Clinical Cases for

the FRCA
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Cases for Surgical Finals: SAQs, EMQs and MCQs
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Clinical Cases for the FRCA: Key Topics Mapped to the
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Alisha Allana

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com/MasterPass/book-series/CRCMASPASS
 Clinical Cases for
the FRCA
Key Topics Mapped to the
RCoA Curriculum

Alisha Allana, MBBS BSc FRCA

Anaesthetic Registrar, Wessex Deanery, UK
First edition published 2022
by CRC Press
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and by CRC Press

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Library of Congress Cataloging-in-Publication Data

Names: Allana, Alisha, author.
Title: Clinical cases for the FRCA : key topics mapped to the RCoA curriculum / by Alisha Allana.
Other titles: Master pass
Description: First edition. | Boca Raton, FL : CRC Press, 2021. | Series: MasterPass series |
Includes bibliographical references and index.
Identifers: LCCN 2021037279 (print) | LCCN 2021037280 (ebook) |
ISBN 9780367742119 (hardback) | ISBN 9780367698034 (paperback) | ISBN 9781003156604 (ebook)
Subjects: MESH: Royal College of Anaesthetists (Great Britain) | Anesthesia—methods |
Perioperative Care—methods | Anesthesiology—education | Clinical Decision-Making. |
United Kingdom | Case Reports | Study Guide
Classifcation: LCC RD81 (print) | LCC RD81 (ebook) | NLM WO 218.2 | DDC 617.9/6—dc23
LC record available at https://lccn.loc.gov/2021037279
LC ebook record available at https://lccn.loc.gov/2021037280

ISBN: 978-0-367-74211-9 (hbk)

ISBN: 978-0-367-69803-4 (pbk)
ISBN: 978-1-003-15660-4 (ebk)

DOI: 10.1201/9781003156604

Typeset in Minion Pro

by codeMantra
Khalil – this book is written for you, and because of you.
Always believe that you can do anything.
CONTENTS
Foreword ix
Preface xi
Acknowledgments xiii
Abbreviations xv
Author xix

1 Neurosurgery, Neuroradiology and Neurocritical Care 1

2 Cardiothoracic Surgery 21
3 Airway Management 47
4 Critical Incidents 57
5 Day Surgery 63
6 General, Urological and Gynaecological Surgery 69
7 Head, Neck, Maxillo-Facial and Dental Surgery 77
8 Management of Respiratory and Cardiac Arrest 83
9 Non-theatre 87
10 Orthopaedic Surgery 91
11 Perioperative Medicine 101
12 Regional Anaesthesia 117
13 Sedation 127
14 Trauma and Stabilisation 131
15 Intensive Care Medicine 135
16 Obstetrics 153
17 Paediatrics 175
18 Pain Medicine 193
19 Ophthalmic 205
20 Plastics and Burns 209
21 Vascular Surgery 215

Index 221

vii
FOREWORD
It has been nearly 30 years since I passed the FRCA, and since I passed, I have
been running exam preparation courses for almost all of those 30 years. I know
frst-hand that exam preparation is hard work, and that much of that work is
made more difcult by the number of resources that have to be consulted to
try and fnd the exact piece of knowledge required to answer an exam ques-
tion. Invariably, bits of information can be readily found, but these ofen pro-
vide subtly difering or conficting statements, requiring further research to
clarify in one’s own mind the truth of the topic in question. Tis can lead to a
curiosity-driven quest across innumerable resources, which, while interesting,
can also be very time-consuming during a period when time is a very precious
resource indeed.
What Dr Allana has managed to produce here is, in my opinion, remarkable.
It is a concise summary of the current opinion and evidence to allow FRCA
exam questions to be answered correctly and confdently. While it is aimed
primarily at the Final FRCA, I can also see it being useful for primary FRCA,
FFICM and EDIC, as well as for those running teaching courses and simulation
programmes, and also as a clinical resource for departments of anaesthesia and
critical care medicine. Te management of each case scenario is laid out clearly
with an intuitive structure and with relevant references to allow the interested
reader to further research into the topics if they wish.
Te decision to ofer this material as a book, rather than an online resource,
is, I believe, very sensible. A book is a resource that can be utilised without
adding to “screen time”, it can be annotated and marked and it can be shared
and passed between candidates in the throes of exam preparation. Part of the
key to exam success is developing a structure to hang your knowledge onto –
having these structured summaries readily to hand and adding your own bits
of “detail” will help all candidates to not only remember the answers in an
exam but also to recall this knowledge better at a future time when it is needed
clinically.
I commend this book to all anaesthetists and intensivists at any stage in their
career, not just those sitting an exam. It is an excellent resource and “aide mem-
oire” for teaching and for clinical work. I wish Dr Allana every success with its
publication.
Dr Jonathan Harrison BM, FRCA
Chairman of SCIP (South Coast Intensive Primary) course
Clinical Director & Consultant Anaesthetist
Portsmouth Hospitals University Trust

ix
PREFACE
Te clinical cases in this book are mapped directly to the Royal College of
Anaesthetists’ curriculum, and can be used to revise for both the written
and viva, Primary and Final sittings. With the addition of critical incidents
throughout, the questions can also be used as the basis for simulation train-
ing and teaching for individual modules. Te answers are based on the most
up-to-date guidelines and protocols, and can be used as a guide to manage
complex theatre cases by all anaesthetists, from the eager novice to the skilled
consultant.
Revision for the FRCA examinations is a long, sometimes challenging, and
hopefully rewarding journey. Nothing compares to the clinical experience and
management of patients frsthand, but the aim of this book is to fll in any gaps,
highlight important cases and support revision of difcult topics.
Alisha Allana

xi
ACKNOWLEDGMENTS
Tanks to my husband, for always having faith in me and being there every step
of the way; and to my parents and siblings, for their unwavering support and
endless supply of food.
Tanks to everyone who facilitated viva preparation for me while I was revising
for the exams, and to all the trainees who allowed me to practice the questions
for this book on them. I hope it helped you as much as it did me!
Particular thanks and a huge amount of appreciation go to the following indi-
viduals who contributed in so many ways to ensure that the text of this book is
as complete and up to date as possible. Your insight, knowledge and experience
have been invaluable in the production of Clinical Cases for the FRCA.

Dr Alice Aarvold
Consultant Anaesthetist
University Hospital Southampton NHS
Foundation Trust
(Airway & Head & Neck)

Dr James Eldridge
Consultant Anaesthetist
Portsmouth Hospitals University NHS
Trust (Obstetrics)

Dr Daniel Growcott
Consultant Anaesthetist
Portsmouth Hospitals University NHS
Trust (Orthopaedics & Regional)

Dr Joanna Harding
Consultant Anaesthetist
University Hospital Southampton NHS
Foundation Trust (Pain Medicine)

Dr Jonathan Huber
Consultant Cardiac Anaesthetist
University Hospital Southampton NHS
Foundation Trust (Cardiac surgery)

Dr Nicholas Jenkins
Consultant Anaesthetist
Portsmouth Hospitals University NHS
Trust (Perioperative Medicine, General & Day Case Surgery)

xiii
 Acknowledgments

Dr Leonid Krivskiy
Consultant Anaesthetist
University Hospital Southampton NHS
Foundation Trust (Toracics)

Dr Jessica Lees
Consultant Anaesthetist
University Hospital Southampton NHS
Foundation Trust (Paediatrics)

Dr Benjamin Tomas
Consultant Neuro-anaesthetist and Intensivist
University Hospital Southampton NHS
Foundation Trust (Neurosurgery)

Dr Hania Ward
Consultant Anaesthetist
University Hospital Southampton NHS
Foundation Trust (Trauma, Ophthalmic & Vascular)

Dr Matthew Williams
Consultant Anaesthetist and Intensivist
Portsmouth Hospitals University NHS
Trust (Intensive Care Medicine & Arrest)

Dr Robin Wilson
Consultant Anaesthetist
University Hospital Southampton NHS
Foundation Trust (Paediatrics)

xiv
 Abbreviations

ABBREVIATIONS
2,3-DPG 2,3-diphosphoglyceric acid
AAGBI Association of Anaesthetists of Great Britain and Ireland
ABG arterial blood gas
ACE angiotensin converting enzyme
ADH anti-diuretic hormone.
ALS advanced life support
ARDS acute respiratory distress syndrome
BMI body mass index
CF cystic fbrosis
COPD chronic obstructive pulmonary disease
CP cerebral palsy
CPAP continuous positive airway pressure
CPB cardiopulmonary bypass
CPET cardiopulmonary exercise testing
CPR cardiopulmonary resuscitation
CSF cerebrospinal fuid
CT computed tomography
CTG cardiotocography
CVP central venous pressure
DIC disseminated intravascular coagulation
DKA diabetic ketoacidosis
ECG electrocardiogram
ECT electroconvulsive therapy
EEG electroencephalogram
ENT ear, nose and throat
FBC full blood count
FEV1 forced expiratory volume in 1 second
FFP fresh frozen plasma

xv
 Abbreviations

FVC forced vital capacity

GCS Glasgow Coma Score
GDD global developmental delay
IASP International Association for the Study of Pain
ICP intra-cranial pressure
INR international normalised ratio
ITU intensive care unit
IV intravenous
IVIg intravenous immunoglobulin
LV lef ventricle
MAC minimum alveolar concentration
MCV mean cell volume
MRI magnetic resonance imaging
NAP National Audit Project
NICE National Institute for Health and Care Excellence
NMDA N-methyl-D-aspartate
NSAIDs non-steroidal anti-infammatory drugs
ODP operating department practitioner
OSA obstructive sleep apnoea
PCA patient controlled analgesia
PEEP positive end expiratory pressure
PO oral
P-POSSUM Portsmouth-Physiological and Operative Severity Score for the
enumeration of Mortality and Morbidity
PRES posterior reversible leucoencephalopathy syndrome
ROSC return of spontaneous circulation
RV right ventricle
SIADH syndrome of inappropriate ADH secretion
SIRS systemic infammatory response syndrome
SVR systemic vascular resistance
TCI target controlled infusion

xvi
 Abbreviations

TEG thromboelastogram
TENS transcutaneous electrical nerve stimulation
THRIVE transnasal humidifed rapid-insufation ventilatory exchange
TIA transient ischaemic attack
TIVA total intravenous anaesthesia
TRAM transversus rectus abdominis myocutaneous
U+E urea and electrolytes
UKOSS UK Obstetric Surveillance System
VF ventricular fbrillation
VO2 oxygen uptake
VTE venous thromboembolism

xvii
AUTHOR
Alisha is an anaesthetic registrar in the Wessex deanery, with an interest in
medical education, simulation and patient safety.

xix
1
NEUROSURGERY,
NEURORADIOLOGY AND
NEUROCRITICAL CARE

CASE: SUBARACHNOID HAEMORRHAGE

A 36-year-old female patient is listed for emergency embolisation of a
cerebral aneurysm following a grade IV subarachnoid haemorrhage. She
is intubated and ventilated following a drop in her GCS in the emergency
department. She takes sertraline for depression but has no other known
medical conditions.

