General Flashcards

Question

What are the risks of perioperative anaemia

Answer 1

Poorer wound healing Slower mobilisation, increased risk of thromboembolic events Increased length of hospital stay More likely to be transfused and risks associated Increased risk of cardiac events Increased risk of respiratory, urinary and wound infections

Answer 2

* Pregnancy test if childbearing age and female sex * HbA1c within last 3 months if diabetic **Minor surgery** * Nothing for ASA1-2 * ASA 3-4: consider renal function if at risk of AKI, consider ECG if none in 12 months **Intermediate surgery** * ASA 2: consider renal function if risk of AKI, consider ECG if cardiac disease, renal disease or diabetes * ASA 3-4: consider FBC if cardiac disease/renal disease and symptoms not recently investigated. Consider coag if liver disease, anticoags which could be modified, surgical reason. Do renal function and ECG. Consider lung function and ABGs **Major surgery** * Everyone gets FBC * ASA 1, consider renal function. ASA2-4: renal function tests * ASA1, consider ECG if >65yrs and none in last year. ASA2-4: ECG * ASA 3-4: consider coag in chronic liver disease, if taking anticoag that could be modified or if surgery warrants

Answer 3

Airway Breathing Circulation Disability Endocrine F-Pharmacology GI Haem Infection/immunology Joints (MSK) Kidneys Liver Metabolic Nutrition Obstetric Psychological

Answer 4

* Ascites * Bilirubin * Clotting (PT) * (da) Albumin * Encephalopathy A: < 5% mortality from abdo surgery, 100% survival at 1 yr B: 25% mortality from abdo surgery, 80% survival at 1 yr C: 50% mortality from abdo surgery, 45% survival at 1 yr

Answer 5

* Fluid status: overload can result in pulmonary oedema and effusion * Peritoneal dialysis: need to drain fluid as it will splint the diaphragm * If on immunosuppression for transplant: assess for sx pneumonia

Answer 6

* HTN * Increased risk IHD * Calcified heart valves * Arryhtmias from electrolyte disturbance and myocardial fibrosis * A-V fistula

Answer 7

* Diabetes * Glucocorticoid supplementation e.g. for transplant * Secondary hyperparathyroidism

Answer 8

* Gastroparesis, slower absorption of oral drugs * Hypoalbuminaemia increases free active drug * Acidic environment increases active acidic drug availability * Increased alpha-1-glycoprotein increases binding of basic drugs * Hydrophillic drugs show increased Vd due to increased extracellular water, so serum concentation may decrease * Reduced excretoin of renally excreted drugs and their metabolites

Answer 9

* Dry weight * Current weight * Dialysis mode and timing * Ability to produce urine * Likely blood and fluid losses intraoperatively * Periods of restricted oral intake pre- and post-operatively

Answer 10

* Contraindication to NSAIDs due to direct nephrotoxic effect, reduced renal blood flow, reduction in potassium excretion * Reduced rate of renal excretion of active metabolites of morphine and dihydrocodeine, risks sedation and respiratory depression * Hypotension from neuraxial techniques risks further renal hypoperfusion and cannot be treated with liberal fluid use

Answer 11

* Optimise Hb according to haematinics giving iron replacement if required * Review antiplatelet and anticoagulant medications and hold if appropriate

Answer 12

* Patient identity matched to that on blood label through core identifiers (full name, dob, ID number) * Compatibility label has same 14-digit number as sticker on blood bag * Expiry date and time * Visual check for leak, discoloration, clots or clumps

Answer 13

* Wheeze * Hypotension * Angioedema * Rash * Fever | WHARF

Answer 14

* Discussion about acceptability of each blood component, risks of refusing blood, advanced decision paperwork completed * Discussion of cell salvage * Location of surgery discussed e.g. if day centre does not have cell salvage * Erythropoetin use and haematinic optimisation * Use paediatric blood sampling bottles * Consider controlled hypotension to minimise bleeding * Consider use of tranexamic acid and desmopressin in event of bleeding * Announce transfusion preferences alongside WHO checklist

Answer 15

* Reduced physiological stress * Reduced length of hospital stay * Reduced rate of complications * Improved patient experience

Answer 16

* Pre-operative education with input from physio, OT, nurse specialists, pain team and dieticians * Smoking cessation at least 4 weeks prior * Alochol cessation if any misuse * Identify, investigate and treat anaemia * Optimise diabetic control * Optimise meds for chronic diseases e.g. hypertension * Optimise pre-operative pain management * MRSA and MSSA screening and treatment * Perioperative medication management given

Answer 17

* Clear fluids until two hours pre-operatively, solids until six hours preoperatively * Consider using high-energy drinks preoperatively * Staggered admission on day of surgery to minimise fasting and anxiety * Patient pre-warming * Antimicrobial body wash use preoperatively

Answer 18

* Single shot spinal anaesthetic with light sedation * Avoid intrathecal opoids to minimise need for urinary catheter * GA with fast acting, rapid offset agents if neuraxial technques contraindicated * Multimodeal, opioid-sparing analgesia * Ketamine at induction for patients with chronic pain issues * Anti-emetics intraoperatively * Antiobiotic prophylaxis 30 minutes prior to skin incision * Maintain normothermia

Answer 19

* Assessment of pain at rest and on movement * Regular oral paracetamol * Regular ibuprofen if eGFR>60 and not on aspirin, no other contraindications * Oral opioids for max 48hrs * Use of music for anxiolysis and improvement of patient satisfaction

Answer 20

1. Temporormadibular joint swelling and degeneration: restricted mouth opening, may require fibreoptic intubation 2. Atlantoaxial subluxation: excessive movement of neck during intubation may cause cord compression 3. Cervical ankylosis: limits neck extension 4. Costovertebral ankylosis: restrictive lung defect 5. Interphalangeal and metacarpal involvement: inability to manage PCA

Answer 21

* Fibrosing alveolitis causing restrictive lung defect * Pleurisy with effusion * Pulmonary nodules * Costochondral disease causing reduced chest wall compliance

Answer 22

* Inflammatory pericarditis, pericardial effusion * Rheumatoid nodules in cardiac tissue * Accelerated arthrerosclerosis and coronary artery disease

Answer 23

* Peripheral nerve entrapment (common peroneal, ulnar, median), nerve root compression esp. cervical * Mononeuritis multiplex * Glove and stocking peripheral neuropathy * Autonomic dysfunction

Answer 24

* Annaemia of chronic disease * Iron deficiency due to chronic GI lossess secondary to steroids and NSAIDs * Bone marrow depression due to disease modifying drugs e.g. methotrexate

Answer 25

* Steatosis * Fibrosis * Intrahepatic small vessel arteritis * Amyloidosis

Answer 26

* Alcoholic liver disease * Non-alcoholic liver disease e.g. obesity related * Autoimmune e.g. primary biliary cholangitis * Viral e.g. hep B and C

Answer 27

* Child Pugh * Model for End-Stage Liver Disease

Answer 28

* Increased bioavailability of oral medications due to portosystemic shunting and reduced first pass metabolism * Reduced plasma proteins - increased free fraction of highly protein bound drugs, greater activity of thiopentone and propofol * Increased extracellular water so greater Vd and reduction in concentration of hydrophillic drugs e.g neuromuscular blockers * Impaired metabolism and prolonged action e.g. of opioids and neuromuscular blockers * Reduced manufacture of plasma cholinesterases, prolonged half life of suxamethonium, remifentanil * Reduced rate of excretion of renally excreted drugs due to hepatorenal syndrome

Answer 29

* Risk of pleural effusions: reduced FRC, impaired gas exchange * Ascites with diaphragmatic splinting: atelectasis, V/Q mismatch, reduced FRC * Hepatopulmonary syndrome: failure to clear vasodilatory mediators causes pulmonary vasodilation, V/Q mismatch and hypoxia which cannot be corrected with oxygen

Answer 30

* Chronic inflammation results in vasodilation, sodium and water retention and a hyperdynamic state: hypovolaemia poorly tolerated, but excessive fluid administration risks pulmonary oedema and hepatic congestion * Porto-pulmonary hypertension and right ventricular dysfunction: intraoperative hypoxia, hypercapnia, PPV may lead to right heart failure * Cirrhotic cardiomyopathy: perioperative stress may result in decompensation perioperatively * Coagulopathy and increased bleeding risk means difficult balance between thromboembolism and bleeding, risk of PE and DVT

Answer 31

* Sedative drugs * Infection * Hypoglycaemia * Hypotension * Hypoxia * Electrolyte disturbance

Answer 32

* Increased oxygen extraction by tissues (brain and heart already have high extraction ratios so unable to compensate further) * Right shift of oxygen dissociation curve due to increased 2,3-DPG * Increased cardiac output * Redistribution of cardiac output to areas of high demand such as brain and heart

Answer 33

* Hypothermia causing left shift of oxygen dissociation curve * Increased oxygen requirement due to stress response, pain, fever * Reduced cardiac output due to anaesthetic agents * Blood loss due to surgery * Reduced erythropoiesis due to inflammatory response

Answer 34

* Low ferritin * Low transferrin saturations * High total iron binding capacity * High transferrin Normal/high ferritin suggests functional iron deficiency (problems transporting iron for erythropoeisis)

Answer 35

* High reticulocytes * Elevated LDH * High serum iron * High free plasma haemoglobin * Low plasma haptoglobin

Answer 36

* Snoring * Tired in day * Observed cessation in breathing * Pressure - HTN treated or untreated * BMI > 35 kg/m2 * Age > 50 yrs * Neck circumference > 40cm * Gender - male

Answer 37

* < 2 extremely unlikely to have sleep apnoea * 3-4 intermediate risk of OSA * 5-8 high risk of OSA

Answer 38

* Obesity * Congenital craniofacial abnormalities e.g. Down's, Treacher COllins * Neuromuscular disorders e.g. myotonic dystrophy * ENT disorders e.g. adenotonsillar hypertrophy * Endocrine disorders e.g. hypothyroidism/enlarged goitre

Answer 39

* HTN * Arrythmias * Diabetes T2 * Depression ## Footnote Other cardiac: IHD, pulmonary hypertension, CCF

Answer 40

* Weight loss * Smoking cessation * Reduce alcohol intake * Sleep hygeine

Answer 41

* Anticipate and plan for difficult airway * Avoid GA if feasible, use neuraxial, regional or local * Use short acting agents e.g. propofol and remifentanil * Full reversal of neuromuscular block with neuromuscular monitoring * Use multimodal analgesia, avoid need for long-acting opioid

Answer 42

* Permenant pacemaker: symptomatic bradycardia with AV block * Biventricular pacemarker: heart failure with LVEF < 35% and widened QRS * Implantable cardiac defibrillator: Secondary prevention for survivors of cardiac arrest * Implantable loop recorder: investigate symptoms of cardiac arrythmia not picked up on ECG or holter monitoring

Answer 43

* Response mode changed to synchonous pacing if significant pacemaker dependency * Pause advanced functions e.g. rate response to minute ventilation, sleep/rest mode * Switch off defibrillator function to elimiate risk of firing in response to electromagnetic interference

Answer 44

Pacemaker interprets diathermy current as cardiac electrical current and fails to provide appropriate rate response

Answer 45

* Put PPM in asynchronous mode * Use bipolar diathermy * Apply diathermy plate away from pacemaker * Short bursts of diathermy * Visual assessment of impact of diathermy on ECG monitoring confirmed with pulse palpation or invasive blood pressure monitoring, if electrical capture in doubt

Answer 46

* Correct abnormalities in pO2, pCO2, acid-base and electrolytes * Transcutaneous pacing

Answer 47

* Atropine 500mcg repeated to max 3mg * Glycopyrrolate 200mcg * Isoprenaline 5mcg/min infusion * Adrenaline 2-10mcg/min infusion * If betablocker or CCB overdose, consider aminophylline, dopamine and glucagon

Answer 48

* Atelectasis * Aspiration pneumonitis * Pneumonia * Bronchospasm

Answer 49

* Age >60 years * Frailty * Smoking * Alcohol excess * BMI >40kg/m2

Answer 50

* Emergency surgery * Prolonged surgery * Abdominal, ENT, major vascular, neurosurgery

Answer 51

* Residual neuromuscular block reduces ventilatory efficiency and impairs cough and swallow * Absorption atelectasis following prolonged periods of 100% oxygen * Failure to manage pain may cause reduced mobilisation, failure to cough and deep breathe * Anaesthetic agents and opioids impair response to hypoxia and hypercapnnia

Answer 52

* Optimise existing cardiorespiratory disease * Early smoking cessation * Prehabilitation exercise programmes

Answer 53

* Lung protective ventilation * Short acting neuromuscular blocking agents and quantitative monitoring * Goal direced fluid therapy

Answer 54

* Early mobilisation * Adequate analgesia * Lung expansion techniques, respiratory physiotherapy

Answer 55

* Diabetes * Glomerulonephritis * Polycystic kidney disease * Hypertension

Answer 56

* Pulmonary oedema from fluid overload * Pleural effusion * Fibrinous pleuritis

Answer 57

* Reduced erythropoetin synthesis * Anaemia of chronic disease * Iron deficiency due to altered apetite, absorption, iatrogenic sampling loss

Answer 58

* Tachycardia, hypotension (intravascular fluid depletion) * Electrolyte changes (hypokalaemia) * Dialysis disequilibrium syndrome (cerebral oedema with assoc. symptoms) * Hypoglycaemia

Answer 59

* Protection of fistula * Protection of veins/arteries for future fistula formation * If heparin has been given, does it require reversal for surgery * Haemodynamic status * How haemodialysis will be delivered post-operatively if inpatient stay required * Appropriate drugs for use in ESRF e.g. avoid opiates that accumulate

Answer 60

Multifaceted approach to improvefunctional capacity prior to a major stressor such as surgery

Answer 61

* Reduced length of hospital stay * Less post-operative pain * Fewer post-operative complications

Answer 62

* Smoking cessation * Alcohol intake reduction * Weight optimisation * Anaemia management * Blood glucose control * Pharmacological optimisation of chronic diseases

Answer 63

* Increased stroke volume * Increased skeletal and respiratory muscle mitochondrial numbers, increases VO2 max * Increased blood flow to lungs for gas exchange

Answer 64

* Reduces insulin resistance * Promotes anabolism and reduces protein catabolism

Answer 65

* Improved immune function * Improved wound healong * Improved functional recovery

Answer 66

* Relaxation techniques * Support groups with similar patients

Answer 67

* Senile calcification * Biscuspid valve

Answer 68

* Peak aortic flow velocity >4m/s * Mean transaortic pressure gradient >40mmHg * Valve area<1cm2

