Single  Best  Answers

Dr  Reema  AyyashConsultant  Anaesthetist

James  Cook  University  Hospital

1.  A  67-­‐year-­‐old  smoker  in  PACU  has  had  a  carotid  endarterectomy  under  general  anaesthesia.  4  hours  post-­‐operatively  he  is  complaining  of  chest  pain  for  30mins.  ECG  shows  ST  elevation  in  II,  III  and  aVF.  SpO2 is  88%,  BP  180/100mmHg,  HR  92/min.  Which  management  is  LEAST  likely  to  be  helpful  in  the  immediate  period?

a) O2 15/L  via  Hudson  maskb) GTN  infusion

c) Morphine   titrate  to  pain

d) Coronary  angiography

e) Referral  to  coronary  care  unit

these agents in patients without existing contraindications(hypotension, shock, bilateral renal artery stenosis or historyof worsening of renal function with ACE inhibitor/ARBexposure, renal failure, or drug allergy). The role of routinelong-term ACE inhibitor therapy in low-risk patients afterSTEMI who have been revascularized and treated withaggressive lipid-lowering therapies is less certain (432).ARBs are indicated for ACE inhibitor–intolerant patients.Specifically, valsartan was found to be noninferior to capto-pril in the VALIANT (Valsartan in Acute Myocardial Infarc-tion) trial (424).

The EPHESUS (Eplerenone Post-Acute Myocardial In-farction Heart Failure Efficacy and Survival) study estab-lished the benefit of an aldosterone antagonist, eplerenone,added to optimal medical therapy in eligible patients (creat-inine !2.5 mg/dL in men and !2.0 mg/dL in women,potassium !5.0 mEq/L) 3 to 14 days after STEMI with EF!0.40 and either symptomatic HF or diabetes mellitus (426).A post hoc analysis of the EPHESUS trial suggested atime-dependent treatment effect of eplerenone. Earlier initia-tion of the drug (!7 days) significantly reduced the rates ofall-cause mortality, sudden cardiac death (SCD), and cardio-vascular mortality/hospitalization, whereas initiation "7 dayshad no significant effect on outcomes (433).

8.3. Lipid Management: RecommendationsCLASS I

1. High-intensity statin therapy should be initiated or continued inall patients with STEMI and no contraindications to its use(434–436). (Level of Evidence: B)

CLASS IIa

1. It is reasonable to obtain a fasting lipid profile in patients withSTEMI, preferably within 24 hours of presentation. (Level ofEvidence: C)

Treatment with statins in patients stabilized after an ACS,including STEMI, lowers the risk of coronary heart diseasedeath, recurrent MI, stroke, and the need for coronaryrevascularization (437,438). More intensive statin therapy,compared with less intensive therapy, appears to be associ-ated with an additional lowering of nonfatal clinical end-points (434,436,439). Among currently available statins, onlyhigh-dose atorvastatin (80 mg daily) has been shown toreduce death and ischemic events among patients with ACS(436,440). Approximately one third of patients in thePROVE-IT TIMI 22 (Pravastatin or Atorvastatin Evaluationand Infection Therapy—Thrombolysis in Myocardial Infarc-tion 22) trial had STEMI (436). Cardiovascular event rateswere not significantly reduced with a tiered strategy ofsimvastatin (40-mg daily for 1 month followed by 80 mgdaily) in the A to Z Trial (Aggrastat to Zocor) (439), andconcerns have been raised recently about the safety ofhigh-dose simvastatin (i.e., 80 mg daily) (441). Although thebenefit of high-intensity statins declines among statin-naïvepatients with ACS as a function of decreasing low-densitylipoprotein levels (442), the writing committee recommendsthe use of statins in all patients with STEMI (435). Statintherapy after ACS is beneficial even in patients with baseline

low-density lipoprotein cholesterol levels !70 mg/dL (443).Trials of statin therapy in patients with ACS and stableischemic heart disease have been designed to compare eithermore intensive versus less intensive statin treatment or activestatin versus placebo (434–440). They have not been de-signed to compare clinical outcomes as a function of thespecific low-density lipoprotein cholesterol level achievedwith treatment. Improved compliance with therapy is a strongrationale for timing the initiation of lipid-lowering drugtherapy before discharge after STEMI. Longer-term lipidmanagement after STEMI, including indications for targetingtriglycerides and non–high-density lipoprotein cholesterol,are addressed in the “AHA/ACC Secondary Prevention andRisk Reduction Therapy for Patients With Coronary andOther Vascular Disease: 2011 Update” (257).

8.4. NitratesAlthough nitroglycerin can ameliorate symptoms and signs ofmyocardial ischemia by reducing LV preload and increasingcoronary blood flow, it generally does not attenuate themyocardial injury associated with epicardial coronary arteryocclusion unless vasospasm plays a significant role. Intrave-nous nitroglycerin may be useful to treat patients with STEMIand hypertension or HF. Nitrates should not be given topatients with hypotension, marked bradycardia or tachycar-dia, RV infarction, or 5=phosphodiesterase inhibitor usewithin the previous 24 to 48 hours (444). There is no role forthe routine use of oral nitrates in the convalescent phase ofSTEMI.

8.5. Calcium Channel BlockersAn overview of 28 RCTs involving 19,000 patients demon-strated no beneficial effect on infarct size or the rate ofreinfarction when calcium channel blocker therapy was ini-tiated during either the acute or convalescent phase of STEMI(445). Calcium channel blockers may be useful, however, torelieve ischemia, lower BP, or control the ventricular re-sponse rate to atrial fibrillation (AF) in patients who areintolerant of beta blockers. Caution is advised in patients withLV systolic dysfunction. The use of the immediate-releasenifedipine is contraindicated in patients with STEMI becauseof hypotension and reflex sympathetic activation with tachy-cardia (446).

