Question 1 of 64

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A 48 year old lady has a metallic heart valve and requires a paraumbilical hernia
repair. Perioperatively she is receiving intra venous unfractionated heparin. To
perform the surgery safely a normal coagulation state is required. Which of the
following strategies is routine standard practice?

Administration of 10 mg of vitamin K the night prior to surgery and

stopping the heparin infusion 6 hours pre operatively

Stopping the heparin infusion 6 hours pre operatively

Stop the heparin infusion on induction of anaesthesia

Stopping the heparin infusion 6 hours pre operatively and administration

of intravenous protamine sulphate on commencing the operation

None of the above

Patients with metallic heart valves will generally stop unfractionated heparin 6
hours pre operatively. Unfractionated heparin is generally cleared from the
circulation within 2 hours so this will allow plenty of time and is the method of
choice in the elective setting. Protamine sulphate will reverse heparin but is
associated with risks of anaphylaxis and is thus not generally used unless
immediate reversal of anticoagulation is needed, e.g. coming off bypass.

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Heparin

Causes the formation of complexes between antithrombin and activated

thrombin/factors 7,9,10,11 & 12

Advantages of low molecular weight heparin

 Better bioavailability
Lower risk of bleeding
Longer half life
Little effect on APTT at prophylactic dosages
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Less risk of HIT

Complications
Bleeding
Osteoporosis
Heparin induced thrombocytopenia (HIT): occurs 5-14 days after 1st
exposure
Anaphylaxis

In surgical patients that may need a rapid return to theatre, administration of

unfractionated heparin is preferred; as low molecular weight heparins have a
longer duration of action and are harder to reverse.

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Question 2 of 64
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A 63 year old lady is undergoing colonoscopy with midazolam sedation. Her

respiratory rate slows and she becomes hypoxic and the decision is made to
reverse her sedation. What is the most appropriate agent to administer?

Flumazenil

Doxapram

Naloxone

Procyclidine

Etomidate

Flumazenil antagonises the effects of benzodiazepines by competition at GABA

binding sites. Since many benzodiazepines have longer half lives than flumazenil
patients still require close monitoring after receiving the drug. Whilst doxapram
would increase the respiratory rate, it is not an agent for reversal of midazolam.

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Anaesthetic agents

The table below summarises some of the more commonly used IV induction
agents

Agent Specific features

 Propofol Rapid onset of anaesthesia
Pain on IV injection
Rapidly metabolised with little accumulation of
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metabolites
Proven anti emetic properties
Moderate myocardial depression
Widely used especially for maintaining sedation on ITU,
total IV anaesthesia and for daycase surgery

Sodium Extremely rapid onset of action making it the agent of

thiopentone choice for rapid sequence of induction
Marked myocardial depression may occur
Metabolites build up quickly
Unsuitable for maintenance infusion
Little analgesic effects

Ketamine May be used for induction of anaesthesia

Has moderate to strong analgesic properties
Produces little myocardial depression making it a
suitable agent for anaesthesia in those who are
haemodynamically unstable
May induce state of dissociative anaesthesia resulting
in nightmares

Etomidate Has favorable cardiac safety profile with very little

haemodynamic instability
No analgesic properties
Unsuitable for maintaining sedation as prolonged (and
even brief) use may result in adrenal suppression
Post operative vomiting is common

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Question 3 of 64
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An 80 year old lady is investigated in the pre operative clinic and found to have
severe aortic stenosis. What, if any, is the main peri operative concern?

They cannot adjust their heart rate

They may have ventricular hypertrophy

The patient cannot increase their cardiac output

They are more prone to arrhythmias

There is no concern

Patients with aortic stenosis are a major perioperative concern. They may have
ventricular hypertrophy and this can result in relative myocardial ischaemia and
increase the risk of arrhymias. However, the main concern is that they cannot
increase their cardiac output particularly if vasodilation occurs.

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Aortic stenosis

Narrowing of the aortic valve

May occur as a result of rheumatic fever or with aging and calcific changes
Congenitally may occur earlier due to calcification of a bicuspid aortic valve
(1-2% of population)
Symptoms include exertional angina and syncope
Where the condition is suspected, trans thoracic echocardiography is the
investigation of choice

Severity
 Degree Mean gradient (mmHg) Aortic valve area (cm2)

Mild <25 >1.5

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Moderate 25-40 1.0-1.5

Severe >40 <1

Treatment
Either transcatheter or open aortic valve replacement

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Question 4 of 64
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Which statement relating to the peri operative management of patients with

diabetes mellitus is false?

They should be placed first on the operating list

An intravenous sliding scale should be used in all cases

Potassium supplementation is likely to be required in diabetics on a sliding

scale

Electrolyte abnormalities are more common after major visceral

resections

Blood glucose monitoring is required during general anaesthesia

This is not the case and some type 2 diabetics may be managed using a watch
and wait policy with regular blood glucose monitoring. The cellular shifts of
potassium with sliding scales may cause problems with electrolyte management
which should be anticipated.

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Preparation for surgery

 Elective and emergency patients require different preparation.

Elective cases
Consider pre admission clinic to address medical issues.
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Blood tests including FBC, U+E, LFT's, Clotting, Group and Save
Urine analysis
Pregnancy test
Sickle cell test
ECG/ Chest x-ray

Exact tests to be performed will depend upon the proposed procedure and patient
fitness.

Risk factors for development of deep vein thrombosis should be assessed and a
plan for thromboprophylaxis formulated.

Diabetes
Diabetic patients have greater risk of complications.
Poorly controlled diabetes carries high risk of wound infections.
Patients with diet or tablet controlled diabetes may be managed using a policy of
omitting medication and checking blood glucose levels regularly. Diabetics who
are poorly controlled or who take insulin may require a intravenous sliding scale.
Potassium supplementation should also be given.
Diabetic cases should be operated on first.

Emergency cases
Stabilise and resuscitate where needed.
Consider whether antibiotics are needed and when and how they should be
administered.
Inform blood bank if major procedures planned particularly where coagulopathies
are present at the outset or anticipated (e.g. Ruptured AAA repair)
Don't forget to consent and inform relatives.

Special preparation
Some procedures require special preparation:
Thyroid surgery; vocal cord check.
Parathyroid surgery; consider methylene blue to identify gland.
Sentinel node biopsy; radioactive marker/ patent blue dye.
Surgery involving the thoracic duct; consider administration of cream.
Pheochromocytoma surgery; will need alpha and beta blockade.
Surgery for carcinoid tumours; will need covering with octreotide.
Colorectal cases; bowel preparation (especially left sided surgery)
Thyrotoxicosis; lugols iodine/ medical therapy.

References
Management of adults with diabetes undergoing surgery and elective procedures.
NHS Diabetes. April 2011.
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Question 5 of 64
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A 19 year old man has a skin lesion excised from his back. He is reviewed clinically
at 4 months post procedure and the surgeon notes that the scar has begun to
contract. Which of the following facilitates this process?

Myofibroblasts

Neutrophils

Granuloma formation

Macrophages

Fibroblasts

As wounds mature the fibroblast population differentiates into myofibroblasts

(usually 6 weeks and beyond), these have a contractile phenotype and therefore
help in contracting the wound. Immature fibroblasts, though able to adhere to the
ECM, do not have this ability.

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Wound healing
 Surgical wounds are either incisional or excisional and either clean, clean
contaminated or dirty. Although the stages of wound healing are broadly similar
their contributions will vary according to the wound type.
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The main stages of wound healing include:

Haemostasis
Minutes to hours following injury
Vasospasm in adjacent vessels, platelet plug formation and generation of
fibrin rich clot.

Inflammation
Typically days 1-5
Neutrophils migrate into wound (function impaired in diabetes).
Growth factors released, including basic fibroblast growth factor and
vascular endothelial growth factor.
Fibroblasts replicate within the adjacent matrix and migrate into wound.
Macrophages and fibroblasts couple matrix regeneration and clot
substitution.

Regeneration
Typically days 7 to 56
Platelet derived growth factor and transformation growth factors stimulate
fibroblasts and epithelial cells.
Fibroblasts produce a collagen network.
Angiogenesis occurs and wound resembles granulation tissue.

Remodeling
From 6 weeks to 1 year
Longest phase of the healing process and may last up to one year (or
longer).
During this phase fibroblasts become differentiated (myofibroblasts) and
these facilitate wound contraction.
Collagen fibres are remodeled.
Microvessels regress leaving a pale scar.

The above description represents an idealised scenario. A number of diseases

may distort this process. Neovascularisation is an important early process.
Endothelial cells may proliferate in the wound bed and recanalise to form a vessel.
Vascular disease, shock and sepsis can all compromise microvascular flow and
impair healing.

Conditions such as jaundice will impair fibroblast synthetic function and immunity
with a detrimental effect in most parts of the healing process.

Problems with scars:

 Hypertrophic scars
Excessive amounts of collagen within a scar. Nodules may be present
histologically containing randomly arranged fibrils within and parallel fibres on the
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surface. The tissue itself is confined to the extent of the wound itself and is usually
the result of a full thickness dermal injury. They may go on to develop
contractures.

Image of hypertrophic scarring. Note that it remains confined to the boundaries of

the original wound:

([Link]
Image sourced from Wikipedia ([Link]
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Keloid scars
Excessive amounts of collagen within a scar. Typically a keloid scar will pass
beyond the boundaries of the original injury. They do not contain nodules and may
occur following even trivial injury. They do not regress over time and may recur
following removal.

Image of a keloid scar. Note the extension beyond the boundaries of the original
incision:
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Drugs which impair wound healing:

Non steroidal anti inflammatory drugs
Steroids
Immunosupressive agents
Anti neoplastic drugs

Closure
Delayed primary closure is the anatomically precise closure that is delayed for a
few days but before granulation tissue becomes macroscopically evident.

Secondary closure refers to either spontaneous closure or to surgical closure after

granulation tissue has formed.

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Question 6 of 64
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A 67 year old female undergoes an oesophagogastrectomy for carcinoma of the

distal oesophagus. She complains of chest pain. The following day there is brisk
bubbling into the chest drain when suction is applied. What is the most likely
cause?

Anastomotic leak

Air leak from lung

Chyle leak

Bile leak

Cutaneous wound breakdown

Damage to the lung substance may produce an air leak. Air leaks will manifest
themselves as a persistent pneumothorax that fails to settle despite chest
drainage. When suction is applied to the chest drainage system, active and
persistent bubbling may be seen. Although an anastomotic leak may produce a
small pneumothorax, a large volume air leak is more indicative of lung injury.

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Surgical complications

Complications occur in all branches of surgery and require vigilance in their

detection. In many cases anticipating the likely complications and appropriate
avoidance will minimise their occurrence. For the purposes of the MRCS the
important principles to appreciate are:

The anatomical principles that underpin complications

The physiological and biochemical derangements that occur
The most appropriate diagnostic modalities to utilise
 The principles which underpin their management

This is clearly a very broad area and impossible to cover comprehensively. There is
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considerable overlap with other topic areas within the website.

Avoiding complications

Some points to hopefully avert complications:

World Health Organisation checklist- now mandatory prior to all operations

Prophylactic antibiotics - right dose, right drug, right time.
Assess DVT/ PE risk and ensure adequate prophylaxis
MARK site of surgery
Use tourniquets with caution and with respect for underlying structures
Remember the danger of end arteries and in situations where they occur
avoid using adrenaline containing solutions and monopolar diathermy.
Handle tissues with care- devitalised tissue serves as a nidus for infection
Be very wary of the potential for coupling injuries when using diathermy
during laparoscopic surgery
The inferior epigastric artery is a favorite target for laparoscopic ports and
surgical drains!

Anatomical principles
Understanding the anatomy of a surgical field will allow appreciation of local and
systemic complications that may occur. For example, nerve injuries may occur
following surgery in specific regions. The table below lists some of the more
important nerves to consider and mechanisms of injury

Nerve Mechanism

Accessory Posterior triangle lymph node biopsy

Sciatic Posterior approach to hip

Common peroneal Legs in Lloyd Davies position

Long thoracic Axillary node clearance

Pelvic autonomic nerves Pelvic cancer surgery

Recurrent laryngeal nerves During thyroid surgery

Hypoglossal nerve During carotid endarterectomy

Ulnar and median nerves During upper limb fracture repairs

 These are just a few. The detailed functional sequelae are particularly important
and will often be tested. In addition to nerve injuries certain procedures carry risks
of visceral or structural injury. Again some particular favorites are given below:
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Structure Mechanism

Thoracic duct During thoracic surgery e.g. Pneumonectomy,

oesphagectomy

Parathyroid During difficult thyroid surgery

glands

Ureters During colonic resections/ gynaecological surgery

Bowel Use of Verres Needle to establish pneumoperitoneum

perforation

Bile duct injury Failure to delineate Calots triangle carefully and careless
use of diathermy

Facial nerve Always at risk during Parotidectomy

Tail of pancreas When ligating splenic hilum

Testicular During re-do open hernia surgery

vessels

Hepatic veins During liver mobilisation

Again many could be predicted from the anatomy of the procedure.

Physiological derangements
A very common complication is bleeding and this is covered under the section of
haemorrhagic shock. Another variant is infection either superficial or deep seated.
The organisms are covered under microbiology and the features of sepsis covered
under shock. Do not forget that immunocompromised and elderly patients may
present will atypical physiological parameters.

Selected physiological and biochemical issues are given below:

Complication Physiological/ Biochemical Problem

Arrhythmias following Susceptibility to hypokalaemia (K+ <4.0 in cardiac

cardiac surgery patients)
 Complication Physiological/ Biochemical Problem

Neurosurgical electrolyte SIADH following cranial surgery causing

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disturbance hyponatraemia

Ileus following Fluid sequestration and loss of electrolytes

gastrointestinal surgery

Pulmonary oedema Loss of lung volume makes these patients very

following sensitive to fluid overload
pneumonectomy

Anastamotic leak Generalised sepsis causing mediastinitis or

peritonitis depending on site of leak

Myocardial infarct May follow any type of surgery and in addition to

direct cardiac effects the decreased cardiac output
may well compromise grafts etc.

Try making a short list of problems and causes specific to your own clinical area.

Diagnostic modalities
Depends largely on the suspected complication. In the acutely unwell surgical
patient the following baseline investigations are often helpful:
Full blood count, urea and electrolytes, C- reactive protein (trend rather than
absolute value), serum calcium, liver function tests, clotting (don't forget to
repeat if on-going bleeding)
Arterial blood gases
ECG (+cardiac enzymes if MI suspected)
Chest x-ray to identify collapse/ consolidation
Urine analysis for UTI

These will often identify the most common complications.

Special tests
CT scanning for identification of intra-abdominal abscesses
Doppler USS of leg veins- for identification of DVT
CTPA for PE
Sending peritoneal fluid for U+E (if ureteric injury suspected) or amylase (if
pancreatic injury suspected)
Echocardiogram if pericardial effusion suspected post cardiac surgery and
no pleural window made.

Management of complications
The guiding principal should be safe and timely intervention. Patients should be
 stabilised and if an operation needs to occur in tandem with resuscitation then
generally this should be of a damage limitation type procedure rather than
definitive surgery (which can be more safely undertaken in a stable patient the
following day).
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Remember that recent surgery is a contra indication to thrombolysis and that in

some patients IV heparin may be preferable to a low molecular weight heparin
(easier to reverse).

As a general rule laparotomies for bleeding should follow the core principle of
quadrant packing and then subsequent pack removal rather than plunging large
clamps into pools of blood. The latter approach invariable worsens the situation is
often accompanied by significant visceral injury particularly when done by the
inexperienced. If packing controls a situation it is entirely acceptable practice to
leave packs in situ and return the patient to ITU for pack removal the subsequent
day.

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Question 7 of 64
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Which of the following would be a sensible volume for maintenance intravenous

fluids in a 3 day old term neonate?

50ml/ kg/ hour

50ml/ kg/ day

100ml/kg/hour

100ml/kg/day

200ml/kg/day

Calculate routine maintenance IV fluid rates for children and young people
using the HollidaySegar formula (100 ml/kg/day for the first 10 kg of weight,
50 ml/kg/day for the next 10 kg and 20 ml/kg/day for the weight over 20 kg).
Be aware that over a 24hour period, males rarely need more than 2500 ml and
females rarely need more than 2000 ml of fluids.

From birth to day 1: 50-60 ml/kg/day.

Day 2: 70-80 ml/kg/day.
Day 3: 80-100 ml/kg/day.
Day 4: 100-120 ml/kg/day.
Days 5-8: 120-150 ml/kg/day.

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Paediatric fluid management

Since 2000 there have been at least 4 reported deaths from fluid induced
hyponatraemia in children. This led to the National Patient Safety Agency
 introducing revised guidelines in 2007.
Indications for IV fluids include:
Resuscitation and circulatory support
Replacing on-going fluid losses
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Maintenance fluids for children for whom oral fluids are not appropriate
Correction of electrolyte disturbances

Fluids to be avoided
Outside the neonatal period saline / glucose solutions should not be given. The
greatest risk is with saline 0.18 / glucose 4% solutions. The report states that
0.45% saline / 5% glucose may be used. But preference should be given to isotonic
solutions and few indications exist for this solution either.

Fluids to be used
0.9% saline
5% glucose (though only with saline for maintenance and not to replace
losses)
Hartmann's solution

Potassium should be added to maintenance fluids according patients plasma

potassium levels (which should be monitored).

Intraoperative fluid management

Neonates should receive glucose 10% during surgery.
Other children should receive isotonic crystalloid.

Maintenance fluids

Weight Water Na K
requirement/kg/day mmol/kg/day mmol/kg/day

First 10Kg body 100ml 2-4 1.5-2.5

weight

Second 10Kg 50ml 1-2 0.5-1.5

body weight

Subsequent Kg 20ml 0.5-1.0 0.2-0.7

Glucose will need to be given to neonates- usually 10% at a rate of 60ml/Kg/day.

Reference
NPSA -reducing risk of hyponatraemia when administering intravenous fluids to
children. Issue date March 2007. Further references included in this document.

NICE Guidance NG29. Intravenous fluid therapy in children and young people in
hospital. Published 2015.
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Question 8 of 64
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A 56 year old lady with idiopathic thrombocytopenic purpura has a platelet count
of 50. She is due to undergo a splenectomy. What is the optimal timing of a
platelet transfusion in this case?

24 hours pre-operatively

2 hours pre-operatively

Whilst making the skin incision

After ligation of the splenic artery

On removal of the spleen

ITP causes splenic sequestration of platelets. Therefore a platelet transfusion

should be carefully timed. Too soon and it will be ineffective. Too late and
unnecessary bleeding will occur. The optimal time is after the splenic artery has
been ligated.

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Splenectomy

Indications
Trauma: 1/4 are iatrogenic
Spontaneous rupture: EBV
Hypersplenism: hereditary spherocytosis or elliptocytosis etc
Malignancy: lymphoma or leukaemia
Splenic cysts, hydatid cysts, splenic abscesses

Splenectomy
Technique
 Trauma
GA
Long midline incision
If time permits insert a self retaining retractor (e.g. Balfour/ omnitract)
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Large amount of free blood is usually present. Pack all 4 quadrants of the
abdomen. Allow the anaesthetist to 'catch up'
Remove the packs and assess the viability of the spleen. Hilar injuries and
extensive parenchymal lacerations will usually require splenectomy.
Divide the short gastric vessels and ligate them.
Clamp the splenic artery and vein. Two clamps on the patient side are better
and allow for double ligation and serve as a safety net if your assistant does
not release the clamp smoothly.
Be careful not to damage the tail of the pancreas, if you do then this will
need to be formally removed and the pancreatic duct closed.
Wash out the abdomen and place a tube drain to the splenic bed.
Some surgeons implant a portion of spleen into the omentum, whether you
decide to do this is a matter of personal choice.
Post operatively the patient will require prophylactic penicillin V and
pneumococcal vaccine.

Elective
Elective splenectomy is a very different operation from that performed in the
emergency setting. The spleen is often large (sometimes massive). Most cases
can be performed laparoscopically. The spleen will often be macerated inside a
specimen bag to facilitate extraction.

Complications
Haemorrhage (may be early and either from short gastrics or splenic hilar
vessels
Pancreatic fistula (from iatrogenic damage to pancreatic tail)
Thrombocytosis: prophylactic aspirin
Encapsulated bacteria infection e.g. Strep. pneumoniae, Haemophilus
influenzae and Neisseria meningitidis

Post splenectomy changes

Platelets will rise first (therefore in ITP should be given after splenic artery
clamped)
Blood film will change over following weeks, Howell Jolly bodies will appear
Other blood film changes include target cells and Pappenheimer bodies
Increased risk of post splenectomy sepsis, therefore prophylactic antibiotics
and pneumococcal vaccine should be given.

Post splenectomy sepsis

Typically occurs with encapsulated organisms
Opsonisation occurs but then not recognised
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Question 8 of 64
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 

A 56 year old lady with idiopathic thrombocytopenic purpura has a platelet count
of 50. She is due to undergo a splenectomy. What is the optimal timing of a
platelet transfusion in this case?

24 hours pre-operatively

2 hours pre-operatively

Whilst making the skin incision

After ligation of the splenic artery

On removal of the spleen

ITP causes splenic sequestration of platelets. Therefore a platelet transfusion

should be carefully timed. Too soon and it will be ineffective. Too late and
unnecessary bleeding will occur. The optimal time is after the splenic artery has
been ligated.

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Splenectomy

Indications
Trauma: 1/4 are iatrogenic
Spontaneous rupture: EBV
Hypersplenism: hereditary spherocytosis or elliptocytosis etc
Malignancy: lymphoma or leukaemia
Splenic cysts, hydatid cysts, splenic abscesses

Splenectomy
Technique
 Trauma
GA
Long midline incision
If time permits insert a self retaining retractor (e.g. Balfour/ omnitract)
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Large amount of free blood is usually present. Pack all 4 quadrants of the
abdomen. Allow the anaesthetist to 'catch up'
Remove the packs and assess the viability of the spleen. Hilar injuries and
extensive parenchymal lacerations will usually require splenectomy.
Divide the short gastric vessels and ligate them.
Clamp the splenic artery and vein. Two clamps on the patient side are better
and allow for double ligation and serve as a safety net if your assistant does
not release the clamp smoothly.
Be careful not to damage the tail of the pancreas, if you do then this will
need to be formally removed and the pancreatic duct closed.
Wash out the abdomen and place a tube drain to the splenic bed.
Some surgeons implant a portion of spleen into the omentum, whether you
decide to do this is a matter of personal choice.
Post operatively the patient will require prophylactic penicillin V and
pneumococcal vaccine.

