FRCA SAQ1Practice_ans19113

Final FRCA Practice SAQ Paper 1 - for discussion on Saturday, 19th January 2013

Candidates MUST answer all 12 questions. Candidates will fail the written section if one or

more questions on the SAQ paper are not attempted. All 12 questions carry equal marks,

although their pass marks may vary

Where examiners have indicated the way marks are allocated, candidates are advised to

spend their time accordingly

You will need to have your answers ready prior to the discussion session in order to

benefit from the discussion.

1. a) What are the considerations when administering a general anaesthetic to a

patient in the neuroradiology suite? (50%)

b) List the common interventional neuro-radiological procedures that may require

general anaesthesia. (20%)

c) Outline the possible complications of interventional neuro-radiological procedures.

(30%)

Answer contributed by Dr. Madhuvanti Achawal

a) What are the considerations when administering a general anaesthetic to a patient in the neuroradiology suite? (50%) b) List the common interventional neuro-radiological procedures that may require general anaesthesia. (20%) c) Outline the possible complications of interventional neuro-radiological procedures. (30%)

Interventional neuro radilogical procedures are part of trends towards minimally invasive

neurosurgery. Prolonged procedures, improved patient safety and optimal imaging have

resulted in a trend towards greater use of general anaesthesia, specially for aneurysm

coilings and arterio venous (AV)malformations.

Important considerations while anaesthetising these patients are related to the

disease process, the neuro radiology environment and demands of neuro radiological

procedures.

Neurological disease process demand thorough preoperative examination of the patient

including neurological examination and thorough systemic examination to assess associated

systemic effects. Aneurysmal subarachnoid haemorrhage along with altered GCS, can

present with cardiac dysrrhythmias, pulmonary atelectasis, pneumonia, pulmonary oedema

and electrolyte imbalance.

Neuroradiology suites pose unfamiliar environment, often remote. The staff is not always

familiar with anaesthetic practice and help not always readily available. Ensuring a skilled

assistance, availability of necessary and emergency equipment and dedicated recovery area

and staff is vital.

The anaesthetist works amongst ample radiology equipment and access to the patient is

often with obstacles. Securing airway access, lines and monitoring cables in an appropriate

manner is helpful.

These are intracranial procedures and demand close monitoring of PaCO2, arterial blood

pressure and intravascular volume to manipulate intracranial pressure. To avoid image

degradation respiratory immobility could be essential. Short acting anaesthetic agents

enable postoperative recovery and neurological testing.

Use of radiology contrast and flush demand vigilance for hyperoslarity, hypervolaemia and

later dehydration and renal impairment.

Use of heparin, antiplatelet drugs and thrombolytics is common and hence one must be

prepared to monitor ACT and use protamine.

The procedure could involve transfers between radiology, CT or MRI, theatres and hospitals.

This demands close and vigilant observation and monitoring of patient.

List of procedures that require GA

Embolisation: cerebral aneurysm, arteriovenous malformations (intracranial/ spinal)

Embolisation: tumours, carotid cavernous fistulae, epistaxis

Stenting: Carotid/ cerebral arteries

Sclerotherapy: Venous angiomas

Balloon angioplasy: carotid stenosis and vasospasm

Thrombolysis: acute thromboembolic stroke

Intraarterial chemotherapy: head and neck tumours

Complications

Vascular complications are either haemorrhagic or occlusive and need immediate attention.

Vascular rupture or perforation could be

- spontaneous

- due to hypertention

- brought about by micro catheter, guide wire, coil or injection of contrast.

These can present with signs of raised ICP and demand reversal of anticoagulation and

control of ICP.

Cerebral occlusion leading to infarction and ischaemia can occur due to thromboembolism,

arterial dissection, coil misplacement or vasospasm. These could be avoided by maintaining

collateral flow with controlled hypertention and anticoagulation.

Cerebral vasospasm is one of the most serious consequences of subarachnoid

haemorrhage . Medical treatment consists of oral or intravenous nimodipine,

Haemodilutional, hypervolemic, hypertensive therapy (triple H). Intra arterial nemodipine can

be administered during the procedure.

Systemic shunting of particulate material, pulmonary embolism and neurological deficit and

severe bleeding can occur with embolisation of AV maformations.

2. a) What are the diagnostic (25%) and therapeutic (25%) indications for

bronchoscopy?

b) List the major contraindications for bronchoscopy. (20%)

c) How should a fibreoptic bronchoscope be reprocessed after use? (30%)

Answer contributed by Dr. Ajith Vijayan

INTRODUCTION

Bronchoscopy is a common procedure, and both fibreoptic and rigid bronchoscopies

have their own indications and involve specilized techniques. Indications for bronchoscopy

can be divided into one of the three categories: diagnostic, therapeutic, and preoperative

evaluation of pathology.

In many units rigid scope alone or in combination used for the interventional procedures.

However the units outside the thoracic surgery centres do not have ready access to rigid

bronchoscopy as a back up for , or as an alternative to flexible bronchoscopy.

The main advantages of flexible bronchoscope are:

It is widely available

It does not require general anaesthesia

It provide access to more distal airways and good access to the upper lobe bronchi

Rigid bronchoscope

Control of ventilation and oxygenation

Permits removal of large volumes of tumour

Obstructing airway lesions can be cored out.

most interventional procedures can be carried out via flexible or rigid bronchoscopy.

Diagnotic uses

Evaluate lung lesions of unknown etiology that appear on chest X-ray( lung malignancy top

priority)

To assess airway patency

To ascertain correct placement double-lumen endotracheal tube(DLT), to visualise the

single lumen tube position with in the trachea in difficult circumstances ( persisting

desaturation inspite of endotracheal intubation and adequate ventilation.)

To evaluate problems associated with endotracheal tubes such as tracheal damage,

airway obstruction

To obtain material for microbiologic studies in suspected pulmonary infections

To investigate unexplained hemoptysis

To investigate the etiology of unexplained paralysis of vocal cord, superior venacava

syndrome, chylothorax, pleural effusion.

Evaluate airway injury in thoracic trauma

To evaluate the location and extent of respiratory tract injury after acute inhalation on

noxious fumes or aspiration of gastric contents

To evaluate a suspected tracheo esophageal fistula, interstial lung disease,

bronchiectasis.

Indications for preoperative assessment of pathology with Bronchoscopy

Before lobectomy or pneumenectomy - allows surgeon to evaluate the extent of the tumor

and rule out malignancy of the contralateral lung

Therapeutic uses

Most interventional procedures are , can be undertaken by flexible or rigid bronchoscopy

Flexible bronchoscope

To remove retained secretions or mucosal plugs

To remove foreign bodies

Tumour debulking with diathermy

Argon plasma coagulation

Cryoextraction and photodynamic therapy(PDT)

Metallic stent insertion

Rigid bronchoscope

Massive haemoptysis

Dilatation of stenosis

Removal of larger central foreign body

Silicone and Y-stents insertion

Thermal laser

Tumour resection

Contraindications for Bronchoscopy

For rigid bronchoscopy

Atlanto axial instability

Severe vertebro-basilar insufficiency

previous cervical spine fusion

Severe facial fractures

patients who are at risk of dental damage

Patient refusal

There are no absolute contraindication for flexible fibreoptic bronchoscopy other than patient

refusal

Risks should be weighed against the benefits

Special caution

1. in patients at risk of developing hypoxia

2. cardiac instability

3. bleeding diathesis

How should Fibre optic scope reprocessed after use

Should be undertaken by the trained staff only.

Thorough cleaning with the detergent most important initial step

sterile or bacteria free water is used for rinsing the bronchoscope

20 minutes immersion in 2% gluteraldehyde manual or automated disinfection

this will destroy most bacteria , including mycobacterium tuberculosis and viruses.

Longer immersion times of 60 minutes if atypical mycobacteria or HIV positive with

respiratory symptoms

Patients with suspected Tuberculosis should undergo bronchoscopy at the end of the list.

compatibility of the decontamination methods should be checked with the manufactures of

bronchoscopic instruments and accessories.

NICE clinical guideline 36

Answer contributed by Dr. Raj Ramchandran

A] Indications for bronchoscopy

Diagnostic

Airway obstruction (e.g. tracheomalacia, bronchomalacia)

Persistent/recurrent pneumonia

Tracheo-oesophageal fistula

Brushings for cytology

Diagnostic

Transbronchial biopsy for histology

Failure to wean from ventilator

Haemoptysis

Therapeutic

Removal of foreign body

Suctioning mucus plugs (e.g. in cystic fibrosis)

Facilitate endobronchial intubation for one lung anaesthesia

Laser therapy

Balloon dilatation of trachea/bronchus

Stent insertion

B] Major Contraindications:

Absolute

Lack of patient consent

Untreatable life-threatening arrhythmias

Inability to adequately oxygenate the patient during the procedure

Mechanical ventilation with high positive end expiratory pressure

Relative

Uncooperative patient

Recent MI or unstable angina

Severe tracheal stenosis or obstruction

Uncorrectable coagulopathy

Pulmonary hypertension [increased risk of bleeding]

C] Reprocessing of FOB after use

Principles for Cleaning/disinfection

1. To ensure that all staff comply with appropriate standards of cleaning & disinfection,

written policies and procedures should be developed

2. To follow the endoscope, accessories and AER manufacturers’ advice and

instructions for use regarding the leak testing, cleaning, disinfection,

decontamination, sterilization and storage of endoscopes.

