Single Best Answers Dr Katie Ayyash and Dr Chris Smales

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1. A woman is brought to the emergency department following cardiac arrest 37 days after LSCS. Post mortem shows PE as a cause of death. The death is reported to CMACE as: a) Indirect maternal death

b) Direct maternal death

c) Late maternal death

d) Coincidental maternal death

e) Fortuitous maternal death

2. A patient with Von Willibrand disease presents for emergency appendicectomy. Which of the following would be the LEAST useful in the management of this patient? a) Desmopressin

b) Tranexamic acid

c) Platelets

d) Factor VIII concentrate

e) Fresh frozen plasma

The diagnosis and management of von Willebrand disease: a

United Kingdom Haemophilia Centre Doctors Organizat ion

guideline approved by the Brit ish Commit tee for Standards in

Haematology

Mike A. Laffan,1 Will Lester,2 James S. O’Donnell,3 Andrew Will,4 Robert Campbell Tait,5 Anne Goodeve,6 Carolyn M.

Millar1and David M. Keeling7

1Centre for Haematology, Imperial College London, London, 2Department of Haematology, Queen Elizabeth Hospital, University

Hospitals Birmingham, Birmingham, UK, 3National Centre for Coagulation Disorders, St James’sHospital, Dublin, Ireland, 4Royal

Manchester Children’sHospital, Manchester, 5Department of Haematology, Royal Infirmary, Glasgow, 6Sheffield Diagnostic Genetics

Service, Sheffield Children’sNHS Foundation Trust & Department of Cardiovascular Science, University of Sheffield, Sheffield, and7Oxford University Hospitals, Oxford, UK

Keywords: diagnosis, management, guideline, United King-

dom Haemophilia Centre Doctors Organization, von Wille-

brand.

The guideline group was selected to be representative of UK-

based medical experts. MEDLINE and EMBASE were searched

systematically for publications in English from 2002 using the

key word Willebrand. The writing group produced the

draft guideline, which was subsequently reviewed by the A

United Kingdom Haemophilia Centre Doctors Organization

(UKHCDO) advisory committee, a British Committee for

Standards in Haematology (BCSH) sounding board of

approximately 50 UK haematologists, and the BCSH execu-

tive; comments were incorporated where appropriate. The

‘GRADE’ system was used to quote levels and grades of

evidence, details of which can be found in at http://www.bcsh-

guidelines.com/BCSH_PROCESS/EVIDENCE_LEVELS_AND_

GRADES_OF_RECOMMENDATION/43_GRADE.html. The

objective of this guideline is to provide healthcare profession-

als with clear guidance on the diagnosis and management of

patients with von Willebrand disease.

Guideline update

This is a single guideline replacing two separate guidelines

on diagnosis and management respectively, published in

2004 (Laffan et al, 2004; Pasi et al, 2004). Where there has

been no significant change in understanding or practice, the

reader is referred to the earlier guidelines.

Major changes since last guideline

The principal changes have been increased understanding of

the genetic basis of von Willebrand disease, a relaxation of

definition and a focus on how laboratory tests can guide

management.

What is von Willebrand disease?

Von Willebrand factor (VWF) is a large and complex plasma

glycoprotein that is essential for normal haemostasis. It is

well recognized that deficiency of VWF results in a bleeding

disorder that varies in severity according to the degree of

deficiency and the specific characteristics of the molecule and

which may have features of both primary and secondary hae-

mostatic defects. The complex structure of the protein and

the wide range of plasma levels encountered in the popula-

tion make laboratory assessment and diagnosis a challenging

proposition. Since the last guidelines by this group (Laffan

et al, 2004; Pasi et al, 2004), there have been considerable

advances in understanding the genetics, function and clinical

correlates of VWF, which have been incorporated into this

revised and unified document. Here we define von Wille-

brand disease (VWD) as a bleeding disorder that is predomi-

nantly attributable to reduced levels of VWF activity. We

recognize that this is frequently, but not always, attributable

to a defect in the VWF gene (VWF). Our emphasis remains

on practical guidance rather than taxonomic purity.

When patients present with mucocutaneous bleeding

symptoms suggestive of a primary haemostatic disorder, a

quantitative or qualitative abnormality of VWF is a possible

cause or contributory factor. During the initial assessment it

is important to remember that bleeding histories can be

subjective and the disease characteristics can take time to

Correspondence: Dr G Dolan, UKHCDO Chairman, UKHCDO

Secretariat, City View House, Union Street, Ardwick, Manchester

M12 4JD, UK.