Answer 69

* Transthoracic echocardiogram * Left heart catheter invasive haemodynamic measurements * Low-dose dobutamine stress testing * Cardiac MRI

Answer 70

* Angina * Dyspnoea * Syncope

Answer 71

1. Increased left ventricular systolic pressure results in compensatory left ventricular hypertrophy 2. Left ventricular hypertrophy increases oxygen demand but decreases oxygen supply 3. The bulkier ventricle relaxes less effectively in diastole leading to diastolic dysfunction, pulmonary congestion and shortness of breath 4. Progression of diastolic dysfunction and ventricular hypertrophy lead to subendocardial ischaemia and angina 5. Ejection fraction deteriorates further due to progressive outflow restriction, reduced end diastolic volume, and imbalance between left ventricular oxygen demand and supply leading to syncope and sudden death

Answer 72

* Avoid arrythmias * Avoid tachycardia * Maintain preload * Maintain afterload * Maintain contractility

Answer 73

* Occular weaknes * Generalised muscle weakness more marked promixmally * Respiratory and bulbar weakness * Fatiguability

Answer 74

* B-cell autoantibody production against acetylcholine receptors

Answer 75

* Thymoma * Autoimmune thyroid disease * SLE

Answer 76

* Infection * Surgery * Residual neruomuscular block * Pain * Hypothermia/hyperthermia

Answer 77

* Acetylcholinesterase inhibitors e.g. pyridostigmine (with antimuscarinic to reduce adverse effects) * Long term immunosuppression e.g. steroids * Acute immunomodulation e.g. immunoglobulin * Thymectomy if thymoma

Answer 78

* Use 1/10th of the usual dose required and titrate incrementally if required * Use neuromuscular monitoring, ideally quantitative * Reverse neuromuscular block with sugammadex * Avoid neostigmine which may trigger cholinergic crisis

Answer 79

* Resistance to effect (dose should be increased by 2.5 times) * Prolonged phase II block

Answer 80

* Atropine * Glycopyrrolate

Answer 81

* Tremor * Bradykinesia * Muscular rigidity

Answer 82

* Upper airway dysfunction, reduced ability to clear secretions - aspiration * Fixed flexion deformity of cervical spine may lead to intubation difficulties * Restrictive pulmonary defect fue to rigitidy affecting gas exchange * Respiratory muscle dyskinesis and bradykinesia increases risk of post-operative respiratory failure

Answer 83

* Dopamine precursors which convert to dopamine once past the blood brain barrier e.g. levodopa * Peripherally acting dopamine decarboxylase inhibitors to reduce non-CNS effects of dopamine e.g. carbidopa * Dopamine agonists mimic effect of dopamine in CNS e.g. pramipexole * Monoamine oxidase B inhibitors reduce breakdown of dopamine e.g. seleginine * Catechol-O-methyl transferase iinhibitors reduce breakdown of dopamine e.g. entacapone

Answer 84

* Rotigotine - transdermal patch * Apomorphine - subcut infusion

Answer 85

* "Off period": increased rigity, tremor and bradkinesia * Antidopaminergic syndrome: muscle rigidity, fever, haemodynamic instability, agitation, delerium, coma * Dopaminergic agonist withdrawal: anxiet, depression, nausea, sweating, pain, dizziness, dysphoria, sleep disturbance

Answer 86

* Phenyothiazines e.g. prochlorperazine * Benzamide derivatives e.g. metoclopramide

Answer 87

* Risk of delay of surgery * Risk of bleeding * Risk of stent thrombosis * Implication of antiplatelets on mode of anaesthesia

Answer 88

* Bridging with intavenous antiplatelet e.g. epitfibatide or tirofaban (glyIIb/IIIa inhibitors) or cangrelor P2Y12ADP receptor inhibitor

Answer 89

* Low Hb * Leucocytosis * Increasing age * Reduced creatinine clearance * Previous episode of spontaneous bleeding

Answer 90

* Smoking * Diabetes * Previous PCI * Previous MI

Answer 91

* Spinal surgery * Intracranial surgery * Intraoccular surgery

Answer 92

* Aspirin: inihbits COX reducing production of thromboxane A2 and so reduced platelet activation and aggregation * Clopidogrel: P2Y12 receptor inhibitor prevents ADP binding and activation of glycoproteinIIb/IIIa receptors * Tirofaban: glycoprotein IIb/IIIa receptor blocker prevents cross-linking of fibrinogen to glycoprotin IIb/IIIa receptors on platelets

Answer 93

* Haemoglobinopathy screen using electrophoresis, chromatogaphy or mass spectrometry

Answer 94

* Autosomal recessive - Ch11 mutation causes change from glutamic acid to valine in beta globin

Answer 95

* Small vessel obstruction by sickled cells-> endothelial inflammation->acute and chronic organ damage and pain * Shorter lifespan of sickled cells-> haemolytic anaemia

Answer 96

* Reticulocytes are immature red blood cells * Raised count indicates bone marrow has increased production of new red blood cells in response to increased haemolytic loss

Answer 97

* Adenotonsillar hypertrophy - leads to OSA * Acute chest syndrome * Chronic restrictive lung disease from repeat acute chest syndrome * Increased susceptibility to pneumonia

Answer 98

* Pulmonary hypertension * Ischaemic stroke * Congestive cardiac failure

Answer 99

* Acute large splenic infarction * Hypersplenism * Acute splenic sequestration crisis

Answer 100

Increases production of fetal haemoglobin which interferes with polymerisation of HbS and so reduces tendency to sickle ## Footnote Causes neutropenia

Answer 101

* Hb 100g/L * Target HbS% 30%

Answer 102

* Dehydration * Hypotension * Hypoxia/hypercapnoea * Hypothermia * Acidosis * Infection

Answer 103

* Reduced central respiratory drive e.g. obesity hypoventilation syndrome * Chronic carbon dioxide retention e.g. from COPD * Neuromuscular disorders e.g. myasthenia gravis * Hepatic disease * Renal failure * Cardiac failure * Prexisting neurocognitive decline e.g. dementia

Answer 104

* Decline in CNS function leads to increased sensitivity to sedating agents * Proportionally increased adipose component so larged Vd of lipophillic drugs which then exert a prolonged effect * Impairment of liver or kidney function so reduced clearance of drugs and active metabolites

Answer 105

* Hypothermia * Stroke (haemorrhagic, embolic or ischaemic) * Electrolyte imbalance

Answer 106

* Direct sedation via central opioid receptors * Respiratory depression and hypercarbia

Answer 107

1. Neurological assessment: GCS, pupils, neuromuscular function 2. Check temperature 3. ABG for oxygen, CO2, electrolytes, acid-base and glucose 4. Review anaesthetic chart and notes for risk factors 5. Consider use of reversal and antidote drugs e.g. sugammadex, naloxone 6. Brain imaging e.g. CT head

Answer 108

An inherited disorder of chloride or sodium channels altering conductance and affecting skeletal, smooth and cardiac muscle. Results in myotonia and associated multisystem effects.

Answer 109

Autosomal dominance, may demonstrate anticipation

Answer 110

* Bulbar weakness leads to weak cough, risk of aspiration and obstructive sleep apnoea * Respiratory muscle weakness leads to respiratory failure * Centrally driven respiratory depression can lead to central sleep apnoea and exaggerated respiratory depressant effect of opiates * Restrictive lung defect due to progressive spinal deformity

Answer 111

* Conduction defects and arrhythmia * Cardiomyopathy with left ventricular failure * Pulmonary hypertension * Risk of embolic stroke

Answer 112

* Hypertension * Vasodilation * Tachycardia * Raised pulmonary artery pressure

Answer 113

* Hypoventilation * Rebreathing due to faulty circuit or exhausted soda lime * Hypermetabolic state e.g. fever, malignant hyperthermia * Increased absorption in laparoscopic surgery

Answer 114

* Suxamethonium * Neostigmine N.B. pain of propofol injection can also trigger - use lidocaine

Answer 115

* Hypothermia * Pain * Electrical nerve stimulation e.g. neuromuscular monitoring

Answer 116

* Remove triggers * Class I antiarrythmic sodium channel blockers e.g. lidocaine, phenytoin

Answer 117

* pH> 7.2 * Temp > 35degC * Ionised Ca >1 mmol/L

Answer 118

* Electromagnetically braked cycle ergometer or hand crank * Rapid gas analyser * Pressure differential pneumotachograph * NIBP, ECG, O2 sats monitor

Answer 119

* Hypotension * Arrythmia * Claudication * ECG changes consistent with ischaemia * Significant oxygen desaturation

Answer 120

* The point at which oxygen demand of the body exceeds capacity of the cardiopulmonary system to supply it * Triggering a change to ATP generation to anaerobic metabolism * Resulting in lactate production * Measured in mlO2/kg/min

Answer 121

* V-slope method: graph of VCO2 plotted against VO2. The anaerobic threshold lies at the change in gradient of the graph such that there is an increase in VCO2 for a smaller increase in VO2 to create a new steeper gradient * The nadir of the VE/VO2 curve: ventilation now driven by anaerobic production of CO2

Answer 122

* Peak oxygen consumption (VO2 peak in ml/kg/min) * Peak work rate WRpeak in Watts

Answer 123

* Exercise-limiting peripheral vascular disease * Lower limb amputee * Learning difficulties or dementia sufficient to impair ability to follow instructions * Inability to tolerate mouthpeice or facemask e.g. due to claustrophobia

Answer 124

* ASA - American Society of Anesthesiologists * SORT - Surgical Outcome Risk Tool * CACI - Charlson Age Comobidity Index * RCRI - Revised Cardiac Index * ACS NSQIP - American College of Surgeons National Surgical Quality Improvement Programme * POSSUM - Physiological and Operative Severity Score for the enUmeration of Mortality Morbidity

Answer 125

* High blood solubility, less likely to cause significant gas embolism * Will not support combustion when diathermy is used

Answer 126

* Damage to organ or blood vessel resulting in major haemorrhage * Insufflation of vessel causing gas embolism * Subcutaneous emphysema * Thoracic specific: medisatinal emphysema, pneumothorax

Answer 127

* Head down position may lead to dislodged ET tube e.g. endobronchially or extubation * Head down position may lead to airway oedema and post-operative stridor

Answer 128

* Head down and gas insufflation creates restrictive ventilatory defect, requiring higher pressures to achieve same tidal volumes leading to barotrauma * Atelectasis due to pneumoperitoneum and steep Trendelenburg * Risk of pulmonary aspiration due to passive regurgitation of gastric contents

Answer 129

Surgical * Steep Trendelenburg position with strapping * Long duration of surgery * Lithotomy positioning using leg supports * Restrictive intravenous fluid strategy * Use of antiembolism stockings or intermittend pneumatic compression devices Anaesthetic * Neuraxial anaesthesia may lead to hypotension, and may prevent early detection * Use of vasoactive medication

Answer 130

* Brachial plexus injuries related to use of shoulder bolsters of beanbags * Common peroneal nerve injury due to pressure caused by lithotomy leg supports * Sciatic, femoral or lateral cutaneous nerve injury due to excessive flexion during lithotomy positioning * Cerebral oedema from steep Trendelenburg

Answer 131

* Patient sliding from table * Pressure sores from restraint devices * DVT

Answer 132

New onset liver failure evidenced by jaundice, coagulopathy and encephalopathy in a patient without pre-existing cirrhosis

Answer 133

Progressive deterioration in hepatic function over 28 weeks or more

Answer 134

* Older age > 65 years * Male * Cigarette smoking * Family history of AAA * Hypertension * COPD * Other vascular disease (Cerebral, coronary, peripheral)

Answer 135

* Haemodynamics looking for tachycardia, hypotension * Look for prolonged capillary refill time, mottled skin * Decrease in GCS * ABG assess for lactic acidosis * FBC assess for Hb (or on ABG) * Fluid balance, look for oligoanuria * ECG may show ischaemia

Answer 136

* Tolerate below normal blood pressure, guided by GCS to minimise risk of clot disruption * Use red cells, FFP and platelets in a 1:1:1 ratio * Minimise use of non-blood fluids * Establish large bore intravenous access for intraoperative use

Answer 137

* Back and abdominal pain associated with leaking anuerysm may be severe and not tolerated by patient * Patient agitation due to cerebral hypoperfusion may result in poor cooperation * Use of resuscitative endovascular balloon occlusion of the aorta (REBOA) may cause acute lower body ischaemia with intolerable pain * Associated chronic conditions e.g. COPD and chronic cough may make lying still for prolonged periods unfeasible

Answer 138

* Loss of sympathetic tone associated with pain, which may have compensated for hypovolaemia previously * Relaxation of abdominal muscles with NMBD reduces tamponade of retroperitoneal clot * Initiation of positive pressure ventilation reduces venous return - effect exacerbated in hypovolaeima * Cardiodepressant effect of anaesthetic agents

Answer 139

* Type 1 endoleak (failure to adequately create a seal on an end of the stent to the vessel wall) * Insidious bleeding from the groin entry sites * Failure to control coagulopathy e.g. hypothermic patient, failure to address coagulopathy with blood products * Endovascular arterial injury during guidewire or stent manipulation

Answer 140

* Abdominal compartment syndrome * Ischaemic colitis * AKI * Lower limb ischaemia (distal dislodgement of thrombus)

Answer 141

* Superficial cervical plexus block * Deep cervical plexus block * Intermediate cervical plexus block * Combined superficial and deep cervical plexus blocks * Local anaesthetic infiltration

Answer 142

* Allows monitoring for change in neurology intraoperatively * Artery is closed at patient's normal blood pressure whch may reduce psot-operative haematoma, possibly more stable blood pressure throughout * Lower need for shunt with its risks of bubble/particulate emboli, wall dissection, kinking or thrombosis * Avoids airway instrumentation with associated risks including spike in blood pressure at intubation and extubation

Answer 143

* Cervical plexus blocks have risks of intravascular LA injection, phrenic nerve damage, epidural/subarachnoid spread of LA * Risk of failure and need to convert to GA intraoperatively with resitricted airway access * Surgery may be prolonged with claustrophobia from drapes - affects patient experience * Potential for patient movement causing surgical difficulty

Answer 144

* Surgical manipulation of vagus nerve - bradycardia and hypotension * Impaired carotid baroreceptor reflex due to damage to receptor fibres at incision or removal of plaque, results in periods hypotension * Carotid cross-clamping results in cerebral hypoperfusion and reflex sympathetically mediated compensatory increase in arterial pressure. Reverse effect on removal of cross clamp * Patients with significant carotid artery disease are at increased risk of adverse cardiovascular events which may result in haemodynamic instability * Comorbidities including hypertension and use of antihypertensives which may further impair baroreceptor response