3. A record should be kept of which bronchoscope is used on an individual patient and

also of the decontamination procedure.

4. Decontamination and disinfection should be carried out at the beginning and end of a

list and between patients.

5. Cleaning and disinfection of bronchoscopes should be undertaken by trained staff in

a dedicated room preferably inside a fume cabinet and to wear protective clothing

and respiratory protection

6. Wherever possible, autoclavable or disposable accessories should be used

7. Bronchoscopy staff need to be trained in patient care, infection control, and

instrument decontamination including the safe use of aldehydes and the potential

health risks

N.B: Not sure whether to include cleaning in detail as follows:

Cleaning

1. Need to wipe clean external surfaces with detergent.

2. Suction valve is separately cleaned.

3. Suitable cleaning brush is used to clean the channel and port.

4. To flush the channel through with detergent followed by air.

Disinfection

1. Use automated systems whenever possible as they protect the user from hazardous

processing chemicals. (Automated endoscope reprocessor) (AER)

(NB: To ensure that AER machine disinfection is carried out at the start of each session/day.

This includes filters and pipework for rinse water.)

2. Immerse the bronchoscope in glutaraldehyde

2% Glutaraldehyde disinfectant contact times - in room temperature)

Patient category When Low risk High risk (e.g.TB, immune

suppressed, symptomatic HIV)

Start of list 20 min 20 min

Between patients 20 min 1 hour

End of list 20 min 1 hour

Change the disinfectant when the manufacturer’s recommended use life is reached.

3. Rinse the instrument with sterile or filtered tap water

4. Change the detergent and rinse water regularly (after each cycle) if reused.

5. Dry the instrument with air and/or alcohol. A 70% alcohol rinse may be used for the

channel

6. Accessories should be cleaned and wherever possible sterilised by autoclaving.

7. Alternatives for Glutaraldehyde

-peracetic acid, chlorine dioxide, superoxidised water and ethylene oxide.

Sterilization of FOB done by gas plasma a complex process

Storage of processed endoscopes

1. On completion of disinfection, the endoscope should be purged with compressed air

to facilitate thorough drying. Alternatively, 70% alcohol may be used to dry internal

surfaces and channels.

2. Flexible endoscopes should be stored suspended vertically in ventilated storage

cabinets, to allow circulation of air.

3. They should not be in contact with other endoscopes or flat surfaces. Ideally, control

valves, distal hoods, caps and other detachable components should be stored

separately.

References – CEACCP, British Thoracic Society Guidelines

American thoracic society

Mhra.gov.uk

3. a) Describe how atrial fibrillation may present. (15%)

b) List 5 causes of atrial fibrillation. (25%)

c) What principles underlie the management of atrial fibrillation? (25%)

d) What are the anaesthetic considerations when performing elective DC

Cardioversion? (35%)


a) Describe how atrial fibrillation may present. (15%)

Palpitation, Irregular pulse

breathlessness

fatigue

syncope

light headedness or dizziness

chest discomfort or pain

heart failure

Stroke or TIA may be the first manifestation of AF

b) List 5 causes of atrial fibrillation. (25%)

Cardiac – IHD, Valvular disease (mitral)

Surgery – Cardiac surgery, pneumonectomy, oesophageal surgery etc.

Sepsis

Electrolyte abnormality – hypokalemia, hypomagnesemia

Endocrine - Hyperthyroidism

Accessory pathway - Wolff-Parkinson-White syndrome (WPW)

c) What principles underlie the management of atrial fibrillation? (25%)

Underlying cause to be corrected for acute AF.

If onset less than 48 hrs, symptomatic AF – To try rhythm control by drugs first

and if unsuccessful DC cardioversion [DCCV].

Onset Unknown or more than 48 hrs - clot formation in atria can cause systemic

embolism - need anticoagulation for at least 3 weeks after risk stratification for

thromboembolism or stroke

Rhythm control in this group – chemical or electrical cardio version – to be preceded

by therapeutic anticoagulation

CHADS2 risk stratification – CCF, Hypertension, Age >75 years, and Diabetes

mellitus - all assigned 1point each. A previous transient ischaemic attack (TIA) or

stroke is assigned 2 points. Patients with a CHADS2 score of 0 can be treated with

aspirin. If one risk factor is present, either aspirin or warfarin can be used. In high risk

patients (CHADS2 score >2), warfarin is the anticoagulation drug of choice

If cardio version cannot be postponed for 3 weeks - give heparin before cardio

version and give Warfarin for at least 4 weeks after cardio version

After cardio version, continue anticoagulation long term in patients with a high risk of

AF recurrence

Patients with asymptomatic AF - same antithrombotic therapy as those

with symptomatic AF as per risk stratification

To aim for rate control [if haemodynamically stable] if onset more than 48 hrs and

also in chronic AF unsuitable for cardio version, IHD, when anti-arrhythmic drugs are

contraindicated

d) What are the anaesthetic considerations when performing elective DC

Cardioversion? (35%)

Day case procedure, Non-theatre and remote location such as CCU etc.

Cardiovascularly compromised patient

Pre procedure

To ensure availability of physician ready for cardioversion

Potassium should be normal – to correct electrolyte imbalance prior to the procedure

Omit Digoxin on the day [increased risk of arrhythmia]

To remove GTN patch before shock

For elective procedure – advisable to transfer to anaesthetic room

Adequate fasting or to consider RSI if risk of aspiration

Anaesthesia

Anaesthetic drug for DCCV should produce the least cardiovascular compromise possible

and enable rapid recovery

Slow induction and should use careful titration of the drug needed

To follow ALS protocol for safe cardio version – Oxygen away during shock, synchronisation

must be on - to prevent R on T phenomenon

Post-procedure

Patient to be in recovery position, Oxygen and monitoring to be continued until ready for

home

Reference – NICE Guidelines for managing AF – recommended reading

Answer contributed by Dr. Ajith Vijayan

How Atrial fibrillation may present

Atrial fibrillation is a common arrhythmia, occuring in 5-10% patients over 65 years of age. It

can also occur in a paroxysmal form in younger patients.

Presentation highly variable

Incidental finding (30%),

some deterioration of exercise capacity or well being

On investigation for the cause of CVA

Sudden onset of heart failure – leading to emergency department admission

Rheumatic valvular heart disease - sudden worsening, leading to heart failure

Patient maybe any where from asymptomatic ----- heart failure

very irregular pulse

ECG showing fine oscillation of baseline and no clear P waves

QRS rhythm is rapid and irregular

untreated ventricular rate 120-180/ min

can also present as wide QRS tachycardia when associated with LBBB

List 5 causes of atrial fibrillation

Hypertension, Congestive heart failure, Coronary artery disease &myocardial infarction,

Valvular heart disease, Non cardiac related -Thyrotoxicosis, Acute and chronic pulmonary

disease( pneumonia, COPD)

Principles underlie the management of atrial fibrillation :

Treatment of AF depends on onset, paroxysmal or persistent , structural heart disease

present or not

If the onset<48 hrs associated with haemodynamic instability treatment should include

attempted restoration of sinus rhythm by synchronised cardioversion. If more >48 hrs,

anticoagulation needed. At any point life threatening deterioration in haemodynamic

stability- emergency electrical cardioversion

Immediate correction of precipitating causes, such as electrolyte abnormalities

If electrical cardioversion fails – chemical cardioversion

Amiodarone 300mg IV over 1hr infusion, followed the rate even if by 900 mg IV over 23hr,

amoidarone will at least slow the rate even if it fails to restore sinus rhythm.

In non-life threatening haemodynamic instability, AF>48hrs, anticoagulation needed before

cardioversion. Heparin or 3 weeks of anticoagulation with warfarin depends on the

underlying circumstances

Rate control can be achieved with IV beta blockers (Esmolol, metoprolol)/ rate controlling

calcium antagonists. Amiodarone when these fail

If a delay in organising electrical cardioversion, IV amiodarone should be used. If any known

WPW syndrome or doubts , AV node blocking drugs such as diltiazem, verapamil or

digoxin should not be used

Class IC agents are recommended for rate and rhythm control on long term basis.