8.6. OxygenFew data exist to support or refute the value of the routine useof oxygen in the acute phase of STEMI, and more research isneeded. A pooled Cochrane analysis of 3 trials showed a3-fold higher risk of death for patients with confirmed acuteMI treated with oxygen than for patients with acute MImanaged on room air. Oxygen therapy is appropriate forpatients who are hypoxemic (oxygen saturation !90%) andmay have a salutary placebo effect in others. Supplementaryoxygen may, however, increase coronary vascular resistance(447). Oxygen should be administered with caution to pa-tients with chronic obstructive pulmonary disease and carbondioxide retention.

e106 O’Gara et al. JACC Vol. 61, No. 4, 20132013 ACCF/AHA STEMI Guideline: Full Text January 29, 2013:e78–140

Downloaded From: http://content.onlinejacc.org/ on 07/20/2016

PRACTICE GUIDELINE

2013 ACCF/AHA Guideline for the Management ofST-Elevation Myocardial InfarctionA Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines

Developed in Collaboration With the American College of Emergency Physicians andSociety for Cardiovascular Angiography and Interventions

WRITING COMMITTEE MEMBERS*Patrick T. O’Gara, MD, FACC, FAHA, Chair†;

Frederick G. Kushner, MD, FACC, FAHA, FSCAI, Vice Chair*†; Deborah D. Ascheim, MD, FACC†;Donald E. Casey, Jr, MD, MPH, MBA, FACP, FAHA‡; Mina K. Chung, MD, FACC, FAHA*†;

James A. de Lemos, MD, FACC*†; Steven M. Ettinger, MD, FACC*§;James C. Fang, MD, FACC, FAHA*†; Francis M. Fesmire, MD, FACEP*!¶;

Barry A. Franklin, PHD, FAHA†; Christopher B. Granger, MD, FACC, FAHA*†;Harlan M. Krumholz, MD, SM, FACC, FAHA†; Jane A. Linderbaum, MS, CNP-BC†;

David A. Morrow, MD, MPH, FACC, FAHA*†; L. Kristin Newby, MD, MHS, FACC, FAHA*†;Joseph P. Ornato, MD, FACC, FAHA, FACP, FACEP†; Narith Ou, PharmD†;

Martha J. Radford, MD, FACC, FAHA†; Jacqueline E. Tamis-Holland, MD, FACC†;Carl L. Tommaso, MD, FACC, FAHA, FSCAI#; Cynthia M. Tracy, MD, FACC, FAHA†;

Y. Joseph Woo, MD, FACC, FAHA†; David X. Zhao, MD, FACC*†

ACCF/AHA TASK FORCE MEMBERSJeffrey L. Anderson, MD, FACC, FAHA, Chair;

Alice K. Jacobs, MD, FACC, FAHA, Immediate Past Chair;Jonathan L. Halperin, MD, FACC, FAHA, Chair-Elect;

Nancy M. Albert, PHD, CCNS, CCRN, FAHA; Ralph G. Brindis, MD, MPH, MACC;Mark A. Creager, MD, FACC, FAHA; David DeMets, PHD;

Robert A. Guyton, MD, FACC, FAHA; Judith S. Hochman, MD, FACC, FAHA;Richard J. Kovacs, MD, FACC; Frederick G. Kushner, MD, FACC, FAHA**;E. Magnus Ohman, MD, FACC; William G. Stevenson, MD, FACC, FAHA;

Clyde W. Yancy, MD, FACC, FAHA**

*Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply;see Appendix 1 for detailed information. †ACCF/AHA representative. ‡ACP representative. §ACCF/AHA Task Force on Practice Guidelines liaison.!ACCF/AHA Task Force on Performance Measures liaison. ¶ACEP representative. #SCAI representative. **Former Task Force member during thiswriting effort.

This document was approved by the American College of Cardiology Foundation Board of Trustees and the American Heart Association Science andAdvisory Coordinating Committee in June 2012.

The American College of Cardiology Foundation requests that this document be cited as follows: O’Gara PT, Kushner FG, Ascheim DD, Casey DEJr, Chung MK, de Lemos JA, Ettinger SM, Fang JC, Fesmire FM, Franklin BA, Granger CB, Krumholz HM, Linderbaum JA, Morrow DA, Newby LK,Ornato JP, Ou N, Radford MJ, Tamis-Holland JE, Tommaso CL, Tracy CM, Woo YJ, Zhao DX. 2013 ACCF/AHA guideline for the management ofST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on PracticeGuidelines. J Am Coll Cardiol 2013;61:e78–140, doi:10.1016/j.jacc.2012.11.019.

This article is copublished in Circulation.Copies: This document is available on the World Wide Web sites of the American College of Cardiology (http://www.cardiosource.org) and the

American Heart Association (my.americanheart.org). For copies of this document, please contact Elsevier Inc. Reprint Department, fax (212) 633-3820,e-mail reprints@elsevier.com.

Permissions: Multiple copies, modification, alteration, enhancement, and/or distribution of this document are not permitted without the expresspermission of the American College of Cardiology Foundation. Please contact Elsevier’s permission department at healthpermissions@elsevier.com.

