Critical Care

Question 1

FFP Diseases screened for and not screened for

Answer 1

HBV, HCV, CMV, HIV, Syphillis

Not screened for prion

Question 2

What is bile?

Answer 2

Complex material containing:
Water
Bile salts (form micelles with triglycerides)
Conjugated bilirubin 
Cholesterol
Phospholipids 

1. Aid in fat emulsification into fatty acids for absorption in terminal ileum
2. Help to excrete bilirubin (ie: Hb breakdown product, therefore reduced excretion causes jaundice).
3. Excrete cholesterol

Question 3

DIC blood test findings:

Treatment

Answer 3

1. Thrombocytopenia
2. Raised d-dimer (ie. fibrin breakdown products)
3. Low fibrinogen
4. Raised PT and APTT
5. Reduced individual clotting factors
6. MAHA (microangiopathoc haemolutic anaemia)

Treatment:
Platelets
FFP
Cryoprecipite
PRC if anaemic

Question 4

Cryoprecipitate:

1. Composition and production
2. Uses

Answer 4

1. VII, XIII, fibrinogen, vWF. Produced from centrifuge of FFP, for more concentrated above components.
2. Massive haemorrhage
   DIC
   Last resort in haemophilia ans vWD

Question 5

FFP

1. Components
2. Storage
3. Uses
4. Dose

Answer 5

1. All the clotting factors and fibrinogen and vWF, albumin, complement. When centrifuged, produces cryoprecipitate and cryosurfactant
2. -30deg, used immediately when thawed. Shelf life 1yr
3. Liver disease causing deranged clotting
   DIC
   Massive transfusion
   Factor V problems
4. 15ml/kg

Question 6

Prothrombin Complex Concentrate

Answer 6

Vitamin K dependent clotting factors:
2, 7, 9, 10

For correction of warfarin and prolonged PT

Question 7

Massive Transfusion

1. Definition
2. Complications

Answer 7

1. Patients circulating volume replaced within 24 hours
2. Pulmonary oedema
   Thrombocytopaenia (dilutional)
   Reduced clotting factors (?dilutional)
   Reduced 2-3BPG therefore reduced oxygenation
   Hypothermia
   Hypocalcaemia (citrate chelation)
   Hyperkalaemia

Question 8

1. Cardiac index calculation
2. Normal cardiac index
3. Cutoff for suspicion of cardiogenic shock

Answer 8

1. Cardiac output(ie. SV*HR)/ BSA (body surface area)
2. 2.4-2.5ml/min/m^2
3. <2.2ml/min/m^2

Question 9

Absolute contraindications for organ donation

Answer 9

New variant CJD

HIV

Question 10

Normal adult blood volume

Answer 10

7% of total adult body weight.

Therefore 70kg person will have 4.9L total blood volume

Question 11

Definition of “Massive Haemorrhage”

Answer 11

1. Loss of total circulating volume within 24hr
2. Loss of 50% circulating volume within 3 hours
3. 150ml/min

Question 12

Indications for CVC

Answer 12

Medications
Fluid monitoring
IV access
TPN
Haemodialysis
Transvenous cardiac pacing

Question 13

CVP waveform:

A
C
X
V
Y

Answer 13

A: atrial contraction
C: Closure of tricuspid valve
X: atrial relaXation
V: Venous filling into RA
Y: tricuspid opening

Question 14

CVC Complications

Answer 14

Pneumothorax
Damaging thoracic duct in left IJV causing chylothorax
Haemothorax 
Cardiac: arrhythmias, tamponade
Arterial puncture 
Air embolus

Question 15

Daily recommended protein intake

Answer 15

0.8g/kg/day

Question 16

Daily recommended nitrogen intake

Answer 16

1.5g/kg/day

Question 17

Non-traumatic causes of fat embolism

Answer 17

Bone marrow transplant
Bone tumour lysis

Acute pancreatitis
Fat necrosis of omentum

Liposuction
Sickle cell crisis
Parenteral lipid infusion

Cardiopulmonary bypass

Question 18

Traumatic causes of fat embolism

Answer 18

Fractures: long bone, pelvic, femur, tibia
Orthopaedic procedures: intramedullary reaming, knee arthroplasty
Massive soft tissue injury (ie. major burns)

Question 19

“Sepsis six”

Answer 19

1. Oxygen via non-rebreathe
2. Blood cultures
3. Broad spectrum Abx
4. IV fluids (early goal directed therapy)
5. Monitor lactate and Hb
6. Urinary catheter and monitor hourly output