Sotalol very commonly used has additional class III activities, can be progressively titrated

from 80mg twice daily, to 240 mg Bd

Treat the precipitating reversible causes (electrolyte abnormalities, hypovolaemia, sepsis)

Suitable long term anticoagulation strategy

Class1agents (propafenone, flecainide ) contraindicated in significant ischaemic heart

disease or abnormal LV function. Amoidarone or sotalol should be used in those

circumstances

*Vernakalant – A new anti arrhythmia agent with class III action,( atrial selective potassium &

sodium channel blocker) faster conversion in acute onset AF. Contraindicated in heart failure

,NICE still evaluating

*Dronedarone a benzofuran derivative, analogue of amiodarone, has a better side effect

profile in chronic therapy. contraindicated in NYHA3&4 patients

Anaesthetic consideration when performing elective DC cardioversion

Could be a remote site, ideal to treat as any surgical procedure and a physician should be

available to cardiovert the patient

Preop fasting status, reflux, potassium levels - should be in normal range as myocardium

may become irritable.

Digoxin increases the risk of arrhythmias – omit on the day, continue amiodarone

If AF>24 hrs, no anti coagulation, coming after 3 weeks anticoagulation for persisting AF-

pre procedure TOE to screen the LA clot, can be done under conscious sedation with

propofol. Proceed only if no LA clot.

Standard monitoring, IV access as for a GA day case, ECG leads connected to defibrillator:

check synchronising with R wave

Induction – pre oxygenate , minimal dose of propofol only needed, Etomidate if

haemodynamically unstable, GA spontaneous ventilation with face mask.

RSI/ ETT if risk of aspiration

Obese patients, can be cardioverted in the lateral positon

ALS protocol, remove oxygen during shock. 150 J biphasic/ 200J monophasic. Limit to three

shocks. Aflutter to start with lower energy levels

Recover in the lateral position, recover with full monitoring like any GA with face mask only

Links

British Thoracic Soceity flexible broncho scopy guidelines 2001

British Thoracic Soceity guidelines for advanced diagnostic & therapeutic flexible

bronchoscopy in adults 2011

Joel A Kaplan, Peter D Slinger, Thoracic Anaesthesia 3rd edition

Clinical experience of Rigid bronchoscopy, Tuberc Respr Dis 2012;72;

Kumar & Clark Clinical Medicine - Atrial Fibrillation management

Issue date: June 2006

NICE guidelines

Atrial fibrillation

The management of atrial fibrillation

Guidelines for the management of atrial

fibrillation

The Task Force for the Management of Atrial Fibrillation of the

European Society of Cardiology (ESC)

Developed with the special contribution of the European Heart Rhythm Association 2010

2012 focused update of the ESC Guidelines for the management of atrial fibrillation

4. a) How may ultrasound techniques be used in anaesthetic and critical care

practice? (40%)

b) What information can 2D echo provide in a haemodynamically unstable patient?

(45%)

c) What is the Doppler Effect? How may this be used in echocardiography? (15%)

Answer contributed by Dr. E Balakumar

4. a) How may ultrasound techniques be used in anaesthetic and

critical care practice? (40%)

Uses of ultrasound in anaesthetic and critical care practice include

Diagnostic

a. Pulmonary - pneumothorax, pleural effusion, empyema, consolidation, collapse,

congestion

b. Cardiac - tamponade, valvular abnormalities, wall motion abnormalities,

pulmonary embolism etc

c. Abdominal - intra-abdominal bleeding and organ injury as in trauma patients,

abdominal aortic aneurysms etc

d. Vascular - DVT, flow related problems as in acute limb ischemia, vasospasm using

TCD etc

e. Volume - hypovolemic shock

Therapeutic

a. Pulmonary - Insertion of chest drain, pleural aspiration, percutaneous

tracheostomy, confirmation of endotracheal intubation etc

b. Cardiac – RWMA (ischemia/infarction), Tamponade with guided pericardial drain,

Thrombolysis in PE etc

c. Abdominal - Insertion of ascitic drains, as an alternative to DPL in trauma etc

d. Vascular - Insertion of CVCs

e. Volume - Goal directed fluid therapy using Oesophageal Doppler/TTE

f. Ultrasound guided regional and peripheral nerve blocks in pain management

b) What information can 2D echo provide in a haemodynamically

unstable patient? (45%)

2D can provide vital information (chamber volumes, pressures, ejection fraction, and

valvular function) in management of HD unstable patients. Based on the 2D ECHO

HD unstable patients can be divided into several categories so that appropriate

intervention can be instituted. They are as follows:

a. Normal - unlikely to see in HD unstable patients

b. Empty - Reduced LVEDV/Normal EF/Low LAP - infuse volume

c. Systolic failure - Increased LVEDV as dilated heart/Reduced EF as poorly

contracting/Normal LAP - use inotropes

d. Diastolic failure - Reduced LVEDV as small stiff ventricle/Normal EF as

contractility is preserved/Increased LAP as high filling pressure - control heart rate,

maintain preload, consider combination of vasodilator with low dose inotropes

e. Systolic and diastolic failure - Usually increased LVEDV as dilated heart/Reduced

EF as contractility is poor/Increased LAP as high filling pressure - Key principle is to

improve systolic function while reducing preload - diuretics, and inodilators while

maintaining high normal heart rate

f. Right ventricular failure - Combination of RV systolic failure with secondary LV

diastolic dysfunction with high LAP/RAP - principle as above but maintain adequate

volume and use drugs that will reduce pulmonary vascular resistance

g. Vasodilatation - Reduced LVEDV as decreased venous return secondary to

relative +/- true hypovolemia as in sepsis/Normal EF with hyper dynamic LV/

Reduced LAP - Vasoconstrictors +/- volume

c) What is the Doppler Effect? How may this be used in

echocardiography? (15%)

Change in frequency of a wave for an observer moving relative to its source

(Austrian physicist - Christian Doppler 1842). Re-arranging Doppler equation from

classic format gives v = cx fD/2x fT cosQ where

v velocity of the blood/red blood cells

c speed of the ultrasound transmission through the tissues

fD Doppler frequency shift

fT frequency of the transmitted ultrasound waves

Q insonation angle between the emitted ultrasound beam and the direction of blood

flow

Pulse wave/continuous/colour Doppler

Doppler

a. allows measurement of blood flow velocity which gives information on flow

characteristics, pressure gradients, and anatomical abnormalities within the heart

b. incorporation of Doppler wave values into formulas give vital information on

cardiac performance(SV/CO), valvular function and intracardiac pressure gradients.

5. a) What are i) diagnostic and ii) other clinical features of severe pre-eclampsia?

(35%)

b) What are the indications for magnesium therapy in severe pre-eclampsia

/eclampsia and which administration regimen(s) should be used? (25%)

c) What are the signs and symptoms of magnesium toxicity and how should it be

managed? (40%)

Answer contributed by Dr. Sarah Price

2. a) What are i) diagnostic and ii) other clinical features of severe pre-eclampsia?

(35%)

Pre-eclampsia is a multi-system disease which normally presents after 20 weeks gestation.

The main features are hypertension and proteinuria.

Diagnostic criteria:

1. Hypertension:

Mild hypertension- BP 140/90-149/99 mmHg

Moderate hypertension -BP 150/100- 159/109mmHg

Severe hypertension - BP > 160/110mmHg

2. Proteinuria:

2 dipstick reagent tests with >2+ protein

> 300 mg protein in 24 hr urinary collection

Severe pre-eclampsia is identified by severe hypertension with proteinuria or mild or

moderate hypertension with proteinuria with at least one of the following:

Severe headache

Problems with vision such as blurring or flashing

Severe pain just below ribs or vomiting

Papilloedema

Signs of clonus (> 3 beats)

Liver tenderness

HELLP syndrome

Platelet count falls to < 100 x 109/llitre

abnormal liver enzymes (ALT or AST rises to > 70iu/litre)

b) What are the indications for magnesium therapy in severe pre-eclampsia

/eclampsia and which administration regimen(s) should be used? (25%)

Indications:

Any woman who has had a fit due to (suspected) eclampsia

Consider if:

Patient has severe preeclampsia and birth is planned within 24 hours

Severe hypertension and proteinuria or

mild or moderate hypertension and proteinuria with one or more of the following:

o symptoms of severe headache

o diplopia, or flashing lights in vision

o Severe epigastric pain or vomiting, liver tenderness

o papilloedema

o signs of clonus (≥3 beats)

o HELLP syndrome

o platelet count falling to below 100 x 109 per litre

o abnormal liver enzymes (ALT or AST rising to above 70 iu/litre).

Administration regime:

5 g loading dose, usually as 25mls Magnesium Sulphate 20% IV over 25 minutes

Then 1g per hour using 50mls Magnesium sulphate 20% I.V. over 24 hours (run at

5mls/hr via syringe pump)

If patients on magnesium sulphate suffer a fit consider reloading with a further dose

c) What are the signs and symptoms of magnesium toxicity and how should it be

managed? (40%)

Signs and symptoms are primarily cardiovascular and neurological, and tend to be dose

related. Therapeutic range: 2 – 3.5 mmol / L. Magnesium is excreted renally therefore those

patients with reduced urine output (e.g. pre-eclampsia) are at increased risk of toxicity.