What are the treatment options for this patient?

Conservative
• Supportive therapy on the neuro-intensive care unit to maintain a
dequate cerebral perfusion pressure and optimal gas exchange.
• Avoidance of extremes of blood pressure to minimise the risk of
re-bleeding and ischaemia.
• Excellent blood glucose and core temperature control (primarily
treatment of pyrexia).
• Consideration of seizure prophylaxis.
Pharmacological
• 60 mg oral nimodipine (via a nasogastric tube) every 4 hours for
21 days to minimise the risk of vasospasm.
Interventional
• Surgical clipping.
• Endovascular coiling.

What are the benefts of coiling over clipping for this patient?
• Te International Subarachnoid Aneurysm Trial (ISAT) evaluated
the diference between clipping and coiling for subarachnoid
haemorrhage secondary to aneurysm rupture.
• Coiling demonstrated a reduced risk of mortality at 1 year, but with a
slightly higher incidence of re-bleeding.

What are the complications associated with a subarachnoid haemorrhage?

• Re-bleeding (minimal if the aneurysm is secured).

DOI: 10.1201/9781003156604-1 1
 Clinical Cases for the FRCA

• Hydrocephalus.
• Cerebral vasospasm (most common at days 3–21).
• Arrhythmias and ischaemic cardiac events. A troponin rise is
commonly seen following a subarachnoid haemorrhage, likely
due to endocardial ischaemia secondary to an increase in aferload
and endogenous vasopressor release at the ictus. Patients with
poorer-grade bleeds may also develop Takotsubo’s cardiomyopathy.
• Aspiration, pneumonia and pulmonary oedema (particularly if
co-existing heart disease is present).
• Endocrine pathology e.g. cerebral salt wasting syndrome, diabetes
insipidus, SIADH.

What are the concerns associated with anaesthetising this patient?

Remote site anaesthesia
• Appropriate stafng required e.g. ODP, senior anaesthetist or
emergency help.
• Lack of familiar or appropriate monitoring and equipment, and
potentially out of hours.
• Lack of an appropriate recovery area.
• Poor lighting and limited access to the patient during the
procedure.
Specifc concerns associated with the pathology
• Tis is a critically unwell patient undergoing an emergency high-risk
procedure that requires an experienced senior anaesthetist for
optimal management.
• High risk of perioperative complications.
• Tere may be poor compliance from the patient if they are not sedated,
but have an altered GCS.
• Risks associated with induction of anaesthesia in a potentially
unstarved patient at a remote site.
• Te patient may need an external ventricular drain before or afer the
procedure if hydrocephalus is evolving.

How would you manage this patient during her procedure?

• Take a thorough preoperative history and conduct the relevant
examination and appropriate investigations. Te patient is intubated
so a history can be taken from a family member and from her GP/
hospital notes.
• Ensure a completed consent form and WHO checklist and discuss
the patient with the multidisciplinary team and a consultant
neuroanaesthetist.
• Consider the best location for the initial management of the patient
prior to the procedure e.g. in neurocritical care if unstable.

2
 Neurosurgery and Neurocritical Care

• Apply AAGBI standard monitoring and insert an arterial cannula

for invasive blood pressure monitoring with large bore intravenous
access present.
• Prepare the appropriate emergency drugs and equipment including
the resuscitation and difcult airway trolleys. Check the position of
the endotracheal tube following the transfer.
• Insert a temperature probe, catheter and nasogastric tube (if required)
prior to the procedure to facilitate adequate monitoring, drug
administration and passage of high contrast volumes.
• Depending on the clinical situation before the procedure and any
procedural concerns or complications, the patient may be extubated,
but they may also require ongoing care in the high dependency or
intensive care unit.

BIBLIOGRAPHY
Luoma A. Acute management of aneurismal subarachnoid haemorrhage.
Continuing Education in Anaesthesia, Critical Care & Pain. 2013; 13 (2):
52–58.
Patel S & Reddy U. Anaesthesia for interventional neuroradiology. BJA
Education. 2016; 16 (5): 147–152.

CASE: ANEURYSM CLIPPING

A 59-year-old female patient is undergoing an elective craniotomy for
clipping of an aneurysm. She has severe COPD and a permanent pacemaker
in situ. Her current medication includes captopril, tiotropium, salbutamol
and simvastatin.

What added information would you like prior to this case?

Patient factors
• A full and thorough anaesthetic history focusing on the patient’s
known cardiovascular and respiratory comorbidities, any previous
anaesthetics and an airway assessment.
• A focused pacemaker history, to include the reason for and date of
insertion, the date of the most recent check and any malfunction, the
pacemaker mode and how dependent the patient is on the pacemaker.
• A baseline neurological examination checking for signs of raised
intracranial pressure (fuctuating GCS, headache, vomiting and
visual changes), gross focal neurological signs and any symptoms of
hydrocephalus.

3
 Clinical Cases for the FRCA

• Relevant investigations following the history and examination. Tis

is likely to include an ECG to assess pacemaker function, bedside
observations, blood tests including a full blood count and clotting,
and CT/MRI brain imaging.
Surgical factors
• Te patient’s position during the procedure.
• Te likelihood of diathermy use perioperatively, taking into account
the permanent pacemaker.
• Te urgency and likely duration of the procedure.
• Consideration of alternative procedures given the comorbid state
of the patient. Radiological coiling is minimally invasive; hence,
there would be a decreased requirement for opioid analgesia and its
associated side efects.
Anaesthetic factors
• Tis is a patient with numerous comorbidities undergoing a
major operation. Te case should be supervised by a consultant
neuroanaesthetist.
• Discuss the patient with the neurocritical care unit for the availability
of postoperative level 2/3 care.

Which of her medication, if any, would you stop prior to surgery?

• Continue nimodipine, inhalers and simvastatin.
• Omit captopril on the morning of surgery; administration of ACE
inhibitors can cause signifcant uncontrollable intraoperative
hypotension.

What are the anaesthetic goals in this case?

• Maintenance of cerebral perfusion and gas exchange.
• Maintenance of haemodynamic stability, in particular avoiding the
pressor response to laryngoscopy.
• Rapid postoperative emergence with good analgesia and prevention
of coughing/vomiting.
• Reducing the risk of complications specifc to neurosurgery e.g. air
embolism.

Which anaesthetic agent(s) would you use to anaesthetise this patient?

Tere is no right answer to this question – discuss the agent(s) that you feel most
comfortable with. Te best anaesthetic for this patient is a safe anaesthetic that
fulfls the above goals!
TIVA anaesthetic
• Use the Marsh or Schneider model with propofol and the Minto
model with remifentanil.
• Ensure appropriate efect site concentrations of the drugs in use.

4
 Neurosurgery and Neurocritical Care

• Te concentrations should be titrated to overcome the hypertensive

response to stimuli e.g. during the application of Mayfeld pins.
Volatile agents
• Induction with appropriate doses of propofol and fentanyl.
• Maintenance of anaesthesia with sevofurane (note that sevofurane
uncouples the cerebral blood fow and cerebral metabolic rate of oxygen).
• Avoid nitrous oxide (can worsen pneumocephalus postoperatively).
• Control the hypertensive response to stimuli using an opioid
(alfentanil bolus, remifentanil infusion) and/or a short-acting beta
blocker (esmolol infusion).

If using a TIVA method, what features are important for safety?

• Ensure adequate training and competence of the anaesthetist.
• Use a TCI-specifc infusion pump that has been checked and serviced.
• Ensure that the pump alarms are enabled to alert the anaesthetist to
high pressures and an empty syringe.
• Consider two person checking of the drugs.
• Use Luer-lock connectors and anti-syphon valves.
• Ensure that there is a visible cannula during the procedure.
A crystalloid solution can be used to maintain patency perioperatively
(0.9% saline).

Te surgeon states that the brain appears tight and swollen intraopera-
tively. What is your immediate management?
• Raise the patient to a head-up position if possible.
• Optimise the cerebral blood fow by adjusting the PaCO2 to a
low-normal range and ensuring normoxia.
• Judicious use of mannitol 0.5–1 g/kg (or hypertonic saline, as long
as serum sodium adjustment occurs at a safe rate) afer a discussion
with the surgeon.
• Re-assess the patient using an ABCDE approach and facilitate further
procedures or treatment as directed by the surgical team.

What analgesia regimen would you prescribe for this patient

postoperatively?
• IV morphine and paracetamol intraoperatively and in recovery as
necessary.
• Regular oral morphine and paracetamol postoperatively, which can
be escalated to a morphine or fentanyl PCA if required.
• Avoid NSAIDs in the immediate postoperative period due to the
bleeding risk.
• Prescribe adequate laxatives and consider regular anti-emetics.
• A scalp block can also be performed perioperatively by the surgeon
or anaesthetist.

5
 Clinical Cases for the FRCA

BIBLIOGRAPHY
Nimmo AF et al. Guidelines for the Safe Practice of Total Intravenous Anaesthesia
(TIVA). London: Association of Anaesthetists. 2018.

CASE: TETANUS
A 36-year-old Turkish builder is admitted to the emergency department
with difculty breathing, spasms and neck stifness. You are asked to review
him urgently due to concerns regarding his airway.

What are the potential causes of this patient’s symptoms?

Infective
• Meningitis/encephalitis.
• Oral or dental infection/abscess.
• Generalised sepsis.
• Tetanus.
Non-infective
• Electrolyte disturbances e.g. hypocalcaemia.
• Epileptic seizure.
• Drug reactions/withdrawal.
• Strychnine poisoning (pesticide).
• Psychological cause.

How is tetanus diagnosed?

