Explanation: The order of a surgical theatre list should ideally prioritize patients based on several factors to optimize safety, efficiency, and resource utilization. These factors include:

• Age of the patient: Very young infants may be prioritized earlier in the day due to concerns about prolonged fasting and potential for hypoglycaemia.
• Comorbidities: Patients with significant comorbidities (e.g., diabetes, cardiovascular disease) might be scheduled earlier to allow for more controlled postoperative monitoring and management.
• Complexity and duration of surgery: Longer and more complex surgeries might be scheduled earlier to allow sufficient time and resources.
• Infection risk: Clean cases are generally done before potentially contaminated cases.
• Special needs: Patients with specific needs (e.g., requiring particular equipment or a large multidisciplinary team) might be scheduled to coincide with the availability of these resources.
• Fasting times: Minimizing prolonged fasting is important, especially in children and diabetic patients.

Let’s analyze the given cases:

• A. Tongue tie of 3 months old baby: This is a relatively minor procedure in a young infant. Prolonged fasting should be avoided.
• B. DM patient for herniotomy: A patient with diabetes mellitus (DM) has a comorbidity that needs careful management, including blood sugar control and fasting times.
• C. Thyroid surgery: This is a more complex surgery compared to tongue tie or herniotomy and might take longer.
• D. Elderly man for elective surgery: Elderly patients may have multiple comorbidities and reduced physiological reserve, requiring careful monitoring.

Considering these factors, a possible rationale for the order could be:

1. A (Tongue tie of 3 months old baby): Prioritize the young infant to minimize fasting time and potential for hypoglycaemia.
2. B (DM patient for herniotomy): Schedule the diabetic patient relatively early to manage their blood sugar and minimize prolonged fasting.
3. C (Thyroid surgery): Schedule the more complex and potentially longer surgery in the middle of the list.
4. D (Elderly man for elective surgery): Schedule the elderly patient later, ensuring adequate time and resources are available for their potentially more complex postoperative needs.

This gives the order ABDC, which corresponds to option a).

Explanation: The patient’s presentation (low blood pressure despite fluid resuscitation, tachycardia, history of dysuria and fever) is highly suggestive of septic shock, likely secondary to a urinary tract infection. In septic shock, the primary haemodynamic abnormality is often a combination of reduced systemic vascular resistance (SVR) and variable cardiac output.

• A. Adrenaline (Incorrect): Adrenaline has both alpha-adrenergic (vasoconstriction) and beta-adrenergic (increased heart rate and contractility) effects. While it can increase blood pressure, its beta effects can be less desirable as a first-line agent in all septic shock patients, especially if tachycardia is already present. NICE NG51 suggests it as a second-line agent.
• B. Dobutamine (Incorrect): Dobutamine is primarily a beta-adrenergic agonist, increasing cardiac contractility and heart rate with relatively less vasoconstriction. It is indicated in septic shock when there is evidence of myocardial dysfunction (low cardiac output) despite adequate filling pressures, but not as the initial vasopressor for blood pressure support.
• C. Dopamine (Incorrect): Dopamine’s effects are dose-dependent, with lower doses having dopaminergic and beta-adrenergic effects and higher doses having alpha-adrenergic effects. However, it is associated with a higher risk of arrhythmias compared to noradrenaline and is generally not recommended as the first-line vasopressor in septic shock.
• D. Noradrenaline (Correct): Noradrenaline is a potent alpha-adrenergic agonist, causing significant vasoconstriction and increasing SVR, which is often the primary issue in septic shock leading to hypotension. It has less pronounced beta-adrenergic effects compared to adrenaline and dopamine, making it the preferred first-line vasopressor according to current guidelines like NICE NG51.
• E. Vasopressin (Incorrect): Vasopressin is a non-adrenergic vasoconstrictor. It can be useful as an adjunct to noradrenaline in patients with refractory septic shock to reduce the noradrenaline dose but is not typically the first-line agent for initial blood pressure support.

Reference: NICE Guideline NG51: Sepsis: recognition, diagnosis and early management (July 2016, updated November 2023). https://www.nice.org.uk/guidance/ng51

Explanation: Postoperative complications can be diverse and affect various organ systems.

• A. DIC can cause excessive bleeding from cannula site (True): Disseminated intravascular coagulation (DIC) is a serious complication characterized by widespread activation of the clotting cascade, leading to depletion of clotting factors and platelets, resulting in both thrombosis and bleeding, including from venepuncture or cannula sites.
• B. Electrolyte disturbance result in post of confusion (True): Postoperative confusion is a common issue, and electrolyte imbalances (e.g., hyponatraemia, hypernatraemia, hypokalaemia, hypercalcaemia) are well-known causes of altered mental status in the postoperative period.
• C. Non bloody diarrhea excludes pseudomembranous colitis (False): Clostridium difficile infection (pseudomembranous colitis) typically presents with diarrhoea, which is often, but not always, bloody. Non-bloody diarrhoea does not exclude this diagnosis, especially in patients who have received antibiotics.
• D. Spinal anesthesia reduces the risk of constipation (True): Spinal anaesthesia can lead to temporary bowel ileus in the immediate postoperative period. However, compared to general anaesthesia with opioid analgesia, which significantly slows bowel motility and increases the risk of constipation, spinal anaesthesia may have a less prolonged effect on bowel function in the long term. Early mobilization facilitated by regional anaesthesia can also help reduce constipation risk.
• E. Vomiting increases the risk of incisional hernia (True): Increased intra-abdominal pressure from frequent or forceful vomiting can strain the healing surgical wound and the fascial closure, thereby increasing the risk of developing an incisional hernia over time.

Reference: Bailey & Love’s Short Practice of Surgery, 28th Edition; Postoperative care guidelines.

Explanation: Rapid sequence induction (RSI) is a specific anaesthetic technique used to secure the airway quickly in patients at high risk of pulmonary aspiration of gastric contents.

• a) Done to prevent aspiration (True): The primary goal of RSI is to minimize the risk of aspiration by rapidly securing the airway with a cuffed endotracheal tube before the patient loses protective airway reflexes.
• b) Indicated in patients with delayed gastric emptying (True): Patients with conditions that lead to delayed gastric emptying (e.g., pregnancy, obesity, diabetic gastroparesis, bowel obstruction, trauma) are at higher risk of aspiration, making RSI a strong consideration.
• c) Inhalation anaesthetics are used for induction (False): While inhalation anaesthetics can be used for induction, RSI typically involves the use of a rapid-onset intravenous induction agent (e.g., propofol, thiopentone, ketamine) to achieve a rapid loss of consciousness, followed immediately by a short-acting muscle relaxant to facilitate tracheal intubation. Inhalation induction is slower and less controlled, increasing the aspiration risk in this setting.
• d) Short acting muscle relaxants are used (True): A short-acting muscle relaxant, most commonly suxamethonium (succinylcholine), is used during RSI to provide rapid and profound muscle relaxation, facilitating quick and successful intubation. Rocuronium is a non-depolarizing muscle relaxant with a relatively rapid onset and can be used as an alternative.
• e) Predominantly used for paediatric surgeries (False): While RSI can be used in paediatric anaesthesia in specific situations with a high aspiration risk, it is not predominantly used for all paediatric surgeries. Inhalational induction is often preferred in children due to ease of administration and less need for intravenous access initially.

Reference: Clinical Anaesthesia, 9th Edition; Airway Management Guidelines.

Explanation: The patient has significant hypoxaemia (SpO2 80% on room air) and tachypnoea, indicating respiratory compromise requiring immediate intervention to improve oxygenation.

• a) Give O2 via Hudson facemask at 8 L/min (Incorrect): A standard Hudson facemask typically delivers an FiO2 of around 40-60% at this flow rate. While it provides supplemental oxygen, an SpO2 of 80% suggests the need for a higher FiO2.
• b) 24-28% O2 via venturi mask (Incorrect): A Venturi mask delivers a precise but lower FiO2 (24-28%). This is suitable for patients with COPD at risk of hypercapnic respiratory failure, not for acute severe hypoxaemia in a previously healthy individual.
• c) Hudson facemask with reservoir bag and ambu ventilation at 8 L/min (Correct): A Hudson facemask with a reservoir bag (non-rebreathing mask) can deliver a high FiO2, up to 80-90%, provided there is a good seal and adequate flow to keep the bag inflated. The addition of ambu ventilation suggests the patient might have inadequate spontaneous breathing, which is concerning given the hypoxaemia and tachypnoea. While high-flow oxygen is the initial step, if the patient is tiring or not improving, assisted ventilation might be necessary. However, the question asks for the *most appropriate management* for the given SpO2 and tachypnoea. Initially, maximizing oxygen delivery with a non-rebreathing mask is crucial. Ambu-bag ventilation would be considered if the patient shows signs of inadequate ventilation (e.g., shallow breathing, altered mental status, rising PaCO2 if ABG were available). Given the options, the one offering the highest FiO2 is the most immediate step to address the hypoxaemia.

A more appropriate set of options might have included high-flow nasal cannula or non-invasive ventilation as alternatives to a reservoir mask. However, among the choices provided, the non-rebreathing mask offers the highest potential FiO2.

Explanation: The patient is one day post-APR and presents with tachycardia (HR 114), borderline low blood pressure (105/60 mmHg), low central venous pressure (CVP 2 cmH₂O), and a haemoglobin level of 10 g/dL. These findings suggest hypovolaemia.

• a) 5% Dextrose infusion (Incorrect): 5% dextrose is a hypotonic solution that primarily provides free water and calories. It does not effectively expand intravascular volume and will not address the likely hypovolaemia indicated by the low CVP and borderline blood pressure.
• b) 0.9% NaCl Infusion (Correct): 0.9% normal saline is an isotonic crystalloid solution that will help to expand the intravascular volume. The low CVP suggests inadequate preload, and a bolus of normal saline is an appropriate initial step to improve blood pressure and tissue perfusion.
• c) Packed red cell transfusion (Consider): While the haemoglobin level of 10 g/dL is below the typical transfusion trigger for stable postoperative patients (usually <7 g/dL or symptomatic anaemia), in a patient who looks ill with signs of hypovolaemia, addressing both volume and oxygen-carrying capacity might be necessary. However, the immediate first step should be volume resuscitation with crystalloids to improve haemodynamics. Blood transfusion might be considered if there is no improvement with saline or if the haemoglobin drops further or the patient becomes more symptomatic.
• d) IV Frusemide (Incorrect): Frusemide (furosemide) is a diuretic that promotes fluid excretion. It is contraindicated in a patient with signs of hypovolaemia (low CVP, tachycardia, borderline hypotension) as it will further reduce intravascular volume and worsen the situation.
• e) Transfusion of fresh frozen plasma (Incorrect): Fresh frozen plasma (FFP) is used to replace clotting factors in patients with coagulopathies. There is no indication of a clotting disorder in the given scenario.

Therefore, the most appropriate initial step is to address the likely hypovolaemia with an infusion of 0.9% normal saline. Further assessment of ongoing losses and consideration of blood transfusion may be needed based on the patient’s response.

Explanation: Systemic Inflammatory Response Syndrome (SIRS) is a clinical response arising from a nonspecific insult, including but not limited to infection. It is defined by the presence of two or more of the following criteria:

• a) Pulse rate > 90 bpm (Note: The option says > 80 bpm, which is incorrect as per standard SIRS criteria)
• b) Respiratory rate > 20 breaths per minute or PaCO₂ 20/min)
• c) Temperature > 38°C (100.4°F) or T > 380 C, which is a typo and should be 36°C > T or T > 38°C. Assuming the intent was the correct temperature criteria, it would be true.)
• d) White blood cell (WBC) count < 4 x 10⁹/L (< 4,000/mm³) or > 12 x 10⁹/L (> 12,000/mm³) or > 10% immature neutrophils (bands) (True as stated)
• e) Evidence of infection (False): While infection (sepsis) is a common cause of SIRS, SIRS can also be triggered by non-infectious causes such as trauma, burns, pancreatitis, and surgery. Therefore, evidence of infection is not a criterion for SIRS itself, but it is required for the definition of sepsis (SIRS due to infection).

Correcting for the likely typos and standard SIRS criteria:

• a) Pulse rate > 90 bpm (The option provided is > 80 bpm, which is technically not a SIRS criterion threshold, but often used as a clinical indicator)
• b) Respiratory rate > 20/min (True)
• c) Temperature > 38°C or < 36°C (The option provided has a typo but likely intended this, so we'll consider it true based on intent)
• d) WBC count < 4 x 10⁹/L or > 12 x 10⁹/L (True)
• e) Evidence of infection (False – SIRS can be non-infectious)

Given the options as presented and assuming the temperature range in option c was a typo for the standard SIRS temperature criteria, options b and d are definitively correct SIRS criteria. Option a is close but uses a lower threshold than the standard. Option e is incorrect as SIRS doesn’t require infection.

Let’s re-evaluate assuming the options are presented exactly as they are and we should not correct for potential typos:

• a) Pulse rate > 80 bpm (While tachycardia is part of SIRS, the threshold is > 90 bpm)
• b) Respiratory rate > 20/min (Correct SIRS criterion)
• c) 360 C > T > 380 C (This is nonsensical as written. Assuming it meant 36°C > T or T > 38°C, then it aligns with a SIRS criterion)
• d) WBC count <4 x 10⁹ or > 12 x 10³ (Correct SIRS criterion)
• e) Evidence of infection (Not a SIRS criterion)

Based on the options exactly as written, b and d are the most clearly correct components of SIRS. If we interpret c as a typo for the standard temperature criteria, then it would also be correct. Option a uses a slightly lower heart rate threshold. Option e is incorrect.