Initially non-specific signs: nausea and vomiting, headache

4 - 5mmol / L

Loss of deep tendon reflexes (First repeatable sign, therefore patella reflex should be

monitored during magnesium therapy)

Muscle weakness

5 - 7.5 mmol/L

Respiratory muscle weakness

Hypotension

Bradycardia

ECG: AV prolongation, widening QRS

>12 mmol / L

Severe arrhythmias

Cardiac arrest

Management:

Specific treatment: stop infusion, calcium gluconate (2.5 to 5 ml) – physiological

antagonist.

Non-specific: protection of airway, intubation and ventilation if respiratory

compromise, CPR if full arrest.

Suggested reading

NICE guidance for multiple pregnancy and pre-eclampsia

Local guidance for multiple pregnancy and pre-eclampsia

CEACCP journal article on pre-eclampsia and magnesium

6. All health care professionals have a responsibility to act if they suspect that a child

has been subjected to physical abuse.

a) In what situations may the anaesthetist encounter possible child abuse? (25%)

b) List clinical features that would arouse suspicion that physical child abuse has

occurred. (40%)

c) What should the anaesthetist do if they suspect child abuse has taken place? (35%)

Answer Contributed by Dr. James Walkington

6. All health care professionals have a responsibility to act if they suspect that a child has

been subjected to physical abuse.


Resuscitation of a child who has sustained injuries under circumstances that cannot

be wholly explained or are consistent with intentional abuse or trauma

Paediatric Intensive Care unit – particularly following head injury

When asked to conduct anaesthesia for formal forensic examination

During a routine pre operative visit or surgical procedure you may notice suspicious

signs of physical or sexual abuse.

Rarely a child may disclose directly to the anaesthetist

b) List clinical features that would arouse suspicion that physical child abuse has occurred.

(40%)

Unusual or excessive bruising, particularly in the non ambulant baby/child.

Cigarette burns.

Bite marks.

Unusual injuries in inaccessible places e.g. neck, ear, hands, feet & buttocks.

Intra-oral trauma.

Damage to intra-oral frena, or unexplained frenum injury in a non-ambulant child.

Genital/ anal trauma (where no clear history of direct trauma is offered or part of the

clinical presentation).

Trauma without adequate history eg. Intra abdominal injury.


The child’s safety is paramount

Essential to involve personnel with expertise in child protection

Advice from duty senior paediatrician or for junior anaesthetists to involve their

consultant

A visual inspection is acceptable but any invasive / intimate examination needs

further consent.

Do not allow the anaesthetic time to become too prolonged waiting for a second

opinion.

Full and clear documentation should be ensured

Although usually undertaken by a senior paediatrician, the parents should be

informed of the concerns unless in doing so it is felt that the child would be placed at

further danger.

Reference:

Child Protection and the Anaesthetist: Safeguarding Children in the Operating

Theatre Jointly developed and produced by the Royal College of Anaesthetists, the

Association of Paediatric Anaesthetists, and the Royal College of Paediatrics and

Child Health, March 2007

Protecting Children and Young People: the responsibility of all doctors July 2012

Answer Contributed by Dr. Subhashini Naik


Anaesthetists may encounter abused children in a number of situations:

1. Resuscitation of a critically ill child who has sustained an injury under circumstances

that cannot wholly be explained by natural circumstances or is consistent with intentional

trauma or abuse.

2. In the paediatric intensive care unit e.g. following severe head injury, where the

above needs to be considered.

3. When called upon to anaesthetise a child for a formal forensic examination, possibly

involving colposcopy, sigmoidoscopy and the collection of specimens. This may also include

medical photography/video records.

4. Rarely a child may tell the anaesthetist about abuse (“disclosure”).

5. During the course of a routine pre-op examination or surgical procedure, the

anaesthetist or surgeon notes unusual or unexplained signs which may be indicative of

physical or sexual abuse.

b) List clinical features that would arouse suspicion that physical child abuse has

occurred. (40%)

There are occasions when a child is anaesthetised (for emergency or elective surgery) and

concerns are noted about possible physical or sexual abuse e.g. on exposure of the child

possible cigarette burns are seen. The interpretation of a flaccid or dilated anus is

particularly difficult. This can be a normal finding in an anaesthetised patient and especially

where a caudal/epidural block has been performed. Great care is required before raising

suspicions about abuse in the child, as knowledge about what constitutes normal

appearance is sparse. Physical signs can rarely be interpreted in isolation.

Suspicious signs which may be indicative of abuse

Unusual or excessive bruising, particularly in the non ambulant baby/child.

-oral trauma.

-oral frena, or unexplained frenum injury in a non-ambulant child.

clinical presentation).

l injury.


If the anaesthetist becomes concerned about the possibility of abuse, during a procedure for

an unrelated condition, then contact with the child’s paediatrician or the on call consultant for

acute paediatrics is advised. If there is genuine uncertainty about whether signs are

consistent with those caused by intentional harm, this should be discussed at an early stage

with a senior paediatric or anaesthetic colleague who may attend and give advice. A visual

inspection (e.g. of a skin lesion) is acceptable, but any additional or intimate / invasive

examination requires additional consent. This should not result in the anaesthetic being

markedly prolonged if

a second opinion is not readily available. It should be emphasised that any member of the

multi-professional team should be able to initiate the process.

It is essential to involve personnel with special expertise in Child Protection. In the first

instance, it may be appropriate to seek advice from the duty paediatric consultant, or for

junior anaesthetists to consult a more senior colleague . In addition, all Trusts have access

to specific child protection experts.These are the Named Doctors and Nurses, who usually

work within the Trust, and Designated Doctors, who often work within the local area. It is

crucial that all anaesthetic departments know who these people are and how to contact them

(see page 8). If there are very serious concerns, Social Services need to be informed this

will generally be decided upon by the Named or Designated Doctor or Nurse.

7. a) Describe the symptoms and signs of Complex Regional Pain Syndrome. (50%)

b) How many symptoms and signs are required to make the diagnosis? (25%)

c) What are the other pre-requisites for the diagnosis? (25%)

Answer Contributed by Dr. Seshu Tatikola

Must include- CRPS-

Complex regional pain syndrome (CRPS) is a debilitating, painful condition in a limb

associated with sensory, motor, autonomic, skin and bone abnormalities. Pain is typically the

leading symptom, but is often associated with limb dysfunction and psychological distress.

Prompt diagnosis and early treatment is required to avoid secondary physical problems

related to disuse of the affected limb and the psychological consequences of living with

undiagnosed chronic pain.

Pain and motor limitation is disproportionate to the pathology and it is a diagnosis by

exclusion

Budapest criteria is based on 4 categories

Sensory

Motor /Trophic

Vasomotor

Sudomotor/Edema

3 symptoms in different categories + 2 signs in different categories

Sensory- Allodynia, Hyperalgesia

Vasomotor- Skin color asymmetry, temperature either hot or cold

Sudomotor- Edema/Sweating changes – or asymmetry

Motor- decreased mobility, tremor, weakness, dystonia, trophic skin, hair nail changes

It is diagnosis by exclusion so all the differential diagnosis should be excluded

Neuropathic pain

Infection

Compartment syndrome

Raynauds

Arterial insufficiency

Lymphatic obstruction

Thoracic outlet syndrome

http://crpsuk.com/2012/02/21/crps-budapest-diagnostic-criteria/

A quite pointed question only diagnosis was asked so all the above must be included.

8. a) What features in the clinical history and examination would increase your

suspicion that an adult patient has obstructive sleep apnoea (OSA)? (25%)

b) List the preoperative investigations that may be useful in the assessment of the

OSA patient. For each investigation, indicate the abnormality you would expect to

find. (35%)

c) An adult patient with known OSA is listed for an open cholecystectomy. How will

the presence of OSA influence your perioperative management of this patient? (40%)

Answer contributed by Dr. J. Biddulph

a) What features in the clinical history and examination would increase your suspicion that

an adult patient has obstructive sleep apnoea (OSA)? (25%)

History of:

o Loud snoring

o Daytime somnolence

o Observed cessation of breathing

o Male

o Age 40-70

o Smoker

o Excess alcohol

o Low physical activity

o Surgical patient

o Pregnancy

o Tonsil and adenoidal hypertrophy

o Craniofacial abnormalities

http://crpsuk.com/2012/02/21/crps-budapest-diagnostic-criteria/

o Neuromuscular disease

On examination:

o Obese BMI > 35

o Neck circumference > 40 cm

o Hypertension



find. (35%)

Full blood count – polycythaemia

Blood glucose – diabetes

U+Es – renal disease ( complication of diabetes)

Oximetry - supine desaturation

Arterial blood gas - hypoxaemia, hypercarbia

Spirometry- obstructive or restrictive lung disease

Sphygmomanometry – hypertension

ECG- ischaemic heart disease, arrhythmias, left / right ventricular hypertrophy

Chest x ray – congestive cardiac failure

Echo- right/left ventricular hypertrophy, cardiac failure

Polysomnography (PSG) apnoea/hypopnoea index (AHI) > 5

c) An adult patient with known (OSA) is listed for an open cholecystectomy. How will

the presence of OSA influence your perioperative management of this patient?