Journal of the American College of Cardiology Vol. 61, No. 4, 2013© 2013 by the American College of Cardiology Foundation and the American Heart Association, Inc. ISSN 0735-1097/$36.00Published by Elsevier Inc. http://dx.doi.org/10.1016/j.jacc.2012.11.019

Downloaded From: http://content.onlinejacc.org/ on 07/20/2016

PRACTICE GUIDELINE

2013 ACCF/AHA Guideline for the Management ofST-Elevation Myocardial InfarctionA Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines

Developed in Collaboration With the American College of Emergency Physicians andSociety for Cardiovascular Angiography and Interventions

WRITING COMMITTEE MEMBERS*Patrick T. O’Gara, MD, FACC, FAHA, Chair†;

Frederick G. Kushner, MD, FACC, FAHA, FSCAI, Vice Chair*†; Deborah D. Ascheim, MD, FACC†;Donald E. Casey, Jr, MD, MPH, MBA, FACP, FAHA‡; Mina K. Chung, MD, FACC, FAHA*†;

James A. de Lemos, MD, FACC*†; Steven M. Ettinger, MD, FACC*§;James C. Fang, MD, FACC, FAHA*†; Francis M. Fesmire, MD, FACEP*!¶;

Barry A. Franklin, PHD, FAHA†; Christopher B. Granger, MD, FACC, FAHA*†;Harlan M. Krumholz, MD, SM, FACC, FAHA†; Jane A. Linderbaum, MS, CNP-BC†;

David A. Morrow, MD, MPH, FACC, FAHA*†; L. Kristin Newby, MD, MHS, FACC, FAHA*†;Joseph P. Ornato, MD, FACC, FAHA, FACP, FACEP†; Narith Ou, PharmD†;

Martha J. Radford, MD, FACC, FAHA†; Jacqueline E. Tamis-Holland, MD, FACC†;Carl L. Tommaso, MD, FACC, FAHA, FSCAI#; Cynthia M. Tracy, MD, FACC, FAHA†;

Y. Joseph Woo, MD, FACC, FAHA†; David X. Zhao, MD, FACC*†

ACCF/AHA TASK FORCE MEMBERSJeffrey L. Anderson, MD, FACC, FAHA, Chair;

Alice K. Jacobs, MD, FACC, FAHA, Immediate Past Chair;Jonathan L. Halperin, MD, FACC, FAHA, Chair-Elect;

Nancy M. Albert, PHD, CCNS, CCRN, FAHA; Ralph G. Brindis, MD, MPH, MACC;Mark A. Creager, MD, FACC, FAHA; David DeMets, PHD;

Robert A. Guyton, MD, FACC, FAHA; Judith S. Hochman, MD, FACC, FAHA;Richard J. Kovacs, MD, FACC; Frederick G. Kushner, MD, FACC, FAHA**;E. Magnus Ohman, MD, FACC; William G. Stevenson, MD, FACC, FAHA;

Clyde W. Yancy, MD, FACC, FAHA**

*Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply;see Appendix 1 for detailed information. †ACCF/AHA representative. ‡ACP representative. §ACCF/AHA Task Force on Practice Guidelines liaison.!ACCF/AHA Task Force on Performance Measures liaison. ¶ACEP representative. #SCAI representative. **Former Task Force member during thiswriting effort.

This document was approved by the American College of Cardiology Foundation Board of Trustees and the American Heart Association Science andAdvisory Coordinating Committee in June 2012.

The American College of Cardiology Foundation requests that this document be cited as follows: O’Gara PT, Kushner FG, Ascheim DD, Casey DEJr, Chung MK, de Lemos JA, Ettinger SM, Fang JC, Fesmire FM, Franklin BA, Granger CB, Krumholz HM, Linderbaum JA, Morrow DA, Newby LK,Ornato JP, Ou N, Radford MJ, Tamis-Holland JE, Tommaso CL, Tracy CM, Woo YJ, Zhao DX. 2013 ACCF/AHA guideline for the management ofST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on PracticeGuidelines. J Am Coll Cardiol 2013;61:e78–140, doi:10.1016/j.jacc.2012.11.019.

This article is copublished in Circulation.Copies: This document is available on the World Wide Web sites of the American College of Cardiology (http://www.cardiosource.org) and the

American Heart Association (my.americanheart.org). For copies of this document, please contact Elsevier Inc. Reprint Department, fax (212) 633-3820,e-mail reprints@elsevier.com.

Permissions: Multiple copies, modification, alteration, enhancement, and/or distribution of this document are not permitted without the expresspermission of the American College of Cardiology Foundation. Please contact Elsevier’s permission department at healthpermissions@elsevier.com.

Journal of the American College of Cardiology Vol. 61, No. 4, 2013© 2013 by the American College of Cardiology Foundation and the American Heart Association, Inc. ISSN 0735-1097/$36.00Published by Elsevier Inc. http://dx.doi.org/10.1016/j.jacc.2012.11.019

Downloaded From: http://content.onlinejacc.org/ on 07/20/2016

2.  A  premature  neonate  (2  weeks  old,  born  at  37  weeks  gestation)  is  having  major  surgery  for  a  congenital  diaphragmatic  hernia  repair.  Analgesia  techniques  include  the  following  except:

a) Paracetamol

b) Oral  codeine

c) Morphine

d) Central  neuraxial  blockade  with  a  local  anaesthetic  agent

e) Ketamine

3.  With  respect  to  perioperative  management  of  a  patient  with  sickle  cell  disease,  the  following  are  useful  EXCEPT:

a) Patient  warming

b) Intravenous  fluids

c) Prophylactic  antibiotics

d) Regional  anaesthetic  techniques

e) Cell  salvage

4.  Suxamethonium  dosing  in  obesity  is  best  administered  according  to:

a) Actual  body  weightb) Lean  body  weight

c) Estimated  body  weight

d) Ideal  body  weight

e) Ideal  body  weight  plus  0.25mg  per  kilogram

5.  A  45-­‐year-­‐old  patient  under  your  care  dies  unexpectedly  during  an  inguinal  hernia  repair  performed  under  general  anaesthesia.  Senior  anaesthetic  colleagues  were  present  during  the  attempted  resuscitation  and  the  relatives  have  been  informed.  What  should  be  your  next  priority  in  this  situation?