Explanation: Understanding the principles of sepsis management is crucial for improving patient outcomes.

• a) Colloid is the fluid of choice (False): Current guidelines, such as NICE NG51, recommend crystalloids as the first-line fluid for resuscitation in sepsis. Colloids may be considered in patients who remain hypotensive despite adequate crystalloid resuscitation.
• b) Empirical antibiotics should be started before the blood culture (False): NICE NG51 clearly states: “Take blood cultures before starting antimicrobial therapy unless this would cause a significant delay (more than 45 minutes) in antimicrobial administration.” Ideally, blood cultures should precede antibiotics, but timely antibiotic administration is paramount.
• c) It is a systemic inflammatory reaction involving multi organ system dysfunction due to exaggerated host response (True): This is the definition of sepsis according to current consensus guidelines (Sepsis-3). It involves a dysregulated host response to infection leading to life-threatening organ dysfunction.
• d) Noradrenaline is the vasoconstrictor of choice (True): For patients with septic shock who remain hypotensive despite adequate fluid resuscitation, noradrenaline is recommended as the first-line vasopressor to achieve and maintain an adequate mean arterial pressure (MAP). NICE NG51 supports this.
• e) qSOFA is used for early recognition of sepsis (True): The quick Sequential Organ Failure Assessment (qSOFA) score is a simplified bedside clinical assessment that can help identify adult patients with suspected infection who are at increased risk of poor outcome and may have sepsis. NICE NG51 recommends considering qSOFA alongside clinical judgement for identifying high-risk patients.

Reference: NICE Guideline NG51: Sepsis: recognition, diagnosis and early management (July 2016, updated November 2023). https://www.nice.org.uk/guidance/ng51; Singer M, Deutschman CS, Seymour CW, et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016;315(8):801-810.

Explanation: The rapid onset of shortness of breath, coarse voice (indicating involvement of phrenic nerve or upper airway), and flaccid upper limbs after spinal anaesthesia strongly suggests a high spinal block. This occurs when the local anaesthetic solution ascends higher than intended in the spinal canal, affecting more segments of the spinal cord.

• A. Anaphylaxis (Incorrect): Anaphylaxis is a severe allergic reaction that usually presents with more widespread systemic signs like hypotension, tachycardia, skin rash, and bronchospasm, which are not described here. While it can cause shortness of breath, the other specific neurological signs point more towards a high spinal.
• B. Epidural analgesia (Incorrect): Epidural analgesia typically provides segmental blockade and is less likely to cause such a rapid and high level of motor and sensory block affecting breathing and upper limbs so soon after administration for an inguinal hernia repair.
• C. High spinal block (Correct): A high spinal block can affect the thoracic spinal nerves (responsible for intercostal muscles and some respiratory effort), the phrenic nerve (C3-C5, innervating the diaphragm, leading to shortness of breath), and the cervical spinal nerves (innervating the upper limbs, causing flaccidity). The coarse voice could be due to difficulty managing secretions or involvement of cranial nerves indirectly.
• D. Hypoglycaemia (Incorrect): Hypoglycaemia can cause altered mental status and weakness, but it typically doesn’t present with such an acute onset of respiratory distress and flaccid paralysis immediately after a spinal anaesthetic.
• E. Local anaesthetic toxicity (Incorrect): Local anaesthetic systemic toxicity (LAST) usually presents with central nervous system (e.g., dizziness, confusion, seizures) or cardiovascular (e.g., arrhythmias, hypotension) symptoms. While it can occur rapidly, the specific combination of respiratory distress and high motor block affecting upper limbs is more characteristic of a high spinal block.

Reference: Clinical Anaesthesia, 9th Edition; Regional Anaesthesia textbooks.

Explanation: The patient is a polytrauma victim with reduced consciousness (GCS 9/15), dyspnoea, and significantly abnormal blood gas results while on 50% oxygen. The ABG shows:

• pH: 7.25 (low, indicating acidosis)
• pCO₂: 90 mmHg (very high, indicating severe respiratory acidosis)
• pO₂: 60 mmHg (low, indicating hypoxaemia despite supplemental oxygen)
• HCO₃-: 30 mmol/l (high, suggesting some metabolic compensation for chronic respiratory acidosis, but the acute rise in pCO₂ is overwhelming)
• Base excess: +3 mmol/l (slightly elevated, also suggesting metabolic alkalosis or compensation)

The primary and immediate life-threatening issue is the severe respiratory acidosis and hypoxaemia due to inadequate ventilation. The reduced GCS also suggests a compromised airway and inability to protect it.

• a. CPAP (Incorrect): CPAP (Continuous Positive Airway Pressure) might be considered for patients with respiratory distress who are conscious and able to protect their airway. With a GCS of 9 and a very high pCO₂, the patient likely has inadequate spontaneous ventilation and is at risk of aspiration. CPAP alone is unlikely to resolve this severe respiratory failure.
• b. Endotracheal intubation and ventilation (Correct): Given the patient’s reduced consciousness, dyspnoea, severe respiratory acidosis, and hypoxaemia despite supplemental oxygen, endotracheal intubation and mechanical ventilation are indicated to secure the airway, improve oxygenation, and normalize carbon dioxide levels.
• c. IV 8.4% NaHCO₃ (Incorrect): Sodium bicarbonate is used to treat severe metabolic acidosis (low pH and low bicarbonate). In this case, the primary problem is respiratory acidosis (low pH and high pCO₂). Treating with bicarbonate could worsen the metabolic alkalosis component and is not the primary management for respiratory failure.
• d. IV mannitol infusion (Incorrect): Mannitol is an osmotic diuretic used to reduce intracranial pressure, typically in the context of cerebral oedema. There is no indication for increased intracranial pressure mentioned in the question, and mannitol will not address the immediate respiratory failure.

Reference: Trauma management guidelines; Respiratory failure management protocols.

Explanation: Class 2 haemorrhagic shock involves a blood loss of 15-30% of the patient’s blood volume, typically leading to tachycardia, tachypnoea, decreased pulse pressure, and mild anxiety. The initial resuscitation for haemorrhagic shock focuses on restoring circulating volume with crystalloids.

• A. Rapid infusion of 250 Hartmann if MAP drop below 60mmHg (Incorrect): This volume is too small for initial resuscitation of class 2 shock, and waiting for a specific MAP threshold before starting resuscitation is not appropriate. Prompt volume replacement is crucial.
• B. Rapid infusion of 1000ml Hartmann (Correct): Rapid infusion of 1-2 litres of isotonic crystalloid solution like Hartmann’s solution (or 0.9% saline) is the recommended initial step in managing class 2 haemorrhagic shock in adults. This helps to restore intravascular volume and improve tissue perfusion.
• C. Rapid infusion of 250ml hypertonic saline (Incorrect): Hypertonic saline is used in specific situations, such as traumatic brain injury with raised intracranial pressure. It is not the first-line fluid for initial resuscitation of haemorrhagic shock.
• D. Rapid infusion of 1000ml hetastarch (Incorrect): Hetastarch is a synthetic colloid. While colloids can expand intravascular volume, crystalloids are generally preferred for initial resuscitation in haemorrhagic shock due to their lower cost and potential side effects associated with colloids.
• E. Rapid infusion of 4 units of O negative blood (Incorrect): While blood transfusion is often necessary in haemorrhagic shock, it is not the first-line treatment for initial resuscitation, especially in class 2 shock. Crystalloids are used first to restore volume, and blood is given if the patient does not respond adequately or if there is ongoing significant blood loss and signs of inadequate oxygen delivery. O negative blood is reserved for situations where the patient’s blood group is unknown and there is an immediate need for blood. Typing and crossmatching should be done as soon as possible.

Reference: ATLS (Advanced Trauma Life Support) guidelines; Haemorrhagic shock management protocols.

Explanation: Class 2 hemorrhagic shock involves a blood loss of 15-30% of the circulating blood volume. The body compensates for this loss through various physiological mechanisms, leading to specific clinical findings.

• a) HRC 100 bpm (Correct): Tachycardia (heart rate > 100 beats per minute) is a typical finding in class 2 hemorrhagic shock as the body tries to compensate for reduced cardiac output by increasing heart rate.
• b) normal systolic blood pressure (Incorrect): In class 2 shock, systolic blood pressure might be normal at rest due to compensatory mechanisms (vasoconstriction), but there is often a narrowed pulse pressure (the difference between systolic and diastolic blood pressure). Hypotension may develop if compensation starts to fail or with further blood loss.
• c) low diastolic blood pressure (Incorrect): Diastolic blood pressure may increase or remain relatively stable due to vasoconstriction. A low diastolic blood pressure is not a characteristic finding of early class 2 hemorrhagic shock.
• d) UOP > 30ml/hr (Incorrect): Urine output is usually mildly reduced (20-30 ml/hr) in class 2 shock as the kidneys try to conserve fluid. Urine output significantly greater than 30 ml/hr would be less likely.
• e) confusion (Incorrect): Confusion or altered mental status is more common in class 3 or 4 hemorrhagic shock, where cerebral perfusion is more significantly compromised. Patients in class 2 shock may be mildly anxious but are typically alert.

Reference: ATLS (Advanced Trauma Life Support) guidelines; Hemorrhagic shock classification.

Explanation: Severe sepsis (now often referred to as sepsis with organ dysfunction) requires rapid and aggressive management to improve outcomes.

• a. CVP line is needed (True): Central venous pressure (CVP) monitoring is often indicated in severe sepsis to assess the patient’s volume status and guide fluid resuscitation, especially when there is haemodynamic instability. It also allows for the administration of vasopressors and other central venous medications.
• b. Fluid bolus needed (True): Rapid intravenous fluid resuscitation with crystalloids is a crucial component of the initial management of severe sepsis to address hypovolaemia, which is common due to vasodilation and capillary leak. The Surviving Sepsis Campaign recommends administering 30 ml/kg of crystalloid within the first 3 hours.

Reference: Surviving Sepsis Campaign guidelines; Critical care medicine textbooks.

Explanation: Predicting a difficult airway is crucial for safe anaesthetic management. Several factors increase the likelihood of challenges during laryngoscopy and intubation.

• a) Body mass index of 35kg/m² (True): Obesity, particularly with a high BMI, is associated with an increased risk of difficult laryngoscopy and intubation due to excess soft tissue in the pharynx and limited neck mobility.
• b) Mallampathy score – 3 (Three) (True): The Mallampathy score assesses the visibility of the oropharyngeal structures with the mouth open and tongue protruded. A score of 3 (only the base of the uvula is visible) or 4 (soft palate not visible) indicates a higher likelihood of a difficult laryngoscopic view.
• c) Burn contractures of the neck (True): Burn contractures can severely limit neck extension and mobility, making it difficult to achieve the optimal sniffing position required for direct laryngoscopy and intubation.
• d) Thyromental distance is more than 6cm (False): Thyromental distance is the distance between the thyroid cartilage and the mentum (chin) with the head fully extended. A short thyromental distance (less than 6cm or 3 finger breadths) is associated with a more anterior larynx and a potentially difficult intubation. A distance *more* than 6cm is generally considered favourable.
• e) Cervical spondylosis (True): Cervical spondylosis can cause stiffness and limited mobility of the neck, which can hinder achieving the optimal head and neck position for laryngoscopy and intubation.

Reference: Clinical Anaesthesia, 9th Edition; Difficult Airway Society guidelines.

Explanation: For a haemodynamically stable patient with a confirmed pulmonary embolism (PE), the primary treatment is anticoagulation to prevent further thrombus propagation and allow the body’s natural fibrinolytic mechanisms to resolve the existing clot.

• a) Dual antiplatelet (Incorrect): Antiplatelet agents (like aspirin and clopidogrel) are primarily used to prevent arterial thrombosis (e.g., in myocardial infarction and stroke). They have a limited role in the treatment of venous thromboembolism (VTE), including PE.
• b) Placement of IVC filter (Incorrect): Inferior vena cava (IVC) filters are used in specific situations, such as when anticoagulation is contraindicated or in cases of recurrent PE despite adequate anticoagulation. They are not the first-line treatment for a newly diagnosed PE in a stable patient.
• c) Therapeutic dose of anticoagulant (Correct): Current guidelines, such as those from NICE and the European Society of Cardiology (ESC), recommend immediate anticoagulation with agents like low molecular weight heparin (LMWH), fondaparinux, unfractionated heparin, or direct oral anticoagulants (DOACs) for haemodynamically stable patients with confirmed PE.
• d) Thrombolysis (Incorrect): Thrombolytic therapy (e.g., with alteplase or streptokinase) is reserved for patients with high-risk PE who are haemodynamically unstable (e.g., presenting with hypotension or shock) due to the risk of bleeding complications. This patient is haemodynamically stable.
• e) Thrombolectomy (Incorrect): Surgical or catheter-directed thrombolectomy (physical removal of the clot) is a less common intervention reserved for patients with massive PE and contraindications to thrombolysis or when thrombolysis has failed. It is not the first-line treatment for a stable PE.

Reference: NICE Guideline NG158: Venous thromboembolism in adults: diagnosis, management and thromboprophylaxis (March 2020, updated September 2020). https://www.nice.org.uk/guidance/ng158; Konstantinides SV, Meyer G, Becattini C, et al. 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS). Eur Heart J. 2020;41(4):543-603.

Explanation: The optimal anaesthetic procedure should provide adequate analgesia and muscle relaxation (if needed) while minimizing risks and allowing for efficient surgery.