Elective
Elective splenectomy is a very different operation from that performed in the
emergency setting. The spleen is often large (sometimes massive). Most cases
can be performed laparoscopically. The spleen will often be macerated inside a
specimen bag to facilitate extraction.

Complications
Haemorrhage (may be early and either from short gastrics or splenic hilar
vessels
Pancreatic fistula (from iatrogenic damage to pancreatic tail)
Thrombocytosis: prophylactic aspirin
Encapsulated bacteria infection e.g. Strep. pneumoniae, Haemophilus
influenzae and Neisseria meningitidis

Post splenectomy changes

Platelets will rise first (therefore in ITP should be given after splenic artery
clamped)
Blood film will change over following weeks, Howell Jolly bodies will appear
Other blood film changes include target cells and Pappenheimer bodies
Increased risk of post splenectomy sepsis, therefore prophylactic antibiotics
and pneumococcal vaccine should be given.

Post splenectomy sepsis

Typically occurs with encapsulated organisms
Opsonisation occurs but then not recognised
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Question 9 of 64
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 

Which of the agents listed below is associated with the strongest anti emetic
properties?

Sodium thiopentone

Propofol

Etomidate

Ketamine

Sevoflurane

Propofol has anti emetic properties which is of considerable advantage in day

case anaesthesia.

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Anaesthetic agents

The table below summarises some of the more commonly used IV induction
agents

Agent Specific features

Propofol Rapid onset of anaesthesia

Pain on IV injection
Rapidly metabolised with little accumulation of
metabolites
Proven anti emetic properties
Moderate myocardial depression
Widely used especially for maintaining sedation on ITU,
total IV anaesthesia and for daycase surgery
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C 18.7%
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Question 10 of 64
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A 70 year old lady has a cerebrovascular accident and has been recovering in
hospital for the past 3 weeks. She has been deemed to have an unsafe swallow.
What is the best option for long term feeding?

Endoscopically inserted PEG feeding tube

Long term fine bore nasogastric feeding tube

Surgically inserted feeding jejunostomy tube

TPN via a central vein

TPN via a peripheral cannula

At 3 weeks, it is unlikely that feeding orally is going to resume and therefore a

definitive long term feeding solution is needed. A PEG is favored over a feeding
jejunostomy in such circumstances.

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Nutrition options in surgical patients

Oral intake Easiest option

May be supplemented by calorie rich dietary
supplements
May contra indicated following certain
procedures
 Naso gastric feeding Usually administered via fine bore naso gastric
feeding tube
Complications relate to aspiration of feed or
gathered by dr. elbarky, for free, not intended for profit by anybody elsewhere.

misplaced tube
May be safe to use in patients with impaired
swallow
Often contra indicated following head injury due
to risks associated with tube insertion

Naso jejunal feeding Avoids problems of feed pooling in stomach (and

risk of aspiration)
Insertion of feeding tube more technically
complicated (easiest if done intra operatively)
Safe to use following oesophagogastric surgery

Feeding jejunostomy Surgically sited feeding tube

May be used for long term feeding
Low risk of aspiration and thus safe for long term
feeding following upper GI surgery
Main risks are those of tube displacement and
peritubal leakage immediately following
insertion, which carries a risk of peritonitis

Percutaneous Combined endoscopic and percutaneous tube

endoscopic insertion
gastrostomy May not be technically possible in those patients
who cannot undergo successful endoscopy
Risks include aspiration and leakage at the
insertion site

Total parenteral The definitive option in those patients in whom

nutrition enteral feeding is contra indicated
Individualised prescribing and monitoring needed
Should be administered via a central vein as it is
strongly phlebitic
Long term use is associated with fatty liver and
deranged LFT's

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Question 11 of 64
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Which of the following is not directly affected by warfarin?

Protein C

Factor II

Factor VII

Factor IX

Factor VIII

Warfarin affects synthesis of factors II, VII, IX, X and protein C.

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Warfarin

Warfarin is an oral anticoagulant which inhibits the reduction of vitamin K to its

active hydroquinone form, which in turn acts as a cofactor in the formation of
clotting factor II, VII, IX and X (mnemonic = 1972) and protein C

Factors that may potentiate warfarin

Liver disease
P450 enzyme inhibitors, e.g.: amiodarone, ciprofloxacin
Cranberry juice
Drugs which displace warfarin from plasma albumin, e.g. NSAIDs
Inhibit platelet function: NSAIDs
 Side-effects
Haemorrhage
Teratogenic
Skin necrosis: when warfarin is first started biosynthesis of protein C is
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reduced. This results in a temporary procoagulant state after initially

starting warfarin, normally avoided by concurrent heparin administration.
Thrombosis may occur in venules leading to skin necrosis.

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C 9.3%
D 8%
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Question 12 of 64
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 

What is the most appropriate method of delivering early post-operative analgesia

to a 6 month old child following an orchidopexy?

TAP block

Caudal block

Wound analgesic infusion catheter

Spinal block

Epidural block

Orchidopexy can be quite uncomfortable immediately following surgery. A caudal

block can be a very effective adjunct and provides good analgesia. A spinal block
and epidural would be inappropriate. A TAP block may cover the inguinal canal but
this is not generally reliable and wound catheters are not used.

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Management of pain

World Health Organisation Analgesic Ladder

Initially peripherally acting drugs such as paracetamol or non-steroidal anti-
inflammatory drugs (NSAIDs) are given.
If pain control is not achieved, the second part of the ladder is to introduce
weak opioid drugs such as codeine or dextropropoxyphene together with
appropriate agents to control and minimise side effects.
The final rung of the ladder is to introduce strong opioid drugs such as
morphine. Analgesia from peripherally acting drugs may be additive to that
from centrally-acting opioids and thus, the two are given together.
 The World Federation of Societies of Anaesthesiologists (WFSA) Analgesic
Ladder
For management of acute pain
Initially, the pain can be expected to be severe and may need controlling with
gathered by dr. elbarky, for free, not intended for profit by anybody elsewhere.

strong analgesics in combination with local anaesthetic blocks and

peripherally acting drugs.
The second rung on the postoperative pain ladder is the restoration of the
use of the oral route to deliver analgesia. Strong opioids may no longer be
required and adequate analgesia can be obtained by using combinations of
peripherally acting agents and weak opioids.
The final step is when the pain can be controlled by peripherally acting
agents alone.

Local anaesthetics
Infiltration of a wound with a long-acting local anaesthetic such as
Bupivacaine
Analgesia for several hours
Further pain relief can be obtained with repeat injections or by infusions via
a thin catheter
Blockade of plexuses or peripheral nerves will provide selective analgesia in
those parts of the body supplied by the plexus or nerves
Can either be used to provide anaesthesia for the surgery or specifically for
postoperative pain relief
Especially useful where a sympathetic block is needed to improve
postoperative blood supply or where central blockade such as spinal or
epidural blockade is contraindicated.

Spinal anaesthesia
Provides excellent analgesia for surgery in the lower half of the body and pain
relief can last many hours after completion of the operation if long-acting drugs
containing vasoconstrictors are used.

- Side effects of spinal anaesthesia include: hypotension, sensory and motor block,
nausea and urinary retention.

Epidural anaesthesia
An indwelling epidural catheter inserted. This can then be used to provide a
continuous infusion of analgesic agents. It can provide excellent analgesia. They
are still the preferred option following major open abdominal procedures and help
prevent post operative respiratory compromise resulting from pain.

- Disadvantages of epidurals is that they usually confine patients to bed, especially

if a motor block is present. In addition an indwelling urinary catheter is required.
Which may not only impair mobility but also serve as a conduit for infection. They
are contraindicated in coagulopathies.

Transversus Abdominal Plane block (TAP)

 In this technique an ultrasound is used to identify the correct muscle plane and
local anaesthetic (usually bupivicaine) is injected. The agent diffuses in the plane
and blocks many of the spinal nerves. It is an attractive technique as it provides a
wide field of blockade but does not require the placement of any indwelling
gathered by dr. elbarky, for free, not intended for profit by anybody elsewhere.

devices. There is no post operative motor impairment. For this reason it is the
preferred technique when extensive laparoscopic abdominal procedures are
performed. They will then provide analgesia immediately following surgery but as
they do not confine the patient to bed, the focus on enhanced recovery can begin
sooner.

-The main disadvantage is that their duration of action is limited to the half life of
the local anaesthetic agent chosen. In addition some anaesthetists do not have
the USS skills required to site the injections.

Patient Controlled Analgesia (PCA)

- Patients administer their own intravenous analgesia and titrate the dose to their
own end-point of pain relief using a small microprocessor - controlled pump.
Morphine is the most popular drug used.

Strong Opioids

Severe pain arising from deep or visceral structures requires the use of strong
opioids

Morphine
Short half life and poor bioavailability.
Metabolised in the liver and clearance is reduced in patients with liver
disease, in the elderly and the debilitated
Side effects include nausea, vomiting, constipation and respiratory
depression.
Tolerance may occur with repeated dosage

Pethidine
Synthetic opioid which is structurally different from morphine but which has
similar actions. Has 10% potency of morphine.
Short half life and similar bioavailability and clearance to morphine.
Short duration of action and may need to be given hourly.
Pethidine has a toxic metabolite (norpethidine) which is cleared by the
kidney, but which accumulates in renal failure or following frequent and
prolonged doses and may lead to muscle twitching and convulsions.
Extreme caution is advised if pethidine is used over a prolonged period or in
patients with renal failure.

Weak opioids
 Codeine: markedly less active than morphine, has predictable effects when given
orally and is effective against mild to moderate pain.

Non opioid analgesics

gathered by dr. elbarky, for free, not intended for profit by anybody elsewhere.

- Mild to moderate pain.

Paracetamol
Inhibits prostaglandin synthesis.
Analgesic and antipyretic properties but little anti-inflammatory effect
It is well absorbed orally and is metabolised almost entirely in the liver
Side effects in normal dosage and is widely used for the treatment of minor
pain. It causes hepatotoxicity in over dosage by overloading the normal
metabolic pathways with the formation of a toxic metabolite.

NSAIDs
Analgesic and anti-inflammatory actions
Inhibition of prostaglandin synthesis by the enzyme Cyclooxygenase which
catalyses the conversion of arachidonic acid to the various prostaglandins
that are the chief mediators of inflammation. All NSAIDs work in the same
way and thus there is no point in giving more than one at a time. .
NSAIDs are, in general, more useful for superficial pain arising from the skin,
buccal mucosa, joint surfaces and bone.
Relative contraindications: history of peptic ulceration, gastrointestinal
bleeding or bleeding diathesis; operations associated with high blood loss,
asthma, moderate to severe renal impairment, dehydration and any history
of hypersensitivity to NSAIDs or aspirin.

Neuropathic pain
National Institute of Clinical Excellence (UK) guidelines:
First line: Amitriptyline (Imipramine if cannot tolerate) or pregabalin
Second line: Amitriptyline AND pregabalin
Third line: refer to pain specialist. Give tramadol in the interim (avoid
morphine)
If diabetic neuropathic pain: Duloxetine

References
1. [Link]
2. Charlton E. The Management of Postoperative Pain . Update in Anaesthesia.
Issue 7 (1997)

Next question 
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B 43.9%
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E 11.5%

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Question 13 of 64
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 

A 72 year old man with prostate cancer is admitted to urology with urinary
retention. He complains of back pain which is not responding to ward analgesia.
Imaging shows several lumbar vertebral body metastasis. What is the most
appropriate management?

Commence a bisphosphonate

Arrange radiotherapy to the lumbar spine

Surgical resection and reconstruction of the vertebral body

Administration of pregabalin

Chemotherapy

The fact that ward based analgesia has been tried suggests that the patient be
considered for palliative radiotherapy. Surgical resection of prostate cancer bony
metastatic disease is not generally performed.

Please rate this question:

 Discuss and give feedback

Next question 

Management of pain

World Health Organisation Analgesic Ladder

Initially peripherally acting drugs such as paracetamol or non-steroidal anti-
inflammatory drugs (NSAIDs) are given.
If pain control is not achieved, the second part of the ladder is to introduce
weak opioid drugs such as codeine or dextropropoxyphene together with
appropriate agents to control and minimise side effects.
The final rung of the ladder is to introduce strong opioid drugs such as
morphine. Analgesia from peripherally acting drugs may be additive to that
from centrally-acting opioids and thus, the two are given together.
 The World Federation of Societies of Anaesthesiologists (WFSA) Analgesic
Ladder
For management of acute pain
gathered by dr. elbarky, for free, not intended for profit by anybody elsewhere.

Initially, the pain can be expected to be severe and may need controlling with
strong analgesics in combination with local anaesthetic blocks and
peripherally acting drugs.
The second rung on the postoperative pain ladder is the restoration of the
use of the oral route to deliver analgesia. Strong opioids may no longer be
required and adequate analgesia can be obtained by using combinations of
peripherally acting agents and weak opioids.
The final step is when the pain can be controlled by peripherally acting
agents alone.

Local anaesthetics
Infiltration of a wound with a long-acting local anaesthetic such as
Bupivacaine
Analgesia for several hours
Further pain relief can be obtained with repeat injections or by infusions via
a thin catheter
Blockade of plexuses or peripheral nerves will provide selective analgesia in
those parts of the body supplied by the plexus or nerves
Can either be used to provide anaesthesia for the surgery or specifically for
postoperative pain relief
Especially useful where a sympathetic block is needed to improve
postoperative blood supply or where central blockade such as spinal or
epidural blockade is contraindicated.

Spinal anaesthesia
Provides excellent analgesia for surgery in the lower half of the body and pain
relief can last many hours after completion of the operation if long-acting drugs
containing vasoconstrictors are used.

- Side effects of spinal anaesthesia include: hypotension, sensory and motor block,
nausea and urinary retention.

Epidural anaesthesia
An indwelling epidural catheter inserted. This can then be used to provide a
continuous infusion of analgesic agents. It can provide excellent analgesia. They
are still the preferred option following major open abdominal procedures and help
prevent post operative respiratory compromise resulting from pain.

- Disadvantages of epidurals is that they usually confine patients to bed, especially

if a motor block is present. In addition an indwelling urinary catheter is required.
Which may not only impair mobility but also serve as a conduit for infection. They
are contraindicated in coagulopathies.
 Transversus Abdominal Plane block (TAP)
In this technique an ultrasound is used to identify the correct muscle plane and
local anaesthetic (usually bupivicaine) is injected. The agent diffuses in the plane
and blocks many of the spinal nerves. It is an attractive technique as it provides a
gathered by dr. elbarky, for free, not intended for profit by anybody elsewhere.

wide field of blockade but does not require the placement of any indwelling
devices. There is no post operative motor impairment. For this reason it is the
preferred technique when extensive laparoscopic abdominal procedures are
performed. They will then provide analgesia immediately following surgery but as
they do not confine the patient to bed, the focus on enhanced recovery can begin
sooner.

-The main disadvantage is that their duration of action is limited to the half life of
the local anaesthetic agent chosen. In addition some anaesthetists do not have
the USS skills required to site the injections.

Patient Controlled Analgesia (PCA)

- Patients administer their own intravenous analgesia and titrate the dose to their
own end-point of pain relief using a small microprocessor - controlled pump.
Morphine is the most popular drug used.

Strong Opioids

Severe pain arising from deep or visceral structures requires the use of strong
opioids

Morphine
Short half life and poor bioavailability.
Metabolised in the liver and clearance is reduced in patients with liver
disease, in the elderly and the debilitated
Side effects include nausea, vomiting, constipation and respiratory
depression.
Tolerance may occur with repeated dosage

Pethidine
Synthetic opioid which is structurally different from morphine but which has
similar actions. Has 10% potency of morphine.
Short half life and similar bioavailability and clearance to morphine.
Short duration of action and may need to be given hourly.
Pethidine has a toxic metabolite (norpethidine) which is cleared by the
kidney, but which accumulates in renal failure or following frequent and
prolonged doses and may lead to muscle twitching and convulsions.
Extreme caution is advised if pethidine is used over a prolonged period or in
patients with renal failure.
 Weak opioids
Codeine: markedly less active than morphine, has predictable effects when given
orally and is effective against mild to moderate pain.
gathered by dr. elbarky, for free, not intended for profit by anybody elsewhere.

Non opioid analgesics

- Mild to moderate pain.

Paracetamol
Inhibits prostaglandin synthesis.
Analgesic and antipyretic properties but little anti-inflammatory effect
It is well absorbed orally and is metabolised almost entirely in the liver
Side effects in normal dosage and is widely used for the treatment of minor
pain. It causes hepatotoxicity in over dosage by overloading the normal
metabolic pathways with the formation of a toxic metabolite.

NSAIDs
Analgesic and anti-inflammatory actions
Inhibition of prostaglandin synthesis by the enzyme Cyclooxygenase which
catalyses the conversion of arachidonic acid to the various prostaglandins
that are the chief mediators of inflammation. All NSAIDs work in the same
way and thus there is no point in giving more than one at a time. .
NSAIDs are, in general, more useful for superficial pain arising from the skin,
buccal mucosa, joint surfaces and bone.
Relative contraindications: history of peptic ulceration, gastrointestinal
bleeding or bleeding diathesis; operations associated with high blood loss,
asthma, moderate to severe renal impairment, dehydration and any history
of hypersensitivity to NSAIDs or aspirin.

Neuropathic pain
National Institute of Clinical Excellence (UK) guidelines:
First line: Amitriptyline (Imipramine if cannot tolerate) or pregabalin
Second line: Amitriptyline AND pregabalin
Third line: refer to pain specialist. Give tramadol in the interim (avoid
morphine)
If diabetic neuropathic pain: Duloxetine

References
1. [Link]
2. Charlton E. The Management of Postoperative Pain . Update in Anaesthesia.
Issue 7 (1997)

Next question 
 Display my notes on this topic
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Question stats

A 17.8%
B 53%
C 7.1%
D 12.6%
E 9.5%

53% of users answered this question correctly

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Question 14 of 64
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 

A 73 year old man is recovering from a stroke but is deemed to have an unsafe
swallow. Apart from his CVA his past medical history includes rate controlled atrial
fibrillation and a previous oesophagectomy. What is the best option for long term
feeding?

Endoscopically inserted PEG tube

Surgically inserted PEG tube

Surgically inserted feeding jejunostomy tube

TPN via peripheral venous access system

TPN via a central line

Most patients with a previous CVA can undergo PEG tube insertion. However, an
oesophagectomy will preclude this as the stomach will now be intrathoracic.

Please rate this question:

 Discuss and give feedback

Next question 

Nutrition options in surgical patients

Oral intake Easiest option

May be supplemented by calorie rich dietary
supplements
May contra indicated following certain
procedures
 Naso gastric feeding Usually administered via fine bore naso gastric
feeding tube
Complications relate to aspiration of feed or
gathered by dr. elbarky, for free, not intended for profit by anybody elsewhere.

misplaced tube
May be safe to use in patients with impaired
swallow
Often contra indicated following head injury due
to risks associated with tube insertion

Naso jejunal feeding Avoids problems of feed pooling in stomach (and

risk of aspiration)
Insertion of feeding tube more technically
complicated (easiest if done intra operatively)
Safe to use following oesophagogastric surgery

Feeding jejunostomy Surgically sited feeding tube

May be used for long term feeding
Low risk of aspiration and thus safe for long term
feeding following upper GI surgery
Main risks are those of tube displacement and
peritubal leakage immediately following
insertion, which carries a risk of peritonitis

Percutaneous Combined endoscopic and percutaneous tube

endoscopic insertion
gastrostomy May not be technically possible in those patients
who cannot undergo successful endoscopy
Risks include aspiration and leakage at the
insertion site

Total parenteral The definitive option in those patients in whom

nutrition enteral feeding is contra indicated
Individualised prescribing and monitoring needed
Should be administered via a central vein as it is
strongly phlebitic
Long term use is associated with fatty liver and
deranged LFT's

Next question 
 Display my notes on this topic

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Question stats

A 26.4%
B 19.7%
C 42.1%
D 4.1%
E 7.6%

42.1% of users answered this question correctly

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Question 15 of 64
gathered by dr. elbarky, for free, not intended for profit by anybody elsewhere.

 

A 55 year old man undergoes an appendicectomy through a lower midline

laparotomy incision. What is the most appropriate modality for providing post
operative analgesia?

Epidural

Spinal

Patient controlled analgesic infusion

Oral tramadol alone

Oral NSAID's alone

Please rate this question:

 Discuss and give feedback

Next question 

Management of pain

World Health Organisation Analgesic Ladder

Initially peripherally acting drugs such as paracetamol or non-steroidal anti-
inflammatory drugs (NSAIDs) are given.
If pain control is not achieved, the second part of the ladder is to introduce
weak opioid drugs such as codeine or dextropropoxyphene together with
appropriate agents to control and minimise side effects.
The final rung of the ladder is to introduce strong opioid drugs such as
morphine. Analgesia from peripherally acting drugs may be additive to that
from centrally-acting opioids and thus, the two are given together.

The World Federation of Societies of Anaesthesiologists (WFSA) Analgesic

Ladder
For management of acute pain
 Initially, the pain can be expected to be severe and may need controlling with
strong analgesics in combination with local anaesthetic blocks and
peripherally acting drugs.
The second rung on the postoperative pain ladder is the restoration of the
gathered by dr. elbarky, for free, not intended for profit by anybody elsewhere.

use of the oral route to deliver analgesia. Strong opioids may no longer be
required and adequate analgesia can be obtained by using combinations of
peripherally acting agents and weak opioids.
The final step is when the pain can be controlled by peripherally acting
agents alone.