Tetanus is caused by toxins released by Clostridium tetani, but it is primarily a
clinical (rather than microbiological) diagnosis based on the patient’s history and
symptoms.
History
• Known or observed injury or trauma with an open wound.
• Sudden onset of symptoms.
• Lack of up-to-date tetanus vaccination.
• Work or home environment associated with metal, soil or manure.
Examination
• Muscle rigidity and spasms, including neck stifness, masseter spasm
and truncal rigidity.
• Autonomic dysfunction and severe haemodynamic instability.
• Respiratory failure.

What are the treatment options for patients with suspected tetanus?
• Treatment is largely supportive. Patients should be managed in the
intensive care unit in a darkened, quiet room and observed closely.

6
 Neurosurgery and Neurocritical Care

• Ensure appropriate airway management with early intubation and

lung protective ventilation if there are any concerns.
• Ensure close monitoring and treatment of haemodynamic instability
with vasopressors and inotropes if required.
• Antimicrobial therapy should be commenced as soon as possible
(intravenous metronidazole is the frst line) and the patient should be
discussed with a microbiology consultant.
• Tetanus human IVIg should be given to neutralise the unbound toxin.
• Consider wound debridement if there is an obvious source of infection.
However, maintenance of cardiovascular and respiratory stability is the
priority.
• Benzodiazepines and sedative agents can be used for spasm and
rigidity control.

What is an autonomic storm?

• Tetanus is associated with rapid and signifcant changes in cardiovas-
cular status.
• An autonomic storm arises due to the sudden release of adrenaline
and noradrenaline into the bloodstream, causing severe hypertension
and tachycardia.
• Tis may be followed by episodes of hypotension, bradyarrhythmias
and cardiac arrest.
• Te patient may also demonstrate other signs of sympathetic nervous
system instability including sweating, ileus and increased secretions.

When you assess the patient, the oxygen saturations are 91% on 15 L
oxygen, the GCS is 10 and there is a marked stridor. What is your
management?
Tis is an anaesthetic and medical emergency that needs immediate management
by the multidisciplinary team. Help should be sought immediately.
• Declare an airway emergency and call for urgent senior help given
the likely risk of a difcult airway/intubation and the obvious need
for the patient to go to intensive care. Whilst awaiting specialist help,
maintain the patient’s airway using a Mapleson C circuit with airway
adjuncts if necessary.
• Ask the anaesthetic assistant to prepare emergency equipment and drugs
for intubation and ventilation and formulate a plan, including the plan
for airway management in the event of failed oxygenation or intubation.
• Te equipment should include an intubation checklist, suction
switched on and readily accessible, a videolaryngoscope, the difcult
airway trolley, an appropriately sized endotracheal tube (with one size
smaller immediately available) and the resuscitation trolley.
• Apply AAGBI standard monitoring and invasive blood pressure
monitoring if possible, but insertion of an arterial cannula should not
delay further management.

7
 Clinical Cases for the FRCA

• Given the risk of haemodynamic instability on induction, draw

up vasopressor and vagolytic agents prior to induction. Perform a
rapid sequence induction, maintaining a stable cardiovascular state using
appropriate doses of the induction agent, opioid and muscle relaxant.
• Te airway should be secured with an appropriately sized
endotracheal tube and lung protective ventilation initiated. Te
patient should be managed on the intensive care unit.
• Ongoing sedation with benzodiazepines may improve hypertonia. If
not, muscle relaxant infusions may be required, with monitoring of
creatine kinase levels and further treatment.

BIBLIOGRAPHY
Taylor AM. Tetanus. Continuing Education in Anaesthesia, Critical Care &
Pain. 2006; 6 (3): 101–104.

CASE: PARKINSON’S DISEASE

A 68-year-old male patient is listed for an elective anterior resection. He was
diagnosed with Parkinson’s disease 2 years ago and is an ex-smoker. You are
asked to review him in the preoperative assessment clinic.

What is Parkinsonism?
• Triad of symptoms: resting tremor, rigidity and bradykinesia.
• Tere are numerous causes of Parkinsonism that lead to an imbalance
between dopamine and acetylcholine levels in the basal ganglia,
including:
• Parkinson’s disease.
• Infective causes.
• Trauma.
• Drugs.

What are the perioperative risks in patients with Parkinson’s disease?

• Patients with Parkinson’s disease have:
• An overall increase in morbidity and mortality.
• A higher likelihood of falls.
• An increased incidence of a difcult airway and aspiration
pneumonitis.
• A higher risk of developing postoperative pulmonary complications.
• An increased likelihood of venous thromboembolism due to
perioperative immobility.

8
 Neurosurgery and Neurocritical Care

• An increased length of stay in intensive care and hospital, with its

associated complications.
• More chance of developing postoperative delirium and cognitive
decline.
• Potential for adverse efects of missed doses of anti-Parkinson’s
medications.

What are the key concerns when assessing this patient preoperatively?
General
• Tis is a high-risk patient undergoing major abdominal surgery.
Te patient should be discussed with the multidisciplinary team
including the surgical team, a consultant anaesthetist and a
neurologist, as well as the intensive care team for consideration of
postoperative level 2/3 care.
• Given that the patient is being assessed in the preoperative clinic,
there is adequate time available for optimisation of the patient prior
to the procedure.
• Carry out a thorough anaesthetic assessment including the
patient’s comorbidities, regular medication, a social history and the
airway.
Systemic symptoms of Parkinson’s disease
• Te patient may demonstrate signs of a difcult airway due to a
fxed fexion neck deformity, rigidity and poor upper airway muscle
function causing increased secretions and a higher risk of aspiration.
In addition, the patient may have delayed gastric emptying secondary
to the side efects of anti-Parkinsonian agents and dysphagia.
• A restrictive pulmonary deficit and obstructive sleep apnoea
are common in patients with Parkinson’s disease, making
ventilation challenging. Lung function tests and a chest x-ray may
be indicated.
• Postural hypotension and arrhythmias are common in patients
with severe Parkinson’s disease and may lead to intraoperative
haemodynamic instability, particularly on induction of
anaesthesia.
Medication
• Te dosage and timing of Parkinson’s medication should be noted
and discussed with a disease specialist.
• Te medication may interact with anaesthetic and analgesic agents
with potential for worsening of symptoms.
• Ensure a return to oral intake as soon as possible through adequate
hydration, analgesia and enhanced recovery where possible.
• Consider a nasogastric tube for medication postoperatively afer
discussing with the surgeon and neurologist.

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 Clinical Cases for the FRCA

What is your plan for analgesia and anti-emesis in this patient?

Analgesia
• Continue medication that the patient may be on for chronic pain,
or convert to an intravenous dose if the patient is unable to take
medication orally.
• Use regional nerve blockade or local anaesthetic infltration where
possible to minimise the use of opioid-based drugs.
• Assess the patient’s dexterity (and therefore their ability to use a PCA)
prior to prescribing analgesic regimens.
• Avoid pethidine and high-dose fentanyl, which may lead to increased
rigidity during the perioperative period.
Anti-emesis
• Anti-emetic medications that act as dopamine receptor antagonists
should be avoided as they may lead to extra-pyramidal side efects or
intensify pre-existing Parkinsonian symptoms.
• Drugs that can be used safely include domperidone (a dopamine
receptor antagonist that does not cross the blood brain barrier),
ondansetron and cyclizine.
• However, other methods of minimising nausea and vomiting should
be favoured including hydration, reassurance, avoidance of opiates
where possible and efective analgesia.

BIBLIOGRAPHY
Chambers DJ, Sebastian J & Ahearn DJ. Parkinson’s disease. BJA Education.
2017; 17 (4): 145–149.

CASE: EPILEPSY
A 26-year-old male patient is listed for shoulder surgery following an injury
while playing cricket last year. He has a history of epilepsy. You are asked to
review him prior to his procedure.

What is epilepsy?
• A neurological condition caused by excessive or abnormal electrical
activity in the brain.
• Tis leads to a spectrum of symptoms including a predisposition to
behavioural changes and seizures.
• Epilepsy is diagnosed following two separate episodes of seizure
activity.
• It is classifed according to the cause and type of seizures:
• Focal (simple or complex).
10
 Neurosurgery and Neurocritical Care

• Generalised (absence, tonic-clonic, myoclonic or atonic).

• Mixed.

How would you assess this patient?

History
• Take a full history including any cardiovascular and respiratory
comorbidities, regular medication and allergies and a social history.
• Ask the patient about any previous anaesthetics.
• Take a focused history regarding the diagnosis of epilepsy, to include:
• Te date of diagnosis.
• Te cause of epilepsy, if known.
• Any previous and current treatment (including the timing of doses).
• Seizure frequency and type.
• Known seizure triggers.
• Comorbidities secondary to the diagnosis or treatment.

Examination
• Routine examinations including an airway assessment. Specifc
examinations would not usually be indicated unless there was an
obvious reason noted from the history.
Investigations
• Baseline observations.
• Anti-epileptic medication levels only if poor compliance with treat-
ment is suspected or a prolonged procedure/inpatient stay is expected.
• Further blood tests or investigations should be guided by the history
and examination and would not usually be necessary for routine
day-case surgery.

What are the key concerns when anaesthetising this patient?

Adequate anti-epileptic medication levels
• Continue regular anti-epileptic medication during the perioperative
period, factoring in timings for each dose.
• Avoid prolonged fasting.
• Minimise perioperative nausea and vomiting.
Minimising risk of seizures
• Avoid drugs that decrease the seizure threshold.
• Ensure optimal oxygenation and avoid hypocapnia, which may
provoke seizures.
• Plan perioperative analgesia, discussing with the surgical team.
Awareness of drug interactions
• Some anti-epileptic drugs act as enzyme inducers or inhibitors,
which needs to be taken into account when choosing anaesthetic and
analgesic agents.
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 Clinical Cases for the FRCA

Which commonly used agents should be avoided in patients with epilepsy?

• Enfurane has been associated with abnormal EEG activity, but is not
commonly used in the UK.
• Methohexitone may provoke seizures, but is not used in the UK.
• Dopamine receptor antagonists e.g. metoclopramide can cause
dystonia and may mimic seizures, thus introducing diagnostic
challenges postoperatively and should be avoided.
• Alfentantil, tramadol and pethidine increase EEG brain activity and
lower the seizure threshold.

