This page intentionally left blank SAQs for the Final FRCA SAQs for the Final FRCA Dr James Nickells FRCA Dr Andy Georgiou FRCA Dr Ben Walton FRCA North Bristol NHS Trust Bristol CAMBRIDGE UNIVERSITY PRESS Cambridge, New York, Melbourne, Madrid, Cape Town, Singapore, São Paulo, Delhi, Dubai, Tokyo Cambridge University Press The Edinburgh Building, Cambridge CB2 8RU, UK Published in the United States of America by Cambridge University Press, New York www.cambridge.org Information on this title: www.cambridge.org/9780521739030 © J Nickells, A Georgiou and B Walton 2009 This publication is in copyright Subject to statutory exception and to the provision of relevant collective licensing agreements, no reproduction of any part may take place without the written permission of Cambridge University Press First published in print format 2009 ISBN-13 978-0-511-64132-9 eBook (NetLibrary) ISBN-13 978-0-521-73903-0 Paperback Cambridge University Press has no responsibility for the persistence or accuracy of urls for external or third-party internet websites referred to in this publication, and does not guarantee that any content on such websites is, or will remain, accurate or appropriate Every effort has been made in preparing this publication to provide accurate and up-to-date information which is in accord with accepted standards and practice at the time of publication Although case histories are drawn from actual cases, every effort has been made to disguise the identities of the individuals involved Nevertheless, the authors, editors and publishers can make no warranties that the information contained herein is totally free from error, not least because clinical standards are constantly changing through research and regulation The authors, editors and publishers therefore disclaim all liability for direct or consequential damages resulting from the use of material contained in this publication Readers are strongly advised to pay careful attention to information provided by the manufacturer of any drugs or equipment that they plan to use From James To the memory of Tessa Whitton, who was always fabulous and continues to be an inspiration From Andy To my parents, Maria and Sotos, without whom I wouldn’t have got this far, and to Lindsay, whose support for this exam was unfailing From Ben To Joseph and Isabella Contents Acknowledgements page ix Introduction SAQ FAQs QUESTION PAPERS 15 Paper 17 Paper 20 Paper 23 Paper 25 Paper 28 Paper 30 Paper 32 Paper 35 Paper 37 MODEL ANSWERS 41 Answers 43 Answers 63 Answers 82 Answers 99 vii Contents viii Answers 117 Answers 135 Answers 153 Answers 171 Answers 188 Index 205 Paper Schematic Diagram of the Triangle of Petit AnteriorlyExternal Oblique PosteriorlyLatissimus Dorsi Base- lliac Crest Figure 20 A 22G 50–100mm block (blunt) needle is inserted just above the iliac crest in the coronal plane at 90o to the skin Two ‘pops’ indicate passage of the needle through the fascia of external and then internal oblique, at which point the needle tip is in the transverse abdominal plane.✯✯ Levobupivacaine 0.375%✯ at a dose of up to 1mg/kg is injected incrementally after aspiration to exclude intravascular puncture Repeated aspiration is carried out after every 5ml injected The same injection is carried out on the contralateral side.✯✯ Monitor carefully for signs of local anaesthetic toxicity and block efficacy following surgical incision The use of ultrasound may improve needle placement and therefore block efficacy.✯ Reference McDonnell JG, O’Donnell B, Curley G, et al The analgesic efficacy of transversus abdominis plane block after abdominal surgery: a prospective randomised controlled trial Anesth Analg 2007; 104: 193–7 Question A 71-year-old gentleman becomes steadily more confused during transurethral resection of the prostate gland (TURP) under spinal anaesthesia You suspect TUR syndrome a) What is the mechanism for this condition? (30%) b) What is the management? (30%) c) How can the risk of developing this be reduced intraoperatively? (30%) Additional Notes Another surprise to us that this has not been asked before as it is a discrete topic, an anaesthetic emergency and involves some basic science Remember, there are many other causes of intraoperative confusion This is a question that under exam conditions requires lists and bullet points, NOT an essay Answer 196 a) The problem with the irrigation fluid used is that it needs to be non-conductive,✯ non-haemolytic✯ and must have neutral visual density.✯ Traditionally the only Paper solutions that could be used were electrolyte-free ones.✯ Recently, new resecting systems have come onto the market that use normal saline✯ but currently only approximately 15% of surgeons are using them The symptoms are caused by a combination of intravascular volume overload,✯✯ dilutional hyponatraemia✯✯ and intracellular oedema.✯✯ There may be additional problems due to glycine absorption such as visual impairment✯ and depressed conscious level,✯ glycine being an inhibitory neurotransmitter.✯ Hypothermia can exacerbate the problem due to the large volume (up to litres) of room-temperature fluid absorbed.✯ b) Like most emergency scenarios, initial management should be along the ‘Airway, Breathing, Circulation’ lines.✯✯ If still operating, ask the surgeon to diathermy all bleeding points and terminate surgery as soon as possible.✯ Insert an arterial line as regular blood gas analysis is likely and take baseline bloods for Na+, K+ and osmolarity.✯ Stop any intravenous fluids that may be being administered.✯ Call for senior help if appropriate as well as alerting the critical care team early on.✯ It may be necessary to intubate and ventilate the patient if he becomes obtunded.✯ Give furosemide 40mg intravenously and monitor response.✯ If Na+ is very low (25ml/cmH2O✯ vital capacity >10ml/kg✯ minute volume 5ml/kg✯ respiratory rate 40✯ Immobility, which may refer to the whole body, or be partial (e.g one limb in plaster of paris)✯✯ Varicose veins Pregnancy✯✯ Oral contraceptive pill✯ Paper Answer Co-morbidities Malignancy✯✯ Infection✯✯ Heart failure (and diseases resulting in poor cardiac output) Trauma, particularly if this results in lower limb immobility✯✯ Thrombophilia, e.g lupus anticoagulant in SLE, polycythaemia Type of surgery Estimated duration > 30 minutes✯ Major pelvic or abdominal✯✯ Major orthopaedic, e.g hip or knee✯✯ Additional factors contributing to Virchow’s Triad (venous stasis, abnormal coagulation and intimal damage) General anaesthesia (vs regional)✯ Critical illness Dehydration✯ Laparoscopic surgery with pneumoperitoneum The patient’s risk of VTE may then be stratified as low, medium or high based on the number of the above risk factors present b) Various levels of intervention Stop oral contraceptive pill weeks preoperatively if alternative contraceptive available, accepted by the patient and suitably high-risk situation Early mobilisation✯✯ Important for all patients (unless specific contraindications, e.g patient in traction) Graduated thromboembolic disease stockings (TEDS)✯✯ Suitable for all surgical patients unless contraindicated by arterial insufficiency of lower limbs confirmed with ankle-brachial pressure index of