Answer 145

* Avoid shunt where possible to avoid bubble or particulate emboli * Meticulous surgical technique to avoid dislodgement of atheroma * Perioperative administration of antiplatelets * Heparin before cross clamping * Pharmacological management of perioperative hypotension to avoid ischaemic stroke and hypertension to avoid haemorrhagic stroke

Answer 146

* Stroke * Cerebral hyperperfusion syndrome (due to impaired autoregulation) * Myocardial infarction * Hypoxia due to post-operative haematoma compromising the airway

Answer 147

* Open repair optimal in younger patients with fewer co-morbidities because intraoperative risks are higher but there are fewer long-term problems with the graft e.g. endoleak. This gentleman is elderly and has comorbidities which place greater importance on avoiding intraoperative risks compared to long-term graft problems * EVAR can be performed with neuraxial techniques or LA to groin, avoiding intubation and post-operative respiratory complications in a patient with COPD * Avoids presence of large abdominal wound, the pain of which could impair breathing post-operatively * Reduces need for opioid analgesia post-operatively, less risk of respiratory depressant and confusion effects * Infrarenal aneurysms tend to be the most straightforward by EVAR, so operating time should be tolerable awake * Facilitates early ambulation to prevent deconditioning in an elderly patient * Reduced risk of large blood loss in a patient with limited reserve to tolerate it * In view of patient's age, likely to have other comorbidities e.g. cardiobascular - minimally invasive technqiue carries less haemodynamic stress

Answer 148

Patient factors: * Advanced age >70 yrs * Pre-existing renal impairment CKD 3a or above * Diabetes * Hypertension * High BMI * Peripheral arterial disease * ACEI * Cardiac failure * Liver disease Anaesthetic factors: * Preoperative dehydration * Failure to maintain MAP within 20% of baseline Surgical factors: * Repeat use of nephrotoxic drugs required e.g. contrast, aminoglycosides * Complex EVAR e.g. fenestrated graft carries risk of stent maldeployment and obstruction of renal arteries * Surgical complications resulting in bleeding and hypotension * Embolisation of atheroma into renal arteries

Answer 149

* Avoid perioperative dehydration by monitoring input/output, providing fluids if requiring, minimising starvation time * Avoid perioperative hypotension, using vasopressors if indicated by cardiac output monitoring * Avoid nephrotoxic drugs perioperatively e.g. omission of ACEI on day of surgery, care with repeat doses of aminoglycosides, limit contrast load * Maintain glucose in normal range in diabetic patients, consider variable rate insulin infusion * Minimise surgical complications

Answer 150

* Acute increase in afterload may precipitate myocardial ischaemia, failure or arrest * Loss of venous capacitance of distal part of body decreases circulating volume, risks pulmonary oedema * Impaired blood flow distal to cross clamp risks mesenteric, renal, lower limb and spinal cord ischaemia * Cross clamp over an atheromatous plauque can lead to embolic phenomena Mitigate: * Deepen anaesthesia to vasodilate arterial tree proximal to clamp * Vasodilatory infusions e.g. GTN for same purpose * Maintain adequate gas exchange to ensure adequate edelivery of oxygen to myocardium and avoid cardio-depressant effect of hypercapnoea * Avoid siting clamp at heavily atheromatous part of aorta

Answer 151

* Sudden decrease in afterload causes hypotension * Reduction in perfusion pressure at aortic root (due to reduction in afterload) reduces coronary perfusion pressure and may precipitate myocardial ischaemia * Reperfusion of lower body causes recirculation of ischaemic metabolites and inflammatory mediators which have a cardio-depressant effect * Sequestration of circulating volume back into capacitance vessels causes relative hypovolaemia and reduced venous return Mitigate: * Gradual release of cross-clamp * Adequate intravascular filling prior to cross-clamp removal * Use of vasoconstrictors and inotropes * Stop vasodilatory infusions * Increase minute ventilation, aiming for normocapnoea to minimise effects of respiratory acidosis compounding inevitable metabolic acidosis * Treat electrolyte imbalance to minimise risk of arrythmia and maintain cardiac contractility

Answer 152

* Partial left heart bypass (left atrium/pulmonary vein-bypass-aorta distal to clamp or common femoral artery) * Gott shunt (cannula connecting aorta pre-clamp and post-clamp) * Partial femoro-femoral bypass (femoral vein-bypass-femoral artery)

Answer 153

* Anterior spinal artery: formed from branches of the two vertebral arteries at foramen magnum, supplies anterior 2/3 of cord (spinothalamic and corticospinal tracts) * Two posterior spinal arteries: formed from vertebral arteries or PICA, supply poster 1/3 of cord (dorsal columns) * Segmental arterial supply - paired bracnhes perfuse the spinal cord along its length. Artery of Adamkiewicz is the biggest and forms major supply to lumbosacral spinal cord, arising between T8-L4 and originates from intercostal or lumbar artery.

Answer 154

* Spinal drain to minimise CSF pressure * Maintain MAP with adequate volume replacement and vasopressor as required * Lowest possible site for aortic clamping (to minimise clamping above significant segmental arteries) * Sequential clamping of aorta with neurophysioloical monitoring to detect the dominant segmental arteries * Minimise clamp time | Spinal cord perfusion pressure = mean arterial pressure - CSF pressure

Answer 155

Trigeminal nerve: nasal air passages Glossopharyngeal nerve: oropharynx Vagus nerve: larynx

Answer 156

* Mucosal atomisation device * Spray-as-you-go * Topicalisation of nasal passages with local anaesthetic soaked pledgets * Nebulised local anaesthetic * Cricothyroid puncture for translaryngeal block * Individual nerve blocks e.g. glossopharnyngeal nerve block

Answer 157

* 9mg/kg lean body weight

Answer 158

* Previous difficult airway * Limited mouth opening * Previous radiotherapy * Limited neck movement * Aberrant anatomy e.g. airway tumour, previous surgery, Ludwig's angina * Syndromes associated with difficult airway e.g. Pierre-Robin, Treacher Collins * Morbid obesity/OSA

Answer 159

* Visualisation of tracheal lumen * Capnography trace consistent with tracheal intubation (7 consistent waves)

Answer 160

* Patient not able to comply with instruction e.g. confusion, language barrier, young age * Local anaesthetic allergy * Severe laryngeal or subglottic stenosis through which the tube/fibreoscope may not pass * Operator inexperience * Threat of airway obstruction * Airway bleeding or risk of significant airway bleeding

Answer 161

* Sore throat/hoarse voice * Vocal cord dysfunction * Foreign body causing obstruction e.g. teeth, throat pack, blood clot * External compression of airway due to surgical site swelling or bleeding * Laryngeal oedema * Laryngospasm * Longer term: tracheomalacia, tracheal stenosis

Answer 162

* Coughing * Atelectasis causing ventilation perfusion mismatch * Bronchospasm * Pulmonary aspiration * Post-obstructive pulmonary oedema * Mucociliary dysfunction

Answer 163

* Tachycardia and hypertension may cause reduced ejection fraction in patients with coronary artery disease * Risk of myocardial infarction due to increased oxygen demand * Tachycardia and hypertension secondary to catecholamine release - may cause bleeding at surgical site

Answer 164

* Airway: * Known difficult airway * Airway deterioration due to trauma/oedema/bleeding * Resitricted airway access e.g. mandibular wiring * Obesity/OSA * Risk of aspiration * Respiratory: asthma, smoking * Cardiovascular: IHD, arrythmia * Neurological: Myasthenia gravis, head injury, posterior fossa surgery * GI: Full stomach, reflux * MSK: Muscular dystrophy, rheumatoid arthritis ## Footnote Past question asked for 4 airway and 4 general risk factors that may predict difficult extubation DAS give generalpatient factors as: cardiovascular, respiratory, metabolic (e.g. temperature) and neuromuscular. Other: location, skilled help, monitoring, equipment

Answer 165

* Surgery in airway/head and neck * Surgery requiring double lumen tube * Prolonged duration of surgery * Trendelenberg/prone positioning risks airway oedema

Answer 166

Patient: * Pneumothorax * Haemothorax * Pneumo/haemomediastinum * Atelectasis * Aspiration pneumonitis Equipment: * Tracheostomy tube blocked with blood or secretions * Dislodged tube * Cuff puncture or deflation * Cuff inflated with speaking valve in situ * Ventilator circuit blockage or disconnection * Inappropriate ventilator settings

Answer 167

* Adequate ventilation and preoxygenation * Correct unstable blood pressure or rhythm * Ensure adequate reversal of neuromuscular blockade * Correct metabolic abnormalities e.g. temperature, glucose

Answer 168

* Extubation in appropriate location * Presence of skilled assistant * Full AAGBI monotoring * Availability of airway kit that was necessary at intubation

Answer 169

* LMA exchange * Airway exchange catheter * Tracheostomy * Remifentanil technique

Answer 170

* Surgical requirement to avoid coughing e.g. occular/neurosurgery * Avoid catecholamine surge in patients with severe ischaemic heart disease * Staged extubation in patients at risk of airway/respiratory adverse consequences e.g. asthma, difficult airway

Answer 171

* Prolonged mechanical ventilation * Airway protection * Pulmonary hygiene in patients unable to clear secretions * As part of a surgical procedure e.g. laryngectomy, maxillofacial flap * Upper airway obstruction

Answer 172

* Trache performed as part of operating procedure * Morbid obesity * Challenging anatomy e.g. short neck, concerns of aberrant vessels * Cervical instability

Answer 173

* Loss of airway * Haemorrhage * Pneumothorax * Derecruitment and hypoxia * Aspiration * Airway trauma e.g. tracheal cartiage fracture

Answer 174

* Remove speaking valve, cap and inner tube * Attempt to pass suction catheter via tracheostomy * Deflate cuff if unable to pass suction catheter * Look, listen and feel at mouth and tracheostomy site * Connect Mapleson C and capnography to tracheostomy If patent: perform tracheal suction, ventilate via trache if not breathing, consider partial obstruction, continue A-E assessment

Answer 175

* Remove tracheostomy tube * Look, listen and feel at mouth and tracheostomy site - if not breathing call resuscitation team. Commence CPR if no pulse/signs of life. * Primary emergency oxygenation: - Oral airway maneouvres whilst covering stoma e.g. bag-valve-mask +/- OPA/NPA +/- supraglottic device - Attempt ventilation via stoma using an LMA applied to stoma * Secondary emergency oxygenation - Attempt oral intubation, preparing for difficult intubation with an uncut tube advanced beyond stoma - Attempt intubation of stoma using size 6 tube, consider using fibroscope/gum boujie/airway exchange

Answer 176

* Primary lung cancer * Secondary lung metastases e.g. from breast or colorectal cancer * Oesophageal cancer * Thyroid cancer * Lymphoma

Answer 177

* Risk of airway collapse on induction of anaesthesia due to loss of intrinsic muscle tone * Risk of obstruction in supine positioning depending on nature of obstruction * Trauma to teeth, oropharynx or larynx associated with rigid bronchoscopy use causing bleeding, obstruction and contamination of aiway * Risk of airway contamination due to aspiration associated with rigid bronchoscopy technique * Risk of maldeployment or migration of stent resulting in airway obstruction * Shared airway limits access to rescue airway in event of complications * Risk of laryngo/bronchospasm associated with airway instrumentation

Answer 178

* Spontaneous ventilation with transnasal humidified rapid insufflation ventilatory exchange if flexible bronchoscopy used * Intermittent ventilation via LMA or ETT using flexible bronchoscopy * HFNO for apnoeic oxygenation via 22mm side port of rigid bronchoscope * Manual low frequency jet ventilation * Intermittent controlled ventilation via circuit attached at 22mm side port of rigid bronchoscope

Answer 179

* Frequency of jets * Driving pressure * Inspiratory time

Answer 180

* 120-300 jets/minute with tidal volumes smaller than dead space works through four principles 1. Laminar flow in smaller airways results in faster jets in centre of airway and more resistance peripherally, where air moves in opposite direction 2. Taylor dispersion/enhanced molecular diffusion - acceleratory effect of the fast moving central jet on diffusion of oxygen down its concentration gradient, so into alveoli 3. Pendelluft principle - regional differences in compliance allows gas transfer between different lung units (some expand and recoil more easily than others) 4. Myocardial oscillations leads to physical movement of lung units in proximity to heart (cardiogenic mixing)

Answer 181

* Gas embolism * Barotrauma * Gas trapping + hyperinflation (effects of haemodynamics) * Inadequate ventilation with hypoxia, hypercapnoea and respiratory acidosis

Answer 182

* Airway bleeding * Stent dislodgement * Laryngeal oedema

Answer 183

* Reduced FEV1 and FEV1/FVC < 70% * Reversibility of above after administration of bronchodilators

Answer 184

* Exposure to asthma triggers e.g. smoking, pets * Comorbidities e.g. obesity, reflux

Answer 185

* Reduce exposure to triggers e.g. smoking cessation * Reduce effect of co-morbidities e.g. weight loss if obese, treat reflux if contributing * Address compliance or inhaler technique issues * Involve GP or respiratory physician in optimisation of pharmacological control * Breathing exercise programme

Answer 186

* Kinked breathing circuit/tube * Mucus plug blocking tube * Endobronchial migration of tube * Pulmonary oedema * Pneumothorax

Answer 187

* Airway irritation e.g. airway secretions, instrumentation of airway, tube at carina * Drugs causing histamine release e.g. antibiotics, neuromuscular blocking drugs, morphine * Vagal stimulation during surgery e.g. peritoneal stretch * Light anaesthesia

Answer 188

* Salbutamol 250mcg * Adrenaline 10-100mcg * Magnesium 2g * Ketamine 20mg * Aminophylline 5mg/kg * Hydrocortisone 200mg

Answer 189

* Increase expiratory time to allow complete exhalation * Use pressure control * Permissive hypercapnoea

Answer 190

* Remove supreglottic airway device * Suction airway * Ventilate with 100% oxygen and bag-valve mask and prepare to intubate

Answer 191

* Hiatus hernia * Delayed gastric emptying e.g. secondary to diabetic gastroparesis * Raised intra-abdominal pressure e.g. obesity

Answer 192

* Prolonged ventilation (gastric insufflation) * Poorly fitting supraglottic airway device and positive pressure ventilation * Light anaesthesia