a) Communication  with  the  clinical  governance   lead  or  risk  manager

b) contact  the  Coroner’s  office

c) Ensure  all  anaesthetic  equipment  and  drugs  are  sequestrated

d) A  thorough   debriefing   of  every  member  of  the  operating  theatre  team

e) Ensure  an  accurate,  signed  record  of  the  event  is  filed  in  the  patient’s  notes

6.  A  55-­‐year-­‐old  gentleman  sustained  a  spinal  injury  at  T4  12  years  ago.  He  has  a  past  history  of  COPD  and  a  previous  difficult  airway.  He  is  scheduled  for  surgery  on  your  list  to  have  his  bladder  stones  removed.  When  you  assess  him  he  tells  you  that  he  has  a  history  of  dysreflexia and  spasms.  What  is  your  anaesthetic  plan?

a) GA  LMA  SV

b) GA  ETT  IPP,  awake  FOI

c) Lumbar  epidural

d) No  anaesthetic  is  required

e) Spinal

7.  An  8  year  old  boy  with  a  recent  history  of  weight  loss,  excessive  thirst  and  polyuria  is  brought  into  the  emergency  department.  His  GCS  is  14  and  a  venous  blood  gas  sample  shows:  pH  7.0,  pCO2 2.4kPa  and  a  glucose  of  35mmol/l.  Urine  is  positive  for  ketones.  Two  hours  after  standard  therapy,  the  patient’s  GCS  is  9.  Blood  glucose  is  now  9mmol/l.Appropriate  therapy  would  include:

a) Hypertonic  saline  with  an  urgent  CT  head  scanb) Antibiotics  and  an  urgent  CT  head  scan

c) Lumbar  puncture  and  antibiotics

d) Furosemide  and  urgent  head  CT  scan

e) Phenytoin   loading

8.  Which  of  the  following  regarding  sugammadex is  true:

a) It  is  a  modified  alpha-­‐cyclodextrin

b) The  drug   forms  complexes  with  steroidal  neuromuscular   blocking  drugs  with  a  ratio  of  1:2

c) Following  sugammadex administration  to  reverse  rocuronium blockade,  the  plasma  concentration  of  rocuroniumwill  rise

d) The  majority  of  the  drug  is  metabolised  and  excreted  by  the  kidneys

e) Sugammadex exerts  its  effect  by  binding   with  rocuronium at  the  neuromuscular   junction

Sugammadex is  a  gamma-­‐cyclodextrin

9.   A  28  year  old  brittle  asthmatic  is  referred  to  ICU  by  the  medical  registrar.  The  patient  has  received  back  to  back  salbutamol  nebulisation  since  admission  an  hour  ago.  He  is  unable  to  speak  and  is  using  his  accessory  muscles.  His  gases:  pH  7.35,  pO2 8.8,  pCO2 6.2,  HCO3 22,  BE  -­‐3.  A  decision  is  made  to  intubate  his  trachea  and  control  his  ventilation  to  help  reduce  his  work  of  breathing.  Intubation  is  uneventful.  Ventilation  strategy  should  be:  

a) Hypoventilation  with  a  low  respiratory  rateb) Zero  PEEP

c) Hyperventilation   to  normocapnia

d) Use  volume  control  ventilation   to  achieve  a  definite  minute  ventilation

e) Add  PEEP  to  increase  pO2

10.  A  65  year  old  male  patient  is  undergoing  laser  excision  of  a  laryngeal  papilloma.  The  airway  is  secured  with  a  laser-­‐flex  endotracheal  tube.  During  the  procedure  the  proximal  cuff  is  burst  by  a  laser  beam  and  a  small  flame  of  fire  appears  in  the  surgical  field.  The  MOST  appropriate  immediate  measure  should  be:

a) Increasing  the  inspired  oxygen  concentration

b) Continuing   with  laser  resection  to  complete  the  procedure  as  soon  as  possible

c) Flooding  the  field  with  normal  salined) Increasing  the  nitrous  oxide  concentration  in  order   to  reduce  the  inspired  

oxygen  concentration

e) Changing   the  endotracheal  tube  immediately

11.  The  national  patient  safety  agency  recommends  a  number  of  methods  to  reduce  the  risk  of  a  throat  pack  being  inadvertently  left  in  situ.  As  part  of  these  recommendations,  they  suggest  that  one  of  the  two  methods  be  used  in  all  cases.  Which  of  the  following  options  contains  BOTH  of  these  suggested  methods:

a) Placing  a  visible  label  on  the  patient  stating  a  throat  pack  is  in  situ  and  removing   it  when  the  throat  pack  is  removed,  or  placing  a  label  on  the  airway  device  (LMA  or  endotracheal  tube)   stating  a  throat  pack  is  in  situ

b) Tying  one  end  of  the  throat  pack  to  the  airway  device,  or  recording   insertion  and  removal  of  the  throat  pack  as  part  of  the  formal  swab  count

c) Recording  insertion  and  removal  of  the  throat  pack  as  part  of  the  formal  swab  count,  or  performing  a  formalised  2-­‐person  check  of  the  insertion  and  removal  of  the  throat  pack

d) Leaving  part  of  the  throat  pack  protruding   externally,  or  putting  a  visible  label  or  mark  on   the  patient  stating  a  throat  pack  is  in  situ

e) Recording  insertion  and  removal  of  the  throat  pack  as  part  of  the  formal  swab  count,  or  attaching  the  throat  pack  securing  to  the  artificial  airway  device