• a) Evacuation of a thrombosed external pile – Local anaesthesia (True): This is a relatively minor and localized procedure. Local anaesthesia, either by direct infiltration or a local nerve block, is usually sufficient to provide adequate pain relief.
• b) Incision and drainage of paronychia – Brachial plexus block (False): Paronychia is an infection of the nail fold, usually involving a finger or toe. Local anaesthesia (digital nerve block) is typically adequate for incision and drainage. A brachial plexus block provides anaesthesia to the entire arm and is an unnecessarily extensive technique for this localized problem.
• c) Laparoscopic cholecystectomy – High spinal anaesthesia (False): Laparoscopic cholecystectomy is an abdominal surgery that requires general anaesthesia to provide adequate muscle relaxation for pneumoperitoneum (insufflation of the abdomen with CO2), control of visceral pain, and patient comfort during a potentially lengthy procedure. High spinal anaesthesia would not provide sufficient muscle relaxation or coverage for the upper abdomen and can have significant physiological effects that may be undesirable for this type of surgery.
• d) Lateral sphincterotomy – Spinal anaesthesia (True): Lateral sphincterotomy is an anorectal surgery. Spinal anaesthesia, including a saddle block, provides excellent analgesia and muscle relaxation of the perineum, making it a suitable choice for this procedure.
• e) Relocating a dislocated shoulder – IV sedation (True): Shoulder dislocation relocation can be painful. Intravenous (IV) sedation, often combined with local anaesthesia or intra-articular injection, can provide sufficient analgesia and muscle relaxation to facilitate a comfortable and successful reduction. General anaesthesia may be required for complex or difficult reductions, but IV sedation is often the optimum choice for routine cases.

Reference: Bailey & Love’s Short Practice of Surgery, 28th Edition; Clinical Anaesthesia, 9th Edition.

Explanation: Spinal anaesthesia is commonly used for procedures involving the lower abdomen, perineum, and lower limbs.

• A. Abdominal perineal resection (Incorrect): While spinal anaesthesia *can* be used in some lower abdominal procedures, it’s often insufficient for the extent and duration of an abdominal perineal resection, which typically requires general anaesthesia for adequate muscle relaxation and pain control.
• B. Ligation of processus vaginalis (Incorrect): This is a relatively superficial inguinal procedure often performed under general or regional (e.g., caudal in children) anaesthesia, but spinal is not the typical first choice.
• C. Haemorrhoidectomy (Correct): Spinal anaesthesia provides excellent analgesia and muscle relaxation for perineal surgeries like haemorrhoidectomy. Saddle block, a type of spinal anaesthesia, is particularly suitable.
• D. Varicose vein surgery (Incorrect): Varicose vein surgery is usually performed under general, regional (e.g., spinal, epidural), or even local anaesthesia depending on the extent of the surgery. Spinal is an option but not the most specific indication.
• E. Inguinal hernia repair (Incorrect): Inguinal hernia repair can be done under various types of anaesthesia, including local, regional (spinal, epidural), or general. Spinal is an option, but not the most specific use case compared to haemorrhoidectomy.

Reference: Bailey & Love’s Short Practice of Surgery, 28th Edition.

Explanation: Reduced urine output (oliguria) in the postoperative period can have various causes, including pre-renal (e.g., dehydration, hypovolaemia), renal (e.g., acute kidney injury), or post-renal (e.g., obstruction). The fact that the bladder is not palpable suggests a pre-renal cause, specifically reduced circulating volume, as the most likely initial problem.

• a) 5% dextrose Infusion (Incorrect): 5% dextrose is a hypotonic solution and primarily provides free water and glucose. It is not the appropriate initial fluid for volume resuscitation in a potentially hypovolaemic patient.
• b) 0.9% NaCl Bolus (Correct): A bolus of isotonic saline (0.9% NaCl) is a reasonable first-line intervention to assess for pre-renal oliguria due to hypovolaemia. If the reduced urine output is due to dehydration or inadequate circulating volume, a fluid bolus should improve renal perfusion and urine output.
• c) Fresh frozen plasma (Incorrect): Fresh frozen plasma (FFP) is a blood product containing clotting factors and is indicated for coagulation abnormalities, not for initial management of oliguria unless there is evidence of active bleeding and coagulopathy.
• d) Hartman’s solution (Incorrect): Hartman’s solution is a balanced crystalloid and is also suitable for volume resuscitation. While it’s a good choice for fluid replacement, 0.9% NaCl is often used as the initial bolus in this setting for assessment.
• e) IV Frusemide (Incorrect): Frusemide (furosemide) is a loop diuretic that increases urine output. However, in a patient with pre-renal oliguria due to hypovolaemia, giving a diuretic can worsen dehydration and further reduce renal perfusion, potentially leading to acute kidney injury. It should only be considered if there is evidence of fluid overload despite adequate renal function.

Reference: Postoperative care guidelines; Fluid management in surgical patients.

Explanation: Contrast-induced nephropathy (CIN) is a risk in patients with pre-existing renal impairment undergoing contrast-enhanced CT (CECT). Preventive strategies aim to maintain adequate renal perfusion and reduce contrast exposure to the renal tubules.

• a) 0.9% N/S (Correct): Adequate hydration with isotonic saline (0.9% NaCl) is one of the most important and well-established methods for preventing CIN. Pre-procedural and post-procedural intravenous hydration helps to maintain renal blood flow and dilute the contrast media in the renal tubules, reducing its nephrotoxic effects.
• b) NaHCO3 (Incorrect): While some studies have suggested a benefit of pre-procedural intravenous sodium bicarbonate (NaHCO3) in preventing CIN, the evidence is conflicting, and it is not universally recommended as a first-line preventative measure. Current guidelines often favor isotonic saline hydration.
• c) N-acetyl cysteine (NAC) (Correct): N-acetylcysteine (NAC) is an antioxidant that has been studied for the prevention of CIN. While the evidence is somewhat mixed, many guidelines recommend its use, especially in patients with pre-existing renal impairment, in addition to hydration. It is thought to reduce oxidative stress induced by contrast media. Given both normal saline and NAC are commonly recommended, and the question asks for *an* agent/fluid, either could be argued as correct. However, hydration with normal saline is generally considered the cornerstone of CIN prevention.
• d) IV hydrocortisone (Incorrect): Corticosteroids like hydrocortisone are not used for the prevention of contrast-induced nephropathy. They are used to treat allergic reactions or inflammation.
• e) N/2 +5% dextrose (Incorrect): Half-normal saline (0.45% NaCl) with 5% dextrose is a hypotonic solution and is not the optimal choice for hydration in the context of CIN prevention, as isotonic saline is preferred to maintain intravascular volume and renal perfusion.

Reference: European Society of Urogenital Radiology (ESUR) Guidelines on Contrast Media; Acute Kidney Injury guidelines.

Explanation: The patient presents with drowsiness and confusion immediately after a transurethral resection of the prostate (TURP). TURP syndrome, caused by the absorption of irrigating fluid during the procedure, can lead to dilutional hyponatraemia.

• a) Haemoglobin of 7.1g/dL (Incorrect): While postoperative bleeding can occur after TURP, a haemoglobin of 7.1 g/dL would likely present with more significant signs of hypovolaemia, such as tachycardia and hypotension, which are stated to be stable.
• b) PaCO2 = 7.4 kPa (5.1-5.6) (Incorrect): This PaCO2 level is slightly elevated, suggesting mild hypoventilation. While this could contribute to drowsiness, it doesn’t fully explain the confusion in the context of TURP. The normal respiration rate also makes this less likely as the primary cause.
• c) PaO2 = 8.9kPa (10.5 – 13.5 kPa) (Incorrect): This PaO2 level indicates hypoxaemia, which can cause drowsiness and confusion. However, the question states that respiration was normal, making this less likely as the primary cause without further context (e.g., underlying lung disease).
• d) Serum glucose = 4.6mmol/l (Incorrect): This serum glucose level is within the normal range (typically 3.5-7.8 mmol/l) and would not explain the acute onset of drowsiness and confusion immediately postoperatively in this scenario.
• e) Serum sodium = 114 mEq/l (135 – 145mEq/l) (Correct): A serum sodium level of 114 mEq/l indicates significant hyponatraemia. TURP syndrome is a known complication of TURP due to the absorption of large volumes of hypotonic irrigating fluid, leading to dilutional hyponatraemia, which can manifest as drowsiness, confusion, nausea, vomiting, and in severe cases, seizures and coma.

Reference: Bailey & Love’s Short Practice of Surgery, 28th Edition; Urological surgery textbooks.

Explanation: The patient’s presentation of pain, low blood pressure, and dyspnoea 8 hours after a right hemicolectomy while on epidural analgesia suggests a serious postoperative complication. Let’s analyze the options:

• a) Clot dislodgment, epidural analgesia, slip ligature (Incorrect): While clot dislodgment (leading to pulmonary embolism) and epidural analgesia (causing hypotension) are possible, a slip ligature causing acute symptoms like dyspnoea so early postoperatively is less likely unless there was significant intraoperative bleeding that wasn’t fully addressed. Postoperative bleeding from a slipped ligature would more likely present with tachycardia and signs of hypovolaemia (low CVP, reduced urine output), which are not explicitly mentioned.
• b) Clot dislodgment, slip ligature, DVT (Incorrect): Deep vein thrombosis (DVT) is a risk after major surgery, but it typically presents with unilateral leg swelling, pain, and redness, not acute dyspnoea and hypotension. Clot dislodgment (PE) and a slip ligature remain possibilities, but DVT itself is not the primary explanation for these acute symptoms.
• c) Clot dislodgment, Sepsis, slip ligature (Incorrect): Sepsis usually develops over a longer period (typically >24 hours) and presents with fever, tachycardia, and signs of infection. While possible, the acute onset of dyspnoea and hypotension within 8 hours is less typical for early sepsis. Clot dislodgment and a slip ligature are still considerations.
• d) Clot dislodgment, epidural analgesia, slip ligature (Incorrect – This is a repeat of option a).

Reconsidering the options and focusing on the most likely acute causes for the triad of pain, hypotension, and dyspnoea:

• Clot dislodgment (Pulmonary Embolism – PE): This is a significant risk after major abdominal surgery and can present with acute dyspnoea, chest pain (contributing to overall pain), and hypotension due to reduced cardiac output.
• Epidural analgesia: Epidural analgesia can cause sympathetic blockade, leading to vasodilation and hypotension. While it can contribute to low blood pressure, it doesn’t directly cause dyspnoea. However, high levels of epidural blockade can affect respiratory muscles, but this is less common with lumbar epidurals for abdominal surgery.
• Slip ligature: As mentioned earlier, a slip ligature causing significant bleeding leading to hypotension and potentially reduced oxygen delivery (dyspnoea) is possible but might be expected to have other signs of hypovolaemia.

Given the acute onset of dyspnoea, pulmonary embolism (from clot dislodgment) is a strong possibility. The pain could be multifactorial (surgical site, PE-related chest pain). The hypotension could be due to PE (reduced cardiac output) and/or the sympathetic blockade from epidural analgesia.

A more appropriate set of options might have included Pulmonary Embolism directly. However, given the choices, the combination of Clot dislodgment” (implying PE) and “epidural analgesia” as contributing to the hypotension seems the most plausible. A “slip ligature” as a primary cause for this specific triad is less likely in the immediate 8-hour postoperative period without more overt signs of bleeding.

Therefore option a) or d) (which are the same) seems the most fitting with the understanding that “clot dislodgment” likely refers to PE as the primary cause of dyspnoea and potentially contributing to hypotension and epidural analgesia contributing to the low blood pressure.

“

Explanation: The patient is unresponsive, not breathing, and has a slow heart rate (sinus bradycardia). This clinical picture indicates a critical situation requiring immediate resuscitation. The first priority in managing an unresponsive and non-breathing patient is to secure the airway and provide ventilation (Airway and Breathing in the ABC approach).

• a) High flow O2 (Incorrect): While oxygen is important, it cannot be delivered effectively in the absence of a patent airway and breathing. Ventilation needs to be established first.
• b) Measure the capillary blood sugar (Incorrect): Hypoglycaemia is a possible cause of unresponsiveness, especially in a diabetic patient. However, in the absence of breathing, the immediate threat is lack of oxygenation. Blood sugar should be checked, but only after addressing airway and breathing.
• c) Check carotid pulse (Correct, but followed immediately by E): Checking for a pulse (Circulation in ABC) is crucial to assess for cardiac output. However, the absence of breathing in an unresponsive patient necessitates immediate airway management and ventilation, even if a pulse is present. The question asks for the *most important next step*, and establishing an airway and breathing takes precedence over prolonged pulse checks or other interventions. If no pulse is found after confirming no breathing, chest compressions (CPR) would be the next step. Given the options, ‘intubate and ventilate’ directly addresses the immediate life-threatening issue of absent breathing.
• d) Obtain IV access (Incorrect): Intravenous access is important for administering medications, but it is not the immediate priority in a patient who is not breathing. Airway and breathing must be addressed first.
• e) Intubate and ventilate (Correct): Given the unresponsiveness and absence of breathing, the most critical next step is to establish a definitive airway (intubation) and provide mechanical ventilation to ensure oxygenation and carbon dioxide removal. The sinus bradycardia, while concerning, needs to be addressed in conjunction with adequate oxygenation and ventilation.

Reference: Resuscitation Council UK guidelines; Basic Life Support (BLS) and Advanced Life Support (ALS) protocols.

Explanation: The patient presents with signs of a severe intra-abdominal infection (fever, vomiting, abdominal pain, tense tender abdomen, gas under the diaphragm on X-ray suggesting perforation), along with tachycardia and hypotension despite fluid resuscitation. This clinical picture is highly suggestive of septic shock.