Answer 193

* Lobar collapse * Pneumonia * Chemical pneumonitis * Acute respiratory distress syndrome

Answer 194

* Adherence to fasting guidelines * Nasogastric insertion and stomach drinage * Premedication with prokinetics * Premedication with acid lowering medications e.g. antacid: sodium citrate, PPI: omeprazole, H2 receptor antagonist: ranitidine

Answer 195

* Lower oesophageal sphincter tone exceeds intragastric pressure * Acute angle at gastro-oesophageal junction and by crura of diaphragm * Upper oesophageal sphincter tone * Protective laryngeal reflexes

Answer 196

* Uncertain fasting status e.g. cognitive dysfunction * Known delayed gastric emptying e.g. autonomic diabetes/parkinsons, acute pain, trauma

Answer 197

* Fasted patient < 1.5ml/kg * Non-fasted patient > 1.5ml/kg

Answer 198

* Mutation of ryanodine receptor * Trigger agent causes sustained release of calcium from sarcoplasmic reticulum into cytoplasm, creatining sustained muscle activity

Answer 199

* Volatile anaesthetics * Suxamethonium

Answer 200

* Unexplained, unexpected rise in heart rate * Unexplained, unexpected rise in etCO2 * Unexplained, unexpected rise in temperature

Answer 201

* Removal of trigger (remove vaporisers, maximum gas flow, 100% oxygen, hyperventilate, apply charcoal filters, change soda lime and breathing circuit) * Patient cooling * Dantrolene 2.5mg/kg bolus then 1mg/kg boluses every 5 minutes until etCO2< 6kPa and core temperature < 38.5 deg C

Answer 202

* Acidosis * Hyperkalaemia * Arrythmias * Myoglobinuria * AKI * DIC * Compartment syndrome

Answer 203

* DNA screening blood test (tests for genetic associations) * Muscle biopsy with in vitro contracture test in response to trigger agents

Answer 204

* Blood relatives of patients with known/suspected MH * Patients with personal history of an episode which may have been due to MH * Patients with clinical myopathy and genetic aetiology implicated in MH susceptibility * Patients with genetic variant in a gene implicated in MH susceptibility * Patients with history of rhabdomyolysis of unknown cause

Answer 205

* Potential adverse effects of unecessary block e.g. nerve injury * Safe doses of local anaesthesia may be exceeded if correct site subsequently blocked * May result in wrong sided surgery * If bilateral block is contraindicated e.g. interscalene, surgery may be cancelled or there may be suboptimal pain relief * Loss of trust and worse patient experience

Answer 206

* Failure of campaign to reduce wrong-sided nerve block rate * Local flexibility in application of "Stop Before You Block"

Answer 207

* Preparation: blocker prepares equipment and gives to assistant, positions patient, scans, cleans site, dons sterile gloves * Stop: just before the block, blocker anounces "stop before you block" and with the assistant checkes mark on patient with consent form and patient (if conscious) * Block: assistant hands equipment to blocker for block to happen immediately * Process restarted if any delay to block or multiple blocks

Answer 208

Environment: * Block performed in non-theatre environment * Distracting environment Technical: * Block distant to surgical site * >1 block * Time delay between WHO checklist and block being performed * Surgical mark not present or obscured * Patient repositioning Human: * Operating list changes * Time pressure * Inadequate communication * Inadequate supervision * Inadequate information from patient

Answer 209

A serious incident that is wholly preventable because guidance providing strong systemic barriers are available at a national level and should be implemented by all healthcare providers

Answer 210

* Mis-selection of a strong potassium containing solution * Wrong route administration of medication * Overdose of insulin due to abbreviations or incorrect device * Overdose of methotrexate for non-cancer treatment

Answer 211

* Antibiotics * Muscle relaxants * Chlorhexidine * Patent blue dye

Answer 212

1 in 10 000

Answer 213

* Sensitisation: IgE antibodies develop against trigger agent * Re-exposure: allergen binds to IgE on mast cell or basophil * Signal transfuction cascade causes release of inflammatory mediators inclyding histamine, leukotrienes * Resulting vasodilation, capillary leak and bronchospasm

Answer 214

* Hypotension

Answer 215

* Bronchospasm * Tachycardia * Angioedema * Cardiac arrest

Answer 216

* Cardiac arrest * Hypotension with systolic < 50mmHg

Answer 217

* Crystalloid e.g. Hartmann's 20ml/kg * Adrenaline 50mcg * Glucagon 1mg if beta blocked and unresponsive to adrenaline * Vasopressin 2 units * Metaraminol or noradrenaline if inadequate response to adrenaline

Answer 218

* As soon as patient is stable * 1-2 hours after event * 24 hours after event *

Answer 219

* Major haemorrhage * Bradyarrythmia * Cardiac ischaemia

Answer 220

Patients: * ASA 5/comorbidity * CFS 5 or above/frailty * Male * Extremes of age System factors: * Emergency surgery * Compex surgery * Longer duration * Out of hours Types of surgery: * Ortho/trauma * Lower GI * Cardiac

Answer 221

* Senior support * Lower doses induction drugs * Vasopressors * Induction in theatre rather than anaesthetic room * Theatre team and surgeons aware of risk

Answer 222

* LMA use * Laryngoscopy * Double lumen tube * Forceful removal of airway * Vigorous oropharyngeal suctioning * Difficult intubation

Answer 223

* Primary teeth * Poor dental health * Crowns, fillings and bridges * Patient over 50 years old * Prominent upper incisors * Isolated teeth

Answer 224

* Assess for possible airway compromise * Locate missing tooth * Reimplant tooth if intact and patient not immunocompromised * Decision as to whether to proceed with surgery * If tooth cannot be reimplanted it should be stored in saline or milk until urgent discussion with dentist

Answer 225

* Avoid GA * Refer for preoperative dental treatment * Avoid laryngoscopy or airway instrumentation e.g. by nasal intubation * Dental guards

Answer 226

* Gastric contents visible in oropharynx * Desaturation * Bronchospasm * Increased airway pressures * Abnormal auscultation * Tachycardia

Answer 227

* Unconscious so unable to indicate pain on injection * Hypotension or hypoxia causing failure to recognise cannula as arterial * Anatomically anomalous artey cannulated

Answer 228

* Poor training - failure to differentiate between artery and vein * Proximity between venous and arterial sampling ports * Failure to label line as arterial

Answer 229

* Vasoactive drugs * Hyperosmolar drugs * Alkaline drugs that crystallise as physiological pH

Answer 230

* Arterial spasm * Chemical arteritis * Release of harmful endogenous substances e.g. thromboxane * Drug precipitation causing thrombosis and ischaemia

Answer 231

* Failure of drug to have intended effect * Pain at and distal to injection site * Loss of distal pulse * Pallor, cyanosis and cool limb * Paraesthesia

Answer 232

* Stop injection * ABC assessment of patient * Keep cannula in situ for intra-arterial treatment but ensure no other use * Intra-arterial iloprost and local anaesthetic * Elevate extremity to improve venous drainage * Anticoagulation * Pain control * Involve vascular surgeons * Consider stellate ganglion block * Duty of candour * Incident reporting

Answer 233

* Drug history * Allergy status * PMH * Height and weight

Answer 234

* Lack of familiarity with drug * Drug requires complex calculations * Distraction whilst drawing up or administering drugs * Tiredness * Lack of double checking drugs * Poor communication

Answer 235

* Cluttered workspace * Low light levels * Drugs with similar packaging * Non-IV lines

Answer 236

* Standardised handover/communication processes * Standardised infusions * Availability of reference databases for doses, calculations, diluents * Regulations for what is drawn up, by whom and at what stage in care of patient * Barcode scanning identification of drugs before use * NR fit equipment

Answer 237

* Incident reporting * Discussion at M&M * Regular audit * Duty of candour

Answer 238

* Better identification of cases * Hygeine hypothesis - increased rates of allergy associated asthma * Obesity * Urbanisation * Survival from premature birth

Answer 239

* TIVA * Neuromuscular blocking drug * Thiopentone * RSI

Answer 240

* Female * Young adult * Difficult airway * Obesity * Previous awareness

Answer 241

* Obstetric procedures * Cardiac surgery * Thoracic surgery * Neurosurgery

Answer 242

* Out of hours * Junior anaesthetist * Emergency surgery

Answer 243

* Quantitative monitoring of neuromuscular blockage * End tidal anaesthetic gas monitoring * Processed EEG * Clinical observations e.g. tachycardia, raised BP

Answer 244

* Post-traumatic stress disorder * Acute stress disorder * Avoidance of medical settings, specifically anaesthesia * Unexplained anxiety due to implicit memory * Poor experience of surgery e.g. pain, awareness of paralysis

Answer 245

**Minimal sedation** - Airway, breathing, cardiovascular unaffected. Normal response to verbal stimulation **Moderate sedation** - No airway intervention required, adequate ventilation, cardiovascular function maintained. Purposeful response to verbal stimulation or light touch. **Deep sedation** - Airway intervention may be required, ventilation may be inadequate, cardiovascular function maintained. Purposeful response to repeated or painful stimulation **GA** - Airway intervention and ventilation often required. Cardiovascular function may be impaired. No response to stimulation

Answer 246

* Fast onset of action * Rapid metabolism by plasma esterases, rapid recovery * Negligibly active metabolites

Answer 247

* Cardiovascular stability * Analgesic effect * Preservation of protective airway reflexes

Answer 248

* Analgesic effect * Rapid offset * Patient able to drive self home after 30 minutes

Answer 249

* Midazolam IV, PO, intranasal * Fentanul IV * Propofol IV * Temazepam PO

Answer 250

* Has not received advice on perioperative management of fasting and insulin regime * May have microvascular and macrovascular complications that have not been assessed e.g. retinopathy, nephropathy, IHD, cerebrovascular disease * May have poor glycaemic control with implications on complication rate e.g. increased risk of poor wound healing and perioperative infections

Answer 251

* Increased mortality * Risk of post-operative respiratory infections * Risk of surgical site infections * Risk of urinary tract infections * Risk of perioperative MI * Risk of AKI * Risk of hypoglycaemia, hyperglycaemia and ketoacidosis

Answer 252

* LA may be preferred to GA as it allows for patient to self detect hypoglycaemia * Facial monitoring may be required during surgery - supraglottic airway could be used to avoid NMBD but patient may have gastroparesis and require intubation * Tympanoplasty is emetogenic - important to facilitate return to normal intake and insulin regimen for patient * Dexamethasone will worsen diabetic control * NSAIDs are relatively contraindicated due to risk of AKI * Hypotensive anaesthesia is sometimes used but may not be suitable if micro and macrovascular disease

Answer 253

* Patients who will miss more than 1 meal * Patients who have poorly controlled diabetes with HbA1c > 69 mmol/mol * Patients with requiring emergency surgery with BM > 10 * Patients who have not taken their basal insulin

Answer 254

* Patient has returned to eating and drinking * CBG < 10 mmol/l, ketones < 0.6 mmol/l * Basal insulin should be given 30 mins before cessation of VRIII

Answer 255

* Stress-induced * Insufficient medication * Sepsis

Answer 256

* Fast onset * Short acting with predictable offset * Minimal adverse effects e.g. urinary retention

Answer 257

* Reduced post-operative pain, reduced requirement for rescue analgesia in recovery * Reduced PONV * Quicker return to oral intake * Quicker time to discharge from recovery * Facilitates day case surgery in patients with comorbidities such as OSA * Can improve patient engagement

Answer 258

Pros: * Increased patient satisfaction due to reduced numbness on non-operative side * Lower incidence hypotension * Earlier return to passing urine Cons: * Risk of wrong sided block error introduced * Increased anaesthesia time - patient needs to lie on side for 10 minutes

Answer 259

* 2% hyperbaric prilocaine 40-60mg (2-3ml) up to 90 mins * 1% 2-chloroprocaine 40-50mg (4-5ml) up to 40 minutes ## Footnote Hyperbaric 2% prilocaine: - 0.5-1ml for saddle block procedure - 3ml for > T10 block

Answer 260

* Hypotension associated with high block * Intrathecal opioid use esp hydrophillic e.g. morphine * Inadequate block with requirement for top-up anaesthesia e.g. IV opiate

Answer 261

* Long acting LA e.g. bupivicaine * Intrathecal opiates * Bladder distension e.g. from excess perioperative fluids Patient factors - age>70, history of urinary voiding difficulty Surgical factors - urological, uro-gyane, inguinal hernia, perianal

Answer 262

Diabetes Mellitus

Answer 263

* Method of dialysis, location of lines or fistula that warrant protection intraoperatively * Volume status * Acid-base status * Electrolyte status * Ability to pass urine * Recent heparin use

Answer 264

* Risk of alloimmunisation complicating future organ compatibility * Risk of hyperkalaemia * Risk of hyperviscosity affecting perfusion of newly grafted kidney

Answer 265

* Maintain cardiac output to optimise renal perfusion * Avoid hyperviscosity which may impair graft perfusion * Avoid fluid overload in patient unable to regulate own fluid status * Avoid excessive potassium administration

Answer 266

* Risks damage to an artery that may be required for fistula formation later * Gives ability to monitor MAP on beat-to-beat basis, ensuring continuous perfusion of graft * Offers ability to monitor cardiac output and guide fluid administration * Offers ability to closely monitor acid-base and electrolytes

Answer 267

* Regular paracetamol * TAP block * Local anaesthesia wound catheters * Opioid PCA with renally safe opioid e.g. fentanyl

Answer 268

* ANaphylaxis * Angioedema * Fever * Arrythmia

Answer 269

Respiratory * Pleural effusions/hepatic hydrothorax * Mechanical lung compression from ascites - decreased FRC, atelectasis and V/Q mismatch Cardiovascular * Hyperdynamic circulation with high cardiac output and low systemic vascular resistance * Relative hypovolaemia secondary to systemic and splanchic vasodilation * Cirrhotic cardiomyopathy

Answer 270

* Facilities: acess to patient records, recovery, guidelines * Staffing: availability of skilled assistant with experience working in IR, named consultant anaesthetist to supervise care, availability of anaesthetic back up * Equipment: anaesthetic machine, monitoring, piped oxygen, suction, tipping trolley, rapid infusors and warmers * Medication: full access to anaesthetic medications, emergency medications and resuscitation medications and trolley

Answer 271

* Risk of reflux increased due to presence of ascites and possible blood in stomach * Risk of impaired ventilatory capacity due to pre-existing lung complications e.g. reduced FRC, pleural effusion * May be prolonged procedure resulting in discomfort * Pain during balloon dilatation of intrahepatic ducts may be severe