12.  A  50  year  old  man  has  had  a  CT  scan  for  an  appendix  mass  and  multiple  lesions  in  the  liver  presumed  to  be  metastatic.  He  is  scheduled  for  a  laparotomy.  In  the  previous  few  months  he  has  been  treated  for  new  onset  asthma  (inhaled  beta  agonist)  and  few  loose  bowel  motions  (loperamide).  During  the  laparotomy  he  becomes  hypotensive  during  tumour  handling.  Appropriate  management  would  include:

a) Intravenous  ketanserin

b) Intravenous  ephedrine

c) Intravenous  metaraminol

d) Intravenous  octreotidee) Intravenous  atracurium

13.  An  84  year  old  woman  scheduled  to  undergo  surgery  for  a  fractured  neck  of  femur  develops  atrial  fibrillation  at  a  rate  of  140bpm  following  induction  of  general  anaesthesia.  Her  blood  pressure  is  60/40mmHg  and  there  is  no  improvement  following  rapid  transfusion  of  500ml  of  colloid.  What  would  be  the  MOST  appropriate  next  intervention?

a) Incremental  doses  of  adenosine

b) Bolus  dose  of  amiodarone  over  30mins

c) Intravenous  infusion  of  esmolol

d) DC  cardioversione) Intravenous  infusion  of  magnesium

14.  Which  of  the  following  is  NOT  part  of  the  “sign  in”  part  of  the  WHO  surgical  safety  checklist?

a) Confirm  consentb) Confirm  surgical  site  markc) Confirm  allergy  statusd) Risk  >500mL  blood  losse) Has  VTE  prophylaxis  been  considered?

Surgical Safety Checklist

Has the patient confirmed his/her identity, site, procedure, and consent?

Yes

Is the site marked? Yes Not applicable

Is the anaesthesia machine and medication check complete?

Yes

Is the pulse oximeter on the patient and functioning?

Yes

Does the patient have a:

Known allergy? No Yes

Difficult airway or aspiration risk? No Yes, and equipment/assistance available

Risk of >500ml blood loss (7ml/kg in children)? No Yes, and two IVs/central access and fluids

planned

Confirm all team members have introduced themselves by name and role.

Confirm the patient’s name, procedure, and where the incision will be made.

Has antibiotic prophylaxis been given within the last 60 minutes?

Yes Not applicable

Anticipated Critical Events

To Surgeon: What are the critical or non-routine steps? How long will the case take? What is the anticipated blood loss?

To Anaesthetist: Are there any patient-specific concerns?

To Nursing Team: Has sterility (including indicator results)

been confirmed? Are there equipment issues or any concerns?

Is essential imaging displayed? Yes Not applicable

Nurse Verbally Confirms: The name of the procedure Completion of instrument, sponge and needle

counts Specimen labelling (read specimen labels aloud,

including patient name) Whether there are any equipment problems to be

addressed

To Surgeon, Anaesthetist and Nurse: What are the key concerns for recovery and

management of this patient?

This checklist is not intended to be comprehensive. Additions and modifications to fit local practice are encouraged. Revised 1 / 2009

(with at least nurse and anaesthetist) (with nurse, anaesthetist and surgeon) (with nurse, anaesthetist and surgeon)

© WHO, 2009

Before induction of anaesthesia Before skin incision Before patient leaves operating room

15.  A  75-­‐year  old  man  is  admitted  to  HDU  following  an  episode  of  severe  chest  pain  and  collapse  with  transient  loss  of  consciousness.  On  admission  he  is  conscious  but  complaining  of  chest  pain  radiating  to  his  back.  Blood  pressure  in  the  right  arm  is  210/110.  The  left  radial  pulse  is  absent  and  there  are  signs  of  left  hemiparesis.  Which  of  the  following  is  the  MOST  likely  diagnosis?

a) Acute  pulmonary   embolism

b) Acute  myocardial  infarction  with  systemic  embolisation

c) Dissecting  aneurysms  of  the  thoracic  aortad) Acute  rupture  of  the  aortic  valve

e) Rupture  of  a  mycotic  aneurysm  of   the  aortic  arch

16.  A  26  year  old  is  undergoing  a  knee  arthroscopy.  He  received  IV  propofol 200mg,  fentanyl  100mcg  and  ondansetron  4mg  at  induction  of  anaesthesia.  A  size  5  LMA  is  inserted  without  difficulty.  Anaesthesia  is  maintained  with  O2,  N2O  and  desflurane.  15  minutes  after  the  start  of  surgery  his  heart  rate  increases  steadily  to  170bpm,  ETCO2 rises  to  11kPa  with  a  steady  decline  in  oxygen  saturation  requiring  an  FiO2 of  1.0  and  a  steadily  increasing  minute  ventilation  up  to  15L/min.  He  has  had  an  uneventful  anaesthetic  in  the  past  for  a  dental  procedure.  You  should:

a) Paralyse  with  a  relaxant,  intubate  his  trachea  and  control  ventilation

b) Measure  his  temperature

c) Stop  inhalational  agents  and  install  a  clean  anaesthetic  breathing  systemd) Check  blood  gases

e) Control  his  heart  rate  with  a  beta  blocker

17.  A  64-­‐year-­‐old  man  is  scheduled  for  phaeko emulsification  of  a  cataract  and  lens  implantation  under  a  subtenons block  today.  He  is  a  type  II  diabetic  and  has  had  2  strokes  for  which  he  is  anti-­‐coagulated  with  warfarin.  His  INR  is  2.6.  He  is  worried  about  the  prospect  of  general  anaesthesia  and  would  prefer  to  be  awake  surgery.  Which  is  the  SINGLE  MOST  appropriate  management?