Local anaesthetics
Infiltration of a wound with a long-acting local anaesthetic such as
Bupivacaine
Analgesia for several hours
Further pain relief can be obtained with repeat injections or by infusions via
a thin catheter
Blockade of plexuses or peripheral nerves will provide selective analgesia in
those parts of the body supplied by the plexus or nerves
Can either be used to provide anaesthesia for the surgery or specifically for
postoperative pain relief
Especially useful where a sympathetic block is needed to improve
postoperative blood supply or where central blockade such as spinal or
epidural blockade is contraindicated.

Spinal anaesthesia
Provides excellent analgesia for surgery in the lower half of the body and pain
relief can last many hours after completion of the operation if long-acting drugs
containing vasoconstrictors are used.

- Side effects of spinal anaesthesia include: hypotension, sensory and motor block,
nausea and urinary retention.

Epidural anaesthesia
An indwelling epidural catheter inserted. This can then be used to provide a
continuous infusion of analgesic agents. It can provide excellent analgesia. They
are still the preferred option following major open abdominal procedures and help
prevent post operative respiratory compromise resulting from pain.

- Disadvantages of epidurals is that they usually confine patients to bed, especially

if a motor block is present. In addition an indwelling urinary catheter is required.
Which may not only impair mobility but also serve as a conduit for infection. They
are contraindicated in coagulopathies.

Transversus Abdominal Plane block (TAP)

In this technique an ultrasound is used to identify the correct muscle plane and
local anaesthetic (usually bupivicaine) is injected. The agent diffuses in the plane
and blocks many of the spinal nerves. It is an attractive technique as it provides a
 wide field of blockade but does not require the placement of any indwelling
devices. There is no post operative motor impairment. For this reason it is the
preferred technique when extensive laparoscopic abdominal procedures are
performed. They will then provide analgesia immediately following surgery but as
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they do not confine the patient to bed, the focus on enhanced recovery can begin
sooner.

-The main disadvantage is that their duration of action is limited to the half life of
the local anaesthetic agent chosen. In addition some anaesthetists do not have
the USS skills required to site the injections.

Patient Controlled Analgesia (PCA)

- Patients administer their own intravenous analgesia and titrate the dose to their
own end-point of pain relief using a small microprocessor - controlled pump.
Morphine is the most popular drug used.

Strong Opioids

Severe pain arising from deep or visceral structures requires the use of strong
opioids

Morphine
Short half life and poor bioavailability.
Metabolised in the liver and clearance is reduced in patients with liver
disease, in the elderly and the debilitated
Side effects include nausea, vomiting, constipation and respiratory
depression.
Tolerance may occur with repeated dosage

Pethidine
Synthetic opioid which is structurally different from morphine but which has
similar actions. Has 10% potency of morphine.
Short half life and similar bioavailability and clearance to morphine.
Short duration of action and may need to be given hourly.
Pethidine has a toxic metabolite (norpethidine) which is cleared by the
kidney, but which accumulates in renal failure or following frequent and
prolonged doses and may lead to muscle twitching and convulsions.
Extreme caution is advised if pethidine is used over a prolonged period or in
patients with renal failure.

Weak opioids
Codeine: markedly less active than morphine, has predictable effects when given
orally and is effective against mild to moderate pain.
 Non opioid analgesics
- Mild to moderate pain.

Paracetamol
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Inhibits prostaglandin synthesis.

Analgesic and antipyretic properties but little anti-inflammatory effect
It is well absorbed orally and is metabolised almost entirely in the liver
Side effects in normal dosage and is widely used for the treatment of minor
pain. It causes hepatotoxicity in over dosage by overloading the normal
metabolic pathways with the formation of a toxic metabolite.

NSAIDs
Analgesic and anti-inflammatory actions
Inhibition of prostaglandin synthesis by the enzyme Cyclooxygenase which
catalyses the conversion of arachidonic acid to the various prostaglandins
that are the chief mediators of inflammation. All NSAIDs work in the same
way and thus there is no point in giving more than one at a time. .
NSAIDs are, in general, more useful for superficial pain arising from the skin,
buccal mucosa, joint surfaces and bone.
Relative contraindications: history of peptic ulceration, gastrointestinal
bleeding or bleeding diathesis; operations associated with high blood loss,
asthma, moderate to severe renal impairment, dehydration and any history
of hypersensitivity to NSAIDs or aspirin.

Neuropathic pain
National Institute of Clinical Excellence (UK) guidelines:
First line: Amitriptyline (Imipramine if cannot tolerate) or pregabalin
Second line: Amitriptyline AND pregabalin
Third line: refer to pain specialist. Give tramadol in the interim (avoid
morphine)
If diabetic neuropathic pain: Duloxetine

References
1. [Link]
2. Charlton E. The Management of Postoperative Pain . Update in Anaesthesia.
Issue 7 (1997)

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Question 16 of 64
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A 62 year old lawyer has a transurethral resection of the prostate which took 1
hour to perform. The ST2 contacts you as the patient has become agitated. He has
a HR 105 bpm and his blood pressure is 170/100 mmHg. He is fluid overloaded.
His blood results reveal a Na of 120mmol/l. What is the most likely cause?

Over administration of 0.9% Normal Saline

Syndrome of inappropriate antidiuretic hormone secretion

Congestive cardiac failure

TURP syndrome

Acute renal failure

Complications of Transurethral Resection: TURP

T ur syndrome
U rethral stricture/UTI
R etrograde ejaculation
P erforation of the prostate

TUR syndrome occurs when irrigation fluid enters the systemic circulation. The
triad of features are:

1. Hyponatraemia: dilutional
2. Fluid overload
3. Glycine toxicity

Management involves fluid restriction and the treatment of the complications

associated with the hyponatraemia.

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Post prostatectomy syndromes

Transurethral prostatectomy is a common and popular treatment for benign

prostatic hyperplasia. The procedure involves insertion of a resectoscope via the
penile urethra. The bladder and prostate are irrigated and strips of prostatic tissue
removed using diathermy.

Indications for surgery in patients with BPH

Refractory urinary retention
Recurrent urinary tract infections due to prostatic hypertrophy
Recurrent gross haematuria
Renal insufficiency secondary to bladder outlet obstruction
Permanently damaged or weakened bladders
Large bladder diverticula that do not empty well secondary to an enlarged
prostate

Complications include haemorrhage, urosepsis, retrograde ejaculation and

electrolyte disturbances from the irrigation fluids used during surgery.

Risk factors for increased morbidity following TURP

Glands >45g
Operating time > 90 minutes
Acute urinary retention as presenting feature

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C 5.6%
D 65.8%
E 5.2%
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Question 17 of 64
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A 28 year old man undergoes a laparotomy for perforated duodenal ulcer and
broad spectrum antibiotics are administered. Post operatively he has hearing
impairment. Which of the following agents is the most likely underlying culprit?

Gentamicin

Ciprofloxacin

Metronidazole

Ampicillin

Co-trimoxazole

Ototoxicity is a recognised adverse reaction with the aminoglycoside antibiotics.

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Antibiotics: mechanism of action

The lists below summarise the site of action of the commonly used antibiotics

Inhibit cell wall formation

penicillins
cephalosporins

Inhibit protein synthesis

aminoglycosides (cause misreading of mRNA)
chloramphenicol
macrolides (e.g. erythromycin)
tetracyclines
fusidic acid
 Inhibit DNA synthesis
quinolones (e.g. ciprofloxacin)
metronidazole
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sulphonamides
trimethoprim

Inhibit RNA synthesis

rifampicin

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Question 18 of 64
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Which of the following drugs is not positively inotropic?

Dopamine

Glucagon

Theophylline

Sodium thiopentone

Dobutamine

Inotropes are a class of drugs that increase the force or cardiac contractility. This
may improve cardiac output. Increased blood pressure may have direct beneficial
effects for the heart in that it improves myocardial perfusion pressure. Dopamine
and dobutamine are both commonly used inotropes, they should be administered
via a central line and in a monitored setting. Glucagon and theophylline are also
positive inotropes (although not commonly used for this purpose). In contrast
sodium thiopentone causes marked myocardial depression.

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Inotropes and cardiovascular receptors

Inotropes are a class of drugs which work primarily by increasing cardiac output.
They should be distinguished from vasoconstrictor drugs which are used
specifically when the primary problem is peripheral vasodilatation.

Catecholamine type agents are commonly used and work by increasing cAMP
levels by adenylate cyclase stimulation. This in turn intracellular calcium ion
mobilisation and thus the force of contraction. Adrenaline works as a beta
adrenergic receptor agonist at lower doses and an alpha receptor agonist at higher
doses. Dopamine causes dopamine receptor mediated renal and mesenteric
 vascular dilatation and beta 1 receptor agonism at higher doses. This results in
increased cardiac output. Since both heart rate and blood pressure are raised,
there is less overall myocardial ischaemia. Dobutamine is a predominantly beta 1
receptor agonist with weak beta 2 and alpha receptor agonist properties.
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Noradrenaline is a catecholamine type agent and predominantly acts as an alpha

receptor agonist and serves as a peripheral vasoconstrictor.

Phosphodiesterase inhibitors such as milrinone act specifically on the cardiac

phosphodiesterase and increase cardiac output.

Inotrope Cardiovascular receptor action

Adrenaline α-1, α-2, β-1, β-2

Noradrenaline α-1,( α-2), (β-1), (β-2)

Dobutamine β-1, (β 2)

Dopamine (α-1), (α-2), (β-1), D-1,D-2

Minor receptor effects in brackets

Effects of receptor binding

α-1, α-2 vasoconstriction

β-1 increased cardiac contractility and HR

β-2 vasodilatation

D-1 renal and spleen vasodilatation

D-2 inhibits release of noradrenaline

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Question 19 of 64
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A 58 year old woman presented to the Emergency Department with a large

fluctuant swelling the site of a recent insect bite. She is anxious, tachycardic, and
pyrexial. An ECG shows atrial fibrillation. She is noted to have a goitre. The
swelling at the site of the bite requires surgical drainage. Which of the following
classes of drug would be most appropriate as part of her preoperative preparation
for surgery?

Alpha 1 adrenoceptor agonist

Alpha 2 adrenoceptor agonist

Alpha adrenoceptor blocker

Beta adrenoceptor agonist

Beta adrenoceptor blocker

The issue here is an interplay between sepsis and thyroid disease. A degree of rate
control is required to facilitate anaesthesia and this is best achieved with beta
blockade in this particular setting.

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Hyperthyroidism

Causes of hyperthyroidism include:

Diffuse toxic goitre (Graves Disease)
Toxic nodular goitre
Toxic nodule
Rare causes

Graves disease
 Graves disease is characterised by a diffuse vascular goitre that appears at the
same time as the clinical manifestations of hyperthyroidism. It is commonest in
younger females and may be associated with eye signs. Thyrotoxic symptoms will
predominate. Up to 50% of patients will have a familial history of autoimmune
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disorders. The glandular hypertrophy and hyperplasia occur as a result of the

thyroid stimulating effects of the TSH receptor antibodies.

Toxic nodular goitre

In this disorder the goitre is present for a long period of time prior to the
development of clinical symptoms. In most goitres the nodules are inactive and in
some cases it is the internodular tissue that is responsible for the hyperthyroidism.

Toxic nodule
Overactive, autonomously functioning nodule. It may occur as part of generalised
nodularity or be a true toxic adenoma. The TSH levels are usually low as the
autonomously functioning thyroid tissue will exert a negative feedback effect.

Signs and symptoms

Symptoms Signs

Lethargy Tachycardia

Emotionally labile Agitation

Heat intolerance Hot, moist palms

Weight loss Exopthalmos

Excessive appetite Thyroid goitre and bruit

Palpitations Lid lag/retraction

Diagnosis
The most sensitive test for diagnosing hyperthyroidism is plasma T3 (which is
raised). Note in hypothyroidism the plasma T4 and TSH are the most sensitive
tests. A TSH level of <0.5U/L suggests hyperthyroidism. TSH receptor antibodies
may be tested for in the diagnosis of Graves.

Treatment
First line treatment for Graves disease is usually medical and the block and replace
regime is the favored option. Carbimazole is administered at higher doses and
thyroxine is administered orally. Patient are maintained on this regime for between
6 and 12 months. Attempts are then made to wean off medication. Where relapse
then occurs the options are between ongoing medical therapy, radioiodine or
surgery.
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Question 20 of 64
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A 55 year old man requires a flexible sigmoidoscopy to investigate bright red rectal
bleeding. What is the most appropriate preparation?

Single phosphate enema the day prior to the procedure

Single phosphate enema 30 minutes pre procedure

Oral sodium picosulphate the day prior to the procedure

Oral sodium picosulphate 30 minutes prior to the procedure

Rectal lavage with saline 1 hour pre procedure

For a limited endoscopy a simple enema will suffice.

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Endoscopy

Endoscopy is a procedure that allows the internal visualisation of the viscera.

Commonly performed procedures include, gastroscopy, colonoscopy, cystoscopy,
ERCP and bronchoscopy. It is different from laparoscopy as it does not usually
involve the inspection of a visceral cavity.

Most endoscopes are flexible instruments with a 3 channels and a video chip with
illumination source at the end. The channels are used for suction, irrigation and
instrumentation. With the flexible instruments there is a control stack with wheels
that allow the tip of the instrument to be manipulated. Some procedures call for
patient sedation and others do not. Endoscopies should usually be performed in
dedicated units with appropriately trained staff and full resuscitation facilities
available.

The preparation for endoscopy depends upon the organ to be examined. The table
 below covers the key aspects

Endoscopy Preparation
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ERCP Clotting, antibiotics, Vitamin K if jaundiced

Diagnostic OGD Nil by mouth for 6 hours

Flexible Phosphate enema 30 minutes pre procedure

sigmoidoscopy

Colonoscopy Check U+E and if normal, prescribe oral purgatives e.g.

picolax

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Question 21 of 64
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A 45 year old man with previous laparotomy is admitted with adhesional small
bowel obstruction. He is managed with prolonged nasogastric drainage. His U+E's
are as follows:
Sodium 129

Potassium 3.4

Urea 8.4

Creatinine 89

Which of the following intravenous fluids should be prescribed?

0.4%/0.18% dextrose saline

0.9% Sodium Chloride

0.9% sodium chloride with 40mmol potassium chloride per litre

Hartmanns solution

5% dextrose with 20mmol KCl

The potassium will decline further if this deficiency is not addressed. Remember
that potassium is predominantly an intracellular cation. U+E's measure the serum
potassium which is relatively buffered by the intra cellular stores. Therefore a fall in
serum potassium represents a very real intracellular deficiency. This requires
supplementary potassium to correct the defect.

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Pre operative fluid management

Fluid management has been described in the British Consensus guidelines on IV

 fluid therapy for Adult Surgical patients (GIFTASUP) and by NICE (CG174
December 2013 updated May 2017)

The Recommendations include:

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Use Ringer's lactate or Hartmann's when a crystalloid is needed for

resuscitation or replacement of fluids. Avoid 0.9% N. Saline (due to risk of
hyperchloraemic acidosis) unless patient vomiting or has gastric drainage.
Use 4%/0.18% dextrose saline or 5% dextrose in maintenance fluids. It
should not be used in resuscitation or as replacement fluids.
Adult maintenance fluid requirements are: Na 50-100 mmol/day and K 40-80
mmol/day in 1.5-2.5L fluid per day.
Patients for elective surgery should NOT be nil by mouth for >2 hours
(unless has disorder of gastric emptying).
Patients for elective surgery should be given carbohydrate rich drinks 2-3h
before. Ideally this should form part of a normal pre op plan to facilitate
recovery.
Avoid mechanical bowel preparation.
If bowel prep is used, simultaneous administration of Hartmann's or Ringer's
lactate should be considered.
Excessive fluid losses from vomiting should be treated with a crystalloid
with potassium replacement. 0.9% N. Saline should be given if there is
hypochloraemia. Otherwise Hartmann's or Ringer lactate should be given for
diarrhoea/ileostomy/ileus/obstruction. Hartmann's should also be given in
sodium losses secondary to diuretics.
High risk patients should receive fluids and inotropes.
An attempt should be made to detect pre or operative hypovolaemia using
flow based measurements. If this is not available, then clinical evaluation is
needed i.e. JVP, pulse volume etc.
In Blood loss or infection causing hypovolaemia should be treated with a
balanced crystalloid or colloid (or until blood available in blood loss). A
critically ill patient is unable to excrete Na or H20 leading to a 5% risk of
interstitial oedema. Therefore 5% dextrose as well as colloid should be
given.
If patients need IV fluid resuscitation, use crystalloids that contain sodium in
the range 130-154 mmol/l, with a bolus of 500 ml over less than 15 minutes
(NICE Guidance CG 174).

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Question 22 of 64
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A 6 year old child requires long term drug therapy to treat a rare genetic disorder.
The drug must be given intravenously. Recently, there have been issues with the
child pulling at current system of the Hickman line and the parents are requesting
an alternative. What is the best option?

Triple lumen subclavian line

Portacath device

Intermittent cannulation as needed

PICC line

Broviac line

Portacaths are a good choice for children as they only need to be accessed when
they are used. Broviacs would pose the same core problems as a Hickman.

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Intravenous access

Venous access
A number of routes for establishing venous access are available.

Peripheral venous cannula

Easy to insert with minimal morbidity. Wide lumen cannulae can provide rapid fluid
infusions. When properly managed infections may be promptly identified and the
cannula easily re sited. Problems relate to their peripheral sites and they are
unsuitable for the administration of vaso active drugs, such as inotropes and
irritant drugs such as TPN (except in the very short term setting).

Central lines
 Insertion is more difficult and most operators and NICE advocate the use of ultra
sound. Coagulopathies may lead to haemorrhage following iatrogenic arterial
injury. Femoral lines are easier to insert and iatrogenic injuries easier to manage in
this site however they are prone to high infection rates. Internal jugular route is
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preferred. They have multiple lumens allowing for administration of multiple

infusions. The lumens are relatively narrow and thus they do not allow particularly
rapid rates of infusion.

Intraosseous access
This is typically undertaken at the anteromedial aspect of the proximal tibia and
provides access to the marrow cavity and circulatory system. Although
traditionally preferred in paediatric practice they may be used in adults and a wide
range of fluids can be infused using these devices.

Tunneled lines
Tunneled lines such as Groshong and Hickman lines are popular devices for
patients with long term therapeutic requirements. These devices are usually
inserted using ultrasound guidance into the internal jugular vein and then tunneled
under the skin. A cuff of woven material is sited near the end and helps to anchor
the device into the tissues. These cuffs require formal dissection to allow the
device to be removed. Tunneled lines can be linked to injection ports that are
located under the skin. These are especially popular in paediatric practice.

Peripherally inserted central cannula

Referred to as PICC lines, these are popular methods for establishing central
venous access. Because they are inserted peripherally they are less prone to major
complications relating to device insertion than conventional central lines.

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Question 23 of 64
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An 83 year old man is admitted for an abdomino-perineal excision of the colon and
rectum for a distal rectal tumour. His co-mobidities include diabetes. His renal
function is normal. What is the best form of thromboprophylaxis?

None

Compression stockings alone for 4 weeks

Daily low dose low molecular weight heparin for 4 weeks

Daily high dose low molecular weight heparin for 4 weeks

Daily administration of high dose unfractionated heparin until discharge

There is good evidence to support the use of extended thromboprophylaxis after

pelvic cancer surgery. Don't confuse low dose and high dose low molecular weight
heparins, re read the options if you got the answer wrong.

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Thromboprophylaxis in surgical patients

Deep vein thrombosis may develop insidiously in many surgical patients. Untreated
it may progress to result in pulmonary embolism.
The following surgical patients are at increased risk of deep vein thrombosis:
Surgery greater than 90 minutes at any site or greater than 60 minutes if the
procedure involves the lower limbs or pelvis
Acute admissions with inflammatory process involving the abdominal cavity
Expected significant reduction in mobility
Age over 60 years
Known malignancy
Thrombophilia
Previous thrombosis
 BMI >30
Taking hormone replacement therapy or the contraceptive pill
Varicose veins with phlebitis
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Mechanical thromboprophylaxis
Early ambulation after surgery is cheap and is effective
Compression stockings (contra -indicated in peripheral arterial disease)
Intermittent pneumatic compression devices
Foot impulse devices

Therapeutic agents

Agent Mode of action Uses

Low molecular Binds Thromboprophylaxis or treatment of

weight heparin antithrombin thromboembolic events in those with
causing normal renal function. It is given as once
inhibition of daily subcutaneous injection
factor Xa

Unfractionated Binds Effective anticoagulation, administered

heparin antithrombin III intravenously it has a rapid onset and its
affecting therapeutic effects decline quickly on
thrombin and stopping and infusion. Its activity is
factor Xa measured using the APTT. If need be it
can be reversed using protamine
sulphate

Dabigatran Orally Used prophylaxis in hip and knee

administered surgery. It does not require therapeutic
direct thrombin monitoring. It should not be used in any
inhibitor patient in whom there is a risk of active
bleeding or imminent likelihood of
surgery. It is reversed using
Idarucizumab

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Question 23 of 64
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 

An 83 year old man is admitted for an abdomino-perineal excision of the colon and
rectum for a distal rectal tumour. His co-mobidities include diabetes. His renal
function is normal. What is the best form of thromboprophylaxis?

None

Compression stockings alone for 4 weeks

Daily low dose low molecular weight heparin for 4 weeks

Daily high dose low molecular weight heparin for 4 weeks

Daily administration of high dose unfractionated heparin until discharge

There is good evidence to support the use of extended thromboprophylaxis after

pelvic cancer surgery. Don't confuse low dose and high dose low molecular weight
heparins, re read the options if you got the answer wrong.