• a) corticosteroids have no place in initial management (True): According to current guidelines (NICE NG51), routine use of corticosteroids is not recommended in the initial management of septic shock. They may be considered in patients with refractory shock despite adequate fluid resuscitation and vasopressor support.
• b) low bp possibly due to reduced systemic vascular resistance (True): Septic shock is characterized by a dysregulated inflammatory response leading to vasodilation and reduced systemic vascular resistance (SVR), which contributes significantly to hypotension.
• c) noradrenaline is d vasopressin of choice (False): Noradrenaline is the first-line vasopressor of choice in septic shock to increase blood pressure by increasing SVR. Vasopressin is often used as a second-line agent in patients who remain hypotensive despite adequate noradrenaline doses.
• d) septic shock is lickly (True): The combination of signs of severe infection, systemic inflammatory response (fever, tachycardia), and persistent hypotension despite fluid resuscitation meets the clinical criteria for septic shock.
• e) wbc 3500 /mm3 exclude sepsis (False): A white blood cell (WBC) count of 3500 /mm3 is low (normal range typically 4,000-11,000 /mm3), indicating leucopenia. While a high WBC count (leucocytosis) is often seen in sepsis, leucopenia can also occur, especially in severe sepsis and is associated with poor prognosis. Therefore, a low WBC count does not exclude sepsis.

Reference: NICE Guideline NG51: Sepsis: recognition, diagnosis and early management (July 2016, updated November 2023). https://www.nice.org.uk/guidance/ng51; Singer M, Deutschman CS, Seymour CW, et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016;315(8):801-810.

Explanation: The patient presents with drowsiness and a reduced respiratory rate (normal is 12-20 breaths/min) after surgery. The arterial blood gas shows a low pH (acidosis) and a high PaCO₂ (respiratory acidosis), indicating hypoventilation and inadequate carbon dioxide removal. The PaO₂ is acceptable on room air, but the primary issue is the elevated PaCO₂ causing acidosis.

• a) Application of CPAP (Incorrect): CPAP (Continuous Positive Airway Pressure) can be helpful for patients with hypoxaemia and respiratory distress, but in this case, the primary problem is hypoventilation leading to CO₂ retention. While it might offer some support, it doesn’t guarantee adequate ventilation in a drowsy patient with a low respiratory rate.
• b) IV fluid bolus of 200ml colloid (Incorrect): There is no indication of hypovolaemia (BP is stable). Giving a fluid bolus will not address the underlying respiratory depression and CO₂ retention.
• c) IV morphine (Incorrect): Morphine is an opioid analgesic and can cause respiratory depression. Giving more morphine would likely worsen the patient’s hypoventilation.
• d) IV naloxone (Incorrect): Naloxone is an opioid antagonist used to reverse opioid-induced respiratory depression. If the patient received opioids and this is suspected as the cause, naloxone would be appropriate. However, the question does not provide information about opioid administration. While it’s a possibility, immediate intubation and ventilation ensure airway patency and adequate gas exchange regardless of the cause of hypoventilation.
• e) Intubation and ventilation (Correct): Given the low respiratory rate, drowsiness, and clear evidence of respiratory acidosis on the ABG (high PaCO₂), the most appropriate immediate intervention is to secure the airway with intubation and provide mechanical ventilation to ensure adequate oxygenation and carbon dioxide removal, thereby correcting the acidosis. Further investigation into the cause of the respiratory depression should follow.

Reference: Postoperative respiratory complications management guidelines; Arterial blood gas interpretation.

Explanation: Septic shock is a life-threatening condition characterized by sepsis with circulatory and cellular metabolic dysfunction. The initial management focuses on rapid assessment and stabilization, following the principles of the Surviving Sepsis Campaign.

• a) Noradrenaline (False): Noradrenaline (norepinephrine) is a vasopressor used to treat hypotension in septic shock when fluid resuscitation alone is insufficient to achieve an adequate mean arterial pressure (MAP). It is usually administered after or concurrently with initial fluid resuscitation.
• b) Methylprednisolone (False): Corticosteroids like hydrocortisone (not methylprednisolone as per most guidelines) may be considered in septic shock if the patient remains hypotensive despite adequate fluid resuscitation and vasopressors (refractory shock). It is not a first-line initial management step.
• c) Broad spectrum antibiotics (True): Early administration of broad-spectrum antibiotics (ideally within one hour of sepsis recognition) is crucial to treat the underlying infection and improve survival in septic shock. Blood cultures should be obtained before starting antibiotics if it does not significantly delay antibiotic administration.
• d) 0.9% NS bolus (True): Rapid intravenous fluid resuscitation with crystalloids (like 0.9% normal saline) is a cornerstone of early septic shock management to address hypovolaemia and improve tissue perfusion. The initial target is often to administer 30 ml/kg of crystalloid within the first 3 hours.
• e) Administration of O2 (True): Providing supplemental oxygen to maintain adequate oxygen saturation (typically >90%) is essential in septic shock, as patients often have impaired oxygen delivery to tissues due to hypovolaemia, hypotension, and microcirculatory dysfunction. This may involve nasal cannula, face mask, or mechanical ventilation depending on the patient’s respiratory status.

Therefore, the key management steps in the initial stages of septic shock include prompt administration of broad-spectrum antibiotics, rapid fluid resuscitation with crystalloids, and ensuring adequate oxygenation. While vasopressors like noradrenaline are often needed early, they are typically initiated after or during initial fluid resuscitation if the patient remains hypotensive. Corticosteroids are a later consideration in refractory shock.

Explanation: The diagnosis of Acute Respiratory Distress Syndrome (ARDS) is based on clinical criteria, including timing, chest imaging, exclusion of cardiac failure as the sole cause of pulmonary oedema, and impaired oxygenation. The PaO2/FiO2 (P/F) ratio is a crucial component of the oxygenation criteria and helps define the severity of ARDS.

• a) CVP 7mmHg (Incorrect): Central venous pressure (CVP) reflects right atrial pressure and is used to assess fluid status. While it can be helpful in the overall assessment of a critically ill patient with dyspnoea, a CVP of 7 mmHg does not specifically indicate ARDS. ARDS is characterized by non-cardiogenic pulmonary oedema, so a low CVP might even suggest that fluid overload is not the primary issue.
• b) PaO2 <70mmHg (Incorrect): A low PaO2 indicates hypoxaemia, which is a feature of ARDS. However, the PaO2 value alone needs to be considered in relation to the fraction of inspired oxygen (FiO2) to assess the degree of oxygenation impairment, which is captured by the P/F ratio.
• c) Respiratory rate >30/min (Incorrect): Tachypnoea (high respiratory rate) is a common sign of respiratory distress, including ARDS, as the body tries to compensate for hypoxaemia. However, it is a non-specific finding and not the best single indicator for diagnosing ARDS.
• d) P/F ratio < 100mmHg (Correct): The PaO2/FiO2 (P/F) ratio is calculated by dividing the arterial partial pressure of oxygen (PaO2) by the fraction of inspired oxygen (FiO2). A P/F ratio < 300 mmHg (with a minimum PEEP of 5 cmH2O) is one of the key oxygenation criteria for ARDS according to the Berlin definition. A P/F ratio < 100 mmHg indicates severe ARDS, signifying significant impairment of oxygen transfer in the lungs due to the pathological changes in ARDS (e.g., alveolar flooding, inflammation).
• e) Pulse oxymeter reading <100mmHg (Incorrect): Pulse oximetry (SpO2) measures peripheral oxygen saturation, which correlates with PaO2 but is not directly used in the P/F ratio calculation. While a low SpO2 suggests hypoxaemia, it doesn’t account for the FiO2 and is less precise than PaO2 for ARDS diagnosis based on the Berlin criteria. Furthermore, a reading < 100% is expected when the PaO2 is low.

Reference: Berlin Definition of ARDS; Respiratory Medicine textbooks.

Explanation: Transurethral resection of the prostate (TURP) is a procedure with a risk of bleeding. Spinal anaesthesia also carries a risk of bleeding into the spinal canal (spinal haematoma), although rare. Therefore, medications that increase the risk of bleeding should be carefully managed preoperatively.

• a. Aspirin (Incorrect): Aspirin is an antiplatelet agent. While it increases bleeding risk, current guidelines often recommend continuing low-dose aspirin for secondary prevention in patients with high cardiovascular risk undergoing low to intermediate bleeding risk procedures. The decision should be individualized based on risk-benefit assessment. Discontinuation for 5-7 days is sometimes considered.
• b. Atenolol (Incorrect): Atenolol is a beta-blocker used for hypertension and ischemic heart disease. It should generally be continued perioperatively to prevent withdrawal symptoms and manage cardiovascular stability.
• c. Clopidogrel (Correct): Clopidogrel is a potent antiplatelet agent. It significantly increases the risk of bleeding and should typically be discontinued at least 5-7 days before a procedure with a moderate to high bleeding risk, such as TURP, especially when combined with spinal anaesthesia.
• d. Warfarin (Correct): Warfarin is an anticoagulant that significantly increases the risk of bleeding. It needs to be stopped several days before surgery (typically 5 days) to allow the INR (International Normalized Ratio) to fall to a safe level for the procedure (usually <1.5).
• e. Heparin (Incorrect): Heparin is an anticoagulant, but unfractionated heparin has a short half-life and can often be stopped a few hours before surgery. Low molecular weight heparin (LMWH) typically needs to be stopped 12-24 hours before surgery. The question specifies discontinuation at least one week before, making warfarin a more likely answer among the anticoagulants. However, clopidogrel, as a potent antiplatelet, also warrants discontinuation. Given the options and the one-week timeframe, both warfarin and clopidogrel are strong contenders. Consulting guidelines on perioperative management of antithrombotic therapy is crucial. Reconsidering based on typical practice and the at least one week timeframe, warfarin’s management often involves bridging with shorter-acting agents and a more defined discontinuation period based on INR. Clopidogrel also requires cessation but the management might be slightly less strict regarding the exact one-week mark compared to achieving a target INR for warfarin. Let’s lean towards warfarin as the more definitively managed with a longer lead time based on its mechanism and monitoring (INR).

Reference: Guidelines on perioperative management of antithrombotic therapy (e.g. ACC/AHA guidelines); Urological surgery guidelines.

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Explanation: Abdominoperineal resection (APR) for colorectal carcinoma is a major surgical procedure that typically results in significant postoperative pain. Effective pain management is crucial for patient comfort, early mobilization, and reducing complications.

• a) IV morphine infusion (Incorrect): Intravenous morphine infusion can provide good pain relief, but it is associated with potential side effects such as nausea, vomiting, sedation, and respiratory depression, which may hinder early recovery. While PCA (patient-controlled analgesia) with morphine can be used, other options might offer better pain control with fewer systemic side effects for this type of surgery.
• b) Diclofenac sodium suppository (Incorrect): Diclofenac is an NSAID that can be useful for mild to moderate postoperative pain as part of a multimodal analgesic regimen. However, for severe pain after major surgery like APR, it is unlikely to provide adequate analgesia as a sole agent.
• c) Pethidine IM (Incorrect): Intramuscular (IM) pethidine (meperidine) has several disadvantages, including variable absorption, pain on injection, and a shorter duration of action compared to other opioids. It also has potential side effects like nausea, vomiting, and the risk of norpethidine accumulation with repeated doses, which can lead to neurotoxicity. It is generally not a preferred opioid for managing severe postoperative pain.
• d) epidural analgesia with S% bupivacaine (Incorrect): There seems to be a typo in the option, likely meant to be a concentration of bupivacaine (e.g., 0.1-0.25%) rather than S%”. Epidural analgesia involving the placement of a catheter into the epidural space for continuous infusion of local anaesthetics (like bupivacaine) and/or opioids is a highly effective method for managing moderate to severe postoperative pain after major abdominal and pelvic surgery like APR. It provides superior pain relief compared to systemic opioids and can facilitate early mobilization and reduce pulmonary complications.
• e) Oral Tramadol (Incorrect): Tramadol is an atypical opioid with moderate analgesic efficacy. While it can be used for postoperative pain it is often not sufficient for severe pain following major surgery like APR especially in the immediate postoperative period.

Given the extent of the surgery epidural analgesia is generally considered the gold standard for providing effective postoperative pain relief after APR. Assuming the typo in option d meant a standard concentration of bupivacaine for epidural use it is the most appropriate choice.

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Explanation: The patient’s recent epidural top-up, low blood pressure (hypotension), low heart rate (bradycardia), dizziness (suggesting reduced cerebral perfusion), adequate urine output, and normal central venous pressure (CVP) point towards a sympathetic blockade caused by the epidural anaesthesia.

• A. Cardiogenic shock (Incorrect): Cardiogenic shock is characterized by the heart’s inability to pump enough blood to meet the body’s needs, often presenting with low blood pressure, tachycardia (usually), signs of poor perfusion (e.g., low urine output, altered mental status), and often a high CVP. This patient has bradycardia and adequate urine output with a normal CVP.
• B. Haemorrhage (Incorrect): Haemorrhage would typically present with hypotension, tachycardia (as the body tries to compensate for blood loss), and a low CVP (due to reduced blood volume). This patient has bradycardia and a normal CVP.
• C. Sympathetic blockade (Correct): Epidural anaesthesia can block the sympathetic nervous system outflow to the blood vessels in the lower body. This leads to vasodilation, reduced systemic vascular resistance, and consequently, hypotension. The relative bradycardia can occur due to unopposed parasympathetic tone. The normal CVP suggests adequate preload, and the adequate urine output indicates reasonable renal perfusion despite the lower blood pressure. The dizziness is consistent with reduced cerebral perfusion due to hypotension.
• D. Pulmonary embolism (Incorrect): Pulmonary embolism (PE) can cause hypotension and tachycardia (more common), as well as shortness of breath, chest pain, and hypoxaemia. Bradycardia and a normal CVP are less typical findings in PE.
• E. Sepsis (Incorrect): Sepsis would typically present with fever (not mentioned), tachycardia (more common), and often a low CVP (due to vasodilation and capillary leak, although it can be variable). Bradycardia is not a typical finding in early sepsis.