During the procedure, the surgeon notes a sudden increase in muscle

tone, which is associated with a heart rate of 145 and a blood pressure of
189/101. How do you proceed?
• Tis may be seizure activity under general anaesthetic. Alert the
theatre team, call for urgent help and conduct a rapid ABCDE
assessment to determine the cause of the patient’s symptoms and rule
out other potential causes.
• Apply 100% oxygen and manually ventilate the patient to assess
compliance. Ensure that the patient has a normal-high end tidal
carbon dioxide level.
• Check and correct electrolyte levels, acid–base balance,
temperature and glucose (an arterial blood gas would be prudent
when possible).
• Ensure adequate anaesthesia, muscle relaxation and analgesia.
• If the suspected seizure activity does not terminate, consider
benzodiazepines, phenytoin or other anti-convulsants, noting what
the patient has already taken preoperatively. Escalate to specialist care
for further advice.
• Once the patient is stable, have a discussion with the surgeons
regarding the expected duration of the procedure and the plan for
postoperative care.

BIBLIOGRAPHY
Carter E & Adapa R. Adult epilepsy and anaesthesia. BJA Education. 2015;
15 (3): 111–117.

CASE: POSTERIOR FOSSA SURGERY

A 48-year-old male patient is undergoing posterior fossa surgery for excision
of a metastatic lesion secondary to lung cancer. He has a body mass index
(BMI) of 41 and initially presented with seizures. You are asked to review
him prior to his procedure.
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 Neurosurgery and Neurocritical Care

What added information would you like before proceeding with this case?
Patient factors
• Take an anaesthetic history focusing on pre-existing comorbidities;
particularly complications associated with obesity e.g. obstructive
sleep apnoea, hypertension and ischaemic heart disease.
• Explore the diagnosis of lung cancer, including investigations and
treatment so far.
• Discuss any interventions for the metastatic brain lesion and in
particular, symptoms he has developed including the seizures
mentioned in the history.
• Ask the patient about previous anaesthetics and conduct an
airway assessment (the he may have a difcult airway due to his
raised BMI).
• Take a medication and social history.
Surgical factors
• Preferred patient positioning. Te options for posterior fossa surgery
include sitting, prone, lateral and park-bench.
• Discuss any potential complications or challenges that may arise
perioperatively with the suggested management in an emergency.

What specifc signs and symptoms may the patient have due to the
tumour?
• Signs suggestive of cerebellar involvement e.g. tremor, ataxic gait and
dysarthria.
• Bulbar cranial nerve palsies. Te patient may have had episodes of
choking or aspiration due to a poor gag refex. Coughing may also be
impaired.
• Te patient presented with seizures, which suggests raised intracranial
pressure. Other symptoms include a headache, nausea, vomiting and
fuctuating conscious levels. Te patient should be assessed for these
on the day of surgery as he may require preoperative medical or
surgical management.
• Fluid and electrolyte imbalance and signs suggestive of
hypovolaemia secondary to vomiting, diabetes insipidus, SIADH or
poor oral intake.
• Side efects of high-dose steroids and other treatment that may have
been initiated following the initial diagnosis.

Te surgeons would like to proceed in the sitting position. What are the
contraindications to surgery in this way?
Absolute
• Presence of a ventriculo-atrial shunt.
• Presence of a patent foramen ovale.
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 Clinical Cases for the FRCA

Tis is due to the potential risk of a venous air embolus entering the arterial
circulation.
Relative
• Poorly controlled hypertension (due to the risk associated with
hypotension when sitting).
• Very young/old patients.
• Chronic obstructive pulmonary disease.
• Autonomic neuropathy.

What specifc complications are associated with surgery in the sitting

position?
• Perioperative haemodynamic instability.
• Venous air embolism.
• Pneumocephalus.
• Tongue swelling.
• Permanent nerve damage (cervical spine fexion injury).

What forms of monitoring would you use when anaesthetising this

patient?
• Full AAGBI standard monitoring including ECG, capnography, pulse
oximetry and core temperature.
• “Train of four” monitoring if using neuromuscular blocking
agents.
• Invasive blood pressure monitoring.
• Central venous pressure monitoring.
• Consider monitoring for venous air embolus:
• Precordial Doppler.
• Transoesophageal echocardiography.
• Somatosensory-evoked potentials if there is a surgical indication.

What are the anaesthetic goals for this patient?

• Maintenance of a stable blood pressure and cerebral perfusion
pressure.
• Quick ofset of anaesthetic to allow for rapid postoperative
neurological monitoring.
• Careful patient positioning and padding to minimise the risk of
complications secondary to the procedure and sitting position.

BIBLIOGRAPHY
Jagannathan S & Krovvidi H. Anaesthetic considerations for posterior fossa
surgery. Continuing Education in Anaesthesia, Critical Care & Pain. 2014;
14 (5): 202–206.
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 Neurosurgery and Neurocritical Care

CASE: CHRONIC SPINAL CORD INJURY

A 32 year-old female patient is listed for an elective Caesarean section. She
has a history of mild asthma, for which she takes salbutamol, and had a
spinal cord injury following a road trafc accident 5 years ago. You are asked
to review her prior to her procedure.

How would you assess this patient?

History
• Take a detailed history of the symptoms, complications and treatment
following the spinal cord injury. Knowledge of the level of the spinal
cord injury will be essential to form an appropriate management
plan. Te history should include:
• Any previous episodes of autonomic dysrefexia.
• Te presence of symptoms suggestive of central sleep apnoea.
• Any prolonged ventilation or tracheostomy.
• Current pressure sores.
• Current treatment of chronic pain and/or spasticity.
• Take a medical history including the severity of asthma and any past
hospital admissions.
• Ask the patient about previous anaesthetics, in particular those
following the road trafc accident and review the anaesthetic charts
if they are available.
Examination
• Conduct cardiovascular, respiratory and neurological examinations
including palpation of the spinous processes to determine the ease of
neuraxial blockade if necessary.
• Carry out an airway assessment. Te patient may present with a
potential difcult airway depending on the level of the spinal cord
injury and/or spinal fxation that may have occurred.
Investigations
• Bedside observations including blood pressure and heart rate at rest.
• Baseline blood tests to include clotting and a cross-match if indicated.
• Further investigations should be guided by the patient’s
comorbidities and symptoms, but may include an ECG, echo and
lung function tests.

What are the key concerns in patients presenting with a chronic spinal
cord injury?
Airway and respiratory system
• Te level of the spinal cord lesion will determine its efect on
ventilation. Lesions above C5 will require ventilatory support.
15
 Clinical Cases for the FRCA

• Decreased lung volumes and poor muscle function secondary to the

neurological injury may predispose the patient to atypical respiratory
tract infections and aspiration.
• Surgical fxation of the cervical spine may cause difculty with
intubation and ventilation.
Cardiovascular system
• Autonomic dysrefexia may occur during perioperative period,
causing massive haemodynamic instability and end-organ damage
e.g. myocardial infarction.
• Tere is an increased risk of undiagnosed ischaemic heart disease in
this patient due to reduced movement and exercise levels.
• Te patient presents with a high risk of venous thromboembolism
secondary to immobility.
• Te patient will have an overall reduction in plasma volume and
haemoglobin concentration, which may be signifcant if there is
signifcant blood loss perioperatively.
Neurological system
• Spasticity and contractures can make patient positioning and the
surgical procedure challenging, and may require extra time.
• Previous spinal surgery can lead to unreliable neuraxial blockade.
• Patients with chronic spinal cord injuries have a high incidence of
chronic pain.
Other
• Impaired haemostasis and temperature control.
• Delayed gastric emptying.
• Chronic urinary retention and a high incidence of urinary tract infections.

What are the options for anaesthesia in this patient?

Te anaesthetic technique should be chosen based on the level of the lesion, the
procedure (in this case, a Caesarean section) and the symptoms and preference
of the patient. It should be decided following a multidisciplinary team discussion
involving the patient, obstetrician, anaesthetist and neurosurgical team.
Te options for anaesthesia are detailed below.
• General anaesthetic.
• Neuraxial blockade (it would be prudent to discuss this with the
neurosurgical team prior to the procedure).
• No anaesthetic (if the patient does not have autonomic dysrefexia and
has no sensation in the neurological distribution of the surgical site).

Te Caesarean section is carried out under a spinal anaesthetic. During

the procedure, the patient suddenly complains of a headache and blurred
vision, with difculty in breathing. On examination her chest is fushed
and her blood pressure is 178/93. How do you manage this?

16
 Neurosurgery and Neurocritical Care

• Call for help, alert the theatre team and conduct a rapid ABCDE
assessment of patient.
• Tis is possible autonomic dysrefexia, which is a medical emergency
and should be treated immediately.
• Pause the surgery as soon as possible.
• Position the patient in a reverse Trendelenburg position.
• Check the level of neuraxial blockade and consider a general
anaesthetic if inadequate.
• Administer a short-acting antihypertensive agent e.g. sublingual
nifedipine.
• Check the urinary catheter to ensure adequate drainage.
• Consider other causes in the diferential diagnosis e.g. pain,
pre-eclampsia.
• Consider level 2/3 care postoperatively if haemodynamic instability
continues and discuss with a specialist.

BIBLIOGRAPHY
Petsas A & Drake J. Perioperative management for patients with a chronic
spinal cord injury. BJA Education. 2015; 15 (3): 123–130.

CASE: AWAKE CRANIOTOMY

A 25 year-old male patient is listed for an awake craniotomy for excision of
a brain tumour. He has no other medical comorbidities.

What are the indications for an awake craniotomy?

• Excision of tumours or arterio-venous malformations from specifc
areas of the brain e.g. close to eloquent speech sensory and motor
areas. Awake surgery allows for continuous monitoring of function
to minimise postoperative neurological impairment.
• Functional neurosurgery including some surgery for epilepsy.
• Insertion of deep brain stimulators.

What added information would you like prior to proceeding with this case?
Patient factors
• Take an anaesthetic history focusing on any medical conditions,
previous anaesthetics and the airway. Te following factors may
preclude an awake craniotomy:
• Any condition that causes involuntary movements.
• Poor compliance with healthcare professionals e.g. due to acute
confusion and learning difculties.

17
 Clinical Cases for the FRCA

• Uncontrollable cough.
• Difculty lying fat e.g. due to a raised BMI and obstructive sleep
apnoea.
• High anxiety levels.
• Language barrier.
• Take a history of the brain tumour to include the diagnosis, any
previous or current symptoms and treatment. Te preoperative
assessment should include a detailed neurological history and
examination to determine the patient’s preoperative status.
Surgical factors
• Discuss the expected duration of surgery including the likely period
of being awake.
• Conduct a multidisciplinary discussion to include the patient
suitability for awake neurosurgery and any challenges that may arise.

What are the key aspects to prepare for this procedure?