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Thromboprophylaxis in surgical patients

Deep vein thrombosis may develop insidiously in many surgical patients. Untreated
it may progress to result in pulmonary embolism.
The following surgical patients are at increased risk of deep vein thrombosis:
Surgery greater than 90 minutes at any site or greater than 60 minutes if the
procedure involves the lower limbs or pelvis
Acute admissions with inflammatory process involving the abdominal cavity
Expected significant reduction in mobility
Age over 60 years
Known malignancy
Thrombophilia
Previous thrombosis
 BMI >30
Taking hormone replacement therapy or the contraceptive pill
Varicose veins with phlebitis
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Mechanical thromboprophylaxis
Early ambulation after surgery is cheap and is effective
Compression stockings (contra -indicated in peripheral arterial disease)
Intermittent pneumatic compression devices
Foot impulse devices

Therapeutic agents

Agent Mode of action Uses

Low molecular Binds Thromboprophylaxis or treatment of

weight heparin antithrombin thromboembolic events in those with
causing normal renal function. It is given as once
inhibition of daily subcutaneous injection
factor Xa

Unfractionated Binds Effective anticoagulation, administered

heparin antithrombin III intravenously it has a rapid onset and its
affecting therapeutic effects decline quickly on
thrombin and stopping and infusion. Its activity is
factor Xa measured using the APTT. If need be it
can be reversed using protamine
sulphate

Dabigatran Orally Used prophylaxis in hip and knee

administered surgery. It does not require therapeutic
direct thrombin monitoring. It should not be used in any
inhibitor patient in whom there is a risk of active
bleeding or imminent likelihood of
surgery. It is reversed using
Idarucizumab

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Question 24 of 64
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A 43 year old lady has undergone a total thyroidectomy for multinodular goitre. You
are called to see her because of respiratory distress. On examination she has a
marked stridor, her wound seems healthy but there is a swelling within the
operative site. What is the most likely explanation for this problem?

Bilateral superior laryngeal nerve injury

Hypocalcaemic tetany

Anxiety

Contained haematoma

Unilateral recurrent laryngeal nerve injury

In this setting a contained haematoma is the most likely cause. This will impair
venous return resulting in laryngeal oedema and respiratory compromise.

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Thyroid disease
 Patients may present with a number of different manifestations of thyroid disease.
They can be broadly sub classified according to whether they are euthyroid or have
clinical signs of thyroid dysfunction. In addition it needs to be established whether
they have a mass or not.
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Assessment
History
Examination including USS
If a nodule is identified then it should be sampled ideally via an image
guided fine needle aspiration
Radionucleotide scanning is of limited use

Thyroid Tumours
Papillary carcinoma
Follicular carcinoma
Anaplastic carcinoma
Medullary carcinoma
Lymphoma's

Multinodular goitre
One of the most common reasons for presentation
Provided the patient is euthyroid and asymptomatic and no discrete nodules
are seen, they can be reassured.
In those with compressive symptoms surgery is required and the best
operation is a total thyroidectomy.
Sub total resections were practised in the past and simply result in recurrent
disease that requires a difficult revisional resection.

Endocrine dysfunction
In general these patients are managed by physicians initially.
Surgery may be offered alongside radio iodine for patients with Graves
disease that fails with medical management or in patients who would prefer
not to be irradiated (e.g. pregnant women).
Patients with hypothyroidism do not generally get offered a thyroidectomy.
Sometimes people inadvertently get offered resections during the early
phase of Hashimotos thyroiditis, however, with time the toxic phase passes
and patients can simply be managed with thyroxine.

Complications following surgery

Anatomical such as recurrent laryngeal nerve damage.
Bleeding. Owing to the confined space haematoma's may rapidly lead to
respiratory compromise owing to laryngeal oedema.
Damage to the parathyroid glands resulting in hypocalcaemia.

Further sources of information

 1. [Link] Association of Clinical
Biochemistry guidelines for thyroid function tests.

2. British association of endocrine surgeons website- [Link]

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Question 25 of 64
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The following are contra indications to the use of lignocaine for local anaesthesia
except:

Accelerated idioventricular rhythm

Current treatment with flecainide

3rd degree heart block without pacemaker

Severe sino atrial block

Protein C deficiency

Lignocaine is widely used as a local anaesthetic. As a class IB antiarrhythmic it

should not be used in people with unstable disorders of cardiac rhythm and ideally
should not be co-administered with other anti-arhythmics.

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Local anaesthetic agents

Lidocaine
An amide
Local anaesthetic and a less commonly used antiarrhythmic (affects Na
channels in the axon)
Hepatic metabolism, protein bound, renally excreted
Toxicity: due to IV or excess administration. Increased risk if liver
dysfunction or low protein states. Note acidosis causes lidocaine to detach
from protein binding.
Drug interactions: Beta blockers, ciprofloxacin, phenytoin
Features of toxicity: Initial CNS over activity then depression as lidocaine
initially blocks inhibitory pathways then blocks both inhibitory and activating
pathways. Cardiac arrhythmias.
 Increased doses may be used when combined with adrenaline to limit
systemic absorption.
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Cocaine
Pure cocaine is a salt, usually cocaine hydrochloride. It is supplied for local
anaesthetic purposes as a paste.
It is supplied for clinical use in concentrations of 4 and 10%. It may be
applied topically to the nasal mucosa. It has a rapid onset of action and has
the additional advantage of causing marked vasoconstriction.
It is lipophillic and will readily cross the blood brain barrier. Its systemic
effects also include cardiac arrhythmias and tachycardia.
Apart from its limited use in ENT surgery it is otherwise used rarely in
mainstream surgical practice.

Bupivacaine
Bupivacaine binds to the intracellular portion of sodium channels and blocks
sodium influx into nerve cells, which prevents depolarization.
It has a much longer duration of action than lignocaine and this is of use in
that it may be used for topical wound infiltration at the conclusion of
surgical procedures with long duration analgesic effect.
It is cardiotoxic and is therefore contra indicated in regional blockage in
case the tourniquet fails.
Levobupivacaine (Chirocaine) is less cardiotoxic and causes less
vasodilation.

Prilocaine
Similar mechanism of action to other local anaesthetic agents. However, it
is far less cardiotoxic and is therefore the agent of choice for intravenous
regional anaesthesia e.g. Biers Block.

All local anaesthetic agents dissociate in tissues and this contributes to their
therapeutic effect. The dissociation constant shifts in tissues that are acidic e.g.
where an abscess is present, and this reduces the efficacy.

Doses of local anaesthetics

Agent Dose plain Dose with adrenaline

Lignocaine 3mg/Kg 7mg/Kg

Bupivacaine 2mg/Kg 2mg/Kg

Prilocaine 6mg/Kg 9mg/Kg

These are a guide only as actual doses depend on site of administration, tissue
vascularity and co-morbidities.
 Maximum total local anaesthetic doses
Lignocaine 1% plain - 3mg/ Kg - 200mg (20ml)
Lignocaine 1% with 1 in 200,000 adrenaline - 7mg/Kg - 500mg (50ml)
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Bupivacaine 0.5% - 2mg/kg- 150mg (30ml)

Maximum doses are based on ideal body weight

Effects of adrenaline
Adrenaline may be added to local anaesthetic drugs. It prolongs the duration of
action at the site of injection and permits usage of higher doses (see above). It is
contra indicated in patients taking MAOI's or tricyclic antidepressants. The toxicity
of bupivacaine is related to protein binding and addition of adrenaline to this drug
does not permit increases in the total dose of bupivacaine, in contrast to the
situation with lignocaine.

References
An excellent review is provided by:
French J and Sharp L. Local Anaesthetics. Ann R Coll Surg Engl 2012; 94: 76-80.

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Question 26 of 64
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A 38 year old lady presents with abdominal pain. On investigation, her serum
calcium is found to be 3.5mmol/L. What is the most appropriate initial
management?

Intravenous bisphosphonates

Oral bisphosphonates

Intravenous calcitonin

Intravenous 0.9% sodium chloride

Intravenous frusemide

The immediate treatment of hypercalcaemia involves intravenous fluid

resuscitation. This may be complemented with the use of bisphosphonates and
sometimes diuretics. However, fluids are administered first and because this
question asks what the most appropriate initial treatment is, intravenous fluids are
the most appropriate answer. Normal saline is usually preferred for this over
dextrose containing solutions.

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Management of hypercalcaemia

Free Ca is affected by pH (increased in acidosis) and plasma albumin

concentration
ECG changes include: Shortening of QTc interval
Urgent management is indicated if:

Calcium > 3.5 mmol/l

 Reduced consciousness

Severe abdominal pain

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Pre renal failure

Management:
Airway Breathing Circulation
Intravenous fluid resuscitation with 3-6L of 0.9% Normal saline in 24 hours
Concurrent administration of calcitonin will also help lower calcium levels
Medical therapy (usually if Corrected calcium >3.0mmol/l)

Bisphosphonates
Analogues of pryrophosphate
Prevent osteoclast attachment to bone matrix and interfere with osteoclast
activity
Inhibit bone resorption.

Agents

Drug Side effects Notes

IV
pyrexia, leucopaenia Most potent agent
Pamidronate

response lasts 30 Used for malignancy associated

IV Zoledronate
days hypercalcaemia

Calcitonin
Quickest onset of action however short duration (tachyphylaxis) therefore
only given with a second agent.

Prednisolone
May be given in hypercalcaemia related to sarcoidosis, myeloma or vitamin
D intoxication.

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Question 27 of 64
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What is the most appropriate management for a 56 year old lady who has shooting
pains in her arm following a mastectomy and axillary node clearance?

Carbamazepine

Pregabalin

Oramorph

Diclofenac

Chemical neurectomy

Pregabalin is generally the first line agent for neuropathic pain.

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Management of pain

World Health Organisation Analgesic Ladder

Initially peripherally acting drugs such as paracetamol or non-steroidal anti-
inflammatory drugs (NSAIDs) are given.
If pain control is not achieved, the second part of the ladder is to introduce
weak opioid drugs such as codeine or dextropropoxyphene together with
appropriate agents to control and minimise side effects.
The final rung of the ladder is to introduce strong opioid drugs such as
morphine. Analgesia from peripherally acting drugs may be additive to that
from centrally-acting opioids and thus, the two are given together.

The World Federation of Societies of Anaesthesiologists (WFSA) Analgesic

Ladder
For management of acute pain
 Initially, the pain can be expected to be severe and may need controlling with
strong analgesics in combination with local anaesthetic blocks and
peripherally acting drugs.
The second rung on the postoperative pain ladder is the restoration of the
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use of the oral route to deliver analgesia. Strong opioids may no longer be
required and adequate analgesia can be obtained by using combinations of
peripherally acting agents and weak opioids.
The final step is when the pain can be controlled by peripherally acting
agents alone.

Local anaesthetics
Infiltration of a wound with a long-acting local anaesthetic such as
Bupivacaine
Analgesia for several hours
Further pain relief can be obtained with repeat injections or by infusions via
a thin catheter
Blockade of plexuses or peripheral nerves will provide selective analgesia in
those parts of the body supplied by the plexus or nerves
Can either be used to provide anaesthesia for the surgery or specifically for
postoperative pain relief
Especially useful where a sympathetic block is needed to improve
postoperative blood supply or where central blockade such as spinal or
epidural blockade is contraindicated.

Spinal anaesthesia
Provides excellent analgesia for surgery in the lower half of the body and pain
relief can last many hours after completion of the operation if long-acting drugs
containing vasoconstrictors are used.

- Side effects of spinal anaesthesia include: hypotension, sensory and motor block,
nausea and urinary retention.

Epidural anaesthesia
An indwelling epidural catheter inserted. This can then be used to provide a
continuous infusion of analgesic agents. It can provide excellent analgesia. They
are still the preferred option following major open abdominal procedures and help
prevent post operative respiratory compromise resulting from pain.

- Disadvantages of epidurals is that they usually confine patients to bed, especially

if a motor block is present. In addition an indwelling urinary catheter is required.
Which may not only impair mobility but also serve as a conduit for infection. They
are contraindicated in coagulopathies.

Transversus Abdominal Plane block (TAP)

In this technique an ultrasound is used to identify the correct muscle plane and
local anaesthetic (usually bupivicaine) is injected. The agent diffuses in the plane
and blocks many of the spinal nerves. It is an attractive technique as it provides a
 wide field of blockade but does not require the placement of any indwelling
devices. There is no post operative motor impairment. For this reason it is the
preferred technique when extensive laparoscopic abdominal procedures are
performed. They will then provide analgesia immediately following surgery but as
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they do not confine the patient to bed, the focus on enhanced recovery can begin
sooner.

-The main disadvantage is that their duration of action is limited to the half life of
the local anaesthetic agent chosen. In addition some anaesthetists do not have
the USS skills required to site the injections.

Patient Controlled Analgesia (PCA)

- Patients administer their own intravenous analgesia and titrate the dose to their
own end-point of pain relief using a small microprocessor - controlled pump.
Morphine is the most popular drug used.

Strong Opioids

Severe pain arising from deep or visceral structures requires the use of strong
opioids

Morphine
Short half life and poor bioavailability.
Metabolised in the liver and clearance is reduced in patients with liver
disease, in the elderly and the debilitated
Side effects include nausea, vomiting, constipation and respiratory
depression.
Tolerance may occur with repeated dosage

Pethidine
Synthetic opioid which is structurally different from morphine but which has
similar actions. Has 10% potency of morphine.
Short half life and similar bioavailability and clearance to morphine.
Short duration of action and may need to be given hourly.
Pethidine has a toxic metabolite (norpethidine) which is cleared by the
kidney, but which accumulates in renal failure or following frequent and
prolonged doses and may lead to muscle twitching and convulsions.
Extreme caution is advised if pethidine is used over a prolonged period or in
patients with renal failure.

Weak opioids
Codeine: markedly less active than morphine, has predictable effects when given
orally and is effective against mild to moderate pain.
 Non opioid analgesics
- Mild to moderate pain.

Paracetamol
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Inhibits prostaglandin synthesis.

Analgesic and antipyretic properties but little anti-inflammatory effect
It is well absorbed orally and is metabolised almost entirely in the liver
Side effects in normal dosage and is widely used for the treatment of minor
pain. It causes hepatotoxicity in over dosage by overloading the normal
metabolic pathways with the formation of a toxic metabolite.

NSAIDs
Analgesic and anti-inflammatory actions
Inhibition of prostaglandin synthesis by the enzyme Cyclooxygenase which
catalyses the conversion of arachidonic acid to the various prostaglandins
that are the chief mediators of inflammation. All NSAIDs work in the same
way and thus there is no point in giving more than one at a time. .
NSAIDs are, in general, more useful for superficial pain arising from the skin,
buccal mucosa, joint surfaces and bone.
Relative contraindications: history of peptic ulceration, gastrointestinal
bleeding or bleeding diathesis; operations associated with high blood loss,
asthma, moderate to severe renal impairment, dehydration and any history
of hypersensitivity to NSAIDs or aspirin.

Neuropathic pain
National Institute of Clinical Excellence (UK) guidelines:
First line: Amitriptyline (Imipramine if cannot tolerate) or pregabalin
Second line: Amitriptyline AND pregabalin
Third line: refer to pain specialist. Give tramadol in the interim (avoid
morphine)
If diabetic neuropathic pain: Duloxetine

References
1. [Link]
2. Charlton E. The Management of Postoperative Pain . Update in Anaesthesia.
Issue 7 (1997)

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Question 28 of 64
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A 72 year old man is due to undergo an oesophagectomy for malignancy. His BMI
is 17.5. What is the best feeding regime immediately following surgery?

Total parenteral nutrition.

Feeding jejunostomy.

Feeding duodenostomy.

Liquid diet orally.

Soft solids orally.

This patient has a condition causing poor absorption, loss of nutrients and high
metabolism. Enteral feeds should be used where possible and many surgeons will
site a jejunostomy for this purpose. Oral diet is not permitted following a resection
until the anastamosis has had time to heal.

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Enteral Feeding

Identify patients as malnourished or at risk (see below)

Identify unsafe or inadequate oral intake with functional GI tract
Consider for enteral feeding
Gastric feeding unless upper GI dysfunction (then for duodenal or jejunal
tube)
Check NG placement using aspiration and pH (check post pyloric tubes with
AXR)
Gastric feeding > 4 weeks consider long-term gastrostomy
Consider bolus or continuous feeding into the stomach
ITU patients should have continuous feeding for 16-24h (24h if on insulin)
Consider motility agent in ITU or acute patients for delayed gastric
 emptying. If this doesn't work then try post pyloric feeding or parenteral
feeding.
PEG can be used 4 hours after insertion, but should not be removed until >2
weeks after insertion.
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Surgical patients due to have major abdominal surgery: if malnourished, unsafe

swallow/inadequate oral intake and functional GI tract then consider pre operative
enteral feeding.

Patients identified as being malnourished

BMI < 18.5 kg/m2
unintentional weight loss of > 10% over 3-6/12
BMI < 20 kg/m2 and unintentional weight loss of > 5% over 3-6/12

AT RISK of malnutrition
Eaten nothing or little > 5 days, who are likely to eat little for a further 5 days
Poor absorptive capacity
High nutrient losses
High metabolism

Reference
Stroud M et al. Guidelines for enteral feeding in adult hospital patients. Gut 2003;
52(Suppl VII):vii1 - vii12.

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 

Question 29 of 64
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A 63 year old man is recovering following an open extended right hemicolectomy

for carcinoma of the colonic splenic flexure. Two days post operatively he
develops a persistent pyrexia. What is the least likely cause?

Ileus

Atelectasis

Anastomotic leak

Wound infection

Urinary tract infection

An ileus in itself is seldom a cause of a pyrexia. It may serve as a proxy marker of

other complications. In this scenario atelectasis would be the most likely
underlying cause, as open extended right hemicolectomies will necessitate a long
midline incision. Anastomotic leaks are less common after right sided colonic
surgery and the timeframe for it is rather short (but are possible). Both wound
infections and UTI's ,may complicate major abdominal surgery at any stage. We
remind you to check the wording of the question, it asks for the "least likely" cause of
pyrexia.

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Pyrexia- post operative

Many surgical patients will develop a pyrexia post operatively. The cause and
investigation depends upon the nature of the infection.
The following scenarios may account for post operative pyrexia:

Cause Features
 Anastomotic leak Swinging pyrexia
Ileus
Increasing abdominal pain
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Raised inflammatory markers

Wound infection Evidence of superficial erythema, discharge of pus

or increasing pain
Usually mild pyrexia (unless major or deep seated
wound infection)
May be accompanied by evidence of wound
dehisence
Inflammatory markers raised

Atelectasis Usually complicates abdominal surgery

Most common after midline laparotomies (pain
impairs ventilation)
Pyrexia usually mild and non swinging
Most patients will have chest signs on examination
Inflammatory markers raised

Central line Patients with complex venous access

sepsis May have marked pyrexia
Access site may show evidence of erythema
Diagnosis is by blood culture from line, line removal
and subsequent tip culture
Groin lines and those for TPN have the highest risk
Inflammatory markers raised

Urinary tract Common in surgical patients

infection Usually occur in patients with indwelling urinary
catheters
Diagnosis is by dipstick and CSU and signs of raised
inflammatory markers
Treatment is with antibiotics (to cover hospital
acquired organisms)

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Question 30 of 64
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Which of the following agents is least suitable for a 23 year old man with burns
and bilateral tibial fractures after being trapped in a car accident for 2 hours?

Suxamethonium

Atracurium

Vecuronium

Pancuronium

Propofol

Suxamethonium may induce hyperkalaemia as it induces generalised muscular

contractions. In patients with likely extensive tissue necrosis this may be sufficient
to produce cardiac arrest.

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Muscle relaxants
 Suxamethonium Depolarising neuromuscular blocker
Inhibits action of acetylcholine at the neuromuscular
junction
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Degraded by plasma cholinesterase and

acetylcholinesterase (affected by lack of
acetylcholinesterase)
Fastest onset and shortest duration of action of all
muscle relaxants
Produces generalised muscular contraction prior to
paralysis
Adverse effects include hyperkalaemia, malignant

Atracurium Non depolarising neuromuscular blocking drug

Duration of action usually 30-45 minutes
Next question
Generalised histamine release on administration 
may
produce facial flushing, tachycardia and hypotension
Not excreted by liver or kidney, broken down in tissues
by hydrolysis
Reversed by neostigmine
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Vecuronium Non depolarising neuromuscular blocking drug
Duration of action approximately 30 - 40 minutes
Degraded by liver and kidney and effects prolonged in
organ dysfunction
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Effects may be reversed by neostigmine

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Pancuronium Non depolarising neuromuscular blocker
Onset of action approximately 2-3 minutes
A 55.6%of action up to 2 hours
Duration
B Effects
12% may be partially reversed with drugs such as
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C 8%
D 7.7%
E 16.6%

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Question 31 of 64
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A 53 year old alcoholic male presents with acute pancreatitis. He is clinically

dehydrated. His blood results show normal renal function and electrolytes. Which
of the intravenous fluids below should be prescribed?

0.9% sodium chloride and 40mmol KCl

5% dextrose

Hartmanns solution

10% dextrose and 20mmol KCl

5% dextrose and 40 mmol KCl

This patient needs fluid replacement due to large third space losses. Hartmann's
solution is recommended. N. Saline would put this patient at risk of
hyperchloraemic acidosis.

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Pre operative fluid management

Fluid management has been described in the British Consensus guidelines on IV

fluid therapy for Adult Surgical patients (GIFTASUP) and by NICE (CG174
December 2013 updated May 2017)

The Recommendations include:

Use Ringer's lactate or Hartmann's when a crystalloid is needed for
resuscitation or replacement of fluids. Avoid 0.9% N. Saline (due to risk of
hyperchloraemic acidosis) unless patient vomiting or has gastric drainage.
Use 4%/0.18% dextrose saline or 5% dextrose in maintenance fluids. It
should not be used in resuscitation or as replacement fluids.
Adult maintenance fluid requirements are: Na 50-100 mmol/day and K 40-80
 mmol/day in 1.5-2.5L fluid per day.
Patients for elective surgery should NOT be nil by mouth for >2 hours
(unless has disorder of gastric emptying).
Patients for elective surgery should be given carbohydrate rich drinks 2-3h
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before. Ideally this should form part of a normal pre op plan to facilitate
recovery.
Avoid mechanical bowel preparation.
If bowel prep is used, simultaneous administration of Hartmann's or Ringer's
lactate should be considered.
Excessive fluid losses from vomiting should be treated with a crystalloid
with potassium replacement. 0.9% N. Saline should be given if there is
hypochloraemia. Otherwise Hartmann's or Ringer lactate should be given for
diarrhoea/ileostomy/ileus/obstruction. Hartmann's should also be given in
sodium losses secondary to diuretics.
High risk patients should receive fluids and inotropes.
An attempt should be made to detect pre or operative hypovolaemia using
flow based measurements. If this is not available, then clinical evaluation is
needed i.e. JVP, pulse volume etc.
In Blood loss or infection causing hypovolaemia should be treated with a
balanced crystalloid or colloid (or until blood available in blood loss). A
critically ill patient is unable to excrete Na or H20 leading to a 5% risk of
interstitial oedema. Therefore 5% dextrose as well as colloid should be
given.
If patients need IV fluid resuscitation, use crystalloids that contain sodium in
the range 130-154 mmol/l, with a bolus of 500 ml over less than 15 minutes
(NICE Guidance CG 174).

