoglobin: 11.5 (lab range 13-15) g/dl)
Red blood cell count: lower side of normal
White cell count: normal
INR: 1.6 (Th. Range 2.0-4.0)
Na+: 142 mEq/L
K+: 5.5 (Range 3.5-5.0) mEq/L
Urea 10.0 mmol/L
Creatinine: 140 (range up to 120) µmol/L
Observations/examination
Pulse: 80/min, irregular
Blood pressure: 170/80 mmHg
Cardiovascular system: Pansystolic murmur at apex
Low-pitched diastolic murmur at apex
Apex beat slightly lateral to mid-axillary line
Respiratory system: Bilateral fine basal crepitations
Respiratory rate: 16/min
ECG: atrial fibrillation, severe left ventricular hypertrophy (LVH), heart rate <100>
A patient presents for dental clearance. He is on multiple drugs: a tricyclic antidepressant, lithium, an atypical antipsychotic agent and a calcium channel blocker for hypertension. He lives alone, has an unkempt appearance, and has dry mouth and tremor.
Observations/examination
ECG: essentially normal.
Chest X-ray: borderline cardiomegaly.
Full blood count: normal, degree of chronic renal failure.
Lithium level: upper limit of normal.
1. How appropriate is the patient for a day-case procedure?
2. Discuss the patient’s medications and their respective side-effects and interactions with anaesthesia.
3. What do his results suggest?
4. What further investigations are needed?
A 56-year-old coal miner requires sigmoid colectomy for carcinoma. He has a home nebuliser. His FEV1 is 0.68 litres, and he has 3% reversibility with salbutamol.
Observations/examination
Shortness of breath 50 yards.
Wheezy chest
Respiratory rate 30/min
Non-productive cough
Chest X-ray: bullous lung disease and prominent pulmonary arteries
ECG: normal
Saturations: 93% on air. PO2 12 kPa; PCO2 4.5 kPa
No FBC
No electrolytes
Drugs
He is currently taking 2.5 mg prednisolone (the dose was recently reduced)
Questions
1. Summarise the case.
2. What are the main issues?
3. How would you optimise this patient preoperatively?
4. What is the likely cause of his COPD?
5. Present the chest X-ray.
6. What are the chest X-ray findings in pulmonary hypertension?
7. Present the ECG.
8. What ECG findings might you find?
9. What are the ECG changes seen in heart strain (left and right)?
10. What are the criteria for pathological Q waves?
11. What is respiratory failure?
- Give blood gas definitions of type 1 and 2 respiratory failure
12. What are blue bloaters and pink puffers?
- Which is this patient?
13. How would you anaesthetise this man?
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