Answer 272

* ASA continuum of sedation * Modified observer's assessment of alertness/sedation scale * Modified Ramsay Sedation Scale

Answer 273

* Greater proportion of unbound drug due to reduced synthesis of plasma proteins, greater effect * Reduced rate of hepatic metabolism, prolonged effect

Answer 274

Intraoperative * Complications from puncture if internal jugular vein e.g. pneumothorax * Arrythmia due to passage of catheter in right atrium * Massive haemorrhage due to portal venous rupture Postoperative * Precipitation of hepatic encephalopathy * Stent occlusion, thrombosis or dislodgement * Sepsis

Answer 275

T10 - pain innervation of bladder dystension travels with sympathetic fibres that have origins as high as T11

Answer 276

* Non conductive when using monopolar resectoscope * Good visibility * Non-haemolytic when absorbed

Answer 277

* Pulmonary oedema * Initial hypertension, reflex bradycardia, CCF then hypotension and cardiovascular collpase * Blindness, headache, confusion, seizures, coma * Nausea and vomiting *

Answer 278

* High intravesical pressure of irrigation fluid * Large quantities of irrigation fluid used * Low venous pressure * Prolonged surgery * Large blood loss

Answer 279

Osm= 2(Na)+2(K)+glucose+urea in mmol/l

Answer 280

* Pro: removes free water in event of pulmonary oedema * Con: worsens associated hyponatraemia

Answer 281

* Cerebral oedema * Central pontine myelinosis

Answer 282

* Broadened QRS complexes * T-wave inversion

Answer 283

* Ascites * Bilirubin: raised * Coag: raised prothrombin time * Da-protein: reduced albumin * Encephalopathy * Fluid: ascites

Answer 284

* Segmental anatomy of liver permits resection of some segments leaving fully functioning segments behind * Hepatic regenerative capacity by hyperplasia of remaining hepatocytes

Answer 285

* Diabetes (alters liver metabolism, reduced immune function, hepatic steatosis) * Obesity * Malnutrition * Cholangitis * Age over 65 years * Higher ASA * Cirrhosis with elevated CHild-Pugh/MELD score

Answer 286

* Fluid restriction * Minimise PEEP * Reverse Trendelenburg * Vasodilatory infusions e.g. GTN, remifentanil * Furosemide for its diuretic and venodilatory actions ## Footnote Aim is to reduce CVP to 5mmHg because bleeding is mainly due to backflow from valveless hepatic veins (afferent supplu is occluded)

Answer 287

* Recommends multimodal analgesia * Inclusion of intrathecal opioids is recommended - thoracic epidural can provide excellent pain relief but its use is limited by hypotension and impedance of early mobilisation * Continuous local anaesthetic wound infiltration catheters provide equivalent analgesia to thoracic epidural with lower complication rates * Local anaesthetic TAP blocks improve pain control and reduce opiate use

Answer 288

* Normotension * Absence of postural hypotension * Normalisation of ST segments * Absence of tachycarrythmias

Answer 289

* Pneumococcus * Meningitis B * Meningitis ACWY

Answer 290

* At least two weeks before elective splenectomy or 2 weeks after traumatic splenectomy * Pneumococcus to be repeated every five years

Answer 291

* Platelet count may be very low, increased risk of bleeding from surgical site and due to minor traumas e.g. cannulation and airway management * Cross match may be complicated by antibody development from previous transfusions * Preoperative platelet count may be improved with steroids or immunoglobulin treatment * Perioperative platelet infusion may be necessary by ideally given after arterial supply to spleen has been interrupted to avoid sequestration

Answer 292

* Synthesis of opsonins that trigger phagocytosis of pathogens * Synthesis of cytokines to regulate immune response * Presentation of blood-borne antigens to lymphocytes * Storage of white blood cells that can be triggered to become a range of specialised T-cells and B cells ## Footnote Non immunological functions: blood reservoir 250mls, stores platelets, removes old RBCs

Answer 293

* Infectious mononucleosis * Haematological malignancy * Portal hypertension due to liver disease

Answer 294

* Avoids the risks of major surgery * Retention of splenic immunological function

Answer 295

* Haemodynamic stability of patient * Grading of splenic injury * Local availability of IR for angioembolisation if necessary * Need for laparotomy for any associated injury

Answer 296

* Uterine rupture * Placental abruption * Amniotic fluid embolism

Answer 297

* Release of procoagulant factors by tumour * Presence of pelvic mass inhibiting venous return * Chrmotherapy increases risk of endothelial damage and release of inflammatory mediators * Presence of long term central venous access for previous chemotherapy * Prolonged surgery and so immobility

Answer 298

* Major surgery and hyperthermic intraperitoneal chemotherapy (HIPEC) increase pain scores - without neuraxial, opioid dose is likely to be higher with risk of side effects nausea, ileus, reduced respiratory function * Reduction in stress response, attenuating the negative impact on patient immunity * Reduction in thromboembolic risk post-operatively * Local anaesthetic associated with reduced risk of recurrence

Answer 299

* Coagulopathy * Electrolyte disturbance * Hyperthermia * Hyperglycaemia * Haemodynamic instability * AKI

Answer 300

* Antimicrobial prophylaxis * Chlorhexidine based skin preparation * Prevent hypothermia * Avoid unecessary drains or tubes * Avoid hyperglycaemia

Answer 301

* Propofol has antiemetic effect * Use of short acting agents e.g. remifentanil is supported by ERAS guidelines * Propofol is associated with reduced risk of cancer recurrence

Answer 302

* Reduced tissue damage results in reduced stress response to surgery * Reduced size of incisions results in lower pain scores and reduced requirement for opioid analgesia * Reduced risk of surgical site infection * Faster post-operative recovery to normal activities * Reduced gut handling, reduced risk of ileus and faster return to enteral feeding * Better visualisation of target structures * Reduced blood loss

Answer 303

* Damage to organ by accidental injury on insertion of trocar e.g. small bowel * Haemorrhage due to accidental injury to vessel on insertion of trocal e.g. iliac artery * Gas embolus secondary to accidental insufflation of vessel with carbon dioxide * Excessive pneumoperitoneum reduces venous return and risks cardiovascular collapse

Answer 304

* Severe heart failure * Right to left cardiac shunt (may be worsened by necessarily higher airway pressures) * Severe uncorrected hypovolaemia * Raised intracranial pressure * Retinal detachment

Answer 305

* Patient sliding, risk of fall * Movement of patient in relation to tube, risk of accidental extubation * Reduced venous return causing hypotension due to venous pooling in lower capacitance vessels

Answer 306

* Atelectasis due to limited diaphragmatic excursion * Raised airway pressures to oppose intrabdominal pressures risks barotrauma

Answer 307

* Compression of vena cava reduces venous return and risks reduced cardiac output * Compression of major arteries increases systemic vascular resistance, reduces cardiac output and increases afterload and so increased myocardial oxygen demand * Vagal stimulation by peritoneal stretch receptors leads to bradycardia * Increased splanchic vessel resistance and reduced blood flow to abdominal organs (BJAEd says this risks ischaemic reperfusion injury)

Answer 308

* Raised intrathoracic pressure to facilitate ventilation impairs venous drainage and increases intracranial pressure * Raised partial pressure of blood carbon dioxide (from absorption of insufflation gas) causes cerebral vasodilation and increases intracranial pressure

Answer 309

* Headache * Palpitations * Sweating

Answer 310

* Plasma or urinary metanephrine * Plasma or urinary homovanillic acid * Plasma or urinary normetanephrine * Plasma or urinary dopamine

Answer 311

* MRI * CT * MIBG scintigraphy * PET scan

Answer 312

* Blood pressure control * Correction of chronic circulating volume depletion * Heart rate and rhythm control * Optimisation of myocardial function * Reversal of glucose and electrolyte disturbances

Answer 313

[1] Non selective alpha antagonist or alpha-1 antagonist e.g. phenoxybenzamine * Start 1-2weeks preop, stop 48hrs preop to avoid intraoperative hypotension * For vasodilation to reduce blood pressure and allow volume expansion [2] Beta receptor antagonist, ideally beta-1 antagonist e.g. atenolol * Commenced after alpha antagonist to aboid hypertensive crisis caused by alpha-mediated vasoconstriction * To manage tachycarrhythmia [3] Calcium channel agonist * Give after alpha blockade * For hypertension control if inadequately controlled by alpha blocker

Answer 314

Vasopressin - systemic vasoconstriction via V1 agonism, increased water reabsorption at distal convoluted tubule and collecting duct via V2 agonism

Answer 315

* HTN * IHD (accelerated) * LVH with associated decompensation and diastolic+systolic dysfunction * Uraemic cardiomyopathy * Calcification of valves * Arryhtmias related to electrolyte distubances

Answer 316

* Fluid overload * Hyperkalaemia * Uraemia * Acidosis

Answer 317

* Minimise warm ischaemic time * Minimise cold ischaemic time

Answer 318

* Avoid hypotension, MAP > 90 mmHg or as guided by patient's BP * Commence immunosuppressive induction intraoperatively * Avoid nephrotoxic drugs e.g. NSAIDs * Avoid hypovolaemia, aim CVP 12-14 cmH2O and consider cardiac output monitoring

Answer 319

* Mucositis from chemotherapy * Difficult airway due to oroharyngeal/cervical lymphadenopathy * Tracheal compression due to mediastinal lymph nodes

Answer 320

* Risk of pulmonary toxicity with high FiO2 oxygen if preceeding bleomcin treatment * Risk of atelectasis and pneumonia due to bronchial compression by lymph nodes * Risk of radiation pneumonitis in months following radiation treatment, or fibrosis in years following radiation

Answer 321

* Chemotherapy induced heart damage including cardiomyopathy, heart failure, myocarditis, pericarditis, arrythmias * Radiation induced heart damage as above + valve disease and accelerated IHD * Compression of major vessels from mediastinal lymph nodes, risk of CVS collapse under GA * Venous access may be difficult due to previous chemotherapy

Answer 322

* Difficulties with cross match due to previous blood transfusions * Pancytopenia due to hypersplenism/bone marrow disease/CTX/RTX/antibody therapy * Need for irradiated blood due to risk of tranfusion associated GVHD

Answer 323

* Risk of lymphocytic infiltration resulting in renal dysfunction * Chemotherapy associated renal injury

Answer 324

* Oral analgesics e.g. paracetamol, NSAIDs and morphine may be contraindicated due to renal dysfunction - likely inadequate pain relief alone * Neuraxial may be contraindicated due to thrombocytopenia, high block would be required with effect on blood pressure and respiratory function * Paravertebral block would avoid hypotension but may be contraindicated due to thrombocytopenia * PCA with renal safe opioid e.g. oxycodone/fentanyl - side effects of opiates e.g. N+V * Rectus sheath/TAP, but does not manage visceral pain and not useful if subcostal incision used

Answer 325

* Better cosmetic outcome than a graft * Better functional outcomes * Can be performed in an area where there are no suitable donor sites for pedicled flap * Better coverage for large defects

Answer 326

* Tobacco smoking * High alcohol intake * Human Papilloma Virus

Answer 327

* Difficult airway due to tumour and/or previous radiotherapy * Smoking related lung disease * Ischaemic heart disease due to smoking * Pulmonary hypertension secondary to long standing lung disease * Chemotherapy and alcohol related cardiomyopathies * Risk of alcohol dependence * Anaemia relating to alcohol, poor nutritional status

Answer 328

Q =∆Pπr4/8ηL

Answer 329

* Maintain arterial pressure: cardiac output directed fluid and vasopressor therapy * Minimise venous pressure: use of remifentanil and muscle relaxant to avoid straining or ventilator dysynchrony, cardiac output directed fluid therapy to prevent oedema which may impede venous outflow * Adequate blood vessel radius: temperature monitoring and normothermia, control pain to minimise sympathetic vasoconstriction, cardiac output monitoring to guide vasopressor therapy * Optimise viscosity: aim haematocrit 0.3-0.35 as optimum balance between oxygen delivery and blood flow | Q =∆Pπr4/8ηL

Answer 330

* Insufficient arterial supply due to thrombosis * Insufficient venous drainage due to anastomotic kinking * Reperfusion injury to flap tissue * Infection

Answer 331

* Correction of dental malocclusion * Cosmesis * Correction of congenital head and neck conditions including secondary surgery after cleft palate repair * Severe obstructive sleep apnoea.