(40%)

Preop

check prior anaesthetic charts for evidence of difficult airway

Optimise conditions associated with OSA (diabetes, hypertension, heart disease)

Ask patient to continue their usual CPAP regime.

Consider the need for prolonged PACU stay or HDU

If the patient is obese check appropriate manpower and equipment is available

Consider proton pump inhibitor to reduce risk of aspiration in the obese OSA patient

Avoid sedative premed

Consider need for epidural analgesia or other regional techniques

Plan for difficult intubation / ventilation

Intra op –

consider rapid sequence induction

Pre oxygenation in reverse trendelenberg position

Avoid gastric insufflation during bag mask valve ventilation

Place patient in ramped position for intubation

Intubate and ventilate patient

Use peep

Short acting opiates

Multimodal analgesia

Monitor neuromuscular blockade

Adequate reversal of neuromuscular blockade

Extubate awake and sitting up.

Post op-

Patients own CPAP

Teds and early mobilisation if obese.

May need continuous oxygen saturation monitoring in an appropriate ward

Prescribe post op oxygen

Answer contributed by Dr. Prasad Lanka

a) What features in the clinical history and examination would increase your

suspicion that an adult patient has obstructive sleep apnoea (OSA)? (25%) .

Definition:

OSA is intermittent complete or partial airway collapse, resulting in frequent episodes

of apnea and hypopnea. It is generally agreed that an apnoea, defined as a cessation of

airflow, has to exceed 10 s duration to be considered significant. No standard definition

of hypopnoea exists. It is usually defined as a reduction in airflow or respiratory effort for

more than 10 s accompanied by a desaturation of 3% or more and/or

electroencephalographic evidence of arousal. "Arousals" are sudden shifts in brain wave

activity

The apnoeas may be obstructive, central or mixed. URAS-Upper Airway Resistance

Syndrome: Increased airway resistance not sufficient to cause apnoea ,hypopnoea.

The grading of OSA is as follows, AHI of five to 15 represents mild sleep apnoea, 15–30

moderate and greater than 30, severe.

OSA Is a common medical condition affecting 2-26% of general population, affecting all

age groups. It’s estimated that 82% 0f men and 92% of women with OSA have not been

diagnosed.

Warning features in History and examination:

Most significant: witnessed apnoeic episodes[usually by partners] ,BMI>35[70%

prevalence in morbidly obese],Greater Neck circumference[>17inches or 42cms ]

snoring. Other

features :Excessive daytime sleepiness, sudden awakening, morning headache,

Structural features that give rise to a narrowed airway[Marfans, Downs], retrognathia

Neuromuscular[brain injury ,stroke], decreased muscle tone[ old age, sedatives, alcohol.]

smoking, estrogen depletion in menopause

Metabolic[hypothyroid],connective tissue disorder, nasal obstruction, laryngeal

obstruction

Explanations : witnessed apnoeic episode is a significant feature,2-3 times more

common in men [ one hypothesis is hormones like oestrogen and progesterone,but

injecting in men and post menopausal women doesn’t cured OSA;sex-based phenotypes

including physical features, occupational and other environmental exposures, and health

behavior put men at higher risks for disease ],older age[reaches plateau after 65

yrs],14% of pregnant women snores compared to 4%[due to↑ weight,pharyngeal edema

,decreased pharyngeal muscle dilator activity].The presence of unexplained respiratory

and heart failure, polycythaemia also suggests OSA.



find. (35%)

1.Epworth: 8 situations[Sitting and reading, Watching TV, Sitting inactive in a public place,

Being a passenger in a motor vehicle for an hour or more, Lying down in the afternoon

Sitting and talking to someone, Sitting quietly after lunch (no alcohol Stopped for a few

minutes in traffic

while driving), each scored 0-3[0=no chance of dozing,1 slight chance,2 moderate chance, 3

high chance]. A score of 10 or more is considered sleepy. A score of 18 or more is very

sleepy.Not very sensitive to diagnose OSA.

2.STOP BANG:

8 QUESTIONS[Snoring,Tired,Observed you stpopped breathing,High Blood

pressure,BMI>35,Age >50,Neck circumference >40 cms, Gender[male].

Low risk of OSA – ‘yes’ to less than three items , score of 5-8 identified patients with high

probability of moderate/severe OSA. For a STOP-Bang score of 5, the odds ratio (OR) for

moderate/severe and severe OSA was 4.8 and 10.4, respectively. For STOP-Bang 6, the

OR for moderate/severe and severe OSA was 6.3 and 11.6, respectively. For STOP-Bang 7

and 8, the OR for moderate/severe and severe OSA was 6.9 and 14.9, respectively A score

of ≥3 has shown a high sensitivity for detecting OSA: 93% and 100% for moderate and

severe OSA, respectively. The probabilities of having OSA were greater as the STOP-Bang

scoreincreased Owing to its high sensitivity at a score of ≥3, the STOPBang questionnaire is

considered very helpful to rule out patients having moderate and severe OSA. However, the

specificity at the same cut-off is low: 47% and 37% for moderate and severe OSA,

respectively, resulting in fairly high false-positive rate.

3.Polysomnography (PSG), also known as a sleep study is the gold standard

,multiparametric test which monitors brain function[EEG],Eye movements[EOG],muscle

activity[EMG],ECG,breathing functions[ respiratory airflow and respiratory effort] and pulse

oximetry. Any breathing irregularities; mainly apneas and hypopneas. Apnea is a complete

or near complete cessation of airflow for at least 10 seconds followed by an arousal and/or

3% oxygen desaturation; hypopnoea is a 50% decrease in airflow for at least 10 seconds

followed by an arousal and/or 3% oxygen desaturation. ..The severity of obstructive sleep

apnoea is graded by Apnoea –Hyponoea index as follows; Normal- AHI<5;Mild 5-

15;Moderate- 15-30; severe >30

c) An adult patient with known OSA is listed for an open cholecystectomy. How

will the presence of OSA influence your perioperative management of this

patient? (40%).

Why OSA increases periop morbidity and mortality: The breathing pauses[apnoea

hypopnoea] cause acute adverse effects, including oxyhemoglobin desaturation,

fluctuations in blood pressure and heart rate, increased sympathetic activity, cortical

arousal, and sleep fragmentation,which can cause cardiovascular[pulmonary

HY,Right heart failure , cerebrovascular complications,Intracranial hypertension and

poor wound healing. Undiagnosed sleep apnoea poses a variety of problems for

anaesthesiologists. OSA patients are known to have a higher incidence of difficult

intubation, postoperative complications, increased intensive care unit admissions,

greater duration of hospital stay and significantly higher incidence of pulmonary

complications.

The anaesthetic management [pre,intra and postop] plan is determined by the

severity of sleep apnoea, how it has been managed prior to anaesthesia, the planned

surgical procedure and the likely postoperative analgesic requirements. Patients with

diagnosed apnoea who are being treated with CPAP should take their equipment to

the operating theatre with them for use postoperatively. sedative premedicants

should be avoided.It’s not known whether Perioperative management of OSA by

means such as non-invasive ventilation [continuous positive airway pressure (CPAP)

or bi-level PAP] and postoperative monitoring may affect outcomes.

Pre op: Assess the patient for the cause of OSA, severity of OSA and the effect of

OSA on other organs. upper airway abnormalities that predispose to breathing

obstruction during sleep may also make tracheal intubation difficult.

STOP-BANG questionnaire,Epworth scoring and sleep studies helps for risk

assessment, moderate to severe OSA patients can be treated with CPAP. As OSA

can cause cardiovascular complications like pulmonary hypetension,right heart

failure ,these need to be ruled out [Echo] and should be optimized prior to the

surgery. 60% of patients will have pulmonary hypertension. Preop CPAP[ may

improve pulmonary hypertension] smoking[cessation].Alcohol [cessation],Obesity[wt

reduction and excercise] may improve the patient condition .

Airway assessment [ prone for difficult ventilation and intubation ] and Post op HDU

with CPAP should be organized. Preop sedative premedicants better avoided .Solo

regional tehniaques or supplementary regional tehniques are useful . Non opioid

[NSAID,Paracetamol,Gabapentin]Pre emptive analgesia may reduce the postop

opioid based rescue analgesia.

If the patient is Obese,preop antacid and VTE prophylaxis is desirable.