E-mail: support@ukhcdo.org

guideline

ª 2014 John Wiley & Sons Ltd

British Journal of Haematology, 2014, 167, 453–465

First published online 12 August 2014

doi:10.1111/bjh.13064

http://onlinelibrary.wiley.com/store/10.1111/bjh.13064/asset/bjh13064.pdf;jsessionid=38EF82C9EF2A3AB90D8AEE2BC4BEC89D.f02t04?v=1&t=iqvd5kng&s=c60c2385455c29531fd5cde06782002ba24026da

3. A neurosurgeon informs you that he needs to use the sitting position to operate on a posterior cranial fossa tumour. Which of the following will provide the BEST choice of detecting a venous air embolism? a) Precordial Doppler

b) End-tidal CO2

c) Right atrial pressure measured by CVP

d) Pulmonary artery pressure

e) Oesophageal stethoscope

The sitting position in neurosurgery

Table 4 Incidence of venous air embolism (VAE) in the sitting position

Ref. Incidence of Monitoring

(year of publication) Author(s) No. of patients VAE (%) technique

197259 Michenfelder, Miller, Gronert 69 32 Doppler

19762 Albin et al 180 25 Doppler

198378 Voorhies, Fraser, 81 50 Doppler

Van Poznak

198473 Standefer, Bay, 382 7 Doppler

Trusso

198557 Matjasko et al 554 23 Doppler

198814 Black et al 333 45 Doppler

199465 Papadopoulos et al 62 76 Transoesophageal echocardiography

position and used an electromagnetic flowmeter to continu-

ously measure blood flow.76 General anaesthesia and

induced hypocapnia reduced flow by 34% in the supine

position. Assumption of the sitting position under anaesthe-

sia further reduced flow by 14%. The authors attributed the

reduction in cerebral blood flow to a reduction in effective

arterial pressure. The consequence of such a reduction in

cerebral blood flow may be offset by the reduction in

CMRO2 and consequent lowering of the ischaemic threshold

associated with anaesthesia.39 In addition, surgical stimula-

tion attenuated the reduction in cerebral blood flow and

internal carotid flow.

Complications

Venous air embolism

Venous air entrainment is a positional hazard confronting

patients placed in the sitting position for cervical spine or

posterior fossa surgery and patients placed with significant

head-up tilt for thyroid and head-neck surgery. Conditions

favouring venous air entrainment include an open vein,

gravitational effect of low central venous pressure and

negative i.v. pressure relative to atmospheric pressure and

poor surgical technique. These conditions may be encoun-

tered in neurosurgical practice with head elevation to

promote venous drainage and to optimize surgical access.

The vertical distance between the head and heart may range

from 20 to 65 cm, depending on the procedure.1

The incidence of VAE is difficult to quantify because

of significant differences in the sensitivities of various

monitoring modalities used and the clinical significance of

the findings (Table 4). The incidence has ranged from 25%2

to 50%78 in studies using praecordial Doppler monitoring.

Other investigators, using the more sensitive transoesopha-

geal echocardiography (TOE) monitoring, have indicated

an incidence as high as 76%.65

The first fatality as a result of VAE in association with

surgery in the sitting position was recorded as early as

1830.9 The complication occurred during a procedure to

remove a facial tumour. Fifty years later, Dr N. Senn from

Milwaukee, Wisconsin, felt compelled to draw the attention

of readers to VAE, ‘one of the most uncontrollable causes

of sudden death’.70 He performed an exhaustive search of

121

Table 5 Monitoring of venous air embolism (VAE); VAE detection

techniques in order of decreasing sensitivity

Monitor Associated clinical signs

Transoesophageal echocardiography Absent

Praecordial Doppler Absent

Pulmonary artery pressure Minor (heart rate, MAP)

End-tidal carbon dioxide Minor (heart rate, MAP)

Right atrial pressure Significant

Electrocardiography Cardiovascular collapse

Oesophageal stethoscope Cardiovascular collapse

the literature available at that time and a series of animal

experimental studies involving injection of various quantit-

ies of air into the jugular vein. Dr Senn concluded that

VAE produces death by ‘mechanical overdistension of the

right ventricle of the heart......and asphyxia from obstruction

to the pulmonary circulation consequent upon embolism

of the pulmonary artery’. To treat VAE, he proposed

‘catheterization and aspiration of the right

auricle......thus relieving the overdistension of the right

ventricle, and, at the same time, to guard against a fatal

embolism of the pulmonary artery’.