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Question 32 of 64
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A 72 year old man is due to undergo an inguinal hernia repair. He suffers from
COPD and has an exercise tolerance of 10 yards. He also has pitting oedema to the
thighs. What is his ASA?

Severe systemic disease of this nature is a constant threat to life. Especially as he

also has evidence of cardiac failure.

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American Society of anesthesiologists physical status scoring

system (ASA)

ASA Description
grade

1 No organic physiological, biochemical or psychiatric disturbance.

The surgical pathology is localised and has not invoked systemic
disturbance

2 Mild or moderate systemic disruption caused either by the surgical

disease process or though underlying pre-existing disease
 3 Severe systemic disruption caused either by the surgical pathology
or pre-existing disease
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4 Patient has severe systemic disease that is a constant threat to life

5 A patient who is moribund and will not survive without surgery

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Question 33 of 64
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A patient receives atropine as pre medication prior to a laparotomy. Which of the

following is least likely to occur?

Pupillary dilation

Dry mouth

Urinary retention

Bradycardia

Decreased salivation

Since it inhibits vagal tone, the use of atropine will typically result in an increased
heart rate.

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Atropine

Atropine is a muscarinic receptor antagonist (competitive antagonist for the

muscarinic acetylcholine receptor). It therefore inhibits parasympathetic [Link]
was traditionally used as a premedication for anaesthesia because it reduced
bronchial secretions, salivary secretions and bradycardia from increased vagal
tone on anaesthetic induction. Modern anaesthetic techniques have reduced the
need for routine use of this drug. Its other effects include urinary retention and
pupillary dilatation.

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Question 34 of 64
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A 43 year old lady with a metallic heart valve has just undergone an elective
paraumbilical hernia repair. In view of her metallic valve, she is given
unfractionated heparin perioperatively. How should the therapeutic efficacy be
monitored, assuming her renal function is normal?

Therapeutic monitoring is not required

Measurement of APTT

Measurement of INR

Measurement of Prothromin time

None of the above

Unlike low molecular weight heparins that do not require monitoring

unfractionated heparin does require monitoring, this is done by measuring the
APTT.

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Heparin

Causes the formation of complexes between antithrombin and activated

thrombin/factors 7,9,10,11 & 12

Advantages of low molecular weight heparin

Better bioavailability
Lower risk of bleeding
Longer half life
Little effect on APTT at prophylactic dosages
Less risk of HIT
 Complications
Bleeding
Osteoporosis
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Heparin induced thrombocytopenia (HIT): occurs 5-14 days after 1st

exposure
Anaphylaxis

In surgical patients that may need a rapid return to theatre, administration of

unfractionated heparin is preferred; as low molecular weight heparins have a
longer duration of action and are harder to reverse.

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Question 35 of 64
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A 5 year old boy undergoes a closure of a loop colostomy. What

thromboprophylaxis should be used?

None

Daily low dose low molecular weight heparin for 2 weeks

Daily low dose low molecular weight heparin until discharged

Unfractionated heparin and compression stockings

Oral dabigatran for 4 weeks

In paediatric surgical practice, the use of heparin type agents is rare. This is
because, even with abdominal surgery, children are ambulant soon after surgery
and DVT's vanishingly rare in this population.

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Thromboprophylaxis in surgical patients

Deep vein thrombosis may develop insidiously in many surgical patients. Untreated
it may progress to result in pulmonary embolism.
The following surgical patients are at increased risk of deep vein thrombosis:
Surgery greater than 90 minutes at any site or greater than 60 minutes if the
procedure involves the lower limbs or pelvis
Acute admissions with inflammatory process involving the abdominal cavity
Expected significant reduction in mobility
Age over 60 years
Known malignancy
Thrombophilia
Previous thrombosis
BMI >30
 Taking hormone replacement therapy or the contraceptive pill
Varicose veins with phlebitis
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Mechanical thromboprophylaxis
Early ambulation after surgery is cheap and is effective
Compression stockings (contra -indicated in peripheral arterial disease)
Intermittent pneumatic compression devices
Foot impulse devices

Therapeutic agents

Agent Mode of action Uses

Low molecular Binds Thromboprophylaxis or treatment of

weight heparin antithrombin thromboembolic events in those with
causing normal renal function. It is given as once
inhibition of daily subcutaneous injection
factor Xa

Unfractionated Binds Effective anticoagulation, administered

heparin antithrombin III intravenously it has a rapid onset and its
affecting therapeutic effects decline quickly on
thrombin and stopping and infusion. Its activity is
factor Xa measured using the APTT. If need be it
can be reversed using protamine
sulphate

Dabigatran Orally Used prophylaxis in hip and knee

administered surgery. It does not require therapeutic
direct thrombin monitoring. It should not be used in any
inhibitor patient in whom there is a risk of active
bleeding or imminent likelihood of
surgery. It is reversed using
Idarucizumab

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B 9%
C 13.7%
D 7%
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Question 36 of 64
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Which of the following intravenous fluid solutions has the greatest chloride
content?

Dextrose / saline

Normal saline

Hartmanns solution

Ringers lactate

5% dextrose

Normal saline has the highest chloride content and excessive administration of
normal saline is a recognised risk factor for the development of hyperchloraemic
metabolic acidosis.

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Intra operative fluid management

 Composition of commonly used intravenous fluids mmol-1

Na K Cl Bicarbonate Lactate
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Plasma 137-147 4-5.5 95-105 22-25 -

0.9% Saline 153 - 153 - -

Dextrose / saline 30.6 - 30.6 - -

Hartmans 130 4 110 - 28

Recommendations for intra operative fluid management

The latest set of NICE guidelines produced in 2013 relating to intravenous fluids
did not specifically address the requirements of intra operative fluid
administration. The reason for this is that administration of fluids in this specific
situation does not lend itself to rigid algorithms.
With the introduction of enhanced recovery programmes 10 years ago there was
an increasing emphasis of the concept of fluid restriction. Historically, patients
received very large volumes of saline rich solutions peri-operatively. Clearing the
sodium load of a single litre of saline may take up to 36 hours or more. This can
have deleterious effects on the tissues including the development of oedema. This
results in poor perfusion, increased risk of ileus and wound breakdown. A tailored
approach to fluid administration is now practiced and far greater usage is made of
cardiac output monitors in providing goal directed fluid therapy.

References
British Consensus Guidelines on Intravenous Fluid Therapy for Adult Surgical
Patients
GIFTASUP (2009) Revised May 2011.

Frost P. Intravenous fluid therapy in adult inpatients. BMJ 2015 (350): 31-34.

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C 11.2%
D 10.5%
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Question 37 of 64
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In relation to operating in the elderly which statement is false?

A 30 minute increment in operation length is associated with increase in

mortality in patients over the age of 80

Hypoalbuminaemia is associated with increased mortality

Statins given preoperatively reduce perioperative cardiac events

Elevated brain (or B-type) natriuretic peptide (BNP) levels before

undergoing non cardiac surgery is associated with high risk of cardiac
mortality and all cause mortality

Beta blockers should be stopped acutely prior to surgery due to risk of

perioperative hypotension

Beta blockers should not be stopped acutely prior to surgery as there may be a
rebound effect associated with increased complications.

Brain natriuretic peptide is a neurohormone synthesized in the cardiac ventricles.

Levels have been used to assess prognosis in heart failure and acute coronary
syndromes. Preoperative elevated brain natriuretic peptide levels identify patients
undergoing non cardiac surgery at high risk of cardiac mortality and all cause
mortality.

All patients with peripheral vascular disease should take statins prior to vascular
surgery as studies have shown a 50% risk reduction and a reduction in
perioperative cardiac events.

Reference
1. Dernellis J, Panaretou M. Assessment of cardiac risk before non-cardiac
surgery: brain natriuretic peptide in 1590 patients. Heart 2006;92:1645-1650
2. Poldermans, D et al Fluvastatin and Perioperative Events in Patients Undergoing
Vascular Surgery. NEJM 2009; 361:980-989

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Proactive care of older people undergoing surgery (POPS)

Comprehensive geriatric assessment

MDT assessment preoperatively
Main predictors of complications are co-morbidities cardiac disease and
reduced functional capacity - preoperative assessment is the key to
preventing adverse postoperative outcomes
Patients screened for risk factors (albumin <30, co morbidities)
Management plan made and disseminated to all involved
Patients education: pain relief, post op exercises, nutrition

Outcomes:
Fewer postoperative medical complications
Reduced length of stay by 4.5 days

References
Proactive care of older people undergoing surgery (POPS)
Danielle Harari et al.
Age and Ageing 2007 36(2):190-196

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B 7.4%
C 25.4%
D 12.7%
 E 46.9%

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Question 38 of 64
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A 70 year old man with a past history of angina undergoes an uncomplicated

operation, for a hydrocele. Postoperatively he is found to be hypotensive,
tachycardic, and has a raised jugular venous pressure. What is the most likely
explanation for the hypotension?

Reduced stroke volume

Reduced parasympathetic tone

Reduced preload

Reduced sympathetic tone

Reduced afterload

It is likely that this patient has cardiac failure with impaired contractility.

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Stroke volume-Cardiac physiology

The stroke volume equates to the volume of blood ejected from the ventricle
during each cycle of cardiac contraction. The volumes for both ventricles are
typically equal and equate roughly to 70ml for a 70Kg man. It is calculated by
subtracting the end systolic volume from the end diastolic volume.

Factors affecting stroke volume

Cardiac size
Contractility
Preload
Afterload
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Question 39 of 64
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A 34 year old man is suffering from septic shock and receives an infusion of
Dextran 70. Which of the following complications may potentially ensue?

Anaphylaxis

Vomiting

Acute hepatic failure

Digital necrosis

Deep vein thrombosis

Dextran 40 and 70 have higher incidence of anaphylaxis than either gelatins

or starches.

Dextrans are branched polysaccharide molecules. Dextran 40 and 70 are available.

The higher molecular weight dextran 70 may persist for up to 8 hours. They inhibit
platelet aggregation and leucocyte plugging in the microcirculation. Thereby
improving flow through the microcirculation, primarily of use in sepsis.
Unlike many other intravenous fluids Dextrans are a recognised cause of
anaphylaxis.

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Post operative fluid management

Composition of commonly used intravenous fluids mmol-1

Na K Cl Bicarbonate Lactate
 Plasma 137-147 4-5.5 95-105 22-25 -

0.9% Saline 153 - 153 - -

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Dextrose / saline 30.6 - 30.6 - -

Hartmans 130 4 110 - 28

Post operative fluid management

In the UK the GIFTASUP and NICE (CG174 2013) guidelines (see reference below)
were devised to try and provide some consensus guidance as to how intravenous
fluids should be administered. A decade ago it was a commonly held belief that
little harm would occur as a result of excessive administration of normal saline
and many oliguric post operative patients received enormous quantities of IV
fluids. As a result they developed hyperchloraemic acidosis. With greater
understanding of this potential complication, the use of electrolyte balanced
solutions (Ringers lactate/ Hartmans) is now favored over normal saline.
The other guidance includes:
Fluids given should be documented clearly and easily available
Assess the patient's fluid status when they leave theatre
If a patient is haemodynamically stable and euvolaemic, aim to restart oral
fluid intake as soon as possible
Review patients whose urinary sodium is < 20
If a patient is oedematous, hypovolaemia if present should be treated first.
This should then be followed by a negative balance of sodium and water,
monitored using urine Na excretion levels
Solutions such as Dextran 70 should be used in caution in patients with
sepsis as there is a risk of developing acute renal injury

References
NICE guidance CG174. Intravenous fluid therapy in adults. December 2013.

British Consensus Guidelines on Intravenous Fluid Therapy for Adult Surgical

Patients. GIFTASUP (2009)

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Question 40 of 64
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A 57 year old man is coming off the cardiac bypass circuit following a successful
coronary artery bypass procedure. Which drug should be administered to
normalise the patients clotting prior to decannulation and chest closure?

Intravenous vitamin K

Protamine sulphate

Aprotinin

Fresh frozen plasma

None of the above

Since cardiac bypass circuits are thrombogenic large doses of intravenous heparin
are administered. This is reversed with protamine sulphate. FFP may be effective
but would carry a significant risk of fluid overload.

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Heparin

Causes the formation of complexes between antithrombin and activated

thrombin/factors 7,9,10,11 & 12

Advantages of low molecular weight heparin

Better bioavailability
Lower risk of bleeding
Longer half life
Little effect on APTT at prophylactic dosages
Less risk of HIT
 Complications
Bleeding
Osteoporosis
Heparin induced thrombocytopenia (HIT): occurs 5-14 days after 1st
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exposure
Anaphylaxis

In surgical patients that may need a rapid return to theatre, administration of

unfractionated heparin is preferred; as low molecular weight heparins have a
longer duration of action and are harder to reverse.

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E 8.6%

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Question 41 of 64
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A 72 year old man is recovering from an inguinal hernia repair when he suffers
from an extensive CVA. He is managed on the rehabilitation unit. However, he is
still not able to feed safely and repeated swallowing assessments have shown that
he tends to aspirate. Which of the following is the best option for long term
feeding?

PEG tube feeding

Feeding jejunostomy

Total parenteral nutrition

Long term naso gastric tube feeding

Withold feeding and palliate

A PEG tube is the best long term option although they are associated with a
significant degree of morbidity. A feeding jejunostomy would require a general
anaesthetic. TPN is not a good option. Long term naso gastric feeding is usually
unsatisfactory.

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Enteral Feeding

Identify patients as malnourished or at risk (see below)

Identify unsafe or inadequate oral intake with functional GI tract
Consider for enteral feeding
Gastric feeding unless upper GI dysfunction (then for duodenal or jejunal
tube)
Check NG placement using aspiration and pH (check post pyloric tubes with
AXR)
Gastric feeding > 4 weeks consider long-term gastrostomy
 Consider bolus or continuous feeding into the stomach
ITU patients should have continuous feeding for 16-24h (24h if on insulin)
Consider motility agent in ITU or acute patients for delayed gastric
emptying. If this doesn't work then try post pyloric feeding or parenteral
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feeding.
PEG can be used 4 hours after insertion, but should not be removed until >2
weeks after insertion.

Surgical patients due to have major abdominal surgery: if malnourished, unsafe

swallow/inadequate oral intake and functional GI tract then consider pre operative
enteral feeding.

Patients identified as being malnourished

BMI < 18.5 kg/m2
unintentional weight loss of > 10% over 3-6/12
BMI < 20 kg/m2 and unintentional weight loss of > 5% over 3-6/12

AT RISK of malnutrition
Eaten nothing or little > 5 days, who are likely to eat little for a further 5 days
Poor absorptive capacity
High nutrient losses
High metabolism

Reference
Stroud M et al. Guidelines for enteral feeding in adult hospital patients. Gut 2003;
52(Suppl VII):vii1 - vii12.

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 

Question 41 of 64
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 

A 72 year old man is recovering from an inguinal hernia repair when he suffers
from an extensive CVA. He is managed on the rehabilitation unit. However, he is
still not able to feed safely and repeated swallowing assessments have shown that
he tends to aspirate. Which of the following is the best option for long term
feeding?

PEG tube feeding

Feeding jejunostomy

Total parenteral nutrition

Long term naso gastric tube feeding

Withold feeding and palliate

A PEG tube is the best long term option although they are associated with a
significant degree of morbidity. A feeding jejunostomy would require a general
anaesthetic. TPN is not a good option. Long term naso gastric feeding is usually
unsatisfactory.

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Enteral Feeding

Identify patients as malnourished or at risk (see below)

Identify unsafe or inadequate oral intake with functional GI tract
Consider for enteral feeding
Gastric feeding unless upper GI dysfunction (then for duodenal or jejunal
tube)
Check NG placement using aspiration and pH (check post pyloric tubes with
AXR)
Gastric feeding > 4 weeks consider long-term gastrostomy
 Consider bolus or continuous feeding into the stomach
ITU patients should have continuous feeding for 16-24h (24h if on insulin)
Consider motility agent in ITU or acute patients for delayed gastric
emptying. If this doesn't work then try post pyloric feeding or parenteral
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feeding.
PEG can be used 4 hours after insertion, but should not be removed until >2
weeks after insertion.

Surgical patients due to have major abdominal surgery: if malnourished, unsafe

swallow/inadequate oral intake and functional GI tract then consider pre operative
enteral feeding.

Patients identified as being malnourished

BMI < 18.5 kg/m2
unintentional weight loss of > 10% over 3-6/12
BMI < 20 kg/m2 and unintentional weight loss of > 5% over 3-6/12

AT RISK of malnutrition
Eaten nothing or little > 5 days, who are likely to eat little for a further 5 days
Poor absorptive capacity
High nutrient losses
High metabolism

Reference
Stroud M et al. Guidelines for enteral feeding in adult hospital patients. Gut 2003;
52(Suppl VII):vii1 - vii12.

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 

Question 42 of 64
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 

A 55 year old man with no co-morbidity is due to undergo a Milligan Morgan

haemorrhoidectomy, what is the most appropriate method of delivering immediate
post operative analgesia?

Pudendal nerve release

Caudal block

Rectal NSAIDS

IV fentanyl

Paracetamol

Following excisional haemorrhoidectomy, severe pain is not unusual, a well placed

caudal anaesthetic will counter this. A pudendal nerve block is an alternative but is
less effective than a caudal.

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Management of pain

World Health Organisation Analgesic Ladder

Initially peripherally acting drugs such as paracetamol or non-steroidal anti-
inflammatory drugs (NSAIDs) are given.
If pain control is not achieved, the second part of the ladder is to introduce
weak opioid drugs such as codeine or dextropropoxyphene together with
appropriate agents to control and minimise side effects.
The final rung of the ladder is to introduce strong opioid drugs such as
morphine. Analgesia from peripherally acting drugs may be additive to that
from centrally-acting opioids and thus, the two are given together.
 The World Federation of Societies of Anaesthesiologists (WFSA) Analgesic
Ladder
For management of acute pain
Initially, the pain can be expected to be severe and may need controlling with
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strong analgesics in combination with local anaesthetic blocks and

peripherally acting drugs.
The second rung on the postoperative pain ladder is the restoration of the
use of the oral route to deliver analgesia. Strong opioids may no longer be
required and adequate analgesia can be obtained by using combinations of
peripherally acting agents and weak opioids.
The final step is when the pain can be controlled by peripherally acting
agents alone.

Local anaesthetics
Infiltration of a wound with a long-acting local anaesthetic such as
Bupivacaine
Analgesia for several hours
Further pain relief can be obtained with repeat injections or by infusions via
a thin catheter
Blockade of plexuses or peripheral nerves will provide selective analgesia in
those parts of the body supplied by the plexus or nerves
Can either be used to provide anaesthesia for the surgery or specifically for
postoperative pain relief
Especially useful where a sympathetic block is needed to improve
postoperative blood supply or where central blockade such as spinal or
epidural blockade is contraindicated.

Spinal anaesthesia
Provides excellent analgesia for surgery in the lower half of the body and pain
relief can last many hours after completion of the operation if long-acting drugs
containing vasoconstrictors are used.

- Side effects of spinal anaesthesia include: hypotension, sensory and motor block,
nausea and urinary retention.

Epidural anaesthesia
An indwelling epidural catheter inserted. This can then be used to provide a
continuous infusion of analgesic agents. It can provide excellent analgesia. They
are still the preferred option following major open abdominal procedures and help
prevent post operative respiratory compromise resulting from pain.

- Disadvantages of epidurals is that they usually confine patients to bed, especially

if a motor block is present. In addition an indwelling urinary catheter is required.
Which may not only impair mobility but also serve as a conduit for infection. They
are contraindicated in coagulopathies.

Transversus Abdominal Plane block (TAP)

 In this technique an ultrasound is used to identify the correct muscle plane and
local anaesthetic (usually bupivicaine) is injected. The agent diffuses in the plane
and blocks many of the spinal nerves. It is an attractive technique as it provides a
wide field of blockade but does not require the placement of any indwelling
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devices. There is no post operative motor impairment. For this reason it is the
preferred technique when extensive laparoscopic abdominal procedures are
performed. They will then provide analgesia immediately following surgery but as
they do not confine the patient to bed, the focus on enhanced recovery can begin
sooner.

-The main disadvantage is that their duration of action is limited to the half life of
the local anaesthetic agent chosen. In addition some anaesthetists do not have
the USS skills required to site the injections.

Patient Controlled Analgesia (PCA)

- Patients administer their own intravenous analgesia and titrate the dose to their
own end-point of pain relief using a small microprocessor - controlled pump.
Morphine is the most popular drug used.

Strong Opioids

Severe pain arising from deep or visceral structures requires the use of strong
opioids

Morphine
Short half life and poor bioavailability.
Metabolised in the liver and clearance is reduced in patients with liver
disease, in the elderly and the debilitated
Side effects include nausea, vomiting, constipation and respiratory
depression.
Tolerance may occur with repeated dosage

Pethidine
Synthetic opioid which is structurally different from morphine but which has
similar actions. Has 10% potency of morphine.
Short half life and similar bioavailability and clearance to morphine.
Short duration of action and may need to be given hourly.
Pethidine has a toxic metabolite (norpethidine) which is cleared by the
kidney, but which accumulates in renal failure or following frequent and
prolonged doses and may lead to muscle twitching and convulsions.
Extreme caution is advised if pethidine is used over a prolonged period or in
patients with renal failure.