Answer 332

* Nasal intubation * Tracheostomy | Retromolar and submandibular intubation are documented procedures too

Answer 333

* Post-operative airway swelling or bleeding * Intermaxillary fixation sometimes applied at the end of surgery which restricts access to airway in an emergency * PONV will obstruct venous return risking compromise to haemostasis and leading to airway bleeding * Risk of retention of throat pack * Airway occlusion by inadequate suctioning of blood products

Answer 334

* Hypotensive anaesthesia e.g. using remifentanil, clonidine, magnesium * Head up position to help venous drainage * Adrenaline or cocaine containing local anaesthetic use by surgeon * Avoid restriction to venous drainage e.g. tube ties * Use of tranexamic acid * Cessation of preoperative antiplatelet or anticoagulant drugs * Low PEEP <5cmH2O

Answer 335

* Readilty titratable to stimulating parts of surgery * Facilitates hypotensive anaesthesia * Facilitates smooth wake-up and extubation to ensure haemostasis and integrity of surgery * Reduced risk of PONV if used in TIVA vs volatile use

Answer 336

* Agreement at pre-list briefing who will insert and remove throat pack * Thoat pack sticker applied to tube * Throat pack allocated by scrub nurse and included in swab count * Throat packs should not be stored in anaesthetic room * Thorat pack removal confirmed in recovery handover

Answer 337

* Thyroid function tests to confirm adequate treatment of thryotoxicosis * Full blood count to assess for agranulocytosis caused by carbimazole and propythyiouracil * Serum calcium baseline as levels may drop post-operatively * CT scan to assess for tracheal compression or deviation * Fibreoptic nasendoscopy to assess ease of laryngoscope and assess for pre-existing vocal cord palsies

Answer 338

* Worsening of tracheal compression on lying down: assess patient's ability to breathe lying down prior to induction, consider head up for induction or awake intubation * Tracheal narrowing due to compression: have smaller endotracheal tube sizes available * Tracheal deviation: consider awake fibreoptic intubation * In a CICO situation if obstruction is distal to level of cricothyroid membrane, eFONA may not help: surgeons available to perform rigid bronchoscopy if rescue required

Answer 339

* Tracheomalacia after long-standing retrosternal goitre * Recurrent layrngeal nerve damage resulting in stridor * Laryngeal odema resulting in stridor * Failure of haemostasis causing bleeding and compression of airway

Answer 340

* Perioral tingling * Tingling of fingers * Tetany * Twitching

Answer 341

* **D**ifficulty swallowing * N**E**WS score suggestive of bleeding e.g. tachycardia * **S**welling of neck * **A**nxiety * **T**achypnoea * **S**tridor * Desaturation | DESATS

Answer 342

* Tranexamic acid * Dexamethasone

Answer 343

Light amplification by simulated emission of radiation

Answer 344

* Solid e.g. Nd-YAG used in surgery for cutting * (Semiconductor e.g. gallium used in DVDs but not medically) * Liquid e.g. yellow pulsed dye used in dermatology for birthmark removal * Gas e.g. argon used for retinal coagulation

Answer 345

* Doors locked, windows covered and signs placed to indicate laser use in theatre * All staff working with laser trained in laser hazards * Laser use restricted to authorised users * Laser protection supervisor for each clinical area where laser is used * Eye protection for staff in laser controlled area * Carbon dioxide fire extinguisher available in areas using laser * Matt equipment where possible to dissapate beam rather than reflect

Answer 346

* Use lowest possible fraction of inspired oxygen, aiming below 25% * Laser safe tube: non-flammable, non-reflective endotracheal tube, saline into endotracheal tube cuff rather than air * Water-based gel to cover hair, if gauze is used in airway, soaked with saline first * Ensure alcoholic skin prep has fully dried before application of drapes * Remove non-essential equipment or gauze from airway when laser in use * Use non-reflective surgical instruments

Answer 347

1. Stop laser 2. Discontinue ventilation and fresh gas flow 3. Remove tracheal tube if on fire 4. Remove flammable material from airway 5. Flood airway with 0.9% saline

Answer 348

* High frequency jet ventilation * High flow nasal oxygen THRIVE technique (transnasal humidified rapid-insufflatory ventilatory exchange) * Spontaneous ventilation with oxygen via nasal cannula

Answer 349

* Grave's disease * Toxic multinodular goitre * Solitary hypersecreting adenoma

Answer 350

* Tachycardia * Tremor * Weight loss

Answer 351

* Propanolol: beta antagonist, inhibits potentiation of adrenergic signalling by T4 and T3, reducing symptoms and signs of thyrotoxicosis * Carbimazole: inhibits thyroid peroxidase in thyroid gland to inhibit production of T4 and T3 * Propylthiouracil: inhibits thyroid peroxidase in thyroid gland to inhibit production of T4 and T3 * Radioactive iodine: taken in by thyroid cells and leads to their destruction

Answer 352

* **S**kin exposure * **C**ut subcuticular sutures * **O**pen skin wound * **O**pen strap muscles to expose tracheal * **P**ack to cover wound * Sit patient up, administer oxygen * SCOOP * Contact ENT, arrange return to theatre * Prepare for difficult airway

Answer 353

* Facial nerve runs through tympanic cavity and so is at risk of injury during middle ear surgery

Answer 354

* EMG monitoring - two electrodes placed in a muscle innervated by facial nerve e.g. obicularis oris, obicularis oculi and potential difference is confirmed, which indicates facial nerve activity. High potential differences later in surgery indicate stimulation of the facial nerve and suggest it is at risk of damage. Audible alarm can be set to trigger above a certain potential difference * Monopolar stimulator probe to confirm location of facial nerve during surgery. On stimulation, muscles innervated by facial nerve twitch. * Drill burrs may have nerve stimulator function built in so there is an audible alarm if they are close to the facial nerve

Answer 355

* Single dose of short-acting muscle relaxant to facilitate intubation and no further doses: risks having not worn off by the time facial nerve monitoring is required * Intubation under deep anaesthesia without muscle relaxant e.g. remifentanil - risks suboptimal intubating conditions * Use of an LMA - only for certain patients, would not be suitable in severe reflux or morbid obesity, may be more difficult to control ventilation for duration of surgery

Answer 356

* Facilitates hypotensive anaesthesia * Allows rapid titration to surgical stimulation in absence of neuromuscular blockade * As a TIVA technique reduces risk of PONV- middle ear surgery is emetogenic * Facilitates smooth extubation - coughing and retching will increase middle ear pressure and should be avoided

Answer 357

* 10-degree reverse Trendelenburg to improve venous drainage * Minimum PEEP to reduce intrathoracic pressure and improve venous drainage * Avoid tracheal tube ties or extreme lateral rotation of head to avoid impeding venous drainage * Optimise ventilation, avoid hypercapnoea which causes vasodilation

Answer 358

* Prolonged surgery * Direct stimulation of vestibular system by drilling adjacent to inner ear * Suction-irrigation acts as a caloric vestibular stimulant * Age demographic of patients- children and young adults are at greater risk of PONV

Answer 359

* Nitrous oxide can diffuse out of the middle ear faster than nitrogen can diffuse in, resulting in subatmospheric middle ear pressure and compromising outcome of surgery * Increased risk of PONV

Answer 360

* GCS < 8 or conscious level renders unable to protect airway reflexes * Impending airway cmpromise secondary to maxillofacial injuries * To facilitate urgent surgery * In suspected brain injruy to control physiological parameters and reduce risk of secondary brain injury * To facilitate management or transfer of an agitated uncooperative patient * Cardiac arrest/respiratory failure

Answer 361

* Foreing bodies in airway e.g. teeth, vomit, blood * Oedema due to trauma may narrow airway * Posterior displacement of fractures facial bones may make face-mask pre-oxygenation painful and make an adequate seal difficult to achieve. Laryngoscopy may be challenging * Confusion or agitation may affect compliance with preoxygenation and positioning * Manual in-line stabilisation limits ability to obtain good laryngoscopy view

Answer 362

1: maxilla fractured from rest of face (transverse) 2: maxilla and nasal complex fractured from rest of face (oblique fractures) 3: whole mid-face dissociates from skull base and facial bones

Answer 363

* Route of intubation as surgery will involve ensuring dental occlusion, consider nasal or submental * Risk of damage or obstruction of airway device due to surgery * Consider need for post-operative ventilation due to airway swelling * Intermaxillary fixation device may make delay emergency reintubation e.g. for post-operative bleeding and airway compromise

Answer 364

* Uncertain ability to oxygenate * Reintubation potentially difficult * Presence of coorbidities e.g. cardiovascular, neuromuscular

Answer 365

* Staged extubation e.g. using LMA or airway exchange catheter * Postpone extubation until conditions optimised * Tracheostomy

Answer 366

* Scalpel 10 blade * Boujie * Size 6 cuffed ET tube

Answer 367

* TMJ involvement, restricted mouth opening * Cervical spine involvement with instability, fusion and restricted neck extension * Kyphosis resulting in difficult positioning

Answer 368

* Manual in-line stabilsation or rigid collar * Use of videolaryngoscope with stylet or boujie * Awake or asleep fibreoptic intubation

Answer 369

* Aortic regurgitation * Conduction disorders * Increased risk IHD

Answer 370

* Kyphosis- restrictive lung defect * Upper lobe pulmonary fibrosis

Answer 371

* Peripheral nerve impingement by bony overgrowth * Spinal cord damage due to compression or fractures * Focal epilepsy

Answer 372

* DMARDs e.g. sulfasalazine, methotrexate * Anti-TNF drugs e.g. infliximab, adalimumab * Othter monoclonal antibodies e.g. secukinumab * JAK inhibitors e.g. upadacitinib * Corticosteroids

Answer 373

* Haematoma compressing airway * Laryngeal oedema due to prone positioning * Migration or displacement of any implant used * Intraoperative damage to recurrent laryngeal nerve associated with anterior cervical surgery

Answer 374

* Ossification of interspinous ligaments * Bony bridges between verterbrae

Answer 375

* Anaemia of chronic disease secondary to chronic periprosthetic infection * Nutritional deficiencies due to reduced mobility affecting ability to self care e.g. iron deficiency, B12 deficiency * Bone marrow disorders e.g. aplastic anaemia, myelofibrosis

Answer 376

* Cardiovascular events e.g. MI * Infections including surgical site * AKI * VTE * Blood transfusion requirement * Unplanned ICU admission

Answer 377

Predicted blood loss > 500ml or > 10% blood volume

Answer 378

* Circulating blood volume is 70ml/kg so 3.5L in patient. 1L blood loss accounts for almost 30% circulating volume and may result hypoperfusion of organs and lactic acidosis * Sympathetic response to volume loss causes tachycardia, peripheral vasoconstriction and risks myocardial ischaemia * Activation of renin-angiotensin-aldosterone system causes reduction in urine output and vasoconstriction * Coagulopathy may develop and exacerbate further bleeding

Answer 379

* Avoid hypothermia * Correct acidosis, aim pH > 7.2 and hypocalcaemia, aim ionised calcium > 1mmol/L * Use of tranexamic acid *

Answer 380

> 70g/L or 80g/L in patients with underlying cardiac disease

Answer 381

* Development of atypical antibodies making future cross-matching more challenging * Transfusion associated circulatory overload * Administration of cold blood with low 2,3DPG and no clotting factors impairs coagulation * Non-haemolytic transfusion reactions * Transfusion errors resulting in incompatible blood transfusion

Answer 382

Within 36 hours of admission or from time of fracture if it occured in hospital

Answer 383

* Hb < 80 g/L * Sodium < 120 or > 150 mmol/L * Potassium < 2.8 or > 6 mmol/L * Uncontrolled diabetes * Acute heart failure * Correctable tachyarrythmia with ventricular rate > 120bpm * Chest infection with sepsis * Reversible coagulopathy

Answer 384

* Advanced age * Male sex * Reduced abbreviated mental test score * Anaemi * Institutional living prior to admission * Two or more active comobidities * Active malignancy (except basal cell carcinoma) within past 20 years

Answer 385

Factor Xa inhibitor, 24 hours

Answer 386

* Regional anaesthesia for multimodal approach to pain relief and to reduce need for long-acting pyschoactive agents * Avoid hypotension, aim MAP > 80mmHg * Minimise risks of post-operative delerium by avoiding long acting sedatives, centrally acting anticholinergists, long-acting opiates * If spinal, limit bupivicaine dose to < 10mg, avoiding intrathecal opioids * If general anaesthesia, avoid excessive depth using pEEG and age adjusted MAC

Answer 387

* Ongoing pain * Hypotension * Constipation * Nausea and vomiting * Urinary retention * Post-operative delerium

Answer 388

* Surgery within 36 hours of (or on the day of or the day after) admission (or from the time of the fracture, if it occurred in hospital) * Surgery on a planned trauma list with consultant or other senior staff supervision * Geriatrician assessment within 72 hours of admission * Mobilisation with physiotherapist to commence no later than the day after surgery * Preoperative cognitive assessment using abbreviated mental test score. * Fracture prevention assessment to include specialist falls and bone health assessments * Nutritional assessment * Post-operative delerium assessment using the 4 "As" Test

Answer 389

* Arrythmia * Aortic stenosis * Stroke * Sepsis secondary to pneumonia or UTI * Diabetes causing hypoglycaemia or hyperosmolar hyperglycaemic state * Polypharmacy with orthostatic hypotension as a side effect

Answer 390

* Loss of more than one vlood volume within 24 hours * 50% total blood volume loss in < 3 hours * Bleeding > 150ml/min * Bleeding that results in systolic blood pressure < 90 mmHg or heart rate > 110 bpm

Answer 391

* Transfusion of more than 10 units of blood in 24 hours * More than 4 units of blood in 1 hour

Answer 392

* Increased heart rate * Decreased blood pressure * Decreased pulse pressure * Increased respiratory rate * Decreased urine output * Decreased GCS

Answer 393

* Early haemorrhage control e.g. tourniquets, surgery * Permissive hypotension * Avoid clear fluids for resuscitation unless profound hypotension and no imminent availability of blood products * Manage trauma-induced coagulopathy empirically intiailly with 1g tranexamic acid, 1:1: RBc:FFP, two five-unit pools of cryoprecipitate and a pack of platelets. Then guided by POC/lab results

Answer 394

* Cryoprecipitate if fibrinogen < 1.5g/l (2g/l in obs) * FFP if INR > 1.5 * Platelets if count < 75 x 10^9/L

Answer 395

* Immediate haemolytic reaction if human errror ABO incompatibility * Febrile non-haemolytic transfusion reaction * Allergy or anaphlactic reaction * Transfusion related acute lung injury * Delayed haemolytic transfusion reaction * Immune sensitisation * Transfusion associated GvHD * Post-transfusion purpura

Answer 396

* Transfusion associated circulatory overload * Infection e.g. CMV or bacterial contamination * Hyperkalaemia * Citrate toxicity * Hypothermia

Answer 397

* Medical history e.g medical cause for drowning e.g. epilepsy, cardiac history * Toxins e.g. drugs, alcohol * Trauma: associated injury * Scene: timings, duration of submersion, contaminants in water, temperature

Answer 398

* Core body temperature - guides re-warming and algorithm for management of cardiac arrest * Capillary blood glucose - hypoglycaemia may be cause of events, target normal blood glucose to maximise neurological outcome * Arterial blood gas - assess for hypoxia, hypercapnoea, lactic acidosis * Coagulation: DIC may occur * Toxicological assays for drugs and alcohol which may have precipitated event * 12 lead ECG - risk of arrhythmias due to hypothermia, hypoxia, acid-base disturbance, may see cardiac event as precipitant to drowning * CXR - identification ARDS * Trauma imaging - if associated injuries likely

Answer 399

* Fluid aspiration washes out surfactant leading to atelectasis * Acute pulmonary oedema follows aspiration of hypotonic fluid * Bronchospasm follows introduction of foreign material into airways * Acute pneumonia * ARDS * Aspiration of stomach contents * Inhaled toxins e.g. pollutants, chlorine

Answer 400

* Acute heart failure due to hypoxia, hypothermia, sympathetic response * Arrythmias due to acid-base disturbtance, hypoxia, electrolyte imbalance * SIRS response to non-fatal drowning * Hypotensive effect of associated injuries e.g. haemorrhage, spinal shock

Answer 401

* Bilateral pedicle fractures of C2 (Hangman's fracture) * Occlusion of neck vasculature * Compression of trachea * Laryngotracheal injury * Vagal inhibition of the heart via carotid sinus and baroreceptor stimulation * Negative pressure pulmonary oedema * Cardiac arrest * Arrythmias * ARDS * Cerebral ischaemic injury