Patient preparation
• Psychological assessment for an awake procedure.
• Ensure adequate information describing the perioperative events and
theatre complex.
Anaesthetic preparation
• Preoperative assessment by an experienced neuroanaesthetist.
• Conduct a multidisciplinary team meeting to discuss specifc factors
such as the anaesthetic plan, positioning, temperature and noise
levels.

What are the options for anaesthesia in this patient?

Awake for the duration of the procedure
• Use conscious sedation, allowing the patient to maintain spontaneous
ventilation and a response to stimuli.
• Agents of choice include propofol, remifentanil, clonidine,
dexmedetomidine and benzodiazepines.
Asleep – awake – asleep
• Induction of general anaesthetic with a target-controlled infusion
using propofol and remifentanil. Securing of airway with endotracheal
tube or laryngeal mask airway.
• Reduction of anaesthetic agent concentrations during the “awake”
period, followed by reintroduction of general anaesthesia for closure.
Asleep/sedated – awake
• As above, but the patient is kept awake for closure.
• In some centres, a general anaesthetic is not required initially.

18
 Neurosurgery and Neurocritical Care

How is a scalp block performed?

• Ensure consent, apply AAGBI monitoring, prepare emergency drugs
and equipment and calculate the maximal dose of permitted local
anaesthetic to avoid the risk of toxicity.
• A scalp block is performed under sedation or general anaesthetic.
• Use a sterile technique, and conduct a “stop before you block”
moment.
• Infltrate local anaesthetic to block specifc nerves:
• Supraorbital nerve (at the supraorbital notch).
• Supratrochlear nerve (medial to the supraorbital notch).
• Zygomaticotemporal nerve (at the temporalis muscle).
• Auriculotemporal nerve (anterior to the auricle).
• Lesser occipital nerve (posterior to the auricle).
• Greater occipital nerve (medial to the occipital artery).
• Greater auricular nerve (posterior to the auricle).

While the surgeon is carrying out cortical mapping, the patient has a
seizure. How do you proceed?
• Alert the theatre team and call for urgent help.
• Ask the surgeons to irrigate the surgical site with ice-cold saline.
• Administer pre-prepared agents for seizure control following a
discussion with the surgeon.
• Consider deepening sedation or general anaesthetic (with appropriate
airway management) if seizure control is not achieved with the above
measures.

What are the known complications associated with an awake craniotomy?

• Loss of the airway/airway obstruction.
• Respiratory depression.
• Aspiration.
• Air embolus.
• Haemodynamic instability.
• Anxiety/lack of compliance perioperatively.
• Local anaesthetic toxicity.

BIBLIOGRAPHY
Burnand C & Sebastian J. Anaesthesia for awake craniotomy. Continuing
Education in Anaesthesia, Critical Care & Pain. 2014; 14 (1): 6–11.

19
2
CARDIOTHORACIC SURGERY

CASE: VENTRICULAR SEPTAL DEFECT

A 6-month-old male infant with a known ventricular septal defect (VSD)
presents for elective repair of his cardiac lesion. You are asked to see the
patient and his parents on the ward prior to his procedure.

What is a ventricular septal defect?

• A VSD is an abnormal communication between the lef and right
ventricles, due to a defect in the interventricular septal wall.
• It is the most commonly occurring congenital cardiac defect.

How can you classify congenital cardiac defects?

Tere are many diferent ways of classifying congenital defects. Here is one
example.
• “Simple” lef to right shunt, leading to increased pulmonary blood fow:
• Atrial septal defect (ASD).
• VSD.
• Atrioventricular septal defect (AVSD).
• Patent ductus arteriosus (PDA).
• “Simple” right to lef shunt, leading to reduced pulmonary blood fow
and cyanosis:
• Pulmonary atresia.
• Tetralogy of Fallot: right ventricular outfow tract obstruction, RV
hypertrophy, VSD, and overriding aorta.
• Tricuspid atresia.
• Ebstein’s anomaly.
• “Complex” lesions, with mixing of pulmonary and systemic blood
and resulting cyanosis:
• Hypoplastic lef heart syndrome.
• Transposition of the great arteries (TGA).
• Truncus arteriosus.
• Total anomalous pulmonary venous drainage (TAPVD).
• Obstructive defects:
• Coarctation of the aorta.
• Aortic stenosis.
• Pulmonary stenosis.

DOI: 10.1201/9781003156604-2 21
 Clinical Cases for the FRCA

What symptoms and signs may be seen in this patient?

Te symptoms and signs in a patient with a VSD vary depending on the size of
the lesion and the degree of lef to right shunting. Some VSDs may be diagnosed
antenatally by foetal ultrasound, although some are diagnosed postnatally
following presentation in the frst 2–6 weeks of life.
Symptoms
• If the VSD is small, patients may be asymptomatic.
• With moderate or large VSDs, patients can manifest with symptoms
related to the increased pulmonary blood fow, and development of
congestive heart failure, including:
• Reduced growth and development or failure to thrive.
• Respiratory distress, which may be more apparent during, or can
limit, feeding.
• Recurrent respiratory tract infections.
• Sweating.
• Poor exercise tolerance.
• No cyanosis unless there has been the development of Eisenmenger
syndrome and therefore shunt reversal.
Signs
• Pansystolic murmur at the lef sternal border.
• Precordial thrill.
• Tachypnoea, dyspnoea, respiratory distress.
• Hepatomegaly.

What are the pathophysiological efects in a patient with a VSD?

• VSDs cause:
• Intracardiac shunting.
• Congestive cardiac failure.
• Te development of pulmonary hypertension over time.
• Small VSDs that exhibit resistance to blood fow across the lesion, and
therefore that limit shunting, are deemed “restrictive”. Large VSDs
that exhibit no resistance to shunt fow across the lesion are deemed
“non-restrictive”.
• A VSD produces a lef to right shunt. Some oxygenated blood
from the lef ventricle passes through the VSD to the right
ventricle, mainly during systole, instead of ejection into the systemic
circulation.
• In order to maintain an adequate systemic cardiac output in
the presence of a lef to right shunt, compensatory mechanisms
are activated such as the sympathetic nervous system and the
renin-angiotensin-aldosterone system. (However, these mechanisms
can actually worsen the pathophysiology and symptomatology.)

22
 Cardiothoracic Surgery

• Te lef to right shunt causes increased pulmonary blood fow, and

pulmonary overcirculation, leading to:
• Increased lef atrial and lef ventricular blood volume, thereby
leading to LV volume overload and dilatation, LV hypertrophy,
and LA dilatation.
• Pulmonary oedema, and over time, reactive pulmonary vascular
changes and an increased PVR, leading to pulmonary hypertension
and RV failure.
• Te RV can also be directly afected by the volume overload and
particularly the high pressure from the LV transmitted through large
non-restrictive VSDs.
• If large, non-restrictive VSDs remain unrepaired, over time
pulmonary hypertension gradually worsens and RV pressures
increase. Ultimately, if pulmonary arterial or RV pressures exceed
systemic arterial or LV pressures, the shunt reverses, and blood fows
right to lef across the VSD, resulting in cyanosis.
• Te development of fxed severe pulmonary hypertension, shunt
reversal and cyanosis signifes the existence of Eisenmenger syndrome.

What are the key considerations in the preoperative assessment of this

patient?
History
• Ask the parents about any symptoms of respiratory tract infections
such as fever, cough, coryza, wheeze or shortness of breath. A recent
infection can predispose the patient to increased comorbidities
following cardiopulmonary bypass.
• Explore symptoms related to cyanosis, dysrhythmias, congestive
cardiac failure and pulmonary hypertension.
• A full anaesthetic history should be taken including a full medical
and birth history; any previous anaesthetics or stays on neonatal
intensive care; regular medication including timings and known
allergies. VSDs can be associated with congenital abnormalities
such as Trisomy 13, 18 and 21, which may increase the risk of other
systemic conditions/defects, in particular airway abnormalities.
• A discussion about the anaesthetic procedure, risks, and consent
should be included in the preoperative assessment, including the
insertion of invasive lines, PICU postoperative stay, and potential
need for blood or blood product transfusion.
Examination
• A full examination including an airway assessment should be done
looking for the signs listed above.
• Venous access in these patients can be challenging. Look for potential
sites during the preoperative examination.

23
 Clinical Cases for the FRCA

Investigations
• Baseline blood tests to include a full blood count, clotting screen,
blood group and screen for antibodies, electrolytes and renal and
liver function. Ensure appropriate blood has been ordered and is
available.
• An ECG (for LA or LV/RV hypertrophy).
• Echo (for VSD location and size, shunt direction, ventricular chamber
size and function, estimates of pulmonary arterial pressure, and the
presence of any other anomalies or defects).
• Chest X-ray (for cardiomegaly, pulmonary oedema and pulmonary
vascular markings).

Te patient is anaesthetised for VSD repair. What ventilatory strategy

would you adopt during the operative period prior to cardiopulmonary
bypass, and why?
• Avoid high inspired concentrations of oxygen.
• Avoid hypocarbia. Aim for high-normal end tidal carbon dioxide.
• Tis patient has a lef to right shunt. High oxygen concentrations
and hypocapnia will decrease the pulmonary vascular resistance,
thereby increasing the degree of lef to right shunt. Tis will lead to
an increase in pulmonary blood fow at the expense of systemic blood
fow, thereby resulting in systemic hypotension, reduced coronary
perfusion pressure, and reduced end-organ perfusion – all of which
should be avoided.

Te patient undergoes uneventful surgical closure of the VSD. List some

issues that could occur in the early postoperative period?
• SIRS response.
• Bleeding and coagulopathy.
• Cardiac tamponade.
• Low cardiac output state (other than due to tamponade).
• Tachy-dysrhythmias or heart block.
• Pulmonary hypertensive crisis.
• Presence of a residual defect.

BIBLIOGRAPHY
Peyton JM & White MC. Anaesthesia for correction of congenital heart disease
(for the specialist or senior trainee). Continuing Education in Anaesthesia,
Critical Care & Pain. 2012; 12 (1): 23–27.
Rolo V, Walker I & Wilson K. Ventricular septal defects. Anaesthesia
Tutorial of the Week. 2015; ATOTW 316. Available online at www.
wfsahq.org.

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 Cardiothoracic Surgery

CASE: MITRAL VALVE REPLACEMENT

A 45-year-old female patient is listed for mitral valve replacement due to
severe mitral valve stenosis.

What is the normal area of the mitral valve?