Intra op:as this patient needs GA, Prepare for difficult ventilation and intubation

Regional [ sub costal TAP block,pain burster,epidural etc],

limit Narcotics, use short acting opioids [Remifentanil] and NSAID

Limit the use of muscle relaxant

Adequate reversal .

Extubate in controlled environment

It’s feasible to do Laparoscopic cholycystectomy under CSE. Laparoscopic

cholecystectomy under segmental thoracic spinal anaesthesia: a feasibility study Van

Zundert AA, Br J Anaesth 2007; 98: 682–6

.

Post –op: Manadatory overnight admission either in HDU or ward with outreach

input , continuous O2 and pulse ox monitoring, PRN CPAP

Article Reviews: Br. J. Anaesth. Loadsman JA ,Hillman DR (2001) 86 (2):254-266.

BJA CEPD Reviews (2003) 3 (3): 75-78

Br. J. Anaesth. (2011) 106 (1):131-139.

9. A patient has died unexpectedly during a routine anaesthetic for minor surgery.

(a) What immediate administrative actions should be considered following such an

event? (70%)

(b) What steps should be taken to support all the people concerned? (30%)

Answer Contributed by Dr. Anita Samaan


(a) What immediate administrative actions should be considered following such an event?

(70%)

Immediate Actions following the unexpected death of a patient

Keeping Records

Accurate and contemporaneous recording of events which are legible, timed and

signed by the anaesthetist are essential. If available, an electronic record should be

kept. All interventions including doses of drugs used should be included in the

record. A full retrospective account of the event should be completed as soon as

possible. A critical incident record should be completed

Dealing with the anaesthetist

In case of a trainee or an SAS doctor, the responsible consultant should attend to

make sure that all the essential steps are carried out and to look after the

anaesthetist. If a consultant is involved then a more senior consultant or the CD

should attend. A decision should be made as to whether the list should continue or

whether it needs to be cancelled

Dealing with the patient

The appropriate doctor will need to inform the coroner of the death. All lines/tubes

and other equipment need to be left in place.

Dealing with relatives

It is important that the relatives are informed and there should be a team approach

to the interview which should be conducted in a quiet room free from interruptions.

The events should be described in simple language and questions should be

answered as honestly as possible

Clinical Directors responsibilities

The Clinical director for anaesthesia should inform the Medical Director of the

death. If there are any issues regarding equipment or drugs then the anaesthetic

machine should be removed for checking and any other anaesthetic

equipment/drugs should be kept for further testing


Supporting the theatre team includes critical incident stress debriefing. The team

should be initially debriefed at a time to suit all staff and preferably within a few

hours of the catastrophe. The aim is to provide and record information, and to gain

feedback while details are still fresh. It is also useful to allay anxieties or

misconceptions experienced by members of theatre team. The presence of a

trained counsellor may be useful to assist staff traumatised by the event

Supporting the anaesthetist

It is vital that members of the anaesthetic department support the anaesthetist who

may be stressed and traumatised. It is important to listen to the individual and

encourage him/her to talk and refrain from being judgemental. Informal,

sympathetic peer review with a few colleagues is often useful.

Support by mentoring

It maybe helpful to appoint a mentor to support the anaesthetist through the

difficult initial months.

Support by the occupational health department

MUST READ This is the glossy from

AAGBI http://www.aagbi.org/sites/default/files/catastrophes05.pdf

http://www.aagbi.org/sites/default/files/catastrophes05.pdf

Answer Contributed by Dr. I.F. Russell



event? (70%)


Another example of a poorly worded question!

Personally, I find it difficult to separate out “administrative” from “practical” as both are

important.

“Administrative” = “activities related to an organization's administration and management.”

I have identified what I think are administrative, but there is lots of “wriggle” room and other

may define some actions differently. May be interesting to discuss the definition! But from

the way the marks are distributed (70% for this section) I suspect that what I call practical

should also be included.

Also, what is the time limit of “immediate”? Is “immediate” the first few minutes or is it many

hours in the case of the death occurring at 02:00! Would informing senior administrative

staff, Coroner, or defence organisation at 09:00 be classed as “immediate” in this scenario?


event? (70%)

If there is a hospital protocol this should be obtained and followed, but in general the

following should occur early: (1) dealing with the incident, (2) dealing with the patient’s

relatives, (3) dealing with the theatre team, and later investigating the event and, if

necessary, formulating implementing and monitoring recommendations to prevent a similar

incident in the future.

(1) Dealing with the event

All lines, tubes and other equipment connected to the patient must be left in place,

undisturbed. If there is any cause for concern regarding the placement of the endotracheal

tube, its position should be confirmed and recorded by an independent anaesthetist but the

tube should not be moved. (Not strictly administrative)

If a trainee, inform supervising consultant. (Probably administrative)

All documentation should be completed, and detailed print outs of anaesthetic record

obtained. If someone (usually a nurse, or midwife has been keeping records (eg during

resuscitation), read these and make sure they make sense. Do not alter anything, but add

amendments in your own “write up” of the event. (Not strictly administrative)

The operating list may need to be cancelled or another team arranged to complete the list.

(Administrative)

As soon as possible inform Clinical Director, who should inform higher Trust mangers – eg

Medical Director. There may be an on-call senior manager who should be informed.

(Administrative).

As soon as possible inform (or get consultant to inform) the Coroner (England and Wales) or

Procurator Fiscal (Scotland) and the patient's general practitioner as soon as possible by

telephone or other immediate means. The Coroner or Procurator Fiscal may decide to

conduct their own investigation. (Administrative)

If there is suspicion of a criminal act then the police need to be informed.

The clinical director or a consultant not involved with the incident should take responsibility

for checking the patient, drugs and equipment. If there is suspicion of equipment failure or a

hazard affecting the theatre, a decision may be required to take the theatre or anaesthetic

machine out of commission until further notice.(partly administrative, partly not

administrative?)

All anaesthetic equipment, drug syringes and ampoules should be kept, and moved to a

secure store room for investigation. An accurate record should be made of all the checks

undertaken including time and date of inspection. All disposable equipment including

syringes and ampoules, airway devices etc. should be kept in a secure box. This is

necessary as further investigation may be required by medical equipment maintenance

personnel, manufacturers or toxicologists. (partly administrative, partly not administrative?)

The anaesthetist involved should contact his/her defence organisation. (Administrative)

It is important to complete a Trust critical or adverse incident form. (Administrative)

The body should be transferred to an appropriate area for further investigation if necessary.

(probably administrative)

Arrange for statements to be made by all who were present during the incident using the

Trust proforma. Statements should be descriptions of what happened rather than

interpretations of events.


(1) Dealing with relatives

Arrangements made to contact relatives if they are not in the hospital. Breaking bad news

should not be done over the telephone. It will be necessary to invite the relatives to come to

hospital informing them that some complication had occurred but no details should be given.

If there is no immediate family to accompany the relative, ask the relative to bring a friend.

Some hospitals have established a bereavement service which can be helpful for grieving

relative

A senior surgeon, anaesthetist and nurse as a minimum should be involved, but chaplain,

interpreter or social workers may also be involved. Decide before the meeting who will take

the lead, but leader can ask others to talk/explain

(2) Dealing with the theatre team

The team should be initially debriefed at a time to suit all staff and preferably within a few

hours of the catastrophe, to gain feedback, and allay anxieties or misconceptions. The

presence of a trained counsellor may be useful to assist staff traumatized by the event.

Longer term counselling may be required by some.

Staff informed that all media enquiries be directed to the Trust media manager.

(3) Dealing with the Anaesthetist

It is vital that members of the anaesthetic department support the anaesthetist who may be

stressed and traumatised with various symptoms – poor sleep, nightmares, using

alcohol/drugs excessively to help cope, depression, feeling lonely or isolated.

It is vital, particularly if there is no fault by the anaesthetist, that the anaesthetic department

protect the individual from, and stand up to, senior administration, whose first knee jerk

reaction is (a) “guilty until proven innocent” and (b) to suspend that anaesthetist. Suspension

will only make things worse in some situations.

It is important to listen to the individual and encourage him/her to talk but refrain from being

judgemental. Informal, sympathetic peer review with a few colleagues is often useful and

one (known and accepted by the anaesthetist) should be assigned as “mentor” to provide

support as long as necessary.

The department may have to cover operating lists & on call etc for the involved anaesthetist

if s/he is unable to continue.

10. a) Who in a Trust are responsible for minimising the risk of transmission of

infection between patients in the operating theatre? (20%)

b) What general practices may be employed in the operating theatre to minimise the

risk of transmission of infection between patients? (30%)

c) What specific considerations determine choice of single use or reusable equipment

in the context of airway equipment and anaesthetic breathing systems? (50%)

Answer contributed by Dr. Ramesh Ananth Manohar

Health care associated infections occur as a result of health care interventions or being in

contact with health care systems. DOH has released the code of practice for prevention and

control of health care associated infections.