Weak opioids
 Codeine: markedly less active than morphine, has predictable effects when given
orally and is effective against mild to moderate pain.

Non opioid analgesics

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- Mild to moderate pain.

Paracetamol
Inhibits prostaglandin synthesis.
Analgesic and antipyretic properties but little anti-inflammatory effect
It is well absorbed orally and is metabolised almost entirely in the liver
Side effects in normal dosage and is widely used for the treatment of minor
pain. It causes hepatotoxicity in over dosage by overloading the normal
metabolic pathways with the formation of a toxic metabolite.

NSAIDs
Analgesic and anti-inflammatory actions
Inhibition of prostaglandin synthesis by the enzyme Cyclooxygenase which
catalyses the conversion of arachidonic acid to the various prostaglandins
that are the chief mediators of inflammation. All NSAIDs work in the same
way and thus there is no point in giving more than one at a time. .
NSAIDs are, in general, more useful for superficial pain arising from the skin,
buccal mucosa, joint surfaces and bone.
Relative contraindications: history of peptic ulceration, gastrointestinal
bleeding or bleeding diathesis; operations associated with high blood loss,
asthma, moderate to severe renal impairment, dehydration and any history
of hypersensitivity to NSAIDs or aspirin.

Neuropathic pain
National Institute of Clinical Excellence (UK) guidelines:
First line: Amitriptyline (Imipramine if cannot tolerate) or pregabalin
Second line: Amitriptyline AND pregabalin
Third line: refer to pain specialist. Give tramadol in the interim (avoid
morphine)
If diabetic neuropathic pain: Duloxetine

References
1. [Link]
2. Charlton E. The Management of Postoperative Pain . Update in Anaesthesia.
Issue 7 (1997)

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Question 43 of 64
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In relation to patients with type 1 diabetes mellitus undergoing surgery, which of

the following statements is untrue?

They should not receive oral carbohydrate loading drinks as part of

enhanced recovery programmes

When a variable rate insulin infusion is required 0.45% sodium chloride

and 5% dextrose with either 0.15% or 0.3% potassium are the fluids of
choice

Hourly intraoperative blood glucose measurements are required

Insulin infusions are only required in patients who will miss more than two
meals or who are nil by mouth for greater than 12 hours

Blood glucose levels persistently greater than 12 should initiate a change

in therapy

Insulin should not be stopped in patients with type 1 diabetes and omission
of more than one meal will usually require a variable rate insulin infusion

Type 1 diabetics who take insulin should have this continued through the
perioperative period.
Fluid guidelines in diabetics differ and are not well covered in NPSA fluid
guidelines.

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Preparation for surgery

Elective and emergency patients require different preparation.

 Elective cases
Consider pre admission clinic to address medical issues.
Blood tests including FBC, U+E, LFT's, Clotting, Group and Save
Urine analysis
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Pregnancy test
Sickle cell test
ECG/ Chest x-ray

Exact tests to be performed will depend upon the proposed procedure and patient
fitness.

Risk factors for development of deep vein thrombosis should be assessed and a
plan for thromboprophylaxis formulated.

Diabetes
Diabetic patients have greater risk of complications.
Poorly controlled diabetes carries high risk of wound infections.
Patients with diet or tablet controlled diabetes may be managed using a policy of
omitting medication and checking blood glucose levels regularly. Diabetics who
are poorly controlled or who take insulin may require a intravenous sliding scale.
Potassium supplementation should also be given.
Diabetic cases should be operated on first.

Emergency cases
Stabilise and resuscitate where needed.
Consider whether antibiotics are needed and when and how they should be
administered.
Inform blood bank if major procedures planned particularly where coagulopathies
are present at the outset or anticipated (e.g. Ruptured AAA repair)
Don't forget to consent and inform relatives.

Special preparation
Some procedures require special preparation:
Thyroid surgery; vocal cord check.
Parathyroid surgery; consider methylene blue to identify gland.
Sentinel node biopsy; radioactive marker/ patent blue dye.
Surgery involving the thoracic duct; consider administration of cream.
Pheochromocytoma surgery; will need alpha and beta blockade.
Surgery for carcinoid tumours; will need covering with octreotide.
Colorectal cases; bowel preparation (especially left sided surgery)
Thyrotoxicosis; lugols iodine/ medical therapy.

References
Management of adults with diabetes undergoing surgery and elective procedures.
NHS Diabetes. April 2011.
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Question 44 of 64
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Which of the following statements relating to use of tourniquets in surgery is

false?

The use of an esmarch bandage tourniquet to exsanguinate the limb

reduces the incidence of neuropraxia.

Excessive inflation pressures are amongst the commonest causes of

nerve injury related to tourniquet use.

Tourniquet deflation causes a fall in CVP.

Children require lower inflation pressures than adults.

In patients developing neuropraxia related to tourniquets the radial nerve

is most frequently affected.

The use of esmarch bandage tourniquet increases the risk of nerve injury as it
increases pressure in the limb. Limb elevation is safer.

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Tourniquets

Tourniquets are used during surgery to minimise blood loss and ensure a clear
operative field. They must be correctly applied and monitored. They are applied to
extremities and in most cases are inflated using a pressure monitoring system.

There are a number of systemic effects that can accompany tourniquet use, these
can be divided into those which occur following inflation and those that occur
once the tourniquet is deflated.

Post inflation
Increased systemic vascular resistance, increased CVP and increased BP
 Slower gradual increase in BP over time
Induced hypercoagulable state
Slow increase in core temperature
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Post deflation
Fall in CVP, BP and SVR
Increased end tidal carbon dioxide
Enhanced fibrinolysis
Fall in core temperature
Raised serum potassium and lactate levels

Contra indications

Absolute Relative

AV fistula Sickle cell disease

Severe peripheral vascular disease History of thromboembolic
Previous vascular surgery events
Bone fracture or thrombosis at the site of Skin grafts
tourniquet application Localised infection
Lymphoedema

Local complications
Damage to skin
Damage to muscle (rarely compartment syndrome)
Damage to vessels
Neuropraxia

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Question 45 of 64
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A 32 year old man requires venous access for chemotherapy for acute myeloid
leukaemia. What is the best option?

Groshong line

Internal jugular central line (triple lumen)

14 G cannula in the dorsum of the hand

18 G cannula in the non dominant hand

Sub cuticular catheter

Groshong lines and Hickman lines are similar and knowledge of these systems is
needed because surgeons are often called upon to either insert or remove them.
Chemotherapy for AML requires long term therapy and multiple blood tests
therefore an indwelling device is preferable.

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Intravenous access

Venous access
A number of routes for establishing venous access are available.

Peripheral venous cannula

Easy to insert with minimal morbidity. Wide lumen cannulae can provide rapid fluid
infusions. When properly managed infections may be promptly identified and the
cannula easily re sited. Problems relate to their peripheral sites and they are
unsuitable for the administration of vaso active drugs, such as inotropes and
irritant drugs such as TPN (except in the very short term setting).

Central lines
 Insertion is more difficult and most operators and NICE advocate the use of ultra
sound. Coagulopathies may lead to haemorrhage following iatrogenic arterial
injury. Femoral lines are easier to insert and iatrogenic injuries easier to manage in
this site however they are prone to high infection rates. Internal jugular route is
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preferred. They have multiple lumens allowing for administration of multiple

infusions. The lumens are relatively narrow and thus they do not allow particularly
rapid rates of infusion.

Intraosseous access
This is typically undertaken at the anteromedial aspect of the proximal tibia and
provides access to the marrow cavity and circulatory system. Although
traditionally preferred in paediatric practice they may be used in adults and a wide
range of fluids can be infused using these devices.

Tunneled lines
Tunneled lines such as Groshong and Hickman lines are popular devices for
patients with long term therapeutic requirements. These devices are usually
inserted using ultrasound guidance into the internal jugular vein and then tunneled
under the skin. A cuff of woven material is sited near the end and helps to anchor
the device into the tissues. These cuffs require formal dissection to allow the
device to be removed. Tunneled lines can be linked to injection ports that are
located under the skin. These are especially popular in paediatric practice.

Peripherally inserted central cannula

Referred to as PICC lines, these are popular methods for establishing central
venous access. Because they are inserted peripherally they are less prone to major
complications relating to device insertion than conventional central lines.

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Question 46 of 64
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Which of the following statements relating to use of total parenteral nutrition is

untrue?

It may cause steatosis and derangement of liver function tests

Administration via a central line or PICC line is preferable to peripheral

administration

It is highly irritant to vessel walls

It should be administered when a patient has an albumin less than15

Administration of TPN for periods of less than 1 week is unlikely to

produce noticable benefits

Albumin is a poor indicator of overall nutrition and the decision to start TPN should
not be based on this parameter alone. Patients should ideally be fed enterally
where possible and if this is likely to occur within 5-7 days then starting TPN is
unlikely to confer benefit.

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Nutrition Monitoring-NICE guidelines

Weight: daily if fluid balance concerns, otherwise weekly reducing to

monthly
BMI: at start of feeding and then monthly
If weight cannot be obtained: monthly mid arm circumference or triceps skin
fold thickness
Daily electrolytes until levels stable. Then once or twice a week.
Weekly glucose, phosphate, magnesium, LFTs, Ca, albumin, FBC, MCV

levels if stable
 2-4 weekly Zn, Folate, B12 and Cu levels if stable
3-6 monthly iron and ferritin levels, manganese (if on home parenteral
regime)
6 monthly vitamin D
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Bone densitometry initially on starting home parenteral nutrition then every

2 years

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Question 47 of 64
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A surgeon is considering using lignocaine to provide local anaesthesia for a minor

surgical procedure. Which of the following may attenuate its action?

Hyperkalaemia

Administration with adrenaline

Administration with bupivicaine

Administration with sodium bicarbonate

Use in tissues which are infected

Local anaesthetics are relatively ineffective when used in infected tissues.

Most anaesthetic agents are amine bases that become ionised due to the relative
alkalinity of tissues. In active infection there may acidosis of the tissues and
therefore local anasthetics may be less effective. Some surgeons mix sodium
bicarbonate as it is reported to reduce the pain experienced by patients during
administration.

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Local anaesthetic agents

Lidocaine
An amide
Local anaesthetic and a less commonly used antiarrhythmic (affects Na
channels in the axon)
Hepatic metabolism, protein bound, renally excreted
Toxicity: due to IV or excess administration. Increased risk if liver
 dysfunction or low protein states. Note acidosis causes lidocaine to detach
from protein binding.
Drug interactions: Beta blockers, ciprofloxacin, phenytoin
Features of toxicity: Initial CNS over activity then depression as lidocaine
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initially blocks inhibitory pathways then blocks both inhibitory and activating
pathways. Cardiac arrhythmias.
Increased doses may be used when combined with adrenaline to limit
systemic absorption.

Cocaine
Pure cocaine is a salt, usually cocaine hydrochloride. It is supplied for local
anaesthetic purposes as a paste.
It is supplied for clinical use in concentrations of 4 and 10%. It may be
applied topically to the nasal mucosa. It has a rapid onset of action and has
the additional advantage of causing marked vasoconstriction.
It is lipophillic and will readily cross the blood brain barrier. Its systemic
effects also include cardiac arrhythmias and tachycardia.
Apart from its limited use in ENT surgery it is otherwise used rarely in
mainstream surgical practice.

Bupivacaine
Bupivacaine binds to the intracellular portion of sodium channels and blocks
sodium influx into nerve cells, which prevents depolarization.
It has a much longer duration of action than lignocaine and this is of use in
that it may be used for topical wound infiltration at the conclusion of
surgical procedures with long duration analgesic effect.
It is cardiotoxic and is therefore contra indicated in regional blockage in
case the tourniquet fails.
Levobupivacaine (Chirocaine) is less cardiotoxic and causes less
vasodilation.

Prilocaine
Similar mechanism of action to other local anaesthetic agents. However, it
is far less cardiotoxic and is therefore the agent of choice for intravenous
regional anaesthesia e.g. Biers Block.

All local anaesthetic agents dissociate in tissues and this contributes to their
therapeutic effect. The dissociation constant shifts in tissues that are acidic e.g.
where an abscess is present, and this reduces the efficacy.

Doses of local anaesthetics

Agent Dose plain Dose with adrenaline

Lignocaine 3mg/Kg 7mg/Kg

 Agent Dose plain Dose with adrenaline

Bupivacaine 2mg/Kg 2mg/Kg

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Prilocaine 6mg/Kg 9mg/Kg

These are a guide only as actual doses depend on site of administration, tissue
vascularity and co-morbidities.

Maximum total local anaesthetic doses

Lignocaine 1% plain - 3mg/ Kg - 200mg (20ml)
Lignocaine 1% with 1 in 200,000 adrenaline - 7mg/Kg - 500mg (50ml)
Bupivacaine 0.5% - 2mg/kg- 150mg (30ml)
Maximum doses are based on ideal body weight

Effects of adrenaline
Adrenaline may be added to local anaesthetic drugs. It prolongs the duration of
action at the site of injection and permits usage of higher doses (see above). It is
contra indicated in patients taking MAOI's or tricyclic antidepressants. The toxicity
of bupivacaine is related to protein binding and addition of adrenaline to this drug
does not permit increases in the total dose of bupivacaine, in contrast to the
situation with lignocaine.

References
An excellent review is provided by:
French J and Sharp L. Local Anaesthetics. Ann R Coll Surg Engl 2012; 94: 76-80.

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Question 48 of 64
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A 22 year old man presents with a peri anal abscess, which is managed by incision
and drainage. The perineal wound measures 3cm by 3cm. Which of the following
is best management option?

Primary closure with interrupted mattress sutures

Delayed primary closure with interrupted mattress sutures

Allow the wound to heal by secondary intention

Insert a seton through the cavity into the rectum to allow a mature fistula
track to develop

Perform a V-Y flap 2 weeks later

Peri anal abscess are typically managed by secondary intention healing. Any
attempt at early closure is at best futile and at worst dangerous. Insertion of a
seton may be considered by an experienced colorectal surgeon, and only if the
tract is clearly identifiable with minimal probing. There is seldom a need for flaps,
ongoing discharge usually indicates a fistula (managed separately).

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Wound healing

Surgical wounds are either incisional or excisional and either clean, clean
contaminated or dirty. Although the stages of wound healing are broadly similar
their contributions will vary according to the wound type.

The main stages of wound healing include:

Haemostasis
Minutes to hours following injury
 Vasospasm in adjacent vessels, platelet plug formation and generation of
fibrin rich clot.
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Inflammation
Typically days 1-5
Neutrophils migrate into wound (function impaired in diabetes).
Growth factors released, including basic fibroblast growth factor and
vascular endothelial growth factor.
Fibroblasts replicate within the adjacent matrix and migrate into wound.
Macrophages and fibroblasts couple matrix regeneration and clot
substitution.

Regeneration
Typically days 7 to 56
Platelet derived growth factor and transformation growth factors stimulate
fibroblasts and epithelial cells.
Fibroblasts produce a collagen network.
Angiogenesis occurs and wound resembles granulation tissue.

Remodeling
From 6 weeks to 1 year
Longest phase of the healing process and may last up to one year (or
longer).
During this phase fibroblasts become differentiated (myofibroblasts) and
these facilitate wound contraction.
Collagen fibres are remodeled.
Microvessels regress leaving a pale scar.

The above description represents an idealised scenario. A number of diseases

may distort this process. Neovascularisation is an important early process.
Endothelial cells may proliferate in the wound bed and recanalise to form a vessel.
Vascular disease, shock and sepsis can all compromise microvascular flow and
impair healing.

Conditions such as jaundice will impair fibroblast synthetic function and immunity
with a detrimental effect in most parts of the healing process.

Problems with scars:

Hypertrophic scars
Excessive amounts of collagen within a scar. Nodules may be present
histologically containing randomly arranged fibrils within and parallel fibres on the
surface. The tissue itself is confined to the extent of the wound itself and is usually
the result of a full thickness dermal injury. They may go on to develop
contractures.
 Image of hypertrophic scarring. Note that it remains confined to the boundaries of
the original wound:
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([Link]
Image sourced from Wikipedia ([Link]
([Link] /images_eMRCS/[Link])

Keloid scars
Excessive amounts of collagen within a scar. Typically a keloid scar will pass
beyond the boundaries of the original injury. They do not contain nodules and may
occur following even trivial injury. They do not regress over time and may recur
following removal.

Image of a keloid scar. Note the extension beyond the boundaries of the original
incision:

([Link]
 Image sourced from Wikipedia ([Link]
([Link] /images_eMRCS/[Link])

Drugs which impair wound healing:

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Non steroidal anti inflammatory drugs

Steroids
Immunosupressive agents
Anti neoplastic drugs

Closure
Delayed primary closure is the anatomically precise closure that is delayed for a
few days but before granulation tissue becomes macroscopically evident.

Secondary closure refers to either spontaneous closure or to surgical closure after

granulation tissue has formed.

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Question 49 of 64
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Which of the following statements relating to pre-operative fluid management is

false?

5% dextrose should be given cautiously in the elderly

Patients undergoing elective colonic resections may continue to drink

water up to 2 hours prior to surgery

Normal saline increases the risk of hyperchloraemic acidosis

A 70kg man will need approximately 100mmol of sodium daily

Carbohydrate rich beverages and loading drinks can cause ileus therefore
should be avoided

Carbohydrate loading is one of the enhanced recovery principles.

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Pre operative fluid management

Fluid management has been described in the British Consensus guidelines on IV

fluid therapy for Adult Surgical patients (GIFTASUP) and by NICE (CG174
December 2013 updated May 2017)

The Recommendations include:

Use Ringer's lactate or Hartmann's when a crystalloid is needed for
resuscitation or replacement of fluids. Avoid 0.9% N. Saline (due to risk of
hyperchloraemic acidosis) unless patient vomiting or has gastric drainage.
Use 4%/0.18% dextrose saline or 5% dextrose in maintenance fluids. It
should not be used in resuscitation or as replacement fluids.
Adult maintenance fluid requirements are: Na 50-100 mmol/day and K 40-80
mmol/day in 1.5-2.5L fluid per day.
 Patients for elective surgery should NOT be nil by mouth for >2 hours
(unless has disorder of gastric emptying).
Patients for elective surgery should be given carbohydrate rich drinks 2-3h
before. Ideally this should form part of a normal pre op plan to facilitate
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recovery.
Avoid mechanical bowel preparation.
If bowel prep is used, simultaneous administration of Hartmann's or Ringer's
lactate should be considered.
Excessive fluid losses from vomiting should be treated with a crystalloid
with potassium replacement. 0.9% N. Saline should be given if there is
hypochloraemia. Otherwise Hartmann's or Ringer lactate should be given for
diarrhoea/ileostomy/ileus/obstruction. Hartmann's should also be given in
sodium losses secondary to diuretics.
High risk patients should receive fluids and inotropes.
An attempt should be made to detect pre or operative hypovolaemia using
flow based measurements. If this is not available, then clinical evaluation is
needed i.e. JVP, pulse volume etc.
In Blood loss or infection causing hypovolaemia should be treated with a
balanced crystalloid or colloid (or until blood available in blood loss). A
critically ill patient is unable to excrete Na or H20 leading to a 5% risk of
interstitial oedema. Therefore 5% dextrose as well as colloid should be
given.
If patients need IV fluid resuscitation, use crystalloids that contain sodium in
the range 130-154 mmol/l, with a bolus of 500 ml over less than 15 minutes
(NICE Guidance CG 174).

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 

Question 50 of 64
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A 63 year old man undergoes an Ivor - Lewis oesophagogastrectomy for

carcinoma of the distal oesophagus. The following day a pale opalescent liquid is
noted to be draining from the right chest drain. What is the most likely explanation?

Lung injury

Chyle leak

Anastomotic leak

Infection

Seroma

Damage to the lymphatic duct may occur during this procedure and some
surgeons administer a lipid rich material immediately prior to surgery to facilitate
its identification in the event of iatrogenic damage.

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Surgical complications

Complications occur in all branches of surgery and require vigilance in their

detection. In many cases anticipating the likely complications and appropriate
avoidance will minimise their occurrence. For the purposes of the MRCS the
important principles to appreciate are:

The anatomical principles that underpin complications

The physiological and biochemical derangements that occur
The most appropriate diagnostic modalities to utilise
The principles which underpin their management
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considerable overlap with other topic areas within the website.

Avoiding complications
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Some points to hopefully avert complications:

World Health Organisation checklist- now mandatory prior to all operations

Prophylactic antibiotics - right dose, right drug, right time.
Assess DVT/ PE risk and ensure adequate prophylaxis
MARK site of surgery
Use tourniquets with caution and with respect for underlying structures
Remember the danger of end arteries and in situations where they occur
avoid using adrenaline containing solutions and monopolar diathermy.
Handle tissues with care- devitalised tissue serves as a nidus for infection
Be very wary of the potential for coupling injuries when using diathermy
during laparoscopic surgery
The inferior epigastric artery is a favorite target for laparoscopic ports and
surgical drains!

Anatomical principles
Understanding the anatomy of a surgical field will allow appreciation of local and
systemic complications that may occur. For example, nerve injuries may occur
following surgery in specific regions. The table below lists some of the more
important nerves to consider and mechanisms of injury

Nerve Mechanism

Accessory Posterior triangle lymph node biopsy

Sciatic Posterior approach to hip

Common peroneal Legs in Lloyd Davies position

Long thoracic Axillary node clearance

Pelvic autonomic nerves Pelvic cancer surgery

Recurrent laryngeal nerves During thyroid surgery

Hypoglossal nerve During carotid endarterectomy

Ulnar and median nerves During upper limb fracture repairs

These are just a few. The detailed functional sequelae are particularly important
and will often be tested. In addition to nerve injuries certain procedures carry risks
 of visceral or structural injury. Again some particular favorites are given below:

Structure Mechanism
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Thoracic duct During thoracic surgery e.g. Pneumonectomy,

oesphagectomy

Parathyroid During difficult thyroid surgery

glands

Ureters During colonic resections/ gynaecological surgery

Bowel Use of Verres Needle to establish pneumoperitoneum

perforation

Bile duct injury Failure to delineate Calots triangle carefully and careless
use of diathermy

Facial nerve Always at risk during Parotidectomy

Tail of pancreas When ligating splenic hilum

Testicular During re-do open hernia surgery

vessels

Hepatic veins During liver mobilisation

Again many could be predicted from the anatomy of the procedure.