• Te normal mitral valve area is more than 4 cm2.
• Mitral stenosis is a valve area of <2 cm2, with severe stenosis <1 cm2.
What are the common causes of mitral stenosis?
• Rheumatic heart disease secondary to rheumatic fever (most common
cause worldwide).
• Degenerative calcifcation.
• Infective endocarditis.
• Congenital (uncommon).
• Infltrative diseases: sarcoidosis/amyloidosis (rare).

Worldwide, rheumatic heart disease is the most common cause. However,

there is global variation in the prevalence of rheumatic heart disease. In high-
income countries with a low prevalence, degenerative calcifcation or infective
endocarditis are potentially more common causes.

What common symptoms might you expect in this patient?

• Fatigue.
• Dyspnoea.
• Reduced exercise tolerance.
• Cough.
• Palpitations (if presence of atrial fbrillation).
• Increased frequency of respiratory tract infections.

How is mitral stenosis classifed?

• Mitral stenosis is classifed based on the valve area and the mean
pressures across the valve found on echo:
• Mild: 1.6–2.0 cm2, pressure <5 mmHg.
• Moderate: 1.5–1.0 cm2, pressure 6–10 mmHg.
• Severe: less than 1.0 cm2, pressure >10 mmHg.

Why is atrial fbrillation more common in patients with mitral stenosis?

• Patients with severe mitral valve stenosis develop increased lef
atrial pressure, due to the impedance to lef ventricular flling from a
progressively narrowed mitral valve.
• A high lef atrial pressure causes increased stretching and dilation of
the lef atrium, increasing the likelihood of atrial dysrhythmias such
as atrial fbrillation.

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 Clinical Cases for the FRCA

• Tese patients should be anticoagulated owing to the higher likelihood

of thrombotic events.

What are the concerns when assessing this patient preoperatively?

A patient with severe mitral valve stenosis is a high-risk patient and her disease
progression and symptoms should be explored thoroughly, together with any
underlying conditions related to the disease.
• Implications of severe mitral valve stenosis: focus on signs, symptoms,
and investigations that evaluate the severity of the pathophysiological
process and degree of impairment of physiological reserve, including
evidence of dysrhythmias, pulmonary venous congestion and
pulmonary oedema, pulmonary hypertension, and right heart failure.
• She is a high-risk patient requiring preoperative assessment and
anaesthesia managed by a cardiac anaesthetist, following preoperative
optimisation with medical therapy.
• If the patient is on warfarin for atrial fbrillation, consider bridging
therapy with an intravenous heparin infusion.
• Evaluate any comorbidities, including the cause of her cardiac disease
and evidence of other end-organ dysfunction.
• Take a routine anaesthetic history and conduct an airway assessment,
including her past medical and social history, and any allergies.

What are the anaesthetic goals for this patient?

Preserve lef ventricular preload
• Low-normal heart rate – to preserve diastolic lef ventricular flling
and lef ventricular end-diastolic volume, which serves to optimise
lef ventricular preload.
• Sinus rhythm – atrial fbrillation, with absence of atrial contraction,
will detrimentally reduce lef ventricular end-diastolic volume.
• Judicious use of fuids, in order to maintain preload while avoiding
worsening pulmonary oedema.
Maintain contractility
• Avoid myocardial depressants. In the presence of right ventricular
failure, inotropic support with right ventricular aferload reduction
strategies may be required.
Optimise aferload
• Preservation of normal lef ventricular aferload. As lef ventricular
cardiac output is relatively fxed, both a high or low aferload will be
poorly tolerated.
Avoid worsening pulmonary hypertension or right ventricular aferload
• Avoid hypoxia, hypercarbia or acidosis, which would detrimentally
increase pulmonary arterial resistance and right ventricular aferload.
Tis includes adequate pain control in the perioperative period.

26
 Cardiothoracic Surgery

Afer surgical mitral valve implantation, the patient is to be weaned from

cardiopulmonary bypass. How would you prepare for this?
• Re-warm the patient as guided by core and peripheral temperature
monitoring. Avoid hypo and hyperthermia.
• De-airing: Te heart needs to be de-aired, as directed by the surgical
team. Transoesophageal echo is useful to search for any residual air.
• Adequate lung ventilation: If possible, visually check the surgical feld
for optimal lung re-expansion. Ventilate with 100% oxygen. Consider
suctioning the endotracheal tube for secretions.
• Re-establish an appropriate heart rhythm and rate and ensure pacing
equipment provides electro-mechanical capture. Aim for a heart rate
of 80–100 and sinus rhythm. Epicardial pacing may be necessary to
achieve this and to optimise sequential atrio-ventricular contraction.
• ST segment monitoring: Evidence of ischaemia should raise concern.
Consider coronary air, graf or coronary occlusion, or an insufcient
coronary perfusion pressure.
• Vasoactive medication: Consider the need for inotropes, vasopressors
and arteriolar or veno-dilators as appropriate. In this case:
• Consider inotropic support: Evaluate the patient’s baseline
ventricular function, the potentially deleterious efects of CPB,
and the anticipated physiological efects of replacing the valve in
the context of the pathology. Tus, consider the need to support
lef ventricular dysfunction, particularly if there is evidence of
chronic deconditioning. Also consider the need to support the
right ventricle if there is evidence of congestive heart failure.
• Consider vasopressor support e.g. to maintain coronary perfusion
pressure in the presence of vasodilation from a SIRS response to CPB.
• Acid–base balance: Correct metabolic acidosis if present.
• Electrolytes: Normalise electrolytes (Na+, K+ and Ca2+) aiming for
high-normal potassium.
• Blood sugar: Avoid hypo or hyperglycaemia.
• Haemoglobin: Optimise the haematocrit with blood products where
necessary.

Following her mitral valve replacement, this patient is transferred to cardiac

intensive care postoperatively. She remains intubated and ventilated. 6 hours
later her blood pressure drops to 74/42 and her heart rate is 120. Her CVP
rises from 12 to 18.

What is the defnition of cardiac tamponade?

• Cardiac tamponade occurs when there is an accumulation of fuid in
the pericardial sac to an extent that it creates an increased pressure
within the pericardial space, thereby inhibiting efective flling of
the heart chambers. Tis leads to a reduction in cardiac output and
causes haemodynamic compromise and obstructive shock.

27
 Clinical Cases for the FRCA

• A blood clot in the pericardial space causing external compression of

the heart can also produce tamponade physiology.
• It can lead to life-threatening end-organ dysfunction, cardiovascular
collapse and cardiac arrest.

A bedside echocardiogram demonstrates the presence of blood in the

pericardium. What is your immediate management of this patient?
Tis is a medical and surgical emergency. Te patient should be assessed and
treated immediately.
• Te fndings suggest that the patient has developed cardiac tamponade
postoperatively.
• Tis is an unstable patient that requires immediate evacuation of
blood from the pericardial space.
• Call for urgent senior anaesthetic help and carry out a rapid
assessment of the patient.
• Activate the cardiac unit’s emergency team – this should include a
cardiothoracic surgeon, the theatre team, and potentially a perfusionist.
• Aim to optimise haemodynamics:
• Administer fuid boluses to increase ventricular flling pressure to
counteract the diastolic flling restriction and improve ventricular
preload.
• Avoid high PEEP or high airway pressures, which would further
compromise ventricular flling.
• Consider vasoactive medication. While inotropes may increase
cardiac output, they also may increase myocardial oxygen
demand. Vasopressors may help to improve coronary and systemic
perfusion but high aferload is poorly tolerated.
• While the above may form temporary haemodynamic stability, the
defnitive treatment is to relieve the tamponade. For a postoperative
cardiac patient: re-sternotomy, relief of the tamponade, and
exploration for a possible bleeding source and surgical haemostasis
should be emergently considered.
• Note that this patient may have a degree of coagulopathy post cardiac
surgery, which should be considered and corrected if present.

As you approach the patient, she arrests. You note that the rhythm on the
monitor is ventricular fbrillation. How do you proceed?
• Follow the Cardiac Advanced Life Support algorithm.
• Tis is a witnessed cardiac arrest with a recognisable rhythm in a patient
who has just undergone cardiac surgery. Under these circumstances,
external chest compressions may be delayed by 1 minute to facilitate
the timely administration of three sequential shocks (for ventricular
fbrillation or pulseless ventricular tachycardia). Terefore, admin-
ister three successive shocks (at 150 J) and then commence external
chest compressions.

28
 Cardiothoracic Surgery

• Administer 300 mg IV amiodarone and prepare for an emergency

resternotomy.
• Continue CPR with a single defbrillation attempt every 2 minutes.
• Resternotomy should occur within 5 minutes of cardiac arrest. Tis
will facilitate internal cardiac massage, defbrillation (20 J) and release
of tamponade.
• Continue ventilation with 100% oxygen and switch of PEEP. Confrm
the position of the endotracheal tube and auscultate to ensure bilateral
air entry.
• Avoid adrenaline unless specifcally directed by a senior clinician,
given the potential for profound hypertension afer ROSC and thus
the potentially catastrophic efect of damage to, and bleeding from,
surgical anastomoses or suture lines.

BIBLIOGRAPHY
Brand J, McDonald A & Dunning J. Management of cardiac arrest following
cardiac surgery. BJA Education. 2017; 18 (1): 16–22.
Holmes K, Gibbison B & Vohra HA. Mitral valve and mitral valve disease. BJA
Education. 2017; 17 (1): 1–9.
Machin D & Allsager C. Principles of cardiopulmonary bypass. Continuing
Education in Anaesthesia Critical Care & Pain. 2006; 6 (5): 176–181.
Ranjan R, Pressman G. Aetiology and epidemiology of mitral stenosis.
E-Journal of Cardiology Practice. 2018; 16: 14. Available at www.escardio.
org/Journals/E-Journal-of-Cardiology-Practice/Volume-16/Aetiology-
and-epidemiology-of-mitral-stenosis. Accessed online 12/06/21.

CASE: HEART TRANSPLANT

A 36-year-old male patient is listed for a laparoscopic appendicectomy. He
has previously had a heart transplant. You are asked to assess him on the
ward prior to his procedure.

Which conditions may lead to consideration of cardiac transplantation?

• Reasons for consideration of heart transplant include patients with
chronic heart failure:
• Who despite maximal medical therapy, exhibit limiting
symptoms, or require frequent hospital admissions, or exhibit
rising natriuretic peptide levels.
• Who exhibit deteriorating renal function or intolerability to
remove congestion without compromising renal function, or who
require reduction or cessation of heart failure medication due to
intolerable side efects e.g. hypotension and renal dysfunction.