According to this

1. Trust chief executive is responsible for the overall standard of care given to patients and

to ensure that this meets the standards.

2. Infection control committee and infection control team are responsible for preparing and

monitoring of policies for infection control.

3. A designated consultant microbiologist is responsible for providing advice on

decontamination and sterilization.

4. AAGBI recommends a designated consultant in the department to liaise with the

infection control department to ensure standards are met.

AAGBI recommends a number of standard precautions to anaesthetists irrespective of

patient’s diagnosis and infection status. They are

1. Hand hygiene: decontamination before every episode of patient contact and hand wash

with soap and water if contaminated.

2. Bare below the elbow with rings removed and cuts / abrasions closed with plasters.

3. Gloves: sterile for high risk procedures like CVP line insertion and central neuraxial

blocks.

4. Face mask with shield for sterile procedures.

5. Theatre caps.

6. Theatre suit in theatre with sterile water repellant gown for sterile procedures.

7. Theatre shoes in theatre with facilities to wash if soiled.

8. Decreased movement in theatre complex with closed doors to avoid unnecessary

movement. Visitors to be provided with theatre attire.

9. Management of theatre lists in a way to accommodate dirty cases at the end or allow

enough time [15 mins] for the plenum ventilation to work after the case. Dirty linen to

be disposed safely. Trolleys to be cleaned. Adequate time between cases for the

theatre to be cleaned.

10. Safe disposal of sharps.

11. Prevention of drug contamination: aseptic preparation of drugs in clean tray, single

use of the ampoule, syringes to be capped, safe disposal of drugs, avoid 3 way taps,

sterile IV cannulation, one way valves and avoid multiple use.

12. Appropriate use of single use anaesthetic equipment and decontamination /

sterilization of reusable equipment

Airway equipment and breathing circuits need to be risk stratified for risk of infection.

Risk can be classified as

1. High risk: any equipment piercing skin, mucous membrane or vascular system. Such

kind of equipment need to be single use or sterilized.

2. Intermediate risk: any equipment in contact with intact mucous membrane. They

need to be single use, disinfected or sterilized.

3. Low risk: any equipment in contact with intact skin. They need to be decontaminated.

In the context of airway equipment AAGBI recommendations are

1. Tubes- single use.

2. Supra glottic airway- single use or to be cleaned according to recommendations.

Single use for adeno tonsillectomy.

3. Catheter mounts and filters- single use.

4. Breathing systems- if filters are used circuits could be used up to 5 days. AAGBI

recommends daily change. Circuits to be changed following infectious patients like

open T.B.

5. Laryngoscope- single use or clean as per recommendation.

6. Bougie- single use or clean as per standard.

7. Bronchoscope- decontaminate with sufficient contact time in an automated

system.

11. a) List the indications for intra-operative cell salvage (ICS). (20%)

b) Which therapeutic substances should not be aspirated into the ICS system? (15%)

c) What are the current controversies regarding the use of ICS in obstetrics and in

patients with malignancy? (25%)

d) What additional measures can be applied to reduce the need for allogeneic blood

transfusion during an operation? (40%)

Answer Contributed by Dr. Muthuraj Kanakaraj

a) List the indications for intra-operative cell salvage (ICS). (20%)

In surgeries with, anticipated blood loss > 1000 ml or > 20 % estimated blood

volume.

Patients with low haemoglobin or increased risk factors for bleeding.

Patients with multiple antibodies or rare blood types.

Patients with objection to receive allogenic donor blood.


Antibiotics not licensed for IV use.

Iodine

Topical clotting agents.

Orthopaedic cement.

c) What are the current controversies regarding the use of ICS in obstetrics and in


Malignancy:

There is a concern that blood with malignant cells, re-infused may result in

metastasis.

But studies done in surgery involving urological and hepatocellular malignancies did

not show any difference in the incidence of metastasis between patients who

received and who did not receive cell salvage blood.

In 2008, NICE approved use of ICS in urological malignancies.

Avoiding blood around the tumour site and use of leukodepletion filters reduces the

incidence of malignant cell numbers.

Obstetrics:

The concern is the re-infusion of foetal contaminants causing amniotic fluid

embolism. But there is no evidence to prove this.

NICE has approved the use of ICS in obstetrics.



Pre-operative:

1. Iron supplements.

2. Erythropoietin.

3. Determining acceptable safe level of haemoglobin appropriate for the patient.

4. Autologous donation before an elective surgery.

5. Thromboembolic prophylaxis dose appropriate to body weight and coagulation

status.

Intra-operative:

1. Maintenance of physiologic body temperature. A fall of 1.5o C of body temperature is

associated with increased blood loss of about 50% in total hip replacements.

2. Hypotensive epidural anaesthesia if appropriate to the patient and surgery.

3. Normovolemic haemodilution.

4. Usage of thrombotic agents like platelet gels and fibrin sealants.

5. Anti-fibrinolytic agents: Tranexamic acid is safe and more effective than aprotinin.

6. Goal directed transfusion, (i.e.) Optimizing coagulation before red cell transfusion.

Needs point of care monitoring of coagulation (TEG)

Post-operative:

Reinfusion of salvaged red cells during the first 8 hours after surgery.

Reference:

AAGBI: Guidelines on Intra operative cell salvage and red cell transfusion.

Perioperative cell salvage CEACCP, volume 10 Number 4 2010.


11. a) List the indications for intra-operative cell salvage (ICS). (20%)


c) What are the current controversies regarding the use of ICS in obstetrics and in patients

with malignancy? (25%)



A) Indications for intra-operative cell salvage (ICS)

ICS is indicated in surgery with:

• Anticipated blood loss of >1000mls or >20% Estimated Blood Volume.

• Patients with a low Hb or increased risk factors for bleeding.

• Patients with multiple antibodies or rare blood types.

• Patients with objections to receiving allogenic (donor) blood.

Procedures and situations which may be suitable for ICS

Vascular Surgery, Trauma & Orthopaedics

Open aortic aneurysm repair - elective and emergency

Splenic/liver trauma

Spinal surgery

Revision hip replacement, Pelvic fractures

Urology

Radical cystectomy, Radical prostatectomy

Nephrectomy

General Surgery

Hepatectomy

Abdominal/thoracic trauma

Cardiac

Open heart surgery

Obstetric Emergency use:

Major obstetric haemorrhage, laparotomy for PPH.

Elective use: anticipated haemorrhage at LSCS e.g. placenta praevia/accreta, large

fibroid

Gynaecology

All major procedures, e.g. pelvic clearance

Head and Neck

Major procedures

Jehovah’s Witnesses or any patient refusing a blood transfusion

B) Which therapeutic substances should not be aspirated into the ICS system? (15%)

• Antibiotics not licensed for IV use

• Iodine or cleaning agents used in surgery

• Topical clotting agents e.g: collagen, cellulose & thrombin

• Orthopaedic cement

C) What are the current controversies regarding the use of ICS in obstetrics and in


Malignancy

1) Manufacturers of ICS devices do not recommend its use in patients undergoing surgery

for malignancy - concerns about the possibility of malignant cells being reinfused and

leading to metastases.

2) However two recent studies have shown no difference in biochemical recurrence or long

term survival after radical prostatectomy and cystectomy and also a recent prospective study

of hepatocarcinoma surgery also showed no difference in recurrence rates

3) In contrast, there is evidence that allogenic transfusion is independently associated with

an increased rate of both postop. infection and disease recurrence .

4) Hence, NICE approved the use of ICS in urological malignancies

- Aspiration of blood from around the tumour site to be avoided.

5) There is in vitro evidence that leucodepletion filters significantly reduce malignant cell

numbers.

Obstetrics

1) Main concern for use of ICS - risk of reinfusing fetal contaminants with risk of causing

amniotic fluid embolus (AFE).

2) However, to date there are no proven cases in the literature of AFE caused by reinfusion

of salvaged blood, and the use of cell salvage in obstetrics is approved by NICE.

3) Leucodepletion filters - Has shown a significant reduction in contamination from amniotic

fluid

4) The other concern of reinfusion of fetal RBCs from the operative field, as the cell saver

cannot distinguish fetal from maternal red cells.

5) If the mother is rhesus negative (and the fetus RhD positive) the extent of maternal

exposure should be determined by Kleihauer testing as soon as possible and a suitable

dose of Anti D given.