While VAE has been described in association with a

wide variety of surgical procedures and positions, it remains

the most feared complication of the operative sitting posi-

tion. Monitoring is therefore directed towards detection and

treatment of VAE. The sensitivities of the techniques in

detecting intracardiac air, in the absence of measurable

cardiopulmonary changes, are variable. Monitoring tech-

niques include praecordial Doppler, right heart catheters,

transoesophageal echocardiography, fractional excretion of

nitrogen (FEN2), capnography, oesophageal stethoscope and

transcutaneous oxygen measurement (Table 5). These tech-

niques are described in detail (see below).

The gradient between the atria is a factor in the patho-

physiology of paradoxical air embolism (PAE). Conditions

which increase RAP relative to LAP may predispose to

PAE when VAE occurs.66 Placement of patients in the

seated position, in some cases, has been shown to result in

an RAP greater than PCWP. Application of positive end-

expiratory pressure (PEEP) may also increase RAP suffi-

ciently to exceed PCWP.66 At one time PEEP was advocated

to prevent and treat VAE.78 However, both application and

British Journal of Anaesthesia 82 (1): 117–28 (1999)

REVIEW ARTICLE

The sitting position in neurosurgery: a critical appraisal

J. M. Porter, C. Pidgeon and A. J. Cunningham*

Departments of Anaesthesia and Neurosurgery, Royal College of Surgeons in Ireland/Beaumont Hospital,

Dublin 9, Ireland

*To whom correspondence should be addressed at: Department of Anaesthesia, Beaumont Hospital,

Dublin 9, Ireland

Br J Anaesth 1999; 82: 117–28

Keywords: surgery, neurological; position, sitting

The use of the sitting or upright position for patients

undergoing posterior fossa and cervical spine surgery facilit-

ates surgical access but presents unique physiological chal-

lenges for the anaesthetist with the potential for serious

complications.2 This patient position provides optimum

access to midline lesions, improves cerebral venous decom-

pression, lowers intracranial pressure (ICP) and promotes

gravity drainage of blood and cerebral spinal fluid (CSF).12

Complications related to the use of this position include

haemodynamic instability, venous air embolism (VAE) with

the possibility of paradoxical air embolism, pneumo-

cephalus, quadriplegia and compressive peripheral neuro-

pathy.73 Alternative positions for surgical access to the

posterior fossa and the cervical spine include the prone and

lateral positions. Prolonged neurosurgical procedures with

pin fixation of the head in abnormal positions necessitate

extensive patient monitoring to ensure cardiorespiratory

homeostasis.

Historical milestones in the adoption of the sitting position

in neurosurgical practice were highlighted by Albin and

colleagues.2 The sitting position today is as controversial

as when first introduced into clinical practice in 1913 by

De Martel.23 The first reported use of this position was for

brain tumour surgery performed under local anaesthesia.

Frazier and Gardner reported the use of this position for

surgery on the Gasserian ganglion in the USA in 1928.30

The advent of the operating microscope in neurosurgical

practice, new inhalation anaesthetic agents and neuromus-

cular blocking drugs, and sophisticated cardiovascular and

respiratory monitoring equipment facilitated the develop-

ment of more complicated and technically challenging

procedures performed in the sitting position.82

Although there have been several studies substantiating

the relative safety of the sitting position for neurosurgery,

its use remains controversial and appears to be diminishing

because of the potential for serious complications and

© British Journal of Anaesthesia

malpractice liability claims. This decline has been observed

both in the UK and USA, and appears to be related to

successful litigation for neurological consequences after

paradoxical air embolism (Michenfelder JD, personal com-

munication). Campkin17 reported that 19 (53%) of 36 UK

neurosurgical centres surveyed in 1981 used the sitting

position for posterior fossa surgery and 11 (30%) for

cervical spinal surgery. Elton and Howell,26 based on a

postal survey of UK neurosurgical centres, claimed a greater

than 50% reduction in the number of neurosurgical centres

using the sitting position during 1981–1991. In 1991,

patients were normally placed in the sitting position for

posterior fossa surgery in eight (20%) of the UK centres

surveyed compared with 19 (53%) in 1981. Black and

colleagues also reported a major change from the sitting to

the horizontal position for patients undergoing posterior

fossa craniotomies over the 4-yr period from 1981 to 1984

at the Mayo Clinic.14 Posterior fossa craniotomies performed

in the sitting position in that institution declined from over

110 per year in the early 1980s to less than 50 by the

mid-decade.