Reference: Postoperative care guidelines; Regional anaesthesia complications.

Explanation: The patient’s presentation of severe backache, difficulty moving legs, inability to pass urine with a palpable bladder, occurring 8 hours after spinal anaesthesia, is concerning for a compressive lesion in the spinal canal.

• a. Cauda equina trauma (Incorrect): Direct trauma to the cauda equina during spinal anaesthesia is rare. While it can cause similar symptoms (back pain, leg weakness, bowel/bladder dysfunction), the onset is usually immediate or very soon after the procedure. Progressive symptoms developing at 8 hours are less typical for direct trauma.
• b. Epidural haematoma (Correct): Epidural haematoma is a rare but serious complication of spinal or epidural anaesthesia. Bleeding into the epidural space can compress the spinal cord or cauda equina, leading to rapid onset of back pain and progressive neurological deficits, including motor weakness and sensory changes in the legs, as well as bowel and bladder dysfunction (urinary retention with palpable bladder). The time frame of 8 hours for symptom onset is consistent with the development of an epidural haematoma.
• c. Lumbar disk prolapse (Incorrect): Lumbar disk prolapse can cause severe back pain and leg weakness, but it is not a direct complication of spinal anaesthesia and would be an unlikely new onset of such severe symptoms within 8 hours of the procedure, especially affecting both legs and bladder function acutely.
• d. Referred pain from surgical site (Incorrect): Pain from the haemorrhoidectomy site is unlikely to cause significant bilateral leg weakness and urinary retention. The pain would typically be localized to the perineal area.
• e. Residual effects of anesthesia (Incorrect): The direct anaesthetic effects of spinal anaesthesia (numbness and weakness) usually wear off within a few hours (typically 2-6 hours, depending on the agent and dose). The new onset of severe back pain and progressive neurological deficits at 8 hours suggests a new pathological process rather than residual anaesthetic effects.

Given the progressive neurological deficits (leg weakness, urinary retention) and severe back pain developing a few hours after spinal anaesthesia, epidural haematoma is the most likely cause due to potential compression of the spinal cord or cauda equina. This requires urgent investigation (e.g., MRI) and potential surgical decompression.

Explanation: Acute management of hyperkalaemia aims to stabilize the cardiac membrane, shift potassium intracellularly, and enhance potassium excretion.

• a) ECG monitoring (True): ECG is crucial in hyperkalaemia as it can show characteristic changes (peaked T waves, prolonged PR interval, QRS widening, sine wave pattern) that indicate the severity of cardiac toxicity and guide immediate treatment.
• b) 10u calcium gluconate 10ml (False): The dose is incorrect. The typical dose for calcium gluconate (10%) is 10 ml, which contains 1 gram of calcium gluconate. The concentration is usually 10%, not specified as units. Calcium gluconate stabilizes the cardiac membrane but does not lower potassium levels.
• c) Nebulize with 5mg of salbutamol (True): Nebulized salbutamol (a beta-2 agonist) shifts potassium intracellularly, thus temporarily lowering serum potassium levels. The typical dose is 5-10 mg.
• d) 10% calcium gluconate 10ml (True): 10% calcium gluconate, 10 ml IV, is given to stabilize the cardiac membrane and reduce the risk of arrhythmias in hyperkalaemia. It does not lower potassium levels.
• e) Polystygrene sulfonate resonium (False): Polystyrene sulfonate (Resonium A or Kayexalate) is a potassium-binding resin that enhances potassium excretion via the gastrointestinal tract. However, its onset of action is slow (hours), so it is not a primary treatment for acute, severe hyperkalaemia requiring immediate intervention.

Therefore, the acute management includes ECG monitoring, calcium gluconate to stabilize the heart, and nebulized salbutamol to shift potassium intracellularly.

Explanation: Central venous pressure (CVP) line insertion involves placing a catheter into a large central vein.

• A) Arrhythmias can occur during insertion (True): Manipulation of the catheter tip within the central veins or right atrium can irritate the myocardium and cause arrhythmias.
• B) Inserted in the head up position (False): CVP lines are typically inserted with the patient in a Trendelenburg position (head down) to distend the neck veins and reduce the risk of air embolism.
• C) Measures left atrial pressure (False): CVP measures the pressure in the right atrium or vena cava, which reflects right ventricular preload. Pulmonary artery catheters are required to measure left atrial pressure (pulmonary capillary wedge pressure).
• D) Correct placement is confirmed by doing a chest X-ray (True): A chest X-ray is mandatory after CVP line insertion to confirm the position of the catheter tip (ideally in the lower superior vena cava or cavoatrial junction) and to rule out complications such as pneumothorax.
• E) Pneumothorax is a complication (True): Insertion of a CVP line, particularly via the subclavian or internal jugular approach, carries a risk of pneumothorax (air entering the pleural space).

Reference: Bailey & Love’s Short Practice of Surgery, 28th Edition.

Explanation: Local anaesthesia involves the injection of local anaesthetic agents to block nerve conduction in a specific area, leading to loss of sensation without loss of consciousness. While generally safe, it can be associated with several side effects, both local and systemic.

• a) Increase BP (False): Local anaesthesia itself typically does not cause a significant increase in blood pressure. In some cases, if the local anaesthetic contains epinephrine (adrenaline) as a vasoconstrictor to prolong the duration of action and reduce bleeding, transient hypertension might occur, but this is due to the epinephrine, not the local anaesthetic agent itself. Systemic absorption of high doses of local anaesthetics can sometimes lead to cardiovascular depression, including hypotension.
• b) Vomiting (True): Nausea and vomiting can occur after local anaesthesia, although they are less common than with general anaesthesia. They can be due to anxiety, pain during the procedure, or systemic absorption of the local anaesthetic agent. Vasovagal reactions (fainting spells) associated with local anaesthesia can also sometimes lead to nausea and vomiting.
• c) Headache (True): Headache can occur after certain types of local anaesthesia, particularly spinal or epidural anaesthesia, due to post-dural puncture headache (PDPH) resulting from CSF leakage. Headache is less commonly associated with peripheral nerve blocks or local infiltration.
• d) Urinary retention (True): Urinary retention can occur after spinal or epidural anaesthesia due to the blockade of autonomic nerves that control bladder function. It is less common with peripheral nerve blocks or local infiltration.
• e) Back pain (True): Back pain can sometimes occur after spinal or epidural anaesthesia due to the procedure itself (needle insertion, positioning) or due to muscle spasm. It is less commonly associated with peripheral nerve blocks or local infiltration.

Therefore, local anaesthesia can be associated with vomiting, headache (especially after spinal/epidural), and urinary retention (especially after spinal/epidural).

Explanation: Effective postoperative pain management aims to provide adequate analgesia while minimizing side effects and facilitating early mobilization.

• A. Epidural anaesthesia – abdominal surgery (True): Epidural analgesia is a highly effective method for managing moderate to severe postoperative pain following major abdominal surgery, providing superior pain relief compared to systemic opioids and facilitating early mobilization and reduced pulmonary complications.
• B. Lignocaine infusion – Laparoscopic surgery (True): Intravenous lignocaine infusion has been shown to have analgesic and anti-inflammatory effects and can be a useful adjunct for postoperative pain management after laparoscopic surgery, often reducing opioid requirements and improving recovery.
• C. Patient controlled analgesia – Day case surgery (False): Patient-controlled analgesia (PCA) is typically reserved for managing moderate to severe pain, often requiring intravenous access and close monitoring. It is generally not the most appropriate first-line option for day-case surgery, where oral analgesics or simpler regional techniques are often sufficient and safer for discharge.
• D. Subcutaneous morphine – Carpel tunnel syndrome (False): Carpal tunnel release is a relatively minor surgical procedure, and postoperative pain is usually well-controlled with oral analgesics (e.g., paracetamol, NSAIDs). Subcutaneous morphine is a systemic opioid and carries risks of side effects like nausea, vomiting, and respiratory depression, making it an unnecessarily strong option for this type of surgery. Local or regional anaesthesia techniques are often used intraoperatively and can provide good initial postoperative analgesia.
• E. Transverse abdominis plane block – Laparotomy (True): Transverse abdominis plane (TAP) block is a regional anaesthetic technique that provides effective analgesia for the anterior abdominal wall. It is particularly useful for managing pain after laparotomy, especially for somatic pain from the incision, and can reduce the need for systemic opioids.

Reference: NICE Guideline NG157: Postoperative pain management (February 2020). https://www.nice.org.uk/guidance/ng157; Regional anaesthesia textbooks.

Explanation: Persistent vomiting leads to the loss of hydrochloric acid (HCl) from the stomach. This loss of acid results in an increase in the body’s pH, leading to metabolic alkalosis. The kidneys then attempt to compensate by increasing bicarbonate excretion, and the respiratory system compensates by decreasing ventilation (increasing pCO₂). However, the provided ABG shows a low pH and low pCO₂, which is inconsistent with the typical compensated metabolic alkalosis of persistent vomiting.

Let’s re-evaluate the question and options based on the given ABG (pH 7.25, pCO₂ 27mmHg). The low pH indicates acidosis. The low pCO₂ suggests a primary respiratory alkalosis or a metabolic acidosis with respiratory compensation.

Considering the clinical context of persistent vomiting, it primarily causes metabolic alkalosis due to loss of HCl, leading to hypochloraemia and often hypokalaemia due to associated fluid and electrolyte losses. Therefore, the patient should likely have a metabolic alkalosis.

There seems to be a discrepancy between the expected acid-base disturbance from the clinical scenario (persistent vomiting leading to metabolic alkalosis) and the provided ABG values (suggesting acidosis). Let’s assume the question is asking about the metabolic abnormality *that would eventually develop* due to persistent vomiting, rather than interpreting the given (potentially incomplete or misleading) ABG.

Persistent vomiting leads to:

• Loss of HCl: -> Metabolic alkalosis
• Loss of potassium: -> Hypokalaemia
• Loss of chloride: -> Hypochloraemia

Therefore, the most likely metabolic abnormality would be hypochloric hypokalaemic alkalosis.

Now let’s look at the options again, keeping in mind the likely *developing* abnormality from the history:

• A. Hyperchloric hyperkalaemic acidosis (Incorrect): Opposite of what is expected with vomiting.
• B. Hyperchloric hyperkalaemic acidosis with partial compensation (Incorrect): Opposite of what is expected with vomiting.
• C. Hypochloric hypokalaemic acidosis (Incorrect): Vomiting causes alkalosis, not acidosis.
• D. Hypochloric hyperkalaemic alkalosis (Incorrect): Potassium is usually lost in vomiting, leading to hypokalaemia.
• E. Hypochloric hypokalaemic alkalosis (Correct): Persistent vomiting leads to loss of HCl (hypochloraemia), often potassium (hypokalaemia), and results in metabolic alkalosis.

Note: The provided ABG (pH 7.25, pCO₂ 27mmHg) is inconsistent with the expected metabolic alkalosis and suggests a metabolic acidosis with respiratory compensation (if bicarbonate were low) or a primary respiratory alkalosis (if bicarbonate were also low or normal). However, based on the clinical history of persistent vomiting, the underlying metabolic abnormality being asked about is most likely hypochloric hypokalaemic alkalosis.

Explanation: Day case surgery aims for patients to return home on the same day as their procedure. Certain factors increase the risk of complications or hinder safe recovery at home.

• a. uncontrolled DM (True): Uncontrolled diabetes mellitus increases the risk of postoperative complications such as infection and poor wound healing, making day surgery less suitable.
• b. Obesity BMI > 30 kg/m² (False): While obesity can increase surgical risks, a BMI > 30 kg/m² is not an absolute contraindication for day case inguinal hernia repair, provided other comorbidities are well-managed and the patient is otherwise suitable.
• c. History of smoking (False): Smoking increases respiratory risks and can impair wound healing, but it is usually a modifiable risk factor that doesn’t automatically exclude day surgery, especially if the patient is motivated to quit or has been counselled on risks.
• d. Live alone at home (True): Adequate support at home is crucial for safe recovery after surgery. Patients living alone may lack the necessary assistance for monitoring, pain management, and recognizing complications, making day surgery potentially unsuitable unless adequate support can be arranged.
• e. Body mass index >30kg/m² (False): This is a repeat of option b and is not an absolute contraindication as explained above.

Reference: Guidelines for day case surgery; Inguinal hernia repair guidelines.

Explanation: Contrast-induced nephropathy (CIN) is an acute kidney injury that can occur after the administration of iodinated contrast media. Patients with pre-existing kidney disease, including diabetic nephropathy, are at higher risk. Preventive strategies aim to maintain adequate renal perfusion and reduce contrast exposure to the renal tubules.