29
 Clinical Cases for the FRCA

• With worsening right heart failure or pulmonary artery pressures.

• Causing anaemia, weight loss, hyponatraemia or liver dysfunction.
• Who exhibit frequent ventricular dysrhythmias despite optimal
therapy.
• Urgent referral is indicated for patients dependent on intravenous
inotropic therapy; those requiring mechanical support for cardiogenic
shock; those requiring positive airway pressure ventilatory support for
intractable pulmonary oedema; or those with refractory ventricular
dysrhythmias.
(Bhagra et al 2019)

What are the contraindications to cardiac transplantation?

• Irreversible liver or renal failure.
• Diabetes: either poorly controlled or causing end-organ dysfunction.
• Obesity or other multi-system disease with poor long-term survival.
• Severe lung disease or pulmonary hypertension.
• Active or recent malignancy.
• Symptomatic cerebral or peripheral vascular disease.
• Active infection.
• Alcohol excess/drug abuse.
• Psychosocial factors such as non-compliance with medication, drug
or alcohol misuse, current smoker and inadequate support.
(Bhagra et al 2019)

What are the long-term consequences of cardiac transplantation?

Efect on organ systems
• Immune-mediated coronary artery disease.
• Te risk of organ rejection requires immunosuppression, long-term
monitoring and surveillance cardiac biopsies.
• Persistence of any systemic disease processes that led to cardiac
failure initially.
• Chronic graf dysfunction.
• Increased susceptibility to infection (including bacterial, viral, fungal
and atypical) due to systemic immunosuppression.
Medication
• Patients require lifelong immunosuppressive agents. For maintenance
immunosuppression, a triple therapy regime is commonly used
including a calcineurin inhibitor (ciclosporin or tacrolimus), an
anti-metabolite (azathioprine or mycophenolate) and a corticosteroid
(prednisolone or methylprednisolone). Over time, a signifcant
proportion of patients can be weaned of steroids.
• Terapeutic drug monitoring is required for some immunosuppressants,
and careful avoidance of food or drug interactions that may potentiate
or inhibit their efect. Some side efects include:

30
 Cardiothoracic Surgery

• Azathioprine – liver toxicity, pancreatitis, leukopenia and risk of

infection.
• Mycophenolate – leukopenia, gastrointestinal symptoms,
contraindicated in pregnancy due to the increased risk of
miscarriage or congenital malformations.
• Ciclosporin or tacrolimus – renal toxicity, diabetes, hypertension,
neurotoxicity and gingival hyperplasia (ciclosporin).
• Prednisolone – hypertension, hyperlipidaemia, diabetes,
osteoporosis, Cushing’s syndrome and fuid retention.
• As well as risk of infections, long-term consequences also include an
increased risk of certain cancers.

What is the commonest cause of pacemaker insertion in patients with a

heart transplant?
• During cardiac transplantation, the donor atria are sutured to the
recipient atria. Recipient atrial activity does not cross the suture
line, so the donor heart rate is dependent on the denervated donor
sino-atrial node.
• Bradycardia due to inefective blood supply to the donor sino-atrial
node, or AV conduction defects, are common reasons for permanent
pacing.

How would you assess this patient preoperatively?

History
• Ensure a thorough cardiac history including the reason for
transplantation, any courses of treatment and disease progression.
Explore symptoms suggestive of ischaemic heart disease or cardiac
failure, bearing in mind that the patient is unlikely to experience
angina due to the denervated heart.
• Take a full drug history including immunosuppressive agents and
any side efects.
• Carry out a review of the patient’s notes and discuss with the specialist
transplant team regarding the patient’s condition, including history
of graf dysfunction, graf rejection, CMV status, and advice for
perioperative management such as therapeutic drug monitoring and
antibiotic prophylaxis.
• Systematic review and other comorbidities should be considered,
as well as previous anaesthetics, airway assessment and social
history.
• History of the patient’s current illness.
Examination
• Cardiovascular examination and airway assessment.
• Examine for signs of sepsis. Discuss with a microbiologist early given
the risk of atypical infections.

31
 Clinical Cases for the FRCA

Investigations
• Baseline observations.
• Baseline blood tests to include a full blood count, renal function and
electrolytes, and markers of infection.
• Baseline ECG, chest X-ray and recent echo.

What are the anaesthetic implications and goals for this patient?
Implications
• Te heart is denervated at the time of donor retrieval. Tis signifcantly
impacts its ability to alter heart rate following transplantation. Te
heart rate is usually maintained by donor sino-atrial activity between
90 and 100 bpm.
• In the denervated heart, there will be an absence of refex autonomic
heart rate changes to events such as laryngoscopy or traction to
abdominal or pelvic viscera.
• Signifcant blood pressure fuctuations can occur due to the lack of heart
rate compensatory responses to changes in systemic vascular resistance.
• Sympathetic stimulation to the denervated transplanted heart
occurs through circulating catecholamines. Tis requires the use
of direct-acting adrenergic sympathomimetic drugs including
ephedrine, isoprenaline, noradrenaline or adrenaline.
• For brady-dysrhythmias, vagolytic drugs such as atropine and
glycopyrrolate will be inefective at the increasing heart rate. Use
direct-acting beta-adrenergic drugs to increase heart rate, or electrical
pacing if necessary.
• For tachy-dysrhythmias, digoxin will be inefective at reducing heart
rate through its vagally mediated mechanism of action. Consider the
use of amiodarone or verapamil.
• Beware of denervation supersensitivity to drugs such as noradrenaline,
adrenaline and adenosine.
• Te Frank-Starling mechanism remains intact, facilitating preload-
induced efects on stroke volume and thus cardiac output. Te
transplanted heart is particularly sensitive to preload changes and
the subsequent efect on cardiac output, given the poor or absent
autonomic heart rate response in denervated hearts.
• Due to denervation, patients may not experience angina despite the
presence of myocardial ischaemia.
• Tere is evidence of a degree of sympathetic and/or parasympathetic
re-innervation over time in some patients following cardiac
transplantation, although this occurs to a variable extent. Regeneration
of autonomic nerve fbres may, for example, improve the transplanted
heart’s ability to vary heart rate or contractility, or to re-establish the
patient’s ability to experience the sensation of angina.
• If the patient is CMV negative, they should receive CMV negative
blood products.

32
 Cardiothoracic Surgery

Goals
• Take extra care during laryngoscopy or airway instrumentation as
gingival hyperplasia may increase the risk of oral bleeding.
• Consider using cis-atracurium for neuromuscular blockade, given
its favourable metabolism and elimination profle in the presence
of hepatic or renal dysfunction. Neostigmine in combination with
glycopyrrolate has been used safely in heart-transplanted patients,
although cases of severe bradycardia or cardiac arrest following
administration have been reported. Ensure immediate availability
of direct-acting catecholaminergic drugs. Alternatively, rocuronium
followed by sugammadex could be considered.
• Ensure a cardiostable anaesthetic. Be aware of the potential for
exaggerated blood pressure variation, both with general anaesthetic
or neuraxial blockade, due to the blunted heart rate response.
Terefore, anticipate the efects of, and avoid, large swings in the
systemic vascular resistance.
• Judicious use of fuids to maintain and optimise preload, given the
preload dependence of the transplanted heart. Avoid hypovolaemia
prior to induction.
• Maintain coronary perfusion pressures.
• Use direct-acting chronotropic and inotropic agents and have external
pacing readily available.
• Consider cardiac output monitoring or intraoperative echo for
monitoring and guiding management.
• Ensure optimal oxygenation, temperature and pain control.
• Use strict aseptic techniques for venous/arterial line or urinary
catheter insertion, or regional/neuraxial anaesthetic procedures, due
to the increased risk of infection.
• Ensure meticulous patient positioning and padding as steroids can
cause thin and fragile skin and increase the risk of pressure sores.
• Seek advice regarding additional stress-dose cover if the patient is
taking signifcant doses of corticosteroids for immunosuppression.
• Postoperatively, remove lines or catheters at the frst appropriate
opportunity, given the increased risk of infection.
• Ensure immunosuppressant therapy is maintained and therapeutic
drug monitoring as advised by the transplant team.
• Avoid NSAIDs if there is a possibility of worsening renal dysfunction.

BIBLIOGRAPHY
Barbara DW et al. Te safety of neuromuscular blockade reversal in patients
with cardiac transplantation. Transplantation. 2016; 100 (12): 2723–2728.
Bhagra SK, Pettit S, Parameshwar J. Cardiac transplantation: indications,
eligibility and current outcomes. Heart. 2019; 105: 252–260.

33
 Clinical Cases for the FRCA

Jurgens PT et al. Perioperative management of cardiac transplant recipi-

ents undergoing non-cardiac surgery: unique challenges created
by advancements in care. Seminars in Cardiothoracic and Vascular
Anaesthesia. 2017; 21 (3): 235–244.
Morgan-Hughes NJ & Hood G. Anaesthesia for a patient with a cardiac
transplant. British Journal of Anaesthesia. 2002; 2 (3): 74–78.
Navas-Blanco JR & Modak RK. Perioperative care of heart transplant recipients
undergoing non-cardiac surgery. Annals of Cardiac Anaesthesia. 2021; 24:
140–148.

CASE: CARDIAC IMPLANTABLE

ELECTRICAL DEVICE
An 81-year-old male patient is listed for a transurethral resection of the
prostate. He has a history of hypertension, COPD and has a permanent
pacemaker in situ. You are asked to review him in the preoperative
assessment clinic.

What are the indications for insertion of cardiac implantable electrical

devices?
Permanent pacemaker (PPM)
• Atrioventricular blockade (unstable 2nd or 3rd degree).
• Sick sinus syndrome.
Biventricular pacemaker
• Moderate/severe cardiac failure (cardiac resynchronisation therapy).
Implantable cardioverter defbrillator (ICD)
• Previous ventricular dysrhythmias with signifcant haemodynamic
compromise or cardiac arrest.
• Post-myocardial infarction at risk of ventricular dysrhythmias.
• Familial conditions with a high risk of sudden death, including long
QT syndrome, Brugada syndrome, hypertrophic cardiomyopathy
and arrhythmogenic right ventricular dysplasia.
• Congenital heart disease.
Implantable loop recorder
• For diagnostic or monitoring purposes.

What are the features of a permanent pacemaker?