The objective of this review is to provide a risk–benefit

analysis of the present day use of the sitting position for

patients undergoing posterior fossa and cervical spine

surgery.

Surgical considerations

The 1960s and 1970s were the heyday for the popularity

of the sitting position for surgical procedures involving the

cervicodorsal spine, and posterior and lateral cranial fossae.

A four-part series of review articles outlining patient man-

agement for these procedures at the Mayo Clinic were

featured in Anesthesia and Analgesia.53–55

Accumulated blood drains out of and away from the

operative site in the sitting position. This allows more rapid

access to bleeding points, a cleaner surgical field and a

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

a) Confirm consent

b) Confirm surgical site mark

c) Confirm allergy status

d) Risk >500mL blood loss

e) Has VTE prophylaxis been considered?

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

a) Morbitz type II

b) HR of 25bpm

c) Complete heart block with broad QRS

d) Ventricular pauses >3secs

e) Recent asystole

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

a) MRI lumbar spine to exclude disease and ligament injury

b) Period of bed rest

c) Epidural steroid injection

d) Morphine controlled release tables

e) Continue current management

Low Back Pain – NICE 2009

7. A 90-year-old is admitted with a fractured NOF and a recent UTI. She has a history of dementia. She has no immediate family and is not able to consent. Which is the MOST appropriate course of action?

a) Proceed to surgery with DNAR intact on grounds of best interest

b) Start a morphine infusion

c) Insert a femoral nerve catheter whilst appointing a mental capacity advocate

d) discuss the options with the nurse in charge

e) Review the DNAR decision

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

a) O2 15/L via Hudson mask

b) GTN infusion

c) Morphine titrate to pain

d) Coronary angiography

e) Referral to coronary care unit

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

a) Acute pulmonary embolism

b) Acute myocardial infarction with systemic embolisation

c) Dissecting aneurysms of the thoracic aorta

d) Acute rupture of the aortic valve

e) Rupture of a mycotic aneurysm of the aortic arch

10. A 10-year-old girl with Down’s syndrome presents for adenotonsillectomy. Her family are refugees and have recently arrived in the UK from Somalia. She has recurrent respiratory infections and tires easily when playing. On examination SpO2 is 93% on air, temperature is 37.2C, and has a non-radiating grade 3/6 systolic murmur. What is the MOST appropriate management of this case?

a) Reassure parents that this is probably an innocent flow murmur and surgery may proceed today

b) Defer the case pending full cardiology assessment including an echocardiogram

c) Ask the paediatic StR to examine the patient and proceed if they think the murmur is innocent

d) Proceed with the case but ensure that the patient receive antibiotic prophylaxis for endocarditis

e) Measure her BP and obtain a 12-lead ECG and proceed with surgery if both are normal

11. A previously fit 78-year old man has a transurethral resection of the prostate (TURP) performed under general anaesthesia taking 90 minutes to complete. Half an hour after arrival in the recovery room he has not regained consciousness. Respiratory effort is adequate and vital signs are stable. Which of the following deranged investigations is most likely to account for his clinical condition?

a) Haemoglobin 7.1g/dl

b) Serum sodium 114mmol/L

c) Serum glucose 2.8mmol/L

d) PaO2 8.9kPa (FiO2 = 0.35)

e) PaCO2 7.4kPa

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

a) Communication with the clinical governance lead or risk manager

b) contact the Coroner’s office

c) Ensure all anaesthetic equipment and drugs are sequestrated

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

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

13. A 55-year-old patient with aortic stenosis and large bowel obstruction presents for a right hemicoletomy. A recent transthoracic echocardiogram revealed an aortic valve orifice of 0.75cm2 and good left ventricular systolic function. The SINGLE safest option for post-operative analgesia is:

a) A continuous thoracic epidural infusion of 0.1% bupivacaine and fentanyl 5mcg/ml

b) Patient controlled thoracic epidural analgesia with 0.1% bupivacaine and fentanyl 5mcg/ml

c) A continuous lumbar epidural infusion of 0.1% bupivacaine and fentanyl 5mcg/ml

d) Nurse administered intramuscular morphine as required

e) Intravenous patient controlled analgesia with morphine sulphate

Severity Valve Area Peak Pressure Mean Pressure Gradient (LV-Aortic)