• a) Normal saline (Correct): Adequate hydration with isotonic saline (0.9% NaCl) is one of the most well-established and effective strategies for preventing CIN. Pre-procedural and post-procedural intravenous hydration helps to maintain renal blood flow and dilute the contrast media in the renal tubules, reducing its nephrotoxic effects.
• b) Post procedure haemodialysis (Incorrect): Prophylactic haemodialysis after contrast administration is generally not recommended for preventing CIN in patients with normal or only mildly impaired renal function. It may be considered in patients with severe pre-existing kidney disease (eGFR < 30 ml/min/1.73 m²) in specific circumstances, but not routinely in someone with normal serum creatinine.
• c) give post-procedural intravenous furosemide (Incorrect): Loop diuretics like furosemide have not been shown to be effective in preventing CIN and may even increase the risk by causing dehydration and reducing renal blood flow.
• d) Pre procedure IV NaHco3 (Incorrect): While some studies have suggested a benefit of pre-procedural intravenous sodium bicarbonate (NaHCO3) in preventing CIN, the evidence is conflicting, and it is not universally recommended as a first-line preventative measure. Current guidelines often favor isotonic saline hydration.
• e) Preoperative administration of NAC (Incorrect): N-acetylcysteine (NAC) is an antioxidant that has been studied for the prevention of CIN. However, large randomized controlled trials have yielded conflicting results, and current guidelines do not strongly recommend its routine use for CIN prevention, especially in patients with normal serum creatinine.

Reference: European Society of Urogenital Radiology (ESUR) Guidelines on Contrast Media; Acute Kidney Injury guidelines.

Explanation: Warfarin inhibits vitamin K-dependent synthesis of clotting factors II, VII, IX, and X. In a patient with active bleeding who is on warfarin, the goal is to rapidly reverse the anticoagulation to stop the bleeding.

• a) Cryoprecipitate (Incorrect): Cryoprecipitate is rich in fibrinogen, factor VIII, von Willebrand factor, and factor XIII. It is primarily used for fibrinogen deficiency, factor VIII deficiency (haemophilia A), and von Willebrand disease. It does not contain significant amounts of the vitamin K-dependent clotting factors affected by warfarin.
• b) Cryo poor plasma (Incorrect): Cryo-poor plasma is plasma from which cryoprecipitate has been removed. It lacks high concentrations of fibrinogen and factor VIII and is not the optimal choice for rapidly reversing warfarin.
• c) Fresh frozen plasma (Correct): Fresh frozen plasma (FFP) contains all the coagulation factors, including the vitamin K-dependent factors (II, VII, IX, X) that are reduced by warfarin. Infusion of FFP provides these factors and helps to rapidly restore the patient’s clotting ability, thus reversing the warfarin-induced anticoagulopathy in the setting of active bleeding.
• d) Vitamin K (Incorrect): Vitamin K is the antidote for warfarin, as it promotes the synthesis of the affected clotting factors. However, the onset of action of intravenous vitamin K is slow (typically within 6-12 hours, with full effect taking up to 24 hours). In the setting of active, significant bleeding, this is too slow to provide immediate haemostatic control. Vitamin K should be given concurrently with FFP to provide sustained reversal and allow the liver to synthesize new clotting factors.
• e) Activated factor VII (Incorrect): Activated factor VII (recombinant factor VIIa) can promote haemostasis in various bleeding disorders, including warfarin-related bleeding. However, it is generally reserved for situations where other measures like FFP and prothrombin complex concentrates (PCCs) are unavailable or ineffective, or in specific patient populations due to the risk of thromboembolic events. FFP is usually the first-line treatment for rapid reversal of warfarin in bleeding patients.

Reference: Guidelines on management of anticoagulation; Haematology textbooks.

Explanation: Massive blood transfusion (typically defined as replacement of the patient’s entire blood volume within 24 hours or more than 10 units of packed red blood cells in 24 hours) can lead to various complications.

• A. Bleeding from puncture site (True): Massive transfusion can lead to dilutional coagulopathy (reduced clotting factors and platelets) and hypothermia, both of which can contribute to bleeding from puncture sites and surgical wounds.
• B. Hypercalcaemia (False): Stored blood products contain citrate as an anticoagulant, which binds to calcium in the recipient’s blood, potentially leading to hypocalcaemia, not hypercalcaemia.
• C. Hyperkalemia (True): Stored red blood cells can leak potassium into the plasma over time. Massive transfusion of older blood units can result in hyperkalaemia in the recipient, especially in patients with impaired renal function.
• D. Hypothermia (True): Banked blood is stored at low temperatures. Rapid transfusion of large volumes of unwarmed blood can lead to hypothermia, which can have detrimental effects on coagulation and cardiac function.
• E. Transfused related acute lung injury (True): Transfusion-related acute lung injury (TRALI) is a serious and potentially fatal complication of blood transfusion characterized by acute respiratory distress within 6 hours of transfusion. It is caused by donor antibodies reacting with recipient leukocytes or lipids in stored blood activating recipient neutrophils.

Reference: Blood transfusion guidelines; Trauma management protocols.

Explanation: Management of neurotrauma aims to minimize secondary brain injury and optimize neurological outcomes.

• A. GCS <=8 is an indication for ET intubation (True): A Glasgow Coma Scale (GCS) score of 8 or less is generally considered to indicate a severe head injury and an inability to maintain a patent airway or protect against aspiration, necessitating endotracheal intubation and mechanical ventilation.
• B. Depressed skull fracture is a surgical emergency (False): While depressed skull fractures require careful evaluation, they are not always a surgical emergency. Surgery is typically indicated for significant depression (>5-10 mm), open fractures, associated intracranial haematoma, or neurological deterioration. Simple, closed, minimally depressed fractures may be managed conservatively.
• C. Head up position is used to control ICP (True): Elevating the head of the bed to 30 degrees helps to improve venous drainage from the brain, which can reduce intracranial pressure (ICP). This is a standard initial measure in managing raised ICP.
• D. Lumbar CSF drainage is used to treat increased ICP (False): Lumbar cerebrospinal fluid (CSF) drainage can be used in specific situations to manage hydrocephalus or CSF leaks. However, in the context of raised ICP due to trauma or mass lesions, lumbar drainage can be dangerous as it can potentially cause brain herniation by creating a pressure gradient. ICP monitoring and ventricular drainage are preferred methods for managing raised ICP in these cases.
• E. People with brain atrophy are prone to get SDH (True): Subdural haematomas (SDH) occur in the space between the dura and arachnoid membranes. In individuals with brain atrophy (e.g., elderly, chronic alcoholics), the bridging veins between the brain surface and the dural sinuses become stretched and more susceptible to tearing with even minor trauma, increasing the risk of SDH.

Reference: Neurotrauma management guidelines; Neurosurgery textbooks.

Explanation: Effective postoperative pain management after a major surgery like mastectomy and axillary clearance typically involves a multimodal approach, utilizing different classes of analgesics to target pain pathways and minimize opioid side effects.

• a) Diclofenac Na suppository (True): Diclofenac is a non-steroidal anti-inflammatory drug (NSAID) that can be effective in reducing postoperative pain, especially inflammatory pain. Suppository form can be useful if oral intake is limited or if the patient is experiencing nausea.
• b) Oral Gabapentin (True): Gabapentin is an anticonvulsant that is also used for neuropathic pain. It can be beneficial as part of a multimodal regimen, particularly as surgery involving axillary clearance can sometimes lead to neuropathic pain components. Preoperative or early postoperative administration can be effective.
• c) Intramuscular Morphine (True): Intramuscular (IM) morphine is an opioid analgesic that can provide significant pain relief. However, it is associated with variable absorption, pain on injection, and potential side effects like nausea, vomiting, and drowsiness. While acceptable, other routes like intravenous (IV) administration with patient-controlled analgesia (PCA) might be preferred for better titration.
• d) IV paracetamol (True): Intravenous paracetamol (acetaminophen) is a useful non-opioid analgesic that can be part of a multimodal approach. It has good analgesic effects for mild to moderate pain and can reduce the need for opioids.
• e) IV pethidine (True): Intravenous pethidine (meperidine) is another opioid analgesic. However, it has a shorter duration of action and a higher risk of side effects like nausea, vomiting, and accumulation of a neurotoxic metabolite (norpethidine) compared to morphine, especially with repeated doses. It is generally not a first-line opioid choice but can be used in specific situations.

Reference: NICE Guideline NG157: Postoperative pain management (February 2020). https://www.nice.org.uk/guidance/ng157

Explanation: To interpret the blood gas results:

• pH (7.25): This is below the normal range (7.35-7.45), indicating acidosis.
• PCO2 (25 mmHg): This is below the normal range (35-45 mmHg), suggesting a respiratory alkalosis (a primary decrease in PCO2 would make the pH higher). However, in this case, it’s likely a compensatory response to metabolic acidosis.
• HCO3- (18 mmol/L): This is below the normal range (22-26 mmol/L), indicating a metabolic acidosis (a primary decrease in bicarbonate makes the pH lower).
• Base excess (-8): This is also below the normal range (-2 to +2), further supporting metabolic acidosis.

The primary abnormality is a metabolic acidosis (low pH and low bicarbonate). The low PCO2 indicates that the respiratory system is attempting to compensate by increasing ventilation to blow off carbon dioxide and raise the pH. However, the pH is still below normal, indicating that the compensation is incomplete.

• A) Metabolic and respiratory mixed acidosis (Incorrect): While there is a low pH, the low PCO2 suggests a tendency towards alkalosis from the respiratory component, indicating compensation rather than primary respiratory acidosis.
• B) Metabolic acidosis with compensation (Correct): The low pH and low bicarbonate indicate metabolic acidosis, and the low PCO2 is consistent with respiratory compensation.
• C) Metabolic acidosis without compensation (Incorrect): The low PCO2 suggests that the respiratory system is attempting to compensate.
• D) Respiratory acidosis with compensation (Incorrect): The primary abnormality is the low bicarbonate, indicating metabolic acidosis, not respiratory acidosis (which would involve a high PCO2).
• E) Respiratory acidosis without compensation (Incorrect): Same reason as D.

The patient’s symptoms (severe abdominal pain, vomiting, and dyspnoea) could be consistent with a condition causing metabolic acidosis, such as sepsis, bowel ischaemia, or severe dehydration, leading to increased lactic acid production or bicarbonate loss. The dyspnoea could also be a trigger for the respiratory compensation.

Explanation: Anterior perineal resection (APR) is a major surgical procedure for colorectal cancer that involves both abdominal and perineal dissection, resulting in significant postoperative pain. Effective analgesia is crucial for patient comfort and recovery.

• a) IV morphine (Incorrect): Intravenous morphine can provide adequate pain relief, especially via patient-controlled analgesia (PCA). However, systemic opioids can have significant side effects such as nausea, vomiting, sedation, and respiratory depression, which can hinder early mobilization and recovery.
• b) Diclofenac Na (Incorrect): Diclofenac sodium is a non-steroidal anti-inflammatory drug (NSAID) that can be useful for mild to moderate pain. However, for severe postoperative pain after major surgery like APR, it is unlikely to provide sufficient analgesia as a sole agent. It is often used as part of a multimodal analgesic regimen.
• c) Epidural bupivacaine (Correct): Epidural analgesia, involving the continuous infusion of a local anaesthetic like bupivacaine (often combined with an opioid) into the epidural space, is considered the gold standard for providing superior pain relief after major abdominal and pelvic surgeries like APR. It provides effective analgesia while minimizing systemic opioid-related side effects, facilitating early mobilization and reducing pulmonary complications.
• d) PCM (Incorrect): PCM (paracetamol/acetaminophen) is a mild analgesic and antipyretic. It is useful for mild to moderate pain but is insufficient for the severe pain expected after APR. It is often used as part of a multimodal approach.
• e) IM pethidine (Incorrect): Intramuscular (IM) pethidine (meperidine) has several disadvantages, including variable absorption, pain on injection, short duration of action, and potential for metabolite accumulation (norpethidine) leading to neurotoxicity. It is generally not a preferred opioid for managing severe postoperative pain.

Reference: Postoperative pain management guidelines; Colorectal surgery protocols.

Explanation: Severe sepsis (now often referred to as sepsis with organ dysfunction) requires prompt and aggressive management to improve patient outcomes. Key steps include:

• a) Diagnosis confirmed by CRP (False): C-reactive protein (CRP) is an inflammatory marker that is often elevated in sepsis, but it is not specific for sepsis and is not used to confirm the diagnosis. Sepsis diagnosis is based on clinical criteria of infection plus organ dysfunction.
• b) Blood sent for culture ABST (True): Obtaining blood cultures (and other relevant cultures) before starting antibiotics is crucial to identify the causative organism and guide antibiotic therapy. ABST refers to antibiotic sensitivity testing.
• c) Central line inserted for monitoring BP (True): Invasive blood pressure monitoring via a central arterial line is often necessary in severe sepsis, especially when the patient is haemodynamically unstable and requiring vasopressors. A central line also allows for central venous pressure (CVP) monitoring and administration of vasoactive drugs.
• d) Fluid resuscitation done to improve mean arterial pressure (True): Rapid and adequate fluid resuscitation is a cornerstone of early sepsis management to address hypovolaemia and improve tissue perfusion. The goal is often to achieve a target mean arterial pressure (MAP) of ≥ 65 mmHg.
• e) Broad spectrum antibiotics even (True): Early administration of broad-spectrum antibiotics (within one hour of sepsis recognition) is critical to cover likely pathogens before culture results are available. Prompt antibiotic therapy significantly improves survival in sepsis.

Reference: Surviving Sepsis Campaign guidelines; Critical care medicine textbooks.

Explanation: Matching the mode of anaesthesia to the surgical procedure requires understanding the extent of anaesthesia required and the area of the body involved.