Answer 402

* MR safe: device poses no MR related hazard to patients or staff when used according to instructions and can be used in any MR setting * MR conditional: equipment poses no MR-related hazard in a specified MR environment unless specific conditions of use e.g. static field strength, rate of change of magnetic field

Answer 403

5 Gauss or 0.5 milliTesla

Answer 404

* Use only MR safe monitoring equipment or MR conditional equipment that has been deemed approipriate to use in the scanner * Check all equipment prior to use, ensuring no breach to insulating surfaces * Use fibreoptic cables for ECG and pulse oximeter to elimate use of electrical current (risk of induction currents and burns) * Telemetric monitor to elimate risk of induction currents in connecting leads * ECG leads should be high impedance, braised and short to minimise risk of induction currents. ECG electrodes should be MR safe * Separate leads from patients skin e.g. with foam insulating padding

Answer 405

* Ensure equipment is MR safe of MR conditional and approved to be used on that scanner * All staff and patients to complete a checklist to ensure no contraindications to entering MRI scanner * Staff and patient remove all ferromagnetic objects from clothes/pockets * Ear protection for patients * Meticulous securing of airway to ensure it does not become dislodged with movement as difficult to access once in scanner * Remote site anaesthesia: ensure senior support available and orientation to equipment and emergency kit

Answer 406

* Recent surgery involving ferromagnetic implant * Ferromagnetic material in eye * Intra-aortic balloon pumps, ventricular assist devices * Neurostimulators * Implantable cardiac devices, valves and stents

Answer 407

* Capacity for consent * Psychiatric illness may make it difficult to obtain full history, may affect compliance with treatment for comorbidities and fasting instructions * Check for dentition (bite block will be used) * Assess for comorbidities that affect suitability for ECT e.g. ischaemic heart disease, significant valve disease, raised intracranial pressure, raised intraoccular pressure * Check for ICD which should be deactivated, or permenant pacemaker which should be set to fixed mode - liase with cardiac physiologist

Answer 408

* Brief 15s parasympathetic response with bradycardia and risk of asystole * Then, prominent sympathetic response with increased heart rate and blood pressure (increased myocardial oxygen consumption and risk of ischaemia) * Risk of post-procedure myocardial stunning with reduced ejection fraction, risk of heart failure

Answer 409

* Increased salivation secondary to parasympathetic ohase, risk of laryngospasm * Increased cerebral oxygen consumption and rise in intracranial pressure * Increased gastric pressure risking reflux and aspiration * Induced seizure results in raised lactate, raised temperature and myalgia

Answer 410

* Dental damage due to seizure and bite block * Myalgia due to seizure and use of suxamethonium * Intraoral damage due to biting

Answer 411

* Potentiation of the effect of muscle relaxant * Renally extrected - NSAIDs reduce lithium excretion and can result in toxic levels * Can cause nephrogenic diabetes insipidus with implications on fluid status * Risk of serotonin syndrome if co-administered with fentanyl, tramadol, ondansetron

Answer 412

* Risk of serotonin syndrome if co-administered with fentanyl, tramadol or ondansetron * Inhibits CYP2D6, preventing metabolism from codeine to morphine and tramadol to active form so these could not provide analgesia * Co-administration with NSAIDs increases bleeding risk as both drugs reduce platelet activity *

Answer 413

Advantages: * Removes requirement to transfer unstable patient * Minimises delays to treatment * Close availability of cardiology specialist equipment, drugs and staff Disadvantages: * Remote, unfamiliar environment * Possible lack of availability of AAGBI monitoring especially capnography * May have limited availability of suction, anaesthetic drugs, difficult airway equipment * Staffing may be limited e.g. skilled assistant, recovery staff, consultant supervision, anaesthetic back-up

Answer 414

* Fasting status * Reflux * Likelihood difficult airway * Post-cardioversion plans e.g. need for transfer elsewhere for further management * Consent/patient preference

Answer 415

* Aspiration * Deterioration in cardiovascular stability due to anaesthetic agents * Failure to gain important anaesthetic history from patient due to reduced GCS and urgency e.g. history of difficult airway * Awareness

Answer 416

* Arterial embolism causing stroke * Asystole * Burns * Electrical injury to staff

Answer 417

* Likely fixed non-tipping table, safer to perform induction on tipping trolley * Lengthy procedure, care for pressure points, temperature monitoring * Use of radiography - protection to staff, acess to patient may be limited by C-arm * Invasive arterial/central venous monitoring may be required * Intubation may be better if plans for transoesophageal echo during proceudre

Answer 418

Core body temperature < 35 degrees C

Answer 419

* Targeted temperature management to a range of 32-36 degrees C for 24 hours followed by gradual rewarming with control of pyrexia for a further 48 hours

Answer 420

* Expose patient * Use antipyretic drugs * Surface cooling device e.g. Arctic Sun * Use of wet towels and ice-packs

Answer 421

* reduced cerebral metabolic rate so reduced oxygen and glucose demand * suppression of relase of oxygen free radicals during reperfusion * suppression of destructive neuroexcitotocix cascase * reduction in expression of pro-apoptotic signals

Answer 422

* Increased catecholaemine release so risk of cardiac ischaemia * arrythmias * cardiac arrest at < 30 degrees * decline in cognitive function * reduced insulin release and increased insulin resistance, elevated blood glucose * reduced GI motility * impaired coagulation * impaired immune function * diuresis and loss of electrolytes

Answer 423

* If VF persists after 3 shocks, delay further shocks until core temperature > 30 degrees C * Withold adrenaline if temperature < 30 degrees C * Administer adrenaline every 6-10 minutes if core temperature 30-34 degrees C * Rewarm, ideally with extracorporeal life support

Answer 424

* Assess if currently in AF through presence of irregularly irregular pulse * Assess for adequate rate control * Assess for underlying causes e.g. Grave's disease, valve disease * Assess for associated heart failure e.g. bibasal crackles, raised JVP

Answer 425

* Grave's disease * PE * Sepsis * Excess caffeine * Excess alcohol

Answer 426

Low dose 2.5mg BD: 24-48 hours (24hrs for hips) High dose 5mg BD: 72 hours

Answer 427

* Anxiety * Electrolyte abnormalities * Hypovolaemia * Critical incident e.g. anaphylaxis, MI, pneumothorax, local anaesthetic toxicity * Iatrogenic - administration of ephedrine

Answer 428

* Ensure adequate sedation or anaesthesia * Synchronised DC cardioversion up to 3 attempts * If unsuccessful give 300mg amiodarone iv over 20 minutes * Consider further synchronised shock ## Footnote For AF, shock at maximum defibrillator output For atrial flutter or SVT 70-120J increasing energy in stepwise manner For VT120-150J increasing energy in stepwise manner

Answer 429

* Magnesium 2g over 10 minutes * Amiodarone 900mg over 24 hours

Answer 430

* Optic nerve for light perception * Opthalmic branch of trigeminal nerve for sensation

Answer 431

Afferent: opthalmic branch of trigeminal neve Efferent: vagus nerve | Synapses in ciliary ganglion

Answer 432

Sinoatrial node

Answer 433

* Pressure in the globe * Traction on extra-ocular muscles

Answer 434

Anterior: limbus which is the corneoscleral junction Posterior: dural sheath around optic nerve

Answer 435

* Provides an akinetic globe for surgery * Considered the least painful regional anaesthetic technique for eye surgery * Good sensory block reduces risk of oculocardiac reflex

Answer 436

* Active secretion of aqueous humour by ciliary bodies * Passive secretion by ultrafiltration of aqueous humour * Drainage via trbecular network and canal of Schlemm * Reverse ultrafiltration into intersitium of sclera, dependent on pressure difference between it and the anterior chamber of the eye

Answer 437

* Fasting status * Airway assessment * History of complications with anaesthesia * Size of perforation * Whether surgery is intended to be sight saving (gives idea of urgency)

Answer 438

* RSI if patient not starved * Minimise rises in introcular pressure by ensuring adequate pain relief, normoxia, normocarbia * Full muscle relaxation with monitoring train-of-four to ensure full relaxation of extraocular muscles * Consider deep extubation or extubation on remifentanil to minimise coughing and training causing spikes in intraocular pressure * Adequate antiemesis to minimise rise in introccular pressures postoperatively * Avoid suxamethonium and ketamine which cause transient rises in intraocular pressure

Answer 439

* Patient refusal * Allergy to LA * Localised sepsis * Inability to cooperate e.g. due to confusion * Inability to lie still due to musculoskeletal, respiratory or cardiac conditions * Inability to tolerate ocular manipulation without blepharospasm * Grossly abnormal coagulation

Answer 440

* Sub Tenon's * Peribulbar * Retrobulbar

Answer 441

* To provide pain-free surgery * To minimise systemic and local complications of anaesthesia * To reduce risk of surgical complications e.g. oculocardiac reflex

Answer 442

* Pre, Stop, Block * Asepsis * Entry site * Length and type of needle * Volume and concentration of LA agent * Quality of block * Immediate complications

Answer 443

* Chemosis * Subconjunctival haemorrhage * Oribtal haemorrhage * Retrobulbar haematoma * Globe perforation

Answer 444

* Barrier function in innate immunity * Prevention of fluid loss * Sensory function * Thermoregulation

Answer 445

Lund-Browder chart

Answer 446

Fluid requirement = 4 x weight (kg) x percentage burned Half total requirement given in first 8 hours, second half given in the next 16 hours | Use warm, isotonic, balanced crystalloid

Answer 447

* Blood loss from associated injuries * Blood loss due to debridement of burned areas * Evaporative losses from debrided areas * Maintenance requirements if not having oral intake

Answer 448

* Ensure urine output > 0.5ml/kg/hr * Monitor serum lactate * Minimise core-peripheral temperature difference * Serial haematocrit assessment * Cardiac output monitoring

Answer 449

* ≥ 2% TBSA in children or ≥ 3% in adults * Full thickness burns * Circumfrential burns * Burns to feet, face, perineum or genitals * Burn not healed in two weeks

Answer 450

* Chest or abdominal burns that restrict ventilation * Cricumferential burns on limbs which restrict perfusion distally

Answer 451

* Minimise patient exposure * Maintain theatre temperatrue 28-33 degrees * Forced air warmers * Intravenous fluid warmers * Under body resistive heating mat

Answer 452

* Limb tourniquets * Topical adrenaline * POC coagulation testing and address coagulation deficiencies

Answer 453

Pedicled: Latissimus dorsi flap Free flap: transverse rectus abdominis myocutaneous free flap

Answer 454

* Poorly controlled diabetes * Haematological issues e.g. polycythaemia or prothrombotic state * Cigarette smoking * Microvascular damage after radiotherapy

Answer 455

* Flap colour * Capillary refill * Oedema/turgor * Temperature * Doppler * Bleeding on pinprick

Answer 456

* Fire in enclosed space * Flames/fumes/smoke/steam * Delayed escape * Loss of consciousness at scene * Fatalities in same incident

Answer 457

* Voice change * Cough * Burns to oropharynx * Soot in sputum, nose and mouth * Crackles on chest consistent with pulmonary oedema * Respiratory distress * Reduced consciousness/agitation

Answer 458

* ABG: hypoxaemia, raised carboxyhaemoglobin level, lactic acidosis * VBG: decreased arteriovenous oxygen difference (inability to use oxygen following carbon monoxide poisoning) * CXR: pulmonary oedema, ARDS * Fibreoptic laryngoscopy: laryngeal oedema, mucosal pallor, erythema and ulceration

Answer 459

* Stridor * Respiratory distress or inadequate gas exchange * Full thickness neck burns * Oropharyngeal oedema * Low GCS * Cardiac arrest * To stabilise airway for transfer ## Footnote RSI, uncut bute, minimum size 8mm tube

Answer 460

* Procedure time > 90 minutes (or 60 minutes if pelvis or lower limb) * Acute admission with inflammatory or intraabdominal pathology * Expected significant reduction in mobility * One or more patient risk facttors e.g. cancer, > 60 yrs, dehydration, critical care admission, thrombophilia, BMI > 30, history of VTE

Answer 461

* Cervical plexus - 50mm * Interscalene - 25mm * Supraclavicular - 50mm * Infraclavicular - 100mm * Axillary - 50mm * Paravertebral - 100mm * Lumbar plexus - 100mm * Sciatic - 100mm posterior approach, 150mm anterior * Popliteal - 50mm posterior, 100mm lateral

Answer 462

* Apnoea is cessation of airflow for 10s * Hypoapneoa is when airflow is halved for 10s

Answer 463

ABO/HLA incompatibility in young patients

Answer 464

* Arrythmia/heart failure * Fever/nausea and vomiting * Steven Johnson's syndrome

Answer 465

* > 90 * preserves renal function in existing kidneys and reduces risk of graft failure

Answer 466

Aims of treatment are: * A reduction of 0.5 mmol/L/hour blood ketone concentration * An increase of 3 mmol/L/hour of venous bicarbonate concentration * A reduction of 3 mmol/L/hour of blood glucose concentration If not met, infusion increased by 1 unit/hr

Answer 467

Severe * Peak flow 33-50% * Cannot complete full sentences * RR >25 * pO2 >8 * SpO2 > 92% * Wheeze, alert Life threatening * Peak flow < 33% * 1-2 words * RR < 10 * pO2 < 8 * SpO2 < 92% * Silent chest, somnolence Near fatal * Cannot do peak flow * No words * Requires ventilation * pO2 < 8, SpO2 < 92%, pCO2 high * Unconscious

Answer 468

* 5mg salbvutamol nebs * 2g Mg * 40mg Pred, 200mg hydrocort * Salbutamo infusion 5-20micrograms/min * Aminophylline 5mg/kg loading then 0.5mg/kg/min * Adrenaline infusion

Answer 469

Ketamine Thiopentone Levobupivicaine/ropivucaine Ephedrine, metaraminol, vasopressin Sevofluorane Erythromycin, rifampicin

Answer 470

* Septal V1–V2 LAD * Anterior V2, V3 and V4 LAD * Anteroseptal V1–V4 LAD * Lateral I, aVL and V5–V6 LCX * Anterolateral V2–V6, I and aVL LCA (LAD + LCX) * Inferior II, III and aVF RCA * Posterior Reciprocal changes V1–V3 RCA

Answer 471

* Fibrosis of soft tissue affecting neck movements and mouth opening * Osteoradionecrosis of mandible and maxilla - exacerbates trismus

Answer 472

* Supraglottic - involves base of tongue and vallecula, may need ATI * Glottic - involves vocal chords, smaller tube * Transglottic - glottic and supraglottic * Subglottic - around cricoid ring, risk of "coring" or severing tumour when tube is advanced, consider rigid fibroscope and HFNO