Question 20

Daily calorie requirements

1. Normal adult
2. Trauma

Answer 20

1. 30kcal/kg/day

2. 50kcal/kg/day

Question 21

AKI definition

Answer 21

Biochemical diagnosis. Acute inability of kidneys to clear nitrogenous waste and other metabolites, reflected in Ur and Creat.
Reversible, <48hr onset

Question 22

Urine output for a child

Answer 22

1ml/kg/hr

Question 23

Indications for burns unit (7)

Answer 23

Inhalation
>10% burn
Sensitive areas (face, hands, perineum)
Weird burn (ie. electricity, chemical)

Kids/old (<5 and >60)
Comorbidities
NAI

Question 24

NICE guidelines for Peri-operative hypothermia

Answer 24

1. Bair hugger
2. Warmed IV and wash fluids
3. Expose patient only when necessary
4. Patient should not leave recovery until temperature >36deg

Question 25

Familial adenomatous syndromes

Answer 25

``` FAP HNPCC juvenile polyposis Hyperplasia Peutz-Jeger ```

Question 26

Gardener syndrome

Answer 26

FAP + other rumours: | Epidermoid cysts, osteomas, retinal tumours

Question 27

HNPCC 1. Genetic defect and chromosomes 2. Other tumours

Answer 27

1. DNA mismatch repair, chromosomes 2 and 3 | 2. Gynae tumours (uterus,ovary), other GI (small bowel, pancreas), renal

Question 28

Prevention of sickle crisis

Answer 28

``` Oxygen Well hydration Warm Transfuse (Hb >9) Analgesia (opioid) Early antibiotics ```

Question 29

Why aortic stenosis is dangerous in surgery

Answer 29

Fixed cardiac output, cannot compensate when there is a reduction in afterload (ie. TPR). Therefore high risk of cardiac events due to reduced coronary perfusion pressure. Spinal anaesthetic particularly risky

Question 30

Loop diuretic mechanism

Answer 30

Loop of henle Blocks Na/K pump, prevents sodium reabsorption by vasa recta. Prevents concentration gradient generated by countercurrent gradient

Question 31

Thiazides diuretic mechanism of action

Answer 31

PCT and DCT Blocks Na/Cl symporter

Question 32

Potassium sparing diuretics 1. MoA 2. Examples

Answer 32

1. DCT. Na/K exchanger, therefore Na absorption reduced, K increased 2. Spironolactone Amiloride

Question 33

Enzyme which warfarin inhibits

Answer 33

Vitamin K epoxide reductase | WEPT - warfarin, extrinsic, PT

Question 34

What is a pancreatic pseudocyst 2. Presentation 3. Management

Answer 34

Encapsulated fluid collection, encased by distinct fibrous capsule. Usually is from leakage of enzyme rich pancreatic fluid from pancreatitis. Lesser sac 2. Abdo pain, N&V, mass 3. 50% spontaneously resolve, conservative management, catheter or surgical drainage. Wait 3 months before draining. Can become infected

Question 35

Lifespan of a RBC

Answer 35

115 days

Question 36

Common organisms to cause OPSI in post-splenectomy

Answer 36

"SHEN" S. Pneumonia Haemophilus B E. Coli Neisseria (Also need annual flu vaccines) Prophylactic penicillin V for 2 years post splenectomy or until 16y/o

Question 37

Splenectomy complications

Answer 37

Immediate: haemorrhage Early: gastric stasis Gastric necrosis Subphrenic abscess Pancreatitis (ie all related to blood supply) Late: pancreatic fistula Thrombocytosis and increased plate size Thrombotic risk OPSI

Question 38

PRC shelf life

Answer 38

35 days, stored at 4deg

Question 39

Respiratory quotient

Answer 39

CO2 excretion/O2 consumption

Question 40

TPN indications

Answer 40

``` Systemic: Burns Malnutrition Pancreatitis Trauma ``` GIT: Enterocutaneous fistula Short gut syndrome Crohn's disease

Question 41

Shelf life of platelets

Answer 41

5 days, kept in incubator at 20-40degrees

Question 42

TPN Cx

Answer 42

``` Metabolic: Glucose imbalances Raised lipids Deranged LFT from enzyme induction due to amino acid imbalance Refeeding FA deficiency ``` NB. Too much glucose increase CO2, therefore increased ventilation required GIT: Mucosal atrophy and bacteria translocation Line complications: Thrombophlebitis Thromboembolic

Question 43

Locations of carbonic anhydrase enzyme (x4)

Answer 43

Places that make HCO3 RBC Renal tubules Pancreas Gastric mucosa (?salivary glands)