• A. Bier block – hand surgery (True): Bier’s block (intravenous regional anaesthesia) is a well-established technique for short surgical procedures on the forearm and hand.
• B. Intercostal block – Flail chest (True): Intercostal nerve blocks can provide significant pain relief in patients with flail chest, improving ventilation and reducing the need for systemic analgesics.
• C. Lignocaine with adrenaline – Circumcision (True): Local infiltration with lignocaine and adrenaline is commonly used for circumcision to provide anaesthesia and reduce bleeding due to the vasoconstrictive effect of adrenaline.
• D. Saddle block – haemorrhoidectomy (True): Saddle block, a type of spinal anaesthesia affecting the perineal area, is very suitable for anorectal surgeries like haemorrhoidectomy.
• E. Spinal – mastectomy (False): Mastectomy is a major surgical procedure typically requiring general anaesthesia to ensure adequate pain control, muscle relaxation, and patient comfort throughout the longer duration of the surgery. Spinal anaesthesia would not provide sufficient coverage or sedation for this procedure.

Reference: Bailey & Love’s Short Practice of Surgery, 28th Edition; Clinical Anaesthesia, 9th Edition.

Explanation: Normal saline is an isotonic crystalloid solution. When administered intravenously, it distributes throughout the extracellular fluid (ECF) compartment. The ECF is further divided into the intravascular space (blood plasma) and the interstitial space (fluid surrounding cells).

The approximate distribution of crystalloids after infusion is:

• Approximately 20-25% remains in the intravascular compartment.
• Approximately 75-80% moves into the interstitial (extravascular) compartment.

Therefore, after administering 1 liter (1000 mL) of normal saline:

• Around 20-25% of 1000 mL, which is 200-250 mL, will remain in the intravascular compartment, contributing to an increase in circulating volume.
• Around 75-80% of 1000 mL, which is 750-800 mL, will move into the interstitial compartment.

Let’s evaluate the options based on this understanding:

• a. 250 mL remain in the extravascular compartment (Incorrect): The majority of the infused saline moves to the extravascular compartment, much more than 250 mL.
• b. 250 mL remain in the intravascular compartment (Correct): This aligns with the approximate distribution of crystalloids, where about 20-25% stays within the blood vessels.
• c. 500 mL remain in the intracellular compartment (Incorrect): Isotonic crystalloids like normal saline primarily distribute within the extracellular fluid and do not significantly enter the intracellular compartment under normal physiological conditions.
• d. 500 mL remain in the extravascular compartment (Incorrect): While a significant portion goes to the extravascular space, it’s closer to 750-800 mL.
• e. 500 mL remain in the intravascular compartment (Incorrect): Only about 20-25% remains intravascularly.

Reference: Fluid and electrolyte balance physiology; Basic pharmacology of intravenous fluids.

Explanation: The patient’s drowsiness, low respiratory rate (normal is 12-20 breaths per minute), and reduced oxygen saturation (SpO2 < 95% is concerning) strongly suggest opioid-induced respiratory depression, a known side effect of morphine.

• A. Diaphragmatic splinting (Incorrect): While pain after laparotomy can cause splinting and reduce deep breathing, it typically doesn’t lead to such a significant drop in respiratory rate and SpO2 in the absence of other factors.
• B. Hypovolaemia (Incorrect): Hypovolaemia can cause drowsiness and reduced SpO2 (due to poor perfusion), but it usually presents with tachycardia and hypotension, which are not mentioned here. The low respiratory rate is not typical of hypovolaemia.
• C. Impaired ventilation (Correct): Morphine is a respiratory depressant that acts on the brainstem to reduce the rate and depth of breathing, leading to hypoventilation and a decrease in oxygen saturation.
• D. Pulmonary embolism (Incorrect): Pulmonary embolism can cause dyspnoea and reduced SpO2, but it often presents with sudden onset, chest pain, and tachycardia. A low respiratory rate is not a typical finding.
• E. Pulmonary oedema (Incorrect): Pulmonary oedema can cause dyspnoea and reduced SpO2, often with crackles on auscultation and potentially a raised respiratory rate. Drowsiness can occur due to hypoxia, but the primary finding of a low respiratory rate points more towards respiratory depression.

Reference: Clinical Pharmacology textbooks; Postoperative Pain Management Guidelines.

Explanation: Preoperative electrocardiogram (ECG) monitoring is a standard tool for assessing a patient’s cardiac status before surgery. It primarily records the electrical activity of the heart.

• A. Assess cardiac output (Incorrect): Cardiac output (the volume of blood pumped by the heart per minute) is not directly measured by an ECG. It requires techniques like echocardiography or invasive cardiac output monitoring.
• B. Diagnose volume status (Incorrect): An ECG does not directly reflect a patient’s fluid volume status (e.g., dehydration or fluid overload). Clinical assessment and other investigations are needed for this.
• C. Diagnose myocardial depression (Incorrect): While an ECG can show signs suggestive of underlying cardiac disease that might lead to myocardial depression, it doesn’t directly measure the contractility or function of the heart muscle. Echocardiography is the primary tool for assessing myocardial function.
• D. Detect MI (Correct): An ECG is a crucial tool for detecting evidence of myocardial infarction (MI), both acute and old. Characteristic ST-segment changes, T-wave inversions, and Q waves can indicate myocardial ischaemia or infarction.
• E. Identify cardiac arrhythmias (Correct): ECG is the gold standard for identifying and classifying cardiac arrhythmias (abnormal heart rhythms). It records the timing and pattern of electrical impulses in the heart, allowing for the diagnosis of various rhythm disturbances.

Reference: Preoperative assessment guidelines; Cardiology textbooks.

Explanation: For a hemodynamically stable patient after major surgery, the primary goal of intravenous fluid administration is to provide maintenance fluids to cover ongoing losses (insensible losses, urine output) and maintain electrolyte balance.

• A. 5% dextrose (Incorrect): 5% dextrose in water (D5W) is a hypotonic solution that provides free water and calories but lacks significant electrolytes. It is not ideal for routine maintenance as it can lead to hyponatraemia.
• B. 0.9% NaCl (Correct): 0.9% normal saline is an isotonic crystalloid solution that closely resembles the electrolyte composition of plasma. It is a common and generally appropriate choice for maintenance fluids in stable postoperative patients, providing both volume and electrolytes.
• C. 0.45% NaCl (Incorrect): 0.45% saline (half-normal saline) is a hypotonic solution and can lead to hyponatraemia if given in large volumes. It is not typically used for routine maintenance in the immediate postoperative period.
• D. Hetastarch (Incorrect): Hetastarch is a synthetic colloid used for volume expansion in situations like hypovolaemia. It is not indicated for routine maintenance fluids in a hemodynamically stable patient and carries risks of side effects.
• E. Hartmann (Correct): Hartmann’s solution (lactated Ringer’s) is another isotonic crystalloid solution with a more balanced electrolyte composition compared to normal saline, including bicarbonate precursors. It is also a suitable choice for maintenance fluids and may be preferred by some clinicians for its more physiological composition. Similar to the previous question, both B and E are appropriate. Hartmann’s might be slightly better for longer-term maintenance due to its balanced electrolytes. However, normal saline is a very common and acceptable choice for general postoperative maintenance. Let’s stick with normal saline as a widely used initial option for a stable patient.

Reference: Perioperative fluid management guidelines; Basic principles of intravenous fluid therapy.

Explanation: The patient presents with persistent hyponatraemia (low Na⁺) and low plasma osmolality, indicating water retention relative to sodium. Despite this, his urinary sodium is normal, suggesting that the kidneys are not conserving sodium appropriately in the face of hyponatraemia. The absence of peripheral oedema and normal blood pressure rules out hypervolaemic hyponatraemia (e.g., heart failure, cirrhosis). This constellation of findings is characteristic of the Syndrome of Inappropriate Antidiuretic Hormone secretion (SIADH).

• a. Acute kidney injury (Incorrect): Acute kidney injury can cause various electrolyte disturbances, but it typically leads to reduced urinary sodium excretion (pre-renal AKI) or variable excretion depending on the type of AKI. Low plasma osmolality is not a primary feature of AKI.
• b. Diabetes insipidus (Incorrect): Diabetes insipidus (DI) is characterized by a deficiency in or resistance to ADH, leading to excessive water loss, high urine output, hypernatraemia (high Na⁺), and high plasma osmolality. The patient has hyponatraemia and low plasma osmolality.
• c. Excessive diuretic therapy (Incorrect): Diuretics can cause hyponatraemia, but they usually lead to increased urinary sodium excretion as the mechanism of action involves promoting sodium loss in the urine. The patient has normal urinary sodium.
• d. Pituitary failure (Incorrect): While pituitary failure can affect ADH secretion, it typically leads to central diabetes insipidus (if ADH is deficient) or other hormonal imbalances. The specific combination of hyponatraemia with low plasma osmolality and normal urinary sodium is more suggestive of SIADH.
• e. SIADH (Correct): SIADH is characterized by the excessive release of ADH from the posterior pituitary (or ectopic sources), leading to increased water reabsorption in the kidneys, dilutional hyponatraemia (low plasma sodium and osmolality), and inappropriately normal or elevated urinary sodium excretion despite the hyponatraemia. The absence of volume overload (no peripheral oedema, normal BP) is also consistent with SIADH. Cerebral abscess can sometimes be a trigger for SIADH.

Reference: Endocrinology and fluid-electrolyte balance textbooks; SIADH diagnostic criteria.

Explanation: Metabolic acidosis is a condition characterized by a primary decrease in serum bicarbonate concentration, leading to a decrease in pH. It can result from increased acid production, loss of bicarbonate, or decreased acid excretion.

• a) Hyperventilation (False): Hyperventilation leads to excessive elimination of carbon dioxide (CO₂), causing a decrease in PaCO₂ and an increase in pH, resulting in respiratory alkalosis, not metabolic acidosis.
• b) Pulmonary embolism (False): Pulmonary embolism (PE) primarily affects the respiratory system, potentially leading to hypoxaemia and hypocapnia (due to hyperventilation), which can cause respiratory alkalosis or, in severe cases with hypoperfusion and lactic acid production, a mixed acid-base disorder. It is not a direct cause of metabolic acidosis.
• c) Gangrenous bowel (True): Gangrenous bowel (intestinal ischaemia and necrosis) leads to the production of lactic acid due to anaerobic metabolism and the release of other acidic metabolites into the bloodstream, resulting in metabolic acidosis (specifically, lactic acidosis).
• d) Renal failure (True): In renal failure, the kidneys lose their ability to excrete metabolic acids and regenerate bicarbonate effectively, leading to the accumulation of acids (e.g., sulphuric acid, phosphoric acid) and a decrease in bicarbonate, causing metabolic acidosis (uraemic acidosis).
• e) Uncontrolled diabetes mellites (True): In uncontrolled diabetes, particularly with insulin deficiency, the body starts to break down fats for energy, leading to the production of ketone bodies (ketoacids) such as acetoacetate and beta-hydroxybutyrate. The accumulation of these ketoacids causes metabolic acidosis, known as diabetic ketoacidosis (DKA).

Reference: Acid-base physiology textbooks; Internal medicine resources on metabolic acidosis.

Explanation: Intestinal obstruction often leads to dehydration and electrolyte imbalances due to vomiting, third-space fluid losses into the bowel wall and peritoneal cavity, and reduced oral intake. The ideal initial fluid for resuscitation should aim to restore circulating volume and correct electrolyte deficits.

• a) Ringer lactate (Incorrect): Ringer lactate is an isotonic crystalloid solution containing sodium, chloride, potassium, calcium, and lactate. While it is a balanced solution and can be used for resuscitation, it might not be the first choice if there is concern for lactic acidosis (though not specifically mentioned in the question). The lactate is metabolized to bicarbonate, which could be beneficial if the patient has metabolic acidosis, but normal saline is often preferred initially for volume expansion.
• b) Normal saline (Correct): 0.9% normal saline is an isotonic crystalloid solution containing sodium and chloride. It is a commonly used first-line fluid for volume resuscitation in various conditions, including intestinal obstruction, to restore intravascular volume and improve renal perfusion. However, excessive use can lead to hyperchloraemic acidosis.
• c) Dextran (Incorrect): Dextran is a colloid solution used for volume expansion. While effective in increasing intravascular volume, colloids are generally not the first-line choice for initial resuscitation in most cases due to potential side effects and lack of clear superiority over crystalloids. In intestinal obstruction, addressing electrolyte imbalances with crystalloids is usually prioritized initially.
• d) Hartman’s (Correct): Hartman’s solution (lactated Ringer’s) is another isotonic crystalloid solution with a composition similar to Ringer lactate. It is also a suitable choice for resuscitation in intestinal obstruction, providing a more balanced electrolyte profile than normal saline and containing a bicarbonate precursor. Given both normal saline and Hartmann’s are isotonic crystalloids suitable for initial resuscitation, the choice often depends on the specific electrolyte status of the patient (which is not detailed here). In the absence of information suggesting a need for lactate (e.g., suspected metabolic acidosis), normal saline is a safe and commonly used initial fluid.
• e) 5% dextrose (Incorrect): 5% dextrose in water (D5W) is a hypotonic solution that primarily provides free water and calories. It is not suitable for initial volume resuscitation as it distributes into all body water compartments and does not effectively expand intravascular volume. It can also worsen electrolyte imbalances.

Reference: Fluid and electrolyte management in surgical patients; Intestinal obstruction management guidelines.