Physiological derangements
A very common complication is bleeding and this is covered under the section of
haemorrhagic shock. Another variant is infection either superficial or deep seated.
The organisms are covered under microbiology and the features of sepsis covered
under shock. Do not forget that immunocompromised and elderly patients may
present will atypical physiological parameters.

Selected physiological and biochemical issues are given below:

Complication Physiological/ Biochemical Problem

Arrhythmias following Susceptibility to hypokalaemia (K+ <4.0 in cardiac

cardiac surgery patients)

Neurosurgical electrolyte SIADH following cranial surgery causing

disturbance hyponatraemia
 Complication Physiological/ Biochemical Problem

Ileus following Fluid sequestration and loss of electrolytes

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gastrointestinal surgery

Pulmonary oedema Loss of lung volume makes these patients very

following sensitive to fluid overload
pneumonectomy

Anastamotic leak Generalised sepsis causing mediastinitis or

peritonitis depending on site of leak

Myocardial infarct May follow any type of surgery and in addition to

direct cardiac effects the decreased cardiac output
may well compromise grafts etc.

Try making a short list of problems and causes specific to your own clinical area.

Diagnostic modalities
Depends largely on the suspected complication. In the acutely unwell surgical
patient the following baseline investigations are often helpful:
Full blood count, urea and electrolytes, C- reactive protein (trend rather than
absolute value), serum calcium, liver function tests, clotting (don't forget to
repeat if on-going bleeding)
Arterial blood gases
ECG (+cardiac enzymes if MI suspected)
Chest x-ray to identify collapse/ consolidation
Urine analysis for UTI

These will often identify the most common complications.

Special tests
CT scanning for identification of intra-abdominal abscesses
Doppler USS of leg veins- for identification of DVT
CTPA for PE
Sending peritoneal fluid for U+E (if ureteric injury suspected) or amylase (if
pancreatic injury suspected)
Echocardiogram if pericardial effusion suspected post cardiac surgery and
no pleural window made.

Management of complications
The guiding principal should be safe and timely intervention. Patients should be
stabilised and if an operation needs to occur in tandem with resuscitation then
generally this should be of a damage limitation type procedure rather than
definitive surgery (which can be more safely undertaken in a stable patient the
 following day).

Remember that recent surgery is a contra indication to thrombolysis and that in

some patients IV heparin may be preferable to a low molecular weight heparin
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(easier to reverse).

As a general rule laparotomies for bleeding should follow the core principle of
quadrant packing and then subsequent pack removal rather than plunging large
clamps into pools of blood. The latter approach invariable worsens the situation is
often accompanied by significant visceral injury particularly when done by the
inexperienced. If packing controls a situation it is entirely acceptable practice to
leave packs in situ and return the patient to ITU for pack removal the subsequent
day.

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Question 51 of 64
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A 52 year old male presents with tearing central chest pain. On examination, he
has an aortic regurgitation murmur. An ECG shows ST elevation in leads II, III and
aVF. What is the likely explanation?

Distal aortic dissection

Anterior myocardial infarct

Inferior myocardial infarct

Proximal aortic dissection

Pulmonary embolism

An inferior myocardial infarction and AR murmur should raise suspicions of an

ascending aorta dissection rather than an inferior myocardial infarction alone. Also
the history is more suggestive of a dissection. Other features may include
pericardial effusion, carotid dissection and absent subclavian pulse.

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Chest pain

Aortic dissection
This occurs when there is a flap or filling defect within the aortic intima.
Blood tracks into the medial layer and splits the tissues with the subsequent
creation of a false lumen. It most commonly occurs in the ascending aorta
or just distal to the left subclavian artery (less common). It is most common
in Afro-carribean males aged 50-70 years.
Patients usually present with a tearing intrascapular pain, which may be
similar to the pain of a myocardial infarct.
The dissection may spread either proximally or distally with subsequent
disruption to the arterial branches that are encountered.
 In the Stanford classification system the disease is classified into lesions
with a proximal origin (Type A) and those that commence distal to the left
subclavian (Type B).
Diagnosis may be suggested by a chest x-ray showing a widened
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mediastinum. Confirmation of the diagnosis is usually made by use of CT

angiography
Proximal (Type A) lesions are usually treated surgically, type B lesions are
usually managed non operatively.

Pulmonary embolism
Typically sudden onset of chest pain, haemoptysis, hypoxia and small
pleural effusions may be present.
Most patients will have an underlying deep vein thrombosis
Diagnosis may be suggested by various ECG findings including S waves in
lead I, Q waves in lead III and inverted T waves in lead III. Confirmation of
the diagnosis is usually made through use of CT pulmonary angiography.
Treatment is with anticoagulation, in those patients who develop a cardiac
arrest or severe compromise from their PE, consideration may be given to
thrombolysis.

Myocardial infarction
Traditionally described as sudden onset of central, crushing chest pain. It
may radiate into the neck and down the left arm. Signs of autonomic
dysfunction may be present. The presenting features may be atypical in the
elderly and those with diabetes.
Diagnosis is made through identification of new and usually dynamic ECG
changes (and cardiac enzyme changes). Inferior and anterior infarcts may
be distinguished by the presence of specific ECG changes (usually II, III and
aVF for inferior, leads V1-V5 for anterior).
Treatment is with oral antiplatelet agents, primary coronary angioplasty and/
or thrombolysis.

Perforated peptic ulcer

Patients usually develop sudden onset of epigastric abdominal pain, it may
be soon followed by generalised abdominal pain.
There may be features of antecendant abdominal discomfort, the pain of
gastric ulcer is typically worse immediately after eating.
Diagnosis may be made by erect chest x-ray which may show a small
amount of free intra-abdominal air (very large amounts of air are more
typically associated with colonic perforation).
Treatment is usually with a laparotomy, small defects may be excised and
overlaid with an omental patch, larger defects are best managed with a
partial gastrectomy.

Boerhaaves syndrome
Spontaneous rupture of the oesophagus that occurs as a result of repeated
 episodes of vomiting.
The rupture is usually distally sited and on the left side.
Patients usually give a history of sudden onset of severe chest pain that
may complicate severe vomiting.
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Severe sepsis occurs secondary to mediastinitis.

Diagnosis is CT contrast swallow.
Treatment is with thoracotomy and lavage, if less than 12 hours after onset
then primary repair is usually feasible, surgery delayed beyond 12 hours is
best managed by insertion of a T tube to create a controlled fistula between
oesophagus and skin.
Delays beyond 24 hours are associated with a very high mortality rate.

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Question 52 of 64
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A 3 year old is involved in trauma and is haemodynamically unstable. Initial

attempts at intravenous access are proving unsuccessful. What is the best course
of action?

Insert a femoral venous central line

Insert a right internal jugular central line

Insert an intra osseous infusion system

Insert a 14 G cannula into the antecubital fossa

Insert a Broviac line

Gaining venous access in small children is challenging at the best of times and
when they are shut down its nearly impossible. Intraosseous infusions are best in
this setting. Broviac lines are long term IV access systems with narrow lumens and
would be unsuitable.

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Intravenous access

Venous access
A number of routes for establishing venous access are available.

Peripheral venous cannula

Easy to insert with minimal morbidity. Wide lumen cannulae can provide rapid fluid
infusions. When properly managed infections may be promptly identified and the
cannula easily re sited. Problems relate to their peripheral sites and they are
unsuitable for the administration of vaso active drugs, such as inotropes and
irritant drugs such as TPN (except in the very short term setting).
 Central lines
Insertion is more difficult and most operators and NICE advocate the use of ultra
sound. Coagulopathies may lead to haemorrhage following iatrogenic arterial
injury. Femoral lines are easier to insert and iatrogenic injuries easier to manage in
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this site however they are prone to high infection rates. Internal jugular route is
preferred. They have multiple lumens allowing for administration of multiple
infusions. The lumens are relatively narrow and thus they do not allow particularly
rapid rates of infusion.

Intraosseous access
This is typically undertaken at the anteromedial aspect of the proximal tibia and
provides access to the marrow cavity and circulatory system. Although
traditionally preferred in paediatric practice they may be used in adults and a wide
range of fluids can be infused using these devices.

Tunneled lines
Tunneled lines such as Groshong and Hickman lines are popular devices for
patients with long term therapeutic requirements. These devices are usually
inserted using ultrasound guidance into the internal jugular vein and then tunneled
under the skin. A cuff of woven material is sited near the end and helps to anchor
the device into the tissues. These cuffs require formal dissection to allow the
device to be removed. Tunneled lines can be linked to injection ports that are
located under the skin. These are especially popular in paediatric practice.

Peripherally inserted central cannula

Referred to as PICC lines, these are popular methods for establishing central
venous access. Because they are inserted peripherally they are less prone to major
complications relating to device insertion than conventional central lines.

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Question 53 of 64
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A 23 year old man with a 4cm lipoma on his flank is due to have this removed as a
daycase. He is otherwise well. What is his ASA?

Absence of co-morbidities and small procedure with no systemic compromise will

equate to an ASA score of 1.

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American Society of anesthesiologists physical status scoring

system (ASA)

ASA Description
grade

1 No organic physiological, biochemical or psychiatric disturbance.

The surgical pathology is localised and has not invoked systemic
disturbance

2 Mild or moderate systemic disruption caused either by the surgical

disease process or though underlying pre-existing disease
 3 Severe systemic disruption caused either by the surgical pathology
or pre-existing disease
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4 Patient has severe systemic disease that is a constant threat to life

5 A patient who is moribund and will not survive without surgery

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Question 54 of 64
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What is the most appropriate analgesic to administer to a term neonate who is

recovering following an inguinal herniotomy?

Co-codamol

Paracetamol

Ibuprofen

Carbamazepine

Codeine

Paracetamol is an effective analgesic in children and pain following herniotomy is

relatively minor. Note that codeine is contra indicated in neonates. The child is too
young to receive ibuprofen.

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Management of pain

World Health Organisation Analgesic Ladder

Initially peripherally acting drugs such as paracetamol or non-steroidal anti-
inflammatory drugs (NSAIDs) are given.
If pain control is not achieved, the second part of the ladder is to introduce
weak opioid drugs such as codeine or dextropropoxyphene together with
appropriate agents to control and minimise side effects.
The final rung of the ladder is to introduce strong opioid drugs such as
morphine. Analgesia from peripherally acting drugs may be additive to that
from centrally-acting opioids and thus, the two are given together.

The World Federation of Societies of Anaesthesiologists (WFSA) Analgesic

 Ladder
For management of acute pain
Initially, the pain can be expected to be severe and may need controlling with
strong analgesics in combination with local anaesthetic blocks and
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peripherally acting drugs.

The second rung on the postoperative pain ladder is the restoration of the
use of the oral route to deliver analgesia. Strong opioids may no longer be
required and adequate analgesia can be obtained by using combinations of
peripherally acting agents and weak opioids.
The final step is when the pain can be controlled by peripherally acting
agents alone.

Local anaesthetics
Infiltration of a wound with a long-acting local anaesthetic such as
Bupivacaine
Analgesia for several hours
Further pain relief can be obtained with repeat injections or by infusions via
a thin catheter
Blockade of plexuses or peripheral nerves will provide selective analgesia in
those parts of the body supplied by the plexus or nerves
Can either be used to provide anaesthesia for the surgery or specifically for
postoperative pain relief
Especially useful where a sympathetic block is needed to improve
postoperative blood supply or where central blockade such as spinal or
epidural blockade is contraindicated.

Spinal anaesthesia
Provides excellent analgesia for surgery in the lower half of the body and pain
relief can last many hours after completion of the operation if long-acting drugs
containing vasoconstrictors are used.

- Side effects of spinal anaesthesia include: hypotension, sensory and motor block,
nausea and urinary retention.

Epidural anaesthesia
An indwelling epidural catheter inserted. This can then be used to provide a
continuous infusion of analgesic agents. It can provide excellent analgesia. They
are still the preferred option following major open abdominal procedures and help
prevent post operative respiratory compromise resulting from pain.

- Disadvantages of epidurals is that they usually confine patients to bed, especially

if a motor block is present. In addition an indwelling urinary catheter is required.
Which may not only impair mobility but also serve as a conduit for infection. They
are contraindicated in coagulopathies.

Transversus Abdominal Plane block (TAP)

In this technique an ultrasound is used to identify the correct muscle plane and
 local anaesthetic (usually bupivicaine) is injected. The agent diffuses in the plane
and blocks many of the spinal nerves. It is an attractive technique as it provides a
wide field of blockade but does not require the placement of any indwelling
devices. There is no post operative motor impairment. For this reason it is the
gathered by dr. elbarky, for free, not intended for profit by anybody elsewhere.

preferred technique when extensive laparoscopic abdominal procedures are

performed. They will then provide analgesia immediately following surgery but as
they do not confine the patient to bed, the focus on enhanced recovery can begin
sooner.

-The main disadvantage is that their duration of action is limited to the half life of
the local anaesthetic agent chosen. In addition some anaesthetists do not have
the USS skills required to site the injections.

Patient Controlled Analgesia (PCA)

- Patients administer their own intravenous analgesia and titrate the dose to their
own end-point of pain relief using a small microprocessor - controlled pump.
Morphine is the most popular drug used.

Strong Opioids

Severe pain arising from deep or visceral structures requires the use of strong
opioids

Morphine
Short half life and poor bioavailability.
Metabolised in the liver and clearance is reduced in patients with liver
disease, in the elderly and the debilitated
Side effects include nausea, vomiting, constipation and respiratory
depression.
Tolerance may occur with repeated dosage

Pethidine
Synthetic opioid which is structurally different from morphine but which has
similar actions. Has 10% potency of morphine.
Short half life and similar bioavailability and clearance to morphine.
Short duration of action and may need to be given hourly.
Pethidine has a toxic metabolite (norpethidine) which is cleared by the
kidney, but which accumulates in renal failure or following frequent and
prolonged doses and may lead to muscle twitching and convulsions.
Extreme caution is advised if pethidine is used over a prolonged period or in
patients with renal failure.

Weak opioids
Codeine: markedly less active than morphine, has predictable effects when given
 orally and is effective against mild to moderate pain.

Non opioid analgesics

- Mild to moderate pain.
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Paracetamol
Inhibits prostaglandin synthesis.
Analgesic and antipyretic properties but little anti-inflammatory effect
It is well absorbed orally and is metabolised almost entirely in the liver
Side effects in normal dosage and is widely used for the treatment of minor
pain. It causes hepatotoxicity in over dosage by overloading the normal
metabolic pathways with the formation of a toxic metabolite.

NSAIDs
Analgesic and anti-inflammatory actions
Inhibition of prostaglandin synthesis by the enzyme Cyclooxygenase which
catalyses the conversion of arachidonic acid to the various prostaglandins
that are the chief mediators of inflammation. All NSAIDs work in the same
way and thus there is no point in giving more than one at a time. .
NSAIDs are, in general, more useful for superficial pain arising from the skin,
buccal mucosa, joint surfaces and bone.
Relative contraindications: history of peptic ulceration, gastrointestinal
bleeding or bleeding diathesis; operations associated with high blood loss,
asthma, moderate to severe renal impairment, dehydration and any history
of hypersensitivity to NSAIDs or aspirin.

Neuropathic pain
National Institute of Clinical Excellence (UK) guidelines:
First line: Amitriptyline (Imipramine if cannot tolerate) or pregabalin
Second line: Amitriptyline AND pregabalin
Third line: refer to pain specialist. Give tramadol in the interim (avoid
morphine)
If diabetic neuropathic pain: Duloxetine

References
1. [Link]
2. Charlton E. The Management of Postoperative Pain . Update in Anaesthesia.
Issue 7 (1997)

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Question 55 of 64
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 

What is the most appropriate analgesic modality for a 52 year old male undergoing
an open elective resection of the splenic flexure colonic cancer?

TAP block

Local anaesthetic wound infiltration

Spinal block

Epidural anaesthetic

Rectal diclofenac

An open resection of a splenic flexure cancer will require a long midline incision
and carries the potential for respiratory compromise. This is best countered with a
well placed epidural. An alternative would be rectus sheath catheter infiltration of
local anaesthetic and PCA.

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Management of pain

World Health Organisation Analgesic Ladder

Initially peripherally acting drugs such as paracetamol or non-steroidal anti-
inflammatory drugs (NSAIDs) are given.
If pain control is not achieved, the second part of the ladder is to introduce
weak opioid drugs such as codeine or dextropropoxyphene together with
appropriate agents to control and minimise side effects.
The final rung of the ladder is to introduce strong opioid drugs such as
morphine. Analgesia from peripherally acting drugs may be additive to that
from centrally-acting opioids and thus, the two are given together.
 The World Federation of Societies of Anaesthesiologists (WFSA) Analgesic
Ladder
For management of acute pain
Initially, the pain can be expected to be severe and may need controlling with
gathered by dr. elbarky, for free, not intended for profit by anybody elsewhere.

strong analgesics in combination with local anaesthetic blocks and

peripherally acting drugs.
The second rung on the postoperative pain ladder is the restoration of the
use of the oral route to deliver analgesia. Strong opioids may no longer be
required and adequate analgesia can be obtained by using combinations of
peripherally acting agents and weak opioids.
The final step is when the pain can be controlled by peripherally acting
agents alone.

Local anaesthetics
Infiltration of a wound with a long-acting local anaesthetic such as
Bupivacaine
Analgesia for several hours
Further pain relief can be obtained with repeat injections or by infusions via
a thin catheter
Blockade of plexuses or peripheral nerves will provide selective analgesia in
those parts of the body supplied by the plexus or nerves
Can either be used to provide anaesthesia for the surgery or specifically for
postoperative pain relief
Especially useful where a sympathetic block is needed to improve
postoperative blood supply or where central blockade such as spinal or
epidural blockade is contraindicated.

Spinal anaesthesia
Provides excellent analgesia for surgery in the lower half of the body and pain
relief can last many hours after completion of the operation if long-acting drugs
containing vasoconstrictors are used.

- Side effects of spinal anaesthesia include: hypotension, sensory and motor block,
nausea and urinary retention.

Epidural anaesthesia
An indwelling epidural catheter inserted. This can then be used to provide a
continuous infusion of analgesic agents. It can provide excellent analgesia. They
are still the preferred option following major open abdominal procedures and help
prevent post operative respiratory compromise resulting from pain.

- Disadvantages of epidurals is that they usually confine patients to bed, especially

if a motor block is present. In addition an indwelling urinary catheter is required.
Which may not only impair mobility but also serve as a conduit for infection. They
are contraindicated in coagulopathies.

Transversus Abdominal Plane block (TAP)

 In this technique an ultrasound is used to identify the correct muscle plane and
local anaesthetic (usually bupivicaine) is injected. The agent diffuses in the plane
and blocks many of the spinal nerves. It is an attractive technique as it provides a
wide field of blockade but does not require the placement of any indwelling
gathered by dr. elbarky, for free, not intended for profit by anybody elsewhere.

devices. There is no post operative motor impairment. For this reason it is the
preferred technique when extensive laparoscopic abdominal procedures are
performed. They will then provide analgesia immediately following surgery but as
they do not confine the patient to bed, the focus on enhanced recovery can begin
sooner.

-The main disadvantage is that their duration of action is limited to the half life of
the local anaesthetic agent chosen. In addition some anaesthetists do not have
the USS skills required to site the injections.

Patient Controlled Analgesia (PCA)

- Patients administer their own intravenous analgesia and titrate the dose to their
own end-point of pain relief using a small microprocessor - controlled pump.
Morphine is the most popular drug used.

Strong Opioids

Severe pain arising from deep or visceral structures requires the use of strong
opioids

Morphine
Short half life and poor bioavailability.
Metabolised in the liver and clearance is reduced in patients with liver
disease, in the elderly and the debilitated
Side effects include nausea, vomiting, constipation and respiratory
depression.
Tolerance may occur with repeated dosage

Pethidine
Synthetic opioid which is structurally different from morphine but which has
similar actions. Has 10% potency of morphine.
Short half life and similar bioavailability and clearance to morphine.
Short duration of action and may need to be given hourly.
Pethidine has a toxic metabolite (norpethidine) which is cleared by the
kidney, but which accumulates in renal failure or following frequent and
prolonged doses and may lead to muscle twitching and convulsions.
Extreme caution is advised if pethidine is used over a prolonged period or in
patients with renal failure.

Weak opioids
 Codeine: markedly less active than morphine, has predictable effects when given
orally and is effective against mild to moderate pain.

Non opioid analgesics

gathered by dr. elbarky, for free, not intended for profit by anybody elsewhere.

- Mild to moderate pain.

Paracetamol
Inhibits prostaglandin synthesis.
Analgesic and antipyretic properties but little anti-inflammatory effect
It is well absorbed orally and is metabolised almost entirely in the liver
Side effects in normal dosage and is widely used for the treatment of minor
pain. It causes hepatotoxicity in over dosage by overloading the normal
metabolic pathways with the formation of a toxic metabolite.

NSAIDs
Analgesic and anti-inflammatory actions
Inhibition of prostaglandin synthesis by the enzyme Cyclooxygenase which
catalyses the conversion of arachidonic acid to the various prostaglandins
that are the chief mediators of inflammation. All NSAIDs work in the same
way and thus there is no point in giving more than one at a time. .
NSAIDs are, in general, more useful for superficial pain arising from the skin,
buccal mucosa, joint surfaces and bone.
Relative contraindications: history of peptic ulceration, gastrointestinal
bleeding or bleeding diathesis; operations associated with high blood loss,
asthma, moderate to severe renal impairment, dehydration and any history
of hypersensitivity to NSAIDs or aspirin.