Answer 473

up to 34.9: ASA1 35-39.9: ASA2 above 40: ASA 3 Class 1 obesity: 30-34.9 Class 2 obesity: 35-39.9 Class 3 obesity: above 40

Answer 474

* Age > 45 * HTN * Male * BMI > 50 * Risk factors for PE e.g. previous VTE

Answer 475

* Diabetes * Chronic respiratory disease * Open abdominal surgery

Answer 476

A: Increased risk of difficult airway, consider oxford pillow, VL B: Increased O2 consumption, reduced compliance and FRC, consider ramping, using higher PEEP and pressures C: BP cuff fitting, consider placing on forearm D: Increased risk of awareness due to rapid redistribution of induction agents, ensure adequate dosing and promptly begin maintenance anaesthesia E: May have diabetes, manage per guidance F: Pharmacokinetic models in TIVA not validated in obese patients, certain drugs are dosed by lean or ideal bodyweight G: Increased risk of GORD, perform RSI I: If metabolic syndrome, increased risk of infection J: Increased weight on joints, cautious positioning, risk of gluteal ischaemia and rhabdo in prolonged surgery

Answer 477

* Most drugs are lean body weight e.g. propofol induction, opioids, LA, NDMB, paracetamol * Adjusted body weight: sugammadex, antibiotics, neostigmine, propofol infusion * Ideal body weight: emergency drugs (not atropine which is LBW) * Total body weight: LMWH, suxamethonium

Answer 478

* BMI >50 * Poor functional capacity * Unstable HTN, IHD, CCF * Unstable/untreated OSA/OHS * Previous VTE * Metabolic syndrome * OS-MRS 4-5 General: * No social support to stay with patient - traditionally for 24hrs * Surgical procedure has high risk of bleeding or infection requiring monitoring * Patient refusal * Long distance between home and nearest appropriate medical treatment facility

Answer 479

* Failure requiring time pressured GA * Delayed mobilisation * Urinary retention * Hypotension * Nerve injury

Answer 480

* Aspiration * Falls * VTE * Respiratory failure * Withdrawal syndromes e.g. parkinsonism-hyperpyrexia syndrome (pyrexia, rigidity, CVS instability and altered mental status), dopamine agonist withdrawal syndrome (nausea, pain, anxiety, depression, orthostatic hypotension)

Answer 481

* > 85 years * Female * AMTS < 7 * Hb < 100 * Living in institution * Multiple co-morbidities * Active malignancy in last 20 years

Answer 482

Coagulative injury to skin caused by thermal, mechanical, chemical energy

Answer 483

* Superficial: pink, moist, blisters, painful * Deep partial thickness: red, non blanching, dry, less sensate * Full thickness: white, waxy, charred, non painful

Answer 484

B: bronchoconstriction, ARDS C: hypovolaemia, myocardial depression, increased capillary permeability leading to tissue oedema, splanchic vasoconstriction leads to AKI/ileus/stress ulceration, DVT D: sympathetic response and increased catecholamines E: reduced insulin secretion, increased cortisol production G: stress ulcer I: immunosuppression, infection J: weight loss, muscle weakness, hyperthermia, compartment syndrome R: renal failure

Answer 485

* Retrosternal goitre * Obstructive symptoms * Failed medical management of hyperthyroidism * Malignancy

Answer 486

* Dyspnoea or snoring which is positional * Dysphagia * ENT have failed indirect laryngoscopy (routine to assess vocal cords)

Answer 487

* Any reason for difficult airway (reduced mouth opening, oropharyngeal tumour) * Need for absolute cervical spine immobilisation

Answer 488

* Anterior Ethmoid * Greater and lesser palatine * Tonsillar * Lingual * Glossopharyngeal * Internal branch superior laryngeal nerve * Recurrent laryngeal nerve

Answer 489

* 50mg/ml lidocaine * 5mg/ml phenylcaine

Answer 490

DUMBELLS Diarrhoea, urination, miosis, bronchorrhoea, emesis, lacrimation, lethargy, salivation

Answer 491

Mad as a hatter (altered mental status) Blind as a bat (mydriasis) Red as a beet (flushing) Full as a flask (urinary retention) Dry as a bone (dry mucous membranes and anhidrosis)

Answer 492

Hyperthermia, rigidity and altered mental status after exposure to dopamine antagonist

Answer 493

* Change in mental status * Autonomic overactivity (hyperthermia, tachycardia, hypertension, sweating) * Neuromuscular hyperactivity (hyperreflexia and clonus) (CAN) ## Footnote Diagnostic criteria: recently started or increased serotonin agent. no increase or start of neuroleptic agent, other causes excluded + symptoms of above

Answer 494

Synthesised in Raphe nuclei Found in hypothalamus, thalamus, limbic system, brainstem, spinal cord, platelets, mast cells

Answer 495

* Release: MDMA, cocaine, oxycodone * Prevent reuptake: SSRI e.g. citalopram, SNRI e.g. venlafaxine * Reduce metabolism: MAOI e.g. seleginine, alpha blocker e.g. hydralazine * Direct agonism: triptans e.g. sumitriptan

Answer 496

Mean pulmonary arterial pressure 25mmHg or more (30 on exercise)

Answer 497

* Pulmonary arterial hypertension e.g. idiopathic * Pulmonary hypertension with left heart disease e.g. CCF * Pulmonary hypertension with lung disease e.g. secondary to COPD * Pulmonary hypertension due to thrombo-embolic disease e.g. recurrent PE * Miscellaneous

Answer 498

* Mild 25-35mmHg * Moderate 35-45mmHg * Severe >45mmHg

Answer 499

* Prostanoids e.g. epoprostenol * Endothelin receptor antagonist e.g. bosentan * Nitric oxide pathway e.g. sildenafil, nitric oxide * Inodilators e.g. levosimendan * Inotropes e.g. dobutamine

Answer 500

* Partial pressure oxygen * Extracellular pH * Partial pressure CO2 * Temperature * Iron status * Age

Answer 501

* CVP 0-8mmHg * Right ventricle 15-30/0-8mmHg * Pulmonary artery 15-30/4-12mmHg * Pulmonary capillary 2-12mmHg

Answer 502

1 in 12, 000

Answer 503

* Antibiotics (co-amox and teic) * Neuromuscular blockers * Chlorhexidine * Patent blue dye

Answer 504

* Allergen exposure leads to B cell production of IgE specific antibodies * On re-exposure, allergen cross links IgE on mast cells leading to degranulation * Mediators e.g. histamine, tryptase, prostoglandin lead to effects of anaphylaxis (vasodilation, bronchospasm, rash, oedema, bradycardia, hypotension, CVS collapse)

Answer 505

1. Withdraw offending agent 2. Trendelenburg manouevre 3. Call for skilled assistance 4. IV bolus of crystalloid 20mg/kg 5. 100% FiO2 6. Adrenaline bolus 50mcg IV or 500mcg IM (1mcg/kg in paeds) 7. Adrenaline infusion starting at 3mcg/min 8. Glucagon or vasopressin if required

Answer 506

As soon as possible within 1-2hrs then at 24hrs

Answer 507

* Degradation of elastin fibres * Collagen disruption

Answer 508

* Male * Smoking * HTN * Age * FH

Answer 509

Glasgow: age, shock, myocardial disease, cerebrovascular disease, renal disease

Answer 510

* Arrhythmias * MI * Acute angle-closure glaucoma * Sustained hypertension

Answer 511

Increased tissue around airways and reduced airway muscle tone Negative pressure during inspiration leads to airway collapse

Answer 512

Deliberately targeting a reduction in MAP by 30% or MAP 50-60 to facilitate surgery

Answer 513

* Dislodgement and decannulation * Tip of tube may cause posterior wall impingement * Tip of tube may sit in subcutaneous tissue

Answer 514

Immediate: aspiration, haemorrhage, tracheal injury, failure Early: infection, dislodgement, pneumothorax Late: tracheal stenosis, tracheomalacia, tracheocutaneous fistula

Answer 515

* Common carotid * Internal jugular vein * Vagus nerve * Recurrent laryngeal nerve * Deep cervical lymph nodes * Ansa cervicalis

Answer 516

* Massive subcutaneous emphysema * Sucking and bubbling at neck wound * Large volume haematemesis/haemoptysis * Airway compromise

Answer 517

* Awake fibreoptic * Awake surgical tracheostomy under LA * Modified RSI with videolaryngoscopy * Direct placement of tube through deficit using fibrescope

Answer 518

* Blind boujie with direct laryngoscopy as this can dislodge fractured cartilage, create false passage or worsen bleeding * Conventional front of neck access: can distort anatomy and make surgical trache more difficult * Cricoid pressure: may not compress oesophagus if fractures, may worsen bleeding * Positive pressure ventilation with bag valve mask: will worsen surgical emphysema

Answer 519

* Respiratory distress * Echymosis of neck * Subcutaneous emphsema * Tracheal deviation * Haemopytsis * Rapidly expanding haematoma

Answer 520

Pedicled: latissimus dorsi Non-pedicled: Deep inferior epigastric perforator, or Transverse rectus abdominis myocutaneous

Answer 521

0.2ml/kg in 100g

Answer 522

* Anaerobic metabolism leads to rise in lactate * pH decreases * Rise in pro-inflammatory mediators

Answer 523

* Nictoine vasoconstriction * Carbon monoxide tissue hypoxia * Prothrombotic state

Answer 524

* Abnormality on ryanodine receptor in sarcoplasmic reticulum * Trigger e.g. suxamethonium or volatiles leads to sustained calcium release from sarcoplasmic reticulum and dysregulated excitation contraction coupling * Continued muscle contraction leads to rise in CO2, glycogen breakdown, lactate production and potassium release from intracellular stores

Answer 525

* Announce critical incident, seek senior assistance * Stop volatile, remove vaporiser * Place charcoal filters or use Water's circuit to hyperventilate with 100% FiO2 * Administer dantrolene 2.5mg/kg bolus then repeat doses at 1mg/kg every 10-15mins * Maintain anaesthesia with IV propofol and neuromuscular blockade * Start active cooling with icepacks, reduce temp of room, lavage e.g. via catheter * Treat hyperkalaemia, acidosis and AKI (e.g. insulin/dex, fluids, hyperventilation, RRT) * Supportive management of arrythmias, CPR for cardiac arrest * Monitor for DIC

Answer 526

1. Cornea 2. Tenon's capsule 3. Fovea 4. Optic nerve 5. Vitreous humour 6. Sclera

Answer 527

* Subtenons: blunt needle, clean eye, insert speculum, lift inferolateral tenon capsule using non toothed forcepts, incision with Westcott's scissors, direct blung needle inferolaterally and inject 2-5mls LA * Peribulbar: sharp needle * Retrobulbar: sharp needle

Answer 528

* 10-20 mmHg * Change in occular contents, scleral rigidity, external pressure on globe

Answer 529

Caused by parasympathetic stimulation Afferent: trigeminal to medulla Efferent: vagus to sinoatrial node

Answer 530

MLT: * Cuffed airway - protects against aspiration and surgical debris * Limits view of posterior third of larynx Supraglottic jet * Optimal surgical access * Vocal cords move with ventilation Subglottic jet * Better ventilatory efficiency than supraglottic jet, no movement of vocal cords * Greatest risk of barotrauma

Answer 531

* Pre-op: FBC- assess Hb and neutropenic status (hydroxyurea), SS%, G+S atypical antibodies, U&Es renal disease, consider CXR/spirometry if recurrent chest infections * Intraop: avoid hypoxia, acidosis, hypothermia, dehydration (first on list, clear fluids 1 hr before), antiemetics * Post-op: analgesia, IV fluids ## Footnote If SS% > 60% may need blood transfusion

Answer 532

Sense * Metformin - biguanide- increased insulin sensitivity (omit lunch dose if TDS) * Pioglitazone - thiazolidinedione - PPAR gamme agonist, increased insulin sensitivity Squeeze * Gliclazide - sulphonylurea - displaces insulin from beta cells (omit day of surgery) * Sitagliptin - DPP4 inhibitor - increased levels of incretin, increased secretion insulin * Exanatide - GLP1 agonist - stimulates secretion of insulin Flush * Dapaglifozin - SGLT2 inhibitors - reduced reabsorption of glucose from PCT (stop 3 days before surgery) ## Footnote MP called Big Thigh was sensitive to his three main enemies: Glic was sulphish, Sita had cut him Deep and his Ex, An, was Greedy He decided to flush them with the help of his Dapper friend Small Gary

Answer 533

History: Duration of goitre Positional dyspnoea/stridor Voice changes O/E: Tracheal deviation, SVCO, able to feel below thyroid gland

Answer 534

* MH * Long QT syndrome > 500ms * Neurophysiological monitoring * Tubeless field surgery * PONV * Cancer surgery * Intubated transfer * Day surgery

Answer 535

Warmed humidified air: * Less mucociliary dysfunction * Reduced atelectasis High flow: * Washes out anatomical dead space * Able to achieve near FiO2 100% Provides PEEP: * Alveolar recruitment * Increased FRC

Answer 536

* Magnesium * Phentolamine * GTN * Esmolol * Nicardipine

Answer 537

* "spray as you go" using e.g. cophenylcaine spray for nose, 10% lidocaine spray and atomisation device for pharynx, 2% lidocaine to larynx via epidural catheter in suction port of scope * specific nerve blocks to superior laryngeal and glossopharyngeal nerves * cricothyroid puncture (insert 22G needle attached to syringe into midline of cricothyroid membrane, aspirate for air, inject lidocaine during exhalation (amount depends on previously used), remove needle to prevent trauma during coughing

Answer 538

1. Hyperglycaemia: no insulin to stimulate glucose uptake into cells, increased release of glucagon and cortisol, increased glycogenolysis and gluconeogenesis in the liver 2. Lipolysis generates free fatty acids which are converted to ketones in beta oxidation 3. Ketone acids dissociate in blood to cause a metabolic acidosis, buffered by available bicarbonate to form carbonic acid 4. Glycosuria because PCT glucose reuptake capacity is overwhelmed by amount of glucose and some is lost in urine causing osmotic diuresis

Answer 539

3-beta hydroxybutyrate acetoacetate acetate

Answer 540

* MSK injury to staff * Patient movement on table, risk of sliding and endobronchial intubation * Increased risk pressure injuries * Positioning may cause abdominal splinting of diaphragm, reducing FRC and pulmonary compliance

General Flashcards

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