a) Advice  the  patient  to  have  the  operation  under  general  anaesthetic  today

b) Stop  the  warfarin  and  proceed  with  a  subtenons block  with  the  INR  is  <1.5

c) Proceed  with  the  operation  using  an  extraconal rather  than  a  subtenonsblock

d) Give  vitamin  K,  recheck  INR  and  proceed  under  subtenons block  when  INR  <1.5

e) Continue  with  surgery  as  planned  today  under  a  subtenons block

18.  A  50-­‐year-­‐ol  man  with  chronic  renal  failure  is  normally  managed  with  haemodialysis requires  a  laparotomy  for  suspected  large  bowel  perforation.  He  is  haemodynamically stable  and  has  had  previous  uneventful  Gas.  His  serum  biochemistry  results  are  as  follows:  Na  139,          K  6.0,  creatinine  730.  Which  would  be  the  MOST  appropriate  option  for  his  anaesthetic  management:

a) Perform  a  rapid  sequence  induction   with  thiopental  and  succinylcholine

b) Haemodialyse him  before  proceeding   with  a  general  anaesthetic

c) Perform  a  combined  spinal-­‐epidural  block  for  the  laparotomy

d) Perform  an  awake  fibreoptic intubation  before   inducing  general  anaesthesia

e) Perform  a  rapid  sequence  induction  with  thiopental  and  rocuronium

19.  Following  major  trauma  and  initial  fluid  resuscitation  a  previously  healthy  59-­‐year-­‐old,  70kg  man  has  a  urine  output  of  15mL/hr.  The  urine  contains  myoglobin.  The  patient  is  cardiovascularly stable  with  a  blood  pressure  of  105/70.  Serum  potassium  concentration  is  5.7mmol/L.  What  is  the  MOST  appropriate  next  step  in  his  management?

a) One  further   litre of  0.9%saline  intravenously  and  diuresis  with  furosemide

b) Commence  renal  replacement  therapy  via  a  femoral  venous   line

c) Increase  renal  perfusion   pressure  with  noradrenaline  via  a  central  line

d) Measure  intr—abdominal   pressure  via  an  intra-­‐vesical  pressure  transducer

e) Fluid  resuscitation  to  a  CVP  >12cmH2O,  diuresis  and  urinary  alkalinsation

20.  The  national  patient  safety  agency  recommends  a  number  of  methods  to  reduce  the  risk  of  a  throat  pack  being  inadvertently  left  in  situ.  As  part  of  these  recommendations,  they  suggest  that  one  of  the  two  methods  be  used  in  all  cases.  Which  of  the  following  options  contains  BOTH  of  these  suggested  methods:

a) Placing  a  visible  label  on  the  patient  stating  a  throat  pack  is  in  situ  and  removing   it  when  the  throat  pack  is  removed,  or  placing  a  label  on  the  airway  device  (LMA  or  endotracheal  tube)   stating  a  throat  pack  is  in  situ

b) Tying  one  end  of  the  throat  pack  to  the  airway  device,  or  recording   insertion  and  removal  of  the  throat  pack  as  part  of  the  formal  swab  count

c) Recording  insertion  and  removal  of  the  throat  pack  as  part  of  the  formal  swab  count,  or  performing  a  formalised  2-­‐person  check  of  the  insertion  and  removal  of  the  throat  pack

d) Leaving  part  of  the  throat  pack  protruding   externally,  or  putting  a  visible  label  or  mark  on   the  patient  stating  a  throat  pack  is  in  situ

e) Recording  insertion  and  removal  of  the  throat  pack  as  part  of  the  formal  swab  count,  or  attaching  the  throat  pack  securing  to  the  artificial  airway  device

21.  An  85-­‐year-­‐old  woman  is  admitted  with  bradycardia,  feeling  unwell,  BP  95/40mmHg.  Which  of  the  following  would  make  you  think  transvenous pacing  is  UNLIKELY   to  be  required:

a) Morbitz type  IIb) HR  of  25bpmc) Complete  heart  block  with  broad  QRSd) Ventricular  pauses  >3secse) Recent  asystole

2010 ResuscitationGuidelines Resuscitation Council (UK)

Adult bradycardia algorithm

5th Floor, Tavistock House North, Tavistock Square, London WC1H 9HR Telephone (020) 7388-4678 x��Fax (020) 7383-0773 x��Email enquiries@resus.org.uk www.resus.org.uk x��Registered Charity No. 286360

October 2010

Seek expert help Arrange transvenous pacing

* Alternatives include: x� Aminophylline x� Dopamine x� Glucagon (if beta-blocker or calcium channel blocker overdose) x� Glycopyrrolate can be used instead of atropine

YES NO Adverse features?

x�Shock x�Syncope x�Myocardial ischaemia x�Heart failure

Atropine 500 mcg IV

YES

NO

NO

YES

x�Assess using the ABCDE approach x�Give oxygen if appropriate and obtain IV access x�Monitor ECG, BP, SpO2, record 12-lead ECG x� Identify and treat reversible causes

(e.g. electrolyte abnormalities)

Observe

Satisfactory response?

!