Normal 2.6-4cm2 <10mmHg <5mmHg

Mild 1.2-1.8cm2 10-40mmHg 12-25mmHg

Moderate 0.8-1.2cm2 40-65mmHg 25-40mmHg

Severe 0.6-0.8cm2 >65mmHg 40-50mmHg

Critical < 0.6cm2 > 50mmHg

• Epidural analgesia can result in signifcant hypotension, which needs to be avoided with severe/critical aortic stenosis

• Intra-muscular injections painful

14. A primiparous woman in the early stages of labour has previously intra-muscular pethidine is requesting epidural analgesia. However, her partner says that he is not happy for this procedure to be performed as they had discussed ante-natally and had decided in the birth plan that an epidural was definitely not an option. How would you proceed in this situation?

a) Agree with the partner and refuse to do the epidural

b) Agree to provide epidural as requested by the woman

c) Suggest Entonox as an alternative form of analgesia

d) Suggest further intramuscular pethidine

e) Change to patient controlled opioid analgesia

15. A 30-year-old primigravida requested an epidural for pain relief in labour. The first attempt to site an epidural at L3/4 was complicated by an accidental dural puncture. The epidural was subsequently sited at L4/5. 24-hours postpartum she has a temperature of 37.3C with a very severe headache and photophobia. What is the most effective therapy for this patient?

a) Administer 1L of 0.9% saline via the epidural catheter over 24hours

b) Administer liberal intravenous fluids

c) Administer an epidural blood patch

d) Administer simple analgesia such as co-codamol

e) Encourage consumption of caffeine containing drinks

16. A 65-year-old man has a laparotomy for alleviation of small bowel obstruction. He has a previously had orthotopic bladder reconstruction for carcinoma of the bladder and has COPD. 48 hours postoperatively on HDU he becomes confused and is unable and unwilling to accept oral fluids. His pulse, BP and urine output are within normal limits. Serum biochemistry reveals Na 147mmol/L, K 3.1mmol/L, Cl 134mmol/L, Urea 14.3mmol/L, Cr 82mmol/L and glucose 14mmol/L. An arterial blood gas analysis on air shows:

pH 7.26, PaCO2 2.57kPa, PaO2 9.92kPa, HCO3 16.3mmol/l, BE -14.6, Lactate 1.6mmol/l

What is the single most appropriate initial intervention?

a) Encourage patient to breathe into a paper bag

b) Intravenous infusion of 8.4% sodium bicarbonate

c) Intravenous sliding scale insulin infusion

d) Potassium supplementation via central venous catheter

e) Rehydration with 0.9% sodium chloride and correction of blood glucose

A hyperchloremic metabolic acidosis is encountered in all patients that undergo urinary diversion using ileal and/or

colonic segments.

Many studies have shown that alkalinizing therapy with sodium bicarbonate is an effective treatment in restoring normal acid-base

balance

17. A drug representative who recommends you use his company’s new drug. Which evidence would most likely persuade you to use the recommended drug?

a) Prospective case matched control

b) Conservative guideline from committee of expert of anaesthetists

c) Randomized control double blinded placebo at a single centre

d) Multi-centre prospective audit of practice and outcome at multiple centers

e) Retrospective look at data from many years at a large DGH

18. A 60-year-old gentleman had a total knee replacement under spinal anaesthetic. He had a continuous femoral nerve catheter inserted for post-operative pain relief. 24hrs post-operatively, he develops patchy sensation in the leg and is unable to flex the knee. What is the MOST likely cause?

a) Muscle ischaemia

b) DVT

c) Spinal cord damage

d) Femoral nerve neuropraxia

e) Tourniquet compression neuropraxia

• Sciatic nerve involvement from tourniquet compression

19. A patient has come for a preoperative check prior to a colon tumour removal. He had a coronary artery bypass 3 years ago and currently suffers from mild angina. What in the history will put his morbidity at high risk?

a) Diet controlled diabetic

b) MI 4 years ago

c) Well controlled hypertension

d) Intermittent claudication at 600 yards

e) Episode of heart failure 3 months ago

20. During insertion of an IV cannula in an anaesthetised patient, you sustain a needle stick injury. The wound is encouraged to bleed, washed and dressed. What is the next MOST appropriate step?