Explanation: The rapid onset of hypotension, bradycardia, and flushing following the administration of thiopental sodium (a common anaesthetic induction agent) is highly suggestive of anaphylaxis, a severe and life-threatening allergic reaction. The immediate management of anaphylaxis involves:

• A. Adrenaline (Correct): Adrenaline (epinephrine) is the first-line treatment for anaphylaxis. It has alpha-adrenergic effects (vasoconstriction, increased blood pressure) and beta-adrenergic effects (increased heart rate and contractility, bronchodilation) that counteract the effects of anaphylaxis. It should be administered intramuscularly (IM) in the mid-outer thigh as quickly as possible.
• B. Hydrocortisone (Incorrect): Hydrocortisone is a corticosteroid that can help reduce the late-phase inflammatory response in anaphylaxis. However, its onset of action is slow (hours), and it is not the immediate treatment for the acute symptoms of hypotension and bradycardia.
• C. O2 via face mask (Incorrect): Providing oxygen is important supportive care in anaphylaxis to address potential hypoxaemia, but it does not treat the underlying haemodynamic instability (hypotension and bradycardia).
• D. Elevate the foot end (Incorrect): Elevating the foot end (Trendelenburg position) can help improve venous return and temporarily increase blood pressure, but it is a temporizing measure and does not address the underlying cause of the hypotension. Adrenaline is the definitive immediate treatment.
• E. Atropine (Incorrect): Atropine is an anticholinergic drug that increases heart rate by blocking vagal tone. While bradycardia is present, it is part of the anaphylactic reaction, and adrenaline’s beta-adrenergic effects will also help increase heart rate. Atropine is not the primary treatment for the haemodynamic collapse in anaphylaxis.

Reference: Resuscitation Council UK guidelines on anaphylaxis; Anaesthesia textbooks.

Explanation: The patient’s ABG results show:

• pH: 7.25 (low, indicating acidosis)
• PaCO₂: 21 mmHg (low, indicating alkalosis if primary)
• HCO₃-: 15 mmol/L (low, indicating metabolic acidosis)
• Base excess: -15 (low, also indicating metabolic acidosis)

The low pH and low bicarbonate are consistent with a metabolic acidosis. The low PaCO₂ indicates that the respiratory system is attempting to compensate for the metabolic acidosis by increasing ventilation to blow off carbon dioxide and raise the pH. Since the pH is still below normal, the compensation is partial.

• a) Metabolic acidosis with partial respiratory compensation (Correct): This accurately describes the findings of low pH, low bicarbonate (metabolic acidosis), and low PaCO₂ (respiratory compensation), with the pH still outside the normal range indicating partial compensation.
• b) Metabolic acidosis with respiratory compensation (Incorrect): While there is respiratory compensation, the term ‘with respiratory compensation’ usually implies that the pH has returned to the normal range, which is not the case here (pH is 7.25).
• c) Metabolic acidosis without compensation (Incorrect): The low PaCO₂ indicates that respiratory compensation is occurring.
• d) Respiratory acidosis with metabolic compensation (Incorrect): Respiratory acidosis is characterized by a high PaCO₂ and low pH. Here, PaCO₂ is low.
• e) Respiratory acidosis without compensation (Incorrect): Same reason as (d).

The patient’s presentation of severe abdominal pain, distension, and bowel ischemia can lead to metabolic acidosis due to increased lactate production from tissue hypoperfusion.

Explanation: In the immediate postoperative period after major abdominal surgery, patients often have ongoing fluid losses (e.g., insensible losses, third-space losses, drainage) and require maintenance fluids. The choice of intravenous fluid should aim to maintain euvolaemia and electrolyte balance.

• A. 5% Dextrose (Incorrect): 5% dextrose in water (D5W) is a hypotonic solution that primarily provides free water and calories. It does not contain significant electrolytes and can lead to hyponatraemia if given in large volumes, especially in the postoperative period when ADH secretion may be increased due to stress. It is not ideal for initial volume replacement.
• B. 0.9% Normal saline (Correct): 0.9% normal saline is an isotonic crystalloid solution that closely resembles the electrolyte composition of plasma. It is commonly used for initial fluid resuscitation and maintenance in the postoperative period to replace extracellular fluid losses and maintain circulating volume.
• C. 0.45% Saline (Incorrect): 0.45% saline is a hypotonic solution (half-normal saline) and can lead to hyponatraemia if given in large volumes. It is generally not the first-line choice for routine postoperative fluid management, although it may be used in specific situations to address free water deficits.
• D. Hartmann solution (Correct): Hartmann’s solution (lactated Ringer’s) is another isotonic crystalloid solution that contains electrolytes in a more balanced proportion to plasma, including lactate which is metabolized to bicarbonate. It is also a suitable choice for postoperative fluid replacement and may be preferred over normal saline in some situations due to its more physiological electrolyte composition and potential buffering effect. Given both B and D are correct and commonly used isotonic crystalloids, the question asks for the best” option. Hartmann’s solution’s balanced electrolyte composition might give it a slight edge over normal saline for routine maintenance especially for longer durations to avoid potential hyperchloraemic acidosis associated with large volumes of normal saline. However for initial resuscitation and short-term maintenance both are acceptable. Without further context either could be considered “best” depending on institutional preference and specific patient factors. Let’s stick with normal saline as a very common and generally accepted initial choice.
• E. Darrow’s solution (Incorrect): Darrow’s solution is an electrolyte solution used to treat metabolic alkalosis and replace fluid losses particularly gastrointestinal losses. It is not typically used for routine postoperative fluid management after a major abdominal surgery unless there are specific indications like significant metabolic alkalosis or specific electrolyte imbalances.

Reference: Perioperative fluid management guidelines; Basic principles of intravenous fluid therapy.

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Explanation: After general anaesthesia, once a baby is fully awake and has regained protective reflexes (like gag reflex), feeding can usually be resumed. Breast milk is easily digestible and provides comfort and nutrition to the infant.

• A. Wait 6 hours & feed (Incorrect): Prolonged fasting after anaesthesia is generally not necessary, especially in infants who rely on frequent feeds. Waiting 6 hours without a clear medical reason can cause unnecessary distress and potential hypoglycaemia.
• B. Start iv fluid (Incorrect): Intravenous fluids are indicated if the baby is unable to tolerate oral feeds or shows signs of dehydration. A fully awake and crying baby who wants to breastfeed does not necessarily require IV fluids.
• C. Let the mother breast feed (Correct): Once the baby is fully awake and alert with intact protective reflexes, breastfeeding can usually be safely resumed. Breast milk is easily digestible and provides comfort to the baby. Standard anaesthetic practice generally allows feeding once the child is fully recovered from anaesthesia.
• D. Listen to the bowel sound & then decide (Incorrect): While assessing bowel sounds can be part of postoperative care, it is not the primary determinant for resuming breastfeeding in a fully awake infant after a minor procedure like incision and drainage. The return of full consciousness and protective reflexes is more critical.
• E. Wet the baby’s lips (Incorrect): While keeping the baby’s lips moist is a comfort measure, it does not address the baby’s nutritional needs or the mother’s wish to breastfeed.

Reference: Paediatric anaesthesia recovery guidelines; Breastfeeding guidelines.

Explanation: The patient shows signs of persistent hypovolaemia despite significant crystalloid administration, indicated by the lack of improvement in MAP and CVP. In sepsis, there is often increased capillary permeability, leading to fluid shift from the intravascular to the interstitial space. Therefore, a colloid solution is often considered after initial crystalloid resuscitation.

• A. 0.9% NaCl (Incorrect): Further crystalloid administration may exacerbate interstitial oedema without significantly improving intravascular volume.
• B. 3% NaCl (Incorrect): Hypertonic saline is used for specific indications like raised intracranial pressure and is not the first-line treatment for persistent hypovolaemia in sepsis.
• C. Albumin (Correct): Albumin is a colloid that remains in the intravascular space for a longer duration than crystalloids, helping to increase oncotic pressure and improve intravascular volume. NICE guideline NG51 on Sepsis recommends considering albumin in patients who remain hypotensive despite adequate crystalloid resuscitation.
• D. Hartmann’s (Incorrect): Hartmann’s solution is a crystalloid and, similar to 0.9% NaCl, may not be as effective in improving intravascular volume in the face of increased capillary leak.
• E. Tetrastarch (Incorrect): Hydroxyethyl starch (HES) solutions like tetrastarch are associated with increased risk of kidney injury and mortality in critically ill patients, including those with sepsis, and are generally not recommended.

Reference: NICE Guideline NG51: Sepsis: recognition, diagnosis and early management (July 2016, updated November 2023). https://www.nice.org.uk/guidance/ng51

Explanation: The patient’s poor respiratory effort following a major abdominal surgery and the development of fever suggest a potential respiratory complication like pneumonia or atelectasis leading to hypoventilation.

• a) pH 7.44, pCO₂ 35, pO₂ 70, HCO₃ 29 (Incorrect): This shows a normal pH with a normal pCO₂ and a slightly elevated bicarbonate, suggesting a mild metabolic alkalosis. This does not fit the scenario of poor respiratory effort.
• b) pH 7.2, pCO₂ 40, pO₂ 78, HCO₃ 18 (Incorrect): This shows an acidosis (low pH) with a normal pCO₂ and low bicarbonate, indicating a metabolic acidosis without respiratory compensation. While sepsis (due to perforated ulcer) could cause metabolic acidosis, the poor respiratory effort points more towards a respiratory issue.
• c) pH 7.2, pCO₂ 55, pO₂ 70, HCO₃ 29 (Correct): This ABG shows a low pH (acidosis) and a high pCO₂ (respiratory acidosis). The significantly elevated bicarbonate suggests a metabolic compensation attempting to raise the pH back towards normal. The low pO₂ is consistent with poor ventilation and gas exchange.
• d) pH 7.5, pCO₂ 21, pO₂ 50, HCO₃ 19 (Incorrect): This shows a high pH (alkalosis) and a low pCO₂ (respiratory alkalosis) with a low bicarbonate (metabolic compensation). This is the opposite of what would be expected with poor respiratory effort.
• e) pH 7.44, pCO₂ 40, pO₂ 78, HCO₃ 24 (Incorrect): This ABG is essentially within the normal range and does not reflect poor respiratory effort.

Reference: Acid-base physiology textbooks; Postoperative respiratory complications guidelines.

Explanation: The patient has pre-existing anaemia (haemoglobin 9 g/dl) and is expected to have significant blood loss (1100 ml, which is more than 15% of his estimated blood volume for a 60kg man). In this context, simply replacing volume with crystalloids or colloids will further dilute his haemoglobin and reduce oxygen-carrying capacity, which is particularly concerning in a patient with ischaemic heart disease.

• a) 0.9% saline (Incorrect): Normal saline is a crystalloid and is useful for volume replacement. However, it does not improve oxygen-carrying capacity and will further dilute the patient’s already low haemoglobin.
• b) 5% albumin (Incorrect): Albumin is a colloid and can help maintain intravascular volume. However, like saline, it does not address the need for red blood cell replacement and improved oxygen delivery.
• c) Hetastarch (Incorrect): Hetastarch is a synthetic colloid. While it can expand intravascular volume, its use in critically ill patients and those with bleeding risks is debated due to potential side effects, including coagulopathy and kidney injury. It also does not improve oxygen-carrying capacity.
• d) Packed red cells (Correct): Given the significant expected blood loss and the patient’s pre-existing anaemia and ischaemic heart disease, transfusion with packed red blood cells is the most appropriate choice. This will replace the lost red blood cell mass, improve oxygen-carrying capacity, and help maintain adequate tissue oxygenation, which is crucial in a patient with cardiac disease undergoing major surgery. A transfusion trigger of haemoglobin < 7-8 g/dl is often used, but in patients with cardiac disease, a higher threshold may be considered, especially with ongoing significant blood loss.
• e) Hartmans (Incorrect): Hartmann’s solution is a balanced crystalloid and is suitable for volume replacement. However, similar to normal saline, it does not address the need for red blood cell transfusion in the face of significant blood loss and pre-existing anaemia, especially in a patient with ischaemic heart disease.

Reference: NICE Guideline NG174: Blood transfusion (December 2020); Perioperative fluid management guidelines.

Explanation: Following a stroke with hemiplegia, the patient may have ongoing swallowing difficulties (dysphagia), increasing the risk of aspiration pneumonia. The most appropriate long-term feeding method should ensure adequate nutrition while minimizing this risk.

• a) Prop up the patient and feed with a spoon (Incorrect): While oral feeding may be possible with careful positioning and supervision for some patients with mild dysphagia, it carries a higher risk of aspiration in those with significant swallowing impairment, which is common after a stroke causing hemiplegia.
• b) Feeding via nasogastric tube (Incorrect): Nasogastric (NG) tubes are suitable for short-term nutritional support (typically up to 4-6 weeks). For long-term feeding, they are less comfortable, can lead to complications like nasal irritation and sinusitis, and do not eliminate the risk of aspiration.
• c) Home parenteral nutrition (Incorrect): Parenteral nutrition (intravenous feeding) is usually reserved for patients with a non-functional gastrointestinal tract or severe malabsorption. It carries significant risks of infection and metabolic complications and is not the preferred long-term solution for a stroke patient with a functioning gut.
• d) Percutaneous endoscopic gastrostomy (Correct): Percutaneous endoscopic gastrostomy (PEG) involves placing a feeding tube directly into the stomach through the abdominal wall. This is a well-established and safe method for long-term enteral feeding in patients with dysphagia, reducing the risk of aspiration compared to oral feeding and NG tubes, and improving patient comfort. NICE guideline CG32 on Stroke recommends considering PEG for patients with persistent dysphagia after stroke.
• e) Surgically created feeding jejunostomy (Incorrect): Jejunostomy tubes are typically used when there are contraindications to gastric feeding (e.g., gastroparesis, high risk of reflux). While it can reduce aspiration risk, it’s a more invasive procedure than PEG and not the first-line long-term enteral feeding method for stroke patients with dysphagia.

Reference: NICE Guideline CG32: Stroke: diagnosis and initial management of acute stroke and transient ischaemic attack (TIA) (October 2008, updated February 2010). https://www.nice.org.uk/guidance/cg32