Interim measures: x�Atropine 500 mcg IV repeat to maximum of 3 mg x�Isoprenaline 5 mcg min-1 IV x�Adrenaline 2-10 mcg min-1 IVx�Alternative drugs * OR x�Transcutaneous pacing

Risk of asystole? x�Recent asystole x�Mobitz II AV block x�Complete heart block with broad QRS x�Ventricular pause > 3 s

22.  When  assessing  a  patient  with  chronic  liver  disease  the  Child-­‐Pugh  scoring  system  may  be  used.  The  following  are  used  in  the  calculation:

a) Ascities,  encephalopathy,  albumin,  bilirubin,  INRb) Ascities,  encephalopathy,  bilirubin,   ALT,  INR

c) Ascities,  encephalopathy,  ALT,  bilirubin,   INR

d) Ascities,  encephalopathy,  albumin,  ammonia,   INR

e) Ascities,  encephalopathy,  albumin,  glucose,   INR

23.  Dynamic  parameters  are  becoming  increasingly  useful  to  assess  fluid  responsiveness  in  the  critically  ill.  Which  of  the  following  is  NOT  a  dynamic  parameter:

a) Stroke  volume  variation

b) Pulmonary  artery  occlusion  pressure

c) Aortic  blood  velocity

d) Pulse  pressure  variation

e) Superior   vena  cava  collapsibility  index

24.  A  4-­‐year-­‐old  girl  develops  laryngospasm  in  the  recovery  room  following  elective  grommet  insertion.  Her  SpO2  falls  to65%  and  she  requires  intubation  facilitated  by  succinylcholine  1mg/kg  IV.  After  intubation  and  ventilation  copious  pink  frothy  fluid  is  aspirated  from  the  tracheal  tube  and  the  Sp02  will  not  increase  above  86%  despite  an  FiO2  =  1.0.  What  is  the  MOST  likely  explanation  for  the  continuing  problems  following  intubation?

a) Negative  pressure  pulmonary  oedema  secondary  to  laryngospasmb) Cardiogenic  shock  secondary  to  the  episode  of  hypoxaemia

c) Pulmonary  aspiration  preceding   the  episode  of  laryngospasm

d) Anaphylactic  shock  most  likely  due   to  succinylcholine

e) Airway  trauma  secondary  to  the  laryngoscopy   and  intubation

25.  A  four-­‐week-­‐old  male  infant  is  admitted  with  a  four  day  history  of  projectile  vomiting  after  feeds.  A  diagnosis  of  pyloric  stenosis  is  made  and  the  child  is  resuscitated  with  appropriate  intravenous  fluids  for  24  hours.  Which  one  of  the  following  biochemical  parameters  provides  the  MOST  reassurance  that  it  is  safe  to  proceed  with  surgery?

a) Serum  bicarbonate  27mmol/Lb) Serum  sodium  137mmol/L

c) Serum  urea  4.9mmol/L

d) Serum  potassium  3.7mmol/L

e) Serum  glucose  5.7mmol/L

26.  An  84  year  old  lady  with  advanced  dementia  is  admitted  with  a  fractured  neck  of  femur.  A  Do  Not  Attempt  Cardiopulmonary  Resuscitation  (DNACPR)  order  is  in  place.  After  discussion  with  her  family,  it  is  agreed  that  the  fracture  should  be  fixed  for  pain  relief.  You  proceed  with  a  spinal  anaesthetic  and  a  single  dose  of  1mg  midazolam.  Just  after  positioning  her  for  surgery,  you  notice  she  has  stopped  breathing  and  you  cannot  feel  her  carotid  pulse.  The  MOST  appropriate  action  now  is:  

a) Administer  boluses  of  flumazenil  and  adrenaline  

b) Ask  a  senior  colleague  for  a  second  opinion  

c) Commence  cardiopulmonary  resuscitation  d) Respect  the  DNACPR  order  

e) Telephone   the  relatives  and  determine  their  wishes.  

27.  A  33  year  old  woman  with  severe  depression  is  detained  in  hospital  under  Section  3  of  the  Mental  Health  Act  1983.  She  agrees  to  a  trial  of  electroconvulsive  therapy  (ECT).  However,  at  your  preoperative  visit,  she  appears  anxious  and  says  she  has  changed  her  mind  and  no  longer  wants  the  procedure.  The  BEST  course  of  action  would  be:  

a) Advise  psychiatry  team  that  as  consent  has  been  withdrawn  ECT  cannot  take  place  

b) Continue  with  treatment  as  she  cannot  refuse  under  Section  3  of  the  Mental  Health  Act  

c) Give  her  an  information   leaflet  on  ECT  and  review  her  again  in  30  minutes  

d) Phone   the  Trust  Legal  Department   for  advice  

e) Prescribe  temazepam 10mg  as  anxiolysis

Provision  of  ECT  for  patients  detained  under  the  Mental  Health  Act

• A  patient  is  detained  under   section  3  if  they  are  already  known  to  mental  health  services,  or  following  admission  under  s2.

• Treatment  cannot  refused  under  section  3,  apart  from  ECT• If  the  patient  refuses  to  consent  to  ECT  and  all  the  treating  team  believe  it  to  be  

in  the  patients  best  interests,  an  assessment  by  a  Second  Opinion  Appointed  Doctor  (SOAD)   is  required

• It  is  important   that  patients  detained  under   the  MHA  give  consent  for  ECT  freely  and  willingly,   it  would  not  be  appropriate   to  continue  with  treatment  on  that  day

• The  trust  legal  department  would  be  a  useful  point  of  contact,  but  would  advise  you  not  to  proceed  if  consent  had  been  withdrawn.