Neuropathic pain
National Institute of Clinical Excellence (UK) guidelines:
First line: Amitriptyline (Imipramine if cannot tolerate) or pregabalin
Second line: Amitriptyline AND pregabalin
Third line: refer to pain specialist. Give tramadol in the interim (avoid
morphine)
If diabetic neuropathic pain: Duloxetine

References
1. [Link]
2. Charlton E. The Management of Postoperative Pain . Update in Anaesthesia.
Issue 7 (1997)

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Question 56 of 64
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 

A 30 year old male is admitted electively for a right inguinal hernia repair under
local anaesthesia. He is otherwise well but his grandfather died from a pulmonary
embolism. What is the most appropriate form of thromboprophylaxis?

Administration of low dose low molecular weight heparin for 2 weeks

Administration of high dose low molecular weight heparin for 2 weeks

No prophylaxis

Low dose low molecular weight heparin and pneumatic compression

stockings

High dose low molecular weight heparin and pneumatic compression

stockings

Inguinal hernia repairs under local anaesthetic have a short operative time and
patients are usually ambulant immediately afterwards. His family history is unlikely
to be significant and he is at very low risk.

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Thromboprophylaxis in surgical patients

Deep vein thrombosis may develop insidiously in many surgical patients. Untreated
it may progress to result in pulmonary embolism.
The following surgical patients are at increased risk of deep vein thrombosis:
Surgery greater than 90 minutes at any site or greater than 60 minutes if the
procedure involves the lower limbs or pelvis
Acute admissions with inflammatory process involving the abdominal cavity
Expected significant reduction in mobility
Age over 60 years
Known malignancy
 Thrombophilia
Previous thrombosis
BMI >30
Taking hormone replacement therapy or the contraceptive pill
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Varicose veins with phlebitis

Mechanical thromboprophylaxis
Early ambulation after surgery is cheap and is effective
Compression stockings (contra -indicated in peripheral arterial disease)
Intermittent pneumatic compression devices
Foot impulse devices

Therapeutic agents

Agent Mode of action Uses

Low molecular Binds Thromboprophylaxis or treatment of

weight heparin antithrombin thromboembolic events in those with
causing normal renal function. It is given as once
inhibition of daily subcutaneous injection
factor Xa

Unfractionated Binds Effective anticoagulation, administered

heparin antithrombin III intravenously it has a rapid onset and its
affecting therapeutic effects decline quickly on
thrombin and stopping and infusion. Its activity is
factor Xa measured using the APTT. If need be it
can be reversed using protamine
sulphate

Dabigatran Orally Used prophylaxis in hip and knee

administered surgery. It does not require therapeutic
direct thrombin monitoring. It should not be used in any
inhibitor patient in whom there is a risk of active
bleeding or imminent likelihood of
surgery. It is reversed using
Idarucizumab

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Question 57 of 64
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A 48 year old lady is being prepared for a Whipples procedure. A right sided
subclavian line is inserted and then anaesthesia is induced. Following intubation
the patient becomes progressively hypoxic and haemodynamically unstable. What
is the most likely underlying explanation?

Drug allergy

Simple pneumothorax

Tension pneumothorax

Halothane toxicity

Haemothorax

Central lines (and particularly subclavian lines) are risk factors for the
development of pneumothorax. In the context of positive pressure ventilation a
tension pneumothorax is a strong possibility and would be associated with
haemodynamic instability.

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Intravenous access

Venous access
A number of routes for establishing venous access are available.

Peripheral venous cannula

Easy to insert with minimal morbidity. Wide lumen cannulae can provide rapid fluid
infusions. When properly managed infections may be promptly identified and the
cannula easily re sited. Problems relate to their peripheral sites and they are
unsuitable for the administration of vaso active drugs, such as inotropes and
irritant drugs such as TPN (except in the very short term setting).
 Central lines
Insertion is more difficult and most operators and NICE advocate the use of ultra
sound. Coagulopathies may lead to haemorrhage following iatrogenic arterial
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injury. Femoral lines are easier to insert and iatrogenic injuries easier to manage in
this site however they are prone to high infection rates. Internal jugular route is
preferred. They have multiple lumens allowing for administration of multiple
infusions. The lumens are relatively narrow and thus they do not allow particularly
rapid rates of infusion.

Intraosseous access
This is typically undertaken at the anteromedial aspect of the proximal tibia and
provides access to the marrow cavity and circulatory system. Although
traditionally preferred in paediatric practice they may be used in adults and a wide
range of fluids can be infused using these devices.

Tunneled lines
Tunneled lines such as Groshong and Hickman lines are popular devices for
patients with long term therapeutic requirements. These devices are usually
inserted using ultrasound guidance into the internal jugular vein and then tunneled
under the skin. A cuff of woven material is sited near the end and helps to anchor
the device into the tissues. These cuffs require formal dissection to allow the
device to be removed. Tunneled lines can be linked to injection ports that are
located under the skin. These are especially popular in paediatric practice.

Peripherally inserted central cannula

Referred to as PICC lines, these are popular methods for establishing central
venous access. Because they are inserted peripherally they are less prone to major
complications relating to device insertion than conventional central lines.

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Question 58 of 64
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A 63 year old man undergoes a laparotomy and small bowel resection. Twelve
hours post operatively he is noted to have a decreased urine output. Which of the
hormones listed below is most likely to be responsible?

Cortisol

Atrial natriuretic hormone

Vasopressin

Insulin

Glucagon

Vasopressin is released in increased quantities following most operative

procedures and will tend to cause water retention. For this reason, excessive
administration of intravenous fluids in an attempt to force a diuresis may cause
fluid overload in post operative patients.

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Response to surgery

Sympathetic nervous system

Noradrenaline from sympathetic nerves and adrenaline from adrenal
medulla
Blood diverted from skin and visceral organs; bronchodilatation, reduced
intestinal motility, increased glucagon and glycogenolysis, insulin reduced
Heart rate and myocardial contractility are increased

Acute phase response

TNF-α, IL-1, IL-2, IL-6, interferon and prostaglandins are released
 Excess cytokines may cause SIRS
Cytokines increase the release of acute phase proteins
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Endocrine response
Hypothalamus, pituitary, adrenal axis
Increases ACTH and cortisol production:

increases protein breakdown

increases blood glucose levels
Aldosterone increases sodium re-absorption
Vasopressin increases water re-absorption and causes vasoconstriction

Vascular endothelium
Nitric oxide produces vasodilatation
Platelet activating factor enhances the cytokine response
Prostaglandins produce vasodilatation and induce platelet aggregation

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Question 59 of 64
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Which of the following would be the optimal fluid management option for a 45 year
old man due to undergo an elective right hemicolectomy?

Remain 'nil by mouth' for at least 6 hours pre-operatively and avoid intra
venous fluids

Remain 'nil by mouth' for at least 6 hours pre-operatively and receive

supplementary intravenous 5% dextrose to replace lost calories

Allow him free access to oral fluids only until 30 minutes prior to surgery

Administer a carbohydrate based loading drink 3 hours pre operatively, and

avoid intravenous fluids

Administer a carbohydrate based loading drink 6 hours pre-operatively and

administer 5% dextrose saline thereafter

Patients for elective surgery should not have solids for 6 hours pre-operatively.
However, clear fluids may be given up to 2 hours pre-operatively. Enhanced
recovery programmes are now the standard of care in many countries around the
world and involve administration of carbohydrate loading drinks.
The routine administration of 5% dextrose in the scenarios given above would
convey little in the way of benefit and increase the risks of electrolyte derangement
post operatively.

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Pre operative fluid management

Fluid management has been described in the British Consensus guidelines on IV

fluid therapy for Adult Surgical patients (GIFTASUP) and by NICE (CG174
December 2013 updated May 2017)
 The Recommendations include:
Use Ringer's lactate or Hartmann's when a crystalloid is needed for
resuscitation or replacement of fluids. Avoid 0.9% N. Saline (due to risk of
hyperchloraemic acidosis) unless patient vomiting or has gastric drainage.
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Use 4%/0.18% dextrose saline or 5% dextrose in maintenance fluids. It

should not be used in resuscitation or as replacement fluids.
Adult maintenance fluid requirements are: Na 50-100 mmol/day and K 40-80
mmol/day in 1.5-2.5L fluid per day.
Patients for elective surgery should NOT be nil by mouth for >2 hours
(unless has disorder of gastric emptying).
Patients for elective surgery should be given carbohydrate rich drinks 2-3h
before. Ideally this should form part of a normal pre op plan to facilitate
recovery.
Avoid mechanical bowel preparation.
If bowel prep is used, simultaneous administration of Hartmann's or Ringer's
lactate should be considered.
Excessive fluid losses from vomiting should be treated with a crystalloid
with potassium replacement. 0.9% N. Saline should be given if there is
hypochloraemia. Otherwise Hartmann's or Ringer lactate should be given for
diarrhoea/ileostomy/ileus/obstruction. Hartmann's should also be given in
sodium losses secondary to diuretics.
High risk patients should receive fluids and inotropes.
An attempt should be made to detect pre or operative hypovolaemia using
flow based measurements. If this is not available, then clinical evaluation is
needed i.e. JVP, pulse volume etc.
In Blood loss or infection causing hypovolaemia should be treated with a
balanced crystalloid or colloid (or until blood available in blood loss). A
critically ill patient is unable to excrete Na or H20 leading to a 5% risk of
interstitial oedema. Therefore 5% dextrose as well as colloid should be
given.
If patients need IV fluid resuscitation, use crystalloids that contain sodium in
the range 130-154 mmol/l, with a bolus of 500 ml over less than 15 minutes
(NICE Guidance CG 174).

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 Question stats

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The British Association for Parenteral and Enteral Nutrition

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British Consensus Guidelines on Intravenous Fluid Therapy for Adult Surgical
Patients

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Question 60 of 64
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Which of the following blood products can be administered to a non ABO matched
recipient?

Whole blood

Platelets

Packed red cells

Stem cells

Irradiated whole blood

In the UK, platelets either come from pooling of the platelet component from four
units of whole donated blood, called random donor platelets, or by plasmapharesis
from a single donor. The platelets are suspended in 200-300 ml of plasma and may
be stored for up to 4 days in the transfusion laboratory where they are continually
agitated at 22oC to preserve function. One adult platelet pool raises the normal
platelet count by 30,000 to 60,000 platelets litre. ABO identical or compatible
platelets are preferred but not necessary in adults; but rhesus compatibility is
required in recipients who are children and women of childbearing age to prevent
haemolytic disease of the newborn.

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Blood products - cross matching

Whole blood fractions

Fraction Key points

 Fraction Key points

Packed red cells Used for transfusion in chronic anaemia and cases where
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infusion of large volumes of fluid may result in

cardiovascular compromise. Product obtained by
centrifugation of whole blood.

Platelet rich Usually administered to patients who are

plasma thrombocytopaenic and are bleeding or require surgery. It is
obtained by low speed centrifugation.

Platelet Prepared by high speed centrifugation and administered to

concentrate patients with thrombocytopaenia.

Fresh frozen Prepared from single units of blood.

plasma Contains clotting factors, albumin and
immunoglobulin.
Unit is usually 200 to 250ml.
Usually used in correcting clotting deficiencies in
patients with hepatic synthetic failure who are due to
undergo surgery.
Usual dose is 12-15ml/Kg-1.
It should not be used as first line therapy for
hypovolaemia.

Cryoprecipitate Formed from supernatant of FFP.

Rich source of Factor VIII and fibrinogen.
Allows large concentration of factor VIII to be
administered in small volume.

SAG-Mannitol Removal of all plasma from a blood unit and substitution

Blood with:
Sodium chloride
Adenine
Anhydrous glucose
Mannitol

Up to 4 units of SAG M Blood may be administered.

Thereafter whole blood is preferred. After 8 units, clotting
factors and platelets should be considered.

Cross matching

Must be cross matched Can be ABO incompatible in adults

Packed red cells Platelets

 Must be cross matched Can be ABO incompatible in adults

Whole blood FFP

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Question 61 of 64
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Of the agents listed below, which is the most appropriate to give a 65 year old man
with a locally unresectable gastrointestinal stromal tumour. Biopsies confirm that
it is KIT positive.

Imatinib

Infliximab

Trastuzumab

Bevacizumab

Cetuximab

Imatinib is licensed for treatment of GIST in the United Kingdom for this situation.
The guidance from the National Institute of Clinical evidence is that patients be
reviewed at 12 weeks after initiating therapy.

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Biological agents

Agents Target Uses

Adalimumab TNF alpha inhibitor Crohns disease

Infliximab Rheumatoid disease
Etanercept

Bevacizumab Anti VEGF (anti angiogenic) Colorectal cancer

Renal
Glioblastoma
 Agents Target Uses

Trastuzumab HER receptor Breast cancer

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Imatinib Tyrosine kinase inhibitor Gastrointestinal stromal

tumours
Chronic myeloid leukaemia

Basiliximab IL2 binding site Renal transplants

Cetuximab Epidermal growth factor EGF positive colorectal

inhibitor cancers

Detailed understanding of the actions of biological agents is well beyond the

scope of the MRCS syllabus. However, many of these drugs are being frequently
encountered in surgical patients.

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Question 62 of 64
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A 66 year old man is admitted following a collapse whilst waiting for a bus. Clinical
examination confirms a ruptured abdominal aortic aneurysm. He is moribund and
hypotensive. What is his ASA?

Patients who are moribund and will not survive without surgery are graded as ASA
5.

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American Society of anesthesiologists physical status scoring

system (ASA)

ASA Description
grade

1 No organic physiological, biochemical or psychiatric disturbance.

The surgical pathology is localised and has not invoked systemic
disturbance

2 Mild or moderate systemic disruption caused either by the surgical

disease process or though underlying pre-existing disease
 3 Severe systemic disruption caused either by the surgical pathology
or pre-existing disease
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4 Patient has severe systemic disease that is a constant threat to life

5 A patient who is moribund and will not survive without surgery

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Question 63 of 64
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Which of the following preparatory regimes should be considered for a 63 year old
man with normal renal function who requires a diagnostic colonoscopy to
investigate iron deficiency anaemia for which he takes ferrous sulphate?

Stop ferrous sulphate 7 days pre procedure and administration of oral

purgatives the day prior to the procedure

Administration of oral purgatives the day prior to the procedure and

continue ferrous sulphate

Continue ferrous sulphate and administration of phosphate enemas on the

day

Cease ferrous sulphate 7 days pre procedure and administration of

phosphate enema 30 minutes pre procedure

No preparation required

Endoscopy requires full bowel preparation. In elderly patients, this can cause
electrolyte disturbance and renal compromise and it is important to check the
patients urea and electrolytes beforehand. Drugs like ferrous sulphate impair the
efficacy of purgatives and give poor endoscopic views as a result and should be
stopped beforehand.

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Endoscopy

Endoscopy is a procedure that allows the internal visualisation of the viscera.

Commonly performed procedures include, gastroscopy, colonoscopy, cystoscopy,
ERCP and bronchoscopy. It is different from laparoscopy as it does not usually
involve the inspection of a visceral cavity.
 Most endoscopes are flexible instruments with a 3 channels and a video chip with
illumination source at the end. The channels are used for suction, irrigation and
instrumentation. With the flexible instruments there is a control stack with wheels
that allow the tip of the instrument to be manipulated. Some procedures call for
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patient sedation and others do not. Endoscopies should usually be performed in

dedicated units with appropriately trained staff and full resuscitation facilities
available.

The preparation for endoscopy depends upon the organ to be examined. The table
below covers the key aspects

Endoscopy Preparation

ERCP Clotting, antibiotics, Vitamin K if jaundiced

Diagnostic OGD Nil by mouth for 6 hours

Flexible Phosphate enema 30 minutes pre procedure

sigmoidoscopy

Colonoscopy Check U+E and if normal, prescribe oral purgatives e.g.

picolax

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Question 64 of 64
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A 72 year old man attends vascular clinic after having an amputation 2 months
ago. He is having difficulty sleeping at night due to persistent tingling at the
amputation site. He is known to have orthostatic hypotension. What is the most
appropriate analgesic modality?

Amitriptylline

Pregabalin

Duloxetine

Morphine

Diclofenac

This patient has phantom limb pain which is a neuropathic pain. First line
management is with amitriptylline or pregabalin. However this patient has
orthostatic hypotension, which is a side effect of amitriptylline, therefore
pregabalin is the treatment of choice.

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Management of pain

World Health Organisation Analgesic Ladder

Initially peripherally acting drugs such as paracetamol or non-steroidal anti-
inflammatory drugs (NSAIDs) are given.
If pain control is not achieved, the second part of the ladder is to introduce
weak opioid drugs such as codeine or dextropropoxyphene together with
appropriate agents to control and minimise side effects.
The final rung of the ladder is to introduce strong opioid drugs such as
morphine. Analgesia from peripherally acting drugs may be additive to that
from centrally-acting opioids and thus, the two are given together.
 The World Federation of Societies of Anaesthesiologists (WFSA) Analgesic
Ladder
For management of acute pain
Initially, the pain can be expected to be severe and may need controlling with
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strong analgesics in combination with local anaesthetic blocks and

peripherally acting drugs.
The second rung on the postoperative pain ladder is the restoration of the
use of the oral route to deliver analgesia. Strong opioids may no longer be
required and adequate analgesia can be obtained by using combinations of
peripherally acting agents and weak opioids.
The final step is when the pain can be controlled by peripherally acting
agents alone.

Local anaesthetics
Infiltration of a wound with a long-acting local anaesthetic such as
Bupivacaine
Analgesia for several hours
Further pain relief can be obtained with repeat injections or by infusions via
a thin catheter
Blockade of plexuses or peripheral nerves will provide selective analgesia in
those parts of the body supplied by the plexus or nerves
Can either be used to provide anaesthesia for the surgery or specifically for
postoperative pain relief
Especially useful where a sympathetic block is needed to improve
postoperative blood supply or where central blockade such as spinal or
epidural blockade is contraindicated.

Spinal anaesthesia
Provides excellent analgesia for surgery in the lower half of the body and pain
relief can last many hours after completion of the operation if long-acting drugs
containing vasoconstrictors are used.

- Side effects of spinal anaesthesia include: hypotension, sensory and motor block,
nausea and urinary retention.

Epidural anaesthesia
An indwelling epidural catheter inserted. This can then be used to provide a
continuous infusion of analgesic agents. It can provide excellent analgesia. They
are still the preferred option following major open abdominal procedures and help
prevent post operative respiratory compromise resulting from pain.

- Disadvantages of epidurals is that they usually confine patients to bed, especially

if a motor block is present. In addition an indwelling urinary catheter is required.
Which may not only impair mobility but also serve as a conduit for infection. They
are contraindicated in coagulopathies.

Transversus Abdominal Plane block (TAP)

 In this technique an ultrasound is used to identify the correct muscle plane and
local anaesthetic (usually bupivicaine) is injected. The agent diffuses in the plane
and blocks many of the spinal nerves. It is an attractive technique as it provides a
wide field of blockade but does not require the placement of any indwelling
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devices. There is no post operative motor impairment. For this reason it is the
preferred technique when extensive laparoscopic abdominal procedures are
performed. They will then provide analgesia immediately following surgery but as
they do not confine the patient to bed, the focus on enhanced recovery can begin
sooner.

-The main disadvantage is that their duration of action is limited to the half life of
the local anaesthetic agent chosen. In addition some anaesthetists do not have
the USS skills required to site the injections.

Patient Controlled Analgesia (PCA)

- Patients administer their own intravenous analgesia and titrate the dose to their
own end-point of pain relief using a small microprocessor - controlled pump.
Morphine is the most popular drug used.

Strong Opioids

Severe pain arising from deep or visceral structures requires the use of strong
opioids

Morphine
Short half life and poor bioavailability.
Metabolised in the liver and clearance is reduced in patients with liver
disease, in the elderly and the debilitated
Side effects include nausea, vomiting, constipation and respiratory
depression.
Tolerance may occur with repeated dosage

Pethidine
Synthetic opioid which is structurally different from morphine but which has
similar actions. Has 10% potency of morphine.
Short half life and similar bioavailability and clearance to morphine.
Short duration of action and may need to be given hourly.
Pethidine has a toxic metabolite (norpethidine) which is cleared by the
kidney, but which accumulates in renal failure or following frequent and
prolonged doses and may lead to muscle twitching and convulsions.
Extreme caution is advised if pethidine is used over a prolonged period or in
patients with renal failure.

Weak opioids
 Codeine: markedly less active than morphine, has predictable effects when given
orally and is effective against mild to moderate pain.

Non opioid analgesics

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- Mild to moderate pain.

Paracetamol
Inhibits prostaglandin synthesis.
Analgesic and antipyretic properties but little anti-inflammatory effect
It is well absorbed orally and is metabolised almost entirely in the liver
Side effects in normal dosage and is widely used for the treatment of minor
pain. It causes hepatotoxicity in over dosage by overloading the normal
metabolic pathways with the formation of a toxic metabolite.

NSAIDs
Analgesic and anti-inflammatory actions
Inhibition of prostaglandin synthesis by the enzyme Cyclooxygenase which
catalyses the conversion of arachidonic acid to the various prostaglandins
that are the chief mediators of inflammation. All NSAIDs work in the same
way and thus there is no point in giving more than one at a time. .
NSAIDs are, in general, more useful for superficial pain arising from the skin,
buccal mucosa, joint surfaces and bone.
Relative contraindications: history of peptic ulceration, gastrointestinal
bleeding or bleeding diathesis; operations associated with high blood loss,
asthma, moderate to severe renal impairment, dehydration and any history
of hypersensitivity to NSAIDs or aspirin.

Neuropathic pain
National Institute of Clinical Excellence (UK) guidelines:
First line: Amitriptyline (Imipramine if cannot tolerate) or pregabalin
Second line: Amitriptyline AND pregabalin
Third line: refer to pain specialist. Give tramadol in the interim (avoid
morphine)
If diabetic neuropathic pain: Duloxetine

References
1. [Link]
2. Charlton E. The Management of Postoperative Pain . Update in Anaesthesia.
Issue 7 (1997)

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