a) Complete an incident form

b) Have a hepatitis B booster

c) Consent the patient for blood-borne virus serology blood once the patient is awake

d) Assess the patients risk factor for blood-borne virus

e) Ask a colleague to take blood from yourself for baseline serology

The decision to start post exposure prophylaxis should be based on risk assessment of the exposure and should NEVER wait until patient testing has been done. Post exposure prophylaxis should be started within 1hr of the exposure

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

a) Acute alcohol withdrawal

b) Sepsis

c) Fat embolism

d) VTE

e) Acute MI

Conditions associated with fat embolism

22. An elderly man with OSA and COPD presents for an inguinal hernia repair. His INR is 1.9. What is the BEST intraoperative management option is?

a) IPPV with desflurane, remifentanil and inguinal block

b) IPPV with sevoflurane, remifentanil and inguinal block

c) SV with propofol, fentanyl and diclofenac

d) IPPV with desflurane, remifentanil and morphine

e) IPPV with sevoflurane, remifentanil and morphine

23. A young woman requires a vaginal polypectomy. She has had a previous episode of infective endocarditis and last time she went to the dentist he gave her oral antibiotics (2 does) for a procedure. What should you do?

a) Give oral antibiotics 2 doses as she is at high risk

b) Give IV antibiotic prior to induction as she is at high risk

c) Don’t give antibiotics

d) Discuss with microbiology

e) Discuss with cardiology

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

a) GA LMA SV

b) GA ETT IPP, awake FOI

c) Lumbar epidural

d) No anaesthetic is required

e) Spinal

25. A 29-year-old man collapsed at home after a history of progressive weakness and a fit. His CT san was normal and lumbar puncture (traumatic tap) showed significantly raised protein levels. Which diagnosis is LEAST likely?

a) Variant CjD

b) GBS

c) TB meningitis

d) Acute bacterial meningitis

e) False evaluation due to traumatic tap

GBS: elevated level of cerebrospinal fluid (CSF) protein, with no elevation in CSF cell

counts Varient CJD: Analysis of CSF for 14-3-3 protein

26. A 60-year-old obese man with no past medical history. He had a THR under a single shot spinal. He is not able to take LMWH so the haematologist recommended rivoroxiban prophylaxis post operatively. What is the minimum interval you would prescribe the 1st dose for?

a) 4 hours from spinal insertion

b) 6 hours from spinal insertion

c) 12 hours from spinal insertion

d) 24 hours from spinal insertion

e) 48 hours from spinal insertion

Regional Anaesthesia and Patients with Abnormal Coagulation (2013)

27. An 11-year-old boy presents for correction of foot deformity. He is Gillick competent and has signed a consent form together with his mum. In the anaesthetic room, he refuses to have a cannula and says that he has changed his mind and does not want to proceed. His mum says that he is nervous and you should carry on. What should you do?

a) Proceed on the basis that he is anxious and has signed the consent form

b) Ask the parents to speak to him in the anaesthetic room to convince him to have the surgery

c) Do not proceed

d) Speak to the hospital solicitor

e) Send him back to the ward, give him a premed and send him later

28. 2 days after a craniotomy for acute subdural haemorrhage following trauma, a patient is noted to have a Na 116mmol/L, urinary Na 55mmol/L (very high), BP 100/60mmHg, FTc on oesophageal Doppler 295msec. ANP and BNP levels are high. What is the treatment indicated?

a) Demeclocycline

b) Normal saline infusion

c) Fluid restriction

d) Frusemide

e) Tolvaptan

29. A 30-year-old woman (weight 130kg, height 170cm) has undergone a laparotomy for closure of a hiatus hernia. On arrival in the recovery room, 15 minutes after the end of surgery, she is complaining of pain. Her SpO2 is 85% breathing room air, but 94% when supplemental oxygen is delivered by nasal prongs at 2L/min. The most likely explanation for the observed oxygen saturation on arrival in the recovery room is:

a) Right lower lobe collapse

b) Use of nitrous oxide intraoperatively

c) Residual neuromuscular blockade

d) Residual inhalational anaesthesia

e) Alveolar hypoventilation

30. A patient who has been receiving for 24hours a low dose epidural anaesthetic infusion with 0.1% bupivacaine for post-operative pain relief complains of total inability to move their legs. What is the most appropriate action?

a) Stop the epidural infusion and assess in 2 hours

b) Change the local anaesthetic solution infused to a more dilute solution

c) Ask the surgical team to request a neurology opinion

d) Request an urgent MRI scan for the lumbar spine

e) Reassure the patient and halve the current infusion