• Although   a  benzodiazepine  would  help  her  anxiety,  it  may  render   the  ECT  less  effective  were  it  to  go  ahead

• It  would  also  make  it  impossible   to  conclude   that  consent  had  subsequently   been  given  if  she  changed  her  mind

• You  should  advise  the  psychiatry  team  that  treatment  cannot  proceed

28.  You  are  asked  to  review  a  22  year  old  man  in  the  recovery  area  following  a  tonsillectomy.  He  was  anaesthetised  by  a  colleague  and  is  now  awake  and  comfortable  but  complains  that  his  upper  right  incisor  tooth  has  been  broken  off  during  the  procedure.  Which  of  the  following  should  take  priority:  

a) Apologise to  the  patient  and  document   this  in  the  notes.  

b) Arrange  an  urgent  chest  x-­‐ray  to  identify   the  location  of  the  tooth  

c) Complete  an  incident   form  and  inform  your  clinical  director  

d) Ensure  the  colleague  who  anaesthetised  the  patient  is  informed.  

e) Examine  the  patient  to  assess  damage  and  possible  location  of  the  tooth  

29.  A  57-­‐year-­‐old  publican  with  a  femur  and  tibia  fracture  has  become  acutely  confused  in  the  day  after  his  operation  for  an  external  fixation  of  his  injuries.  His  HR  is  120bpm,  BP  120/80,  RR  23,  SpO2 95%  on  45%  O2.  What  is  the  MOST  likely  diagnosis?

a) Acute  alcohol  withdrawal

b) Sepsis

c) Fat  embolismd) VTE

e) Acute  MI

Conditions  associated  with  fat  embolism

30.  A  45-­‐year  old  with  a  2-­‐week  history  of  back  with  no  red  flag  symptoms,  has  been  taking  paracetamol  and  ibuprofen.  What  would  you  next  recommend?

a) MRI  lumbar  spine   to  exclude  disease  and  ligament  injury

b) Period  of  bed  rest

c) Epidural  steroid  injection

d) Morphine   controlled   release  tables

e) Continue  current  management

Low  Back  Pain  – NICE  2009

Poor outcome – unsatisfactory improvement

Significantpsychological distressand/or high disability

after having received atleast one less intensivetreatment (see box D)

Pain for more than1 year

Continuing severepain despite:● having completed

an optimal packageof care

● appropriatetreatment of anypsychologicaldistress

Consider referral for a combinedphysical and psychologicaltreatment programme, which:● comprises around 100 hours

over up to 8 weeks● should include a cognitive

behavioural approach andexercise

Good outcome – satisfactory improvement

1 No opioids, COX-2 inhibitors or tricyclic antidepressants and only some NSAIDs have a UK marketing authorisation for treatinglow back pain. If a drug without a marketing authorisation for this indication is prescribed, informed consent should be obtainedand documented.

Box C Drug treatments1

Paracetamol:● Advise regular paracetamol as the first option

When regular paracetamol alone is insufficient (andtaking account of individual risk of side effects andpatient preference), offer NSAIDs and/or weak opioids

NSAIDs: Weak opioids:● Give due

consideration torisk of opioiddependence andside effects

● Examples ofweak opioids arecodeine anddihydrocodeine

Tricyclic antidepressants:● Consider offering if other medications are

insufficient; start at a low dosage and increase upto the maximum antidepressant dosage until:– therapeutic effect is achieved or– unacceptable side effects prevent further increase

Strong opioids:● Consider offering for short-term use to people in

severe pain● Consider referring people requiring prolonged use

for specialist assessment● Give due consideration to risk of opioid dependence

and side effects● Examples of strong opioids are buprenorphine,

diamorphine, fentanyl, oxycodone and tramadol(high dose)

● Give due consideration to riskof side effects, especially inolder people and those atincreased risk of side effects

● Offer treatment with astandard oral NSAID/COX-2 inhibitor

● Co-prescribe a PPI for peopleover 45 (choose the one withthe lowest acquisition cost)

For all medications, base decisions on continuation on individual response

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NICE clinical guideline 88 Quick reference guide4

Low back pain

This guideline refers tothe management ofnon-specific low back painonly. Clinical assessmentshould exclude peoplewith signs and symptomssuggestive of spinalmalignancy, infection,fracture, cauda equinasyndrome, or ankylosingspondylitis or anotherinflammatory disorder.

Care pathway

Care pathway

COX-2: cyclooxygenase 2; IDET: intradiscal electrothermal therapy; MRI: magnetic resonance imaging; NSAIDs: non-steroidalanti-inflammatory drugs; PIRFT: percutaneous intradiscal radiofrequency thermocoagulation; PPI: proton pump inhibitor;SSRI: selective serotonin reuptake inhibitor; TENS: transcutaneous electrical nerve stimulation.

Box B Advice and education

● Provide advice and information to promote self-management● Offer educational advice that:

– includes information on the nature of non-specific low back pain– encourages normal activities as far as possible

● Advise people to stay physically active and to exercise● Include an educational component consistent with this guideline as part of other interventions (but don’t

offer stand-alone formal education programmes)● When considering recommended treatments, take into account the person’s expectations and preferences

(but bear in mind that this won’t necessarily predict a better outcome)

Box A Assessment and imaging

● Do not offer X-ray of the lumbar spine● Only offer MRI for non-specific low back pain in the context of a referral for an opinion on spinal fusion● Consider MRI if one of these diagnoses is suspected:

– spinal malignancy – cauda equina syndrome– infection – ankylosing spondylitis or another– fracture inflammatory disorder

● Keep diagnosis under review at all times

AND

● Promote self-management: advise people with low back pain toexercise, to be physically active and to carry on with normalactivities as far as possible (see box B)

AND

● Offer drug treatments as appropriate to manage pain and to helppeople keep active (see box C)

AND

● Offer one of the following treatments (see box D), taking patientpreference into account. Consider offering:– exercise programme– course of manual therapy– course of acupuncture

Consider offering another of these options if the chosen treatmentdoes not result in satisfactory improvement

Principles of management for all patients

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