D) What additional measures can be applied to reduce the need for allogenic blood


Surgery

To consider staged or laparoscopic surgery as appropriate or possible

Meticulous technique, use of laser scalpels, biological haemostats, fibrin glues and sealants

Anaesthetic

To reduce venous oozing – careful positioning to avoid congestion, to avoid increased

intrathoracic pressures and hypercarbia

To prevent hypothermia

Low threshold for invasive monitoring

To outweigh the merits & demerits of hypotensive anaesthesia and regional anaesthesia as

necessary or appropriate

Drugs

To consider these drugs during major surgery

Antifibrinolytics – EACA, Tranexamic acid

Desmopressin – improves platelet adhesion

References – AAGBI Guidelines on ICS – recommended reading

12. (a) What are the main types of studies that must be done on a drug in order to obtain

marketing authorization (formerly called a product licence) from the Medicines and

Healthcare products Regulatory Agency (MHRA)? (30%)

(b) Define what is meant by ‘a double blind randomised controlled trial with adequate power’,

and explain the reasons for these methods? (50%)

(c) Under what circumstances might an observational study be an acceptable method of

investigation? (20%)

Answer Contributed by Dr. Dan Harper

What are the main types of studies that must be done on a drug in order to obtain



Phase 0: Pharmacodynamics and pharmacokinetics

The first in-human trials given to small number (10-15) in sub therapeutic doses to determine

how the drug is handled within the body

Phase I: Screening for safety

Usually involve small numbers of healthy people. They are designed to find out how the

treatment works in the body and how those treated react to it. This type of trial also aims to

find out the lowest dose at which the treatment is effective, known as the minimum

therapeutic dose, and the highest dose at which it can be taken without causing harm.

Phase II: Establishing the testing protocol

Test the treatment in several hundred people with a given disease or condition. They aim to

find out how well the treatment works in larger numbers, identify common side effects, and

refine the dose and length of treatment.

Phase III: Final testing

Compare the treatment on several thousand patients, to gather more detailed information on

how well it works and in which groups of patients, as well as its safety. The results influence

the prescribing and patient information of a medicine once it is marketed.

Phase IV: Post approval studies

Carried out after a medicine has been licensed, put on the market and prescribed to

patients. Part of the monitoring process, these trials are designed to find out more about the

long term harms and benefits of a medicine, and to discover new uses for it.

NOTE: Phase 0 is not always described in books etc it is a more recent addition.

Technically phase IV trials are performed after the marketing authorisation is granted. I’m

not sure the best way of dividing the marks. Assuming a mark is roughly 5% then 6 are

available for this question. Maybe half a mark for each phase I – IV then a whole mark for

the explanation?

Define what is meant by ‘a double blind randomised controlled trial with adequate power’,

and explain the reasons for these methods? (50%)

This is the gold standard in medical research

Double blind

Blinding in a trial attempts to eliminate bias. Singly blinded trials do not tell the patient which

treatment they are receiving such as active or inactive drug. In some occasions this can be

very difficult to achieve but investigators go to great lengths such as performing dummy

procedures to maintain blinding. Blinding in the patient group is important because it helps

to control the placebo effect.

In double blind trials neither the investigators nor the patients are aware of which treatment

the participant is receiving. This helps to eliminate the chance of the investigators own

agenda might influence the results.

Randomised

The group to which the participant is allocated to is randomly allocated. This can be

achieved in a number of ways but generally patients are allocated a number which a

computer program then allocates to different groups. This is an attempt to ensure that

patient demographics which might influence the outcome such as age, weight, sex medical

history etc are matched between each group.

http://www.mhra.gov.uk/Safetyinformation/Generalsafetyinformationandadvice/Adviceandinformationforconsumers/MymedicineFromlaboratorytopharmacyshelf/Monitoringmedicinesafterlicensing/index.htm

Controlled

The trial is performed in two groups, the treatment and control groups. The control group

might receive dummy medicines or procedures in which case it would be placebo controlled.

In some trials it would be unethical to treat a patient with a placebo for example in patients

with cancer. Here the control group is treated with the current standard of care and the

outcome is compared with that in the group receiving the product under investigation.

Controlling a trial simply allows for a comparison to be made and as long as all other

variables are controlled for the effect seen can then be attributed to the product with

reasonable confidence.

Adequate power

The power of a statistical test is the probability that a test will reject the null hypothesis when

it is in fact false. As the power increases the chance of committing a type II error (false

negative or β) decreases. Power is equal to 1 – β and is sometimes referred to as the

sensitivity. By convention a power of 0.8 (β = 0.2) is an acceptable level of power. A power

of 0.8 means that the study has an 80% chance of producing a p value of <0.05 when the

required difference between variables is observed. A power calculation is performed to

determine the minimum sample size which can be reasonably expected to demonstrate this

observed difference.

Under what circumstances might an observational study be an acceptable method of

investigation? (20%)

An observational study is one in which the allocation of subjects into control and treatment

group is outside the influence of the researcher. Observational study is a collective term for

cohort, cross sectional and case-control studies. The primary reason for using an

observational study is when ethical considerations preclude allocation of asymptomatic,

randomly allocated subjects to certain variables for example the link between smoking and

lung cancer.

This example also demonstrates the other situation in which an observational study might be

employed, specifically when it using a randomized controlled methodology would be

impractical due to the long natural history of cause and effect. Studying the effects of

smoking on cancer would result in a study would run for 20 or more years. In observational

studies the researcher might select a group of patients with lung cancer and work backwards

to identify a causative influence. The same is true when investigating conditions or effects

which are rare and would therefore require a prohibitively large number of subjects in which

to observe the effect. Once again patients are selected with the condition and the

researcher would work retrospectively to try and determine cause and effect.

Answer Contributed by Dr. P Balaji

(a) What are the main types of studies that must be done on a drug in order to obtain



Before obtaining the marketing authorisation, the drug company has to provide more

information and paperwork to prove how the drug work, its side-effect and efficacy. MHRA is

more concerned about the safety and efficacy. Any trial conducted in UK would suffice. Step

wise approach would be to conduct a trial in animals followed by any evidence (trial

information) obtained elsewhere from other countries. This would be followed by Phase-2

trial (observational) in a controlled and restricted manner. Once they are satisfied, they

would provide MA following which RCT could be done to know its efficacy for which every

hospital has to obtain MHRA approval.

Must include: MHRA looks for safety and efficacy. Clinical trials have to be conducted in UK.

(b) Define what is meant by ‘a double blind randomised controlled trial with adequate

power’, and explain the reasons for these methods? (50%)

The randomized controlled trial is one of the simplest but most powerful tools of research. In

essence, the randomized controlled trial is a study in which people are allocated at random

to receive one of several clinical interventions. On most occasions, the term “intervention”

refers to treatment, but it should be used in a much wider sense to include any clinical

manoeuvre offered to study participants that may have an effect on their health status. Such

clinical manoeuvres include prevention strategies, screening programs, diagnostic tests,

interventional procedures, the setting in which health care is provided, and educational

models. Randomized controlled trials are used to examine the effect of interventions on

particular outcomes such as death or the recurrence of disease. Some consider randomized

controlled trials to be the best of all research designs, or “the most powerful tool in modern

clinical research”, mainly because the act of randomizing patients to receive or not receive

the intervention ensures that, on average, all other possible causes are equal between the

two groups.

In addition to randomization, the investigators can incorporate other methodologic strategies

like blinding to reduce the risk of ascertainment and observation biases. A single-blinded

randomized controlled trial is one in which a group of individuals involved in the trial (usually

patients) does not know which intervention is given to each participant. A double-blinded

randomized controlled trial, on the other hand, is one in which two groups of individuals

involved in the trial (usually patients and treating physicians) do not know which intervention

is given to each participant.

The most important limitations of research methods for RCT include the following:

Insufficient power.—A survey of 71 randomized controlled trials showed that most of these

trials were too small (i.e., had insufficient power to detect important clinical differences) and

that the authors of these trials seemed unaware of these facts. So Power is important to

interpret the effectiveness of the trial. More often we talk about the power of a study to detect

an effect of a specified sample size where the power is 1-beta, where beta is type-II error

which is usually designed for 85-90% in order to detect a difference ( as significant) that is

real (due to the drug).

Must include: definition for RCT, double blind and power

(c) Under what circumstances might an observational study be an acceptable method

of investigation? (20%)

Observational studies include Cohort, cross sectional and case-control studies. Often these

studies are the only practicable method of studying various problems, for example, studies of

aetiology, instances where a randomised controlled trial might be unethical, or if the

condition to be studied is rare. Cohort studies are used to study incidence, causes, and

prognosis. Because they measure events in chronological order, they can be used to

distinguish between cause and effect. Cross sectional studies are used to determine

prevalence. They are relatively quick and easy but do not permit distinction between cause

and effect. Case controlled studies compare groups retrospectively. They seek to identify

possible predictors of outcome and are useful for studying rare diseases or outcomes. They

are often used to generate hypotheses that can then be studied via prospective cohort or

other studies. On those circumstances, Observational study would be an acceptable method

of investigation.

Must include that there are various studies like cohort, cross-sectional and case-control and

few examples why it is acceptable and why RCT can't be done. Even a single example

would be sufficient.

Reading materials: Practical statistics for medical research by Douglas Altman; very simple

and easy to read.

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