• Source of energy (battery).
• Pulse generator.
• Pacing leads (unipolar or bipolar).

34
 Cardiothoracic Surgery

How would you assess this patient preoperatively?

History
• Take a thorough cardiovascular history including the extent of
historical or existing cardiac disease or comorbidities. Elicit any
current symptoms focusing on syncope, chest pain and palpitations,
or symptoms of worsening cardiac function.
• Pacemaker review:
• Date and indication for insertion, dependency on the pacemaker,
and underlying rhythm.
• Duration since last check.
• Any concerns or issues.
• Manufacturer and type of device, and lead and box location.
• Pacing mode, including presence of rate modulation or
anti-tachycardia function.
• Patients may be able to produce their personal pacemaker ID card,
which contains useful details regarding some of the above.
• Take a full respiratory history including any infections, hospital
admissions and current symptoms.
• Non-cardiac comorbidities, social and medication history including
medication compliance and anaesthetic history.
Examination
• Cardiovascular and respiratory examinations.
• Airway assessment.
Investigations
• Baseline observations.
• ECG (both pacing spikes and evidence of subsequent electrical
complexes should be apparent).
• Echo if indicated.
• Chest X-ray to review the position of the pacemaker box, assessment
of leads, and to assess for cardiac failure.
• Bloods to include full blood count, urea and electrolytes and clotting
function, particularly if taking anticoagulants.

Te patient’s pacemaker ID card states the mode as VVIR. What does

this mean?
• Tis is a fve-letter code using the standard nomenclature from
the Generic Pacemaker Code developed by the North American
Society of Pacing and Electrophysiology and the British Pacing and
Electrophysiology Group.
• Te frst letter denotes the chamber paced – in this case the right
ventricle is paced.
• Te second letter denotes the chamber sensed – in this case the right
ventricle.

35
 Clinical Cases for the FRCA

• Te third letter denotes the response to sensing – in this case an

inhibitory response to a sensed event.
• Te fourth letter refers to ability for rate modulation; thereby altering
pacing rate to meet changing physiological needs such as physical
exercise.
• Te ffh letter (not present) denotes the presence of an anti-
tachycardia function.
• Terefore VVIR represents rate-responsive ventricular demand
pacing.

What are the key considerations for perioperative care of this patient
regarding his pacemaker?
• Te patient should be reviewed by a cardiac physiologist on admission
for a pacemaker check and to deactivate rate-response, anti-tachycardiac
and defbrillator functions, if present. It is usually both inappropriate
and potentially dangerous to change the mode to a fxed-rate (non-
sensing) mode for surgery, but consider this in a patient who is
highly dependent on their pacemaker and when electro-magnetic
interference during the surgery is likely. A follow-up visit will
be required afer anaesthesia and surgery to check appropriate
functioning of the device and reinstate previous functionality.
• Correct electrolytes prior to induction of anaesthesia.
• Ensure a cardiostable anaesthetic to minimise the risk of perioperative
ischaemic events, dysrhythmias and disturbance of pacemaker
function.
• Ensure immediate access to emergency resuscitation drugs, a
defbrillator with pacing functionality, and isoprenaline, in case
of pacemaker dysfunction. Place defbrillator/pacing pads before
surgery at least 10 cm away from the pacemaker box to avoid
damage.
• Routine AAGBI monitoring is appropriate and will not interfere
with pacemaker function, although ensure the ECG display is set
to detect pacing spikes. Invasive blood pressure monitoring should
be considered for accurate measurement and evidence of reliable
electro-mechanical coupling. Care should be taken with central
venous catheter insertion to avoid lead displacement.
• Fasciculations associated with suxamethonium and shivering may
cause pacemaker dysfunction. Consider using other neuromuscular
blocking agents where possible.
• Discuss antibiotic prophylaxis, given the risk of developing pacing
lead endocarditis.
• Teatre staf should be made aware of the pacemaker and bipolar
diathermy should be used if essential.
• Ensure postoperative recovery in a high dependency environment
with continuous monitoring and access to emergency resuscitation
equipment.

36
 Cardiothoracic Surgery

BIBLIOGRAPHY
Bryant HC, Roberts PR & Diprose P. Perioperative management of patients
with cardiac implantable electronic devices. BJA Education. 2016; 16 (11):
388–396.

CASE: CARDIOMYOPATHY
A 53-year-old male patient is listed for an emergency laparotomy for small
bowel obstruction. He has a history of hypertension and alcohol excess and
is a smoker. He has a dilated cardiomyopathy but has not been reviewed for
this since his diagnosis 2 years ago.

What is a cardiomyopathy?
• A contemporary defnition (2007) from the European Society of
Cardiology (ESC) Working Group on myocardial and pericardial
diseases states that a cardiomyopathy is “a myocardial disorder in
which the heart muscle is structurally and functionally abnormal,
in the absence of coronary artery disease, hypertension, valvular
disease and congenital heart disease sufcient to cause the observed
myocardial abnormality”.
• Te ESC Working Group classifes cardiomyopathies into the
following categories:
• Hypertrophic cardiomyopathy.
• Dilated cardiomyopathy.
• Arrhythmogenic right ventricular cardiomyopathy.
• Restrictive cardiomyopathy.
• Unclassifed (such as Takotsubo cardiomyopathy).

What are the risk factors for the development of a dilated cardiomyopathy?
• Family history.
• Male gender.
• Afro-Caribbean ethnicity.
• Sickle cell disease.
• Alcohol excess/substance misuse.
• Muscular dystrophy.
• Hypothyroidism.
• Exposure to cardiotoxic chemotherapy agents.

What signs and symptoms associated with dilated cardiomyopathies

would you explore in this patient?
• Evidence of heart failure:
• Dyspnoea.

37
 Clinical Cases for the FRCA

• Reduced exercise tolerance.

• Orthopnoea.
• Paroxysmal nocturnal dyspnoea.
• Peripheral oedema.
• Ascites.
• Dysrhythmias/palpitations.
• Evidence of thromboembolic events or complications.

How does a dilated cardiomyopathy lead to cardiac failure?

• Ventricular enlargement and dilatation cause systolic dysfunction
and reduced stroke volume due to overstretching of the actin and
myosin flaments.
• Given the increase in ventricular radius increases wall tension
(through the Law of Laplace), the aferload (as defned by the
ventricular wall tension in systole) increases, leading to the increased
myocardial oxygen demand.
• Compensatory mechanisms occur. Sympathetic stimulation increases
heart rate and contractility to initially help maintain cardiac output.
Activation of the renin-angiotensin-aldosterone system and ADH
secretion raises systemic vascular resistance (angiotensin II, ADH) to
maintain mean arterial pressure, and increases intravascular volume
(aldosterone, ADH) and therefore preload (if on the ascending part of
the Frank-Starling curve).
• Although these compensatory mechanisms initially help to preserve
cardiac output, they ultimately worsen the ventricular dilatation,
wall tension, and oxygen demand, which further perpetuates systolic
dysfunction and cardiac failure.

How would you assess this patient preoperatively?

Tis is a high-risk patient undergoing emergency major surgery with a high
likelihood of perioperative morbidity and mortality due to their pre-existing
health conditions and current pathology.
• Te preoperative assessment should include a review by a consultant
surgeon and anaesthetist, assessing the need for surgery and risk
stratifying the patient using an appropriate tool e.g. P-POSSUM
score. Tis should be discussed with the patient prior to surgery.
• Te patient should be discussed with the intensive care team
preoperatively, for consideration of optimisation prior to surgery
and for management postoperatively. Ensure ongoing resuscitation if
appropriate.
History
• Ensure a thorough cardiovascular history focusing on the patient’s
current symptoms, as described above to ascertain the degree of
systolic dysfunction, cardiac failure if present and any evidence of

38
 Cardiothoracic Surgery

end-organ dysfunction or thromboembolic events. Conduct a review

of the patient’s previous notes and any discussions with the cardiology
team regarding the patient’s diagnosis and any initiated treatment.
• Take a history of the patient’s other comorbidities including their
smoking and alcohol history and current intake/medical conditions
associated with either.
• Discuss previous anaesthetics, the airway and drug history.
• Explore the time course of the patient’s current illness, oral intake
and treatment so far including antimicrobial therapy.
Examination
• Bedside observations.
• Cardiovascular and respiratory examinations.
• Airway assessment.
Investigations
• Routine baseline bloods for evidence of coagulopathy, hepatic or renal
dysfunction, evidence of anaemia, and biomarkers of heart failure.
Measure an arterial blood gas to determine the patient’s resting
efciency of gas exchange and lactate.
• Chest X-ray for assessment of pulmonary oedema, or co-existent
infection.
• ECG in particular for atrial dysrhythmias, conduction defects, or ST
segment/T wave abnormalities.
• Echo for lef and right ventricular size and function, the presence
of valvular dysfunction (such as mitral regurgitation caused by
stretching of the mitral annulus from ventricular dilatation), atrial
size, estimated pulmonary artery systemic pressure, and the presence
of sluggish intracardiac blood fow or an intracardiac thrombus.
Te degree of investigations or preoperative optimisation should be balanced
against the urgency for surgery. For example, an echo would be particularly helpful
to evaluate the degree of cardiac failure. Tis would provide insights into the degree
to which the patient is likely to tolerate anaesthesia and surgery, whether prolonged
or specialist postoperative critical care support is likely to be required, and assists in
enhancing a risk assessment of perioperative morbidity and mortality.

What are the priorities for the anaesthetic management of this patient?
Tink about how you can optimise preload, heart rate and rhythm, contractility
and aferload for this patient. In addition, consider how positioning, ventilation,
surgical procedures and complications (such as bleeding) will afect the physiology.
Aim to optimise oxygen delivery and minimise oxygen consumption by the heart.
Preoperative
• Ensure a thorough work-up, as described above.
• Optimise cardiac medication if evidence of heart failure and control
dysrhythmias.

39
 Clinical Cases for the FRCA

Intraoperative
• Ensure a cardiostable anaesthetic led by an experienced team.
• Monitoring: ensure large bore intravenous access and intra-arterial,
central venous pressure and cardiac output monitoring to guide
treatment.
• Avoid tachycardia.
• Aim to maintain sinus rhythm. Dysrhythmias will be poorly
tolerated. Ensure electrolytes are optimised (including Mg2+) and
treat dysrhythmias early with anti-arrhythmic drugs or cardioversion
as appropriate.
• Maintain an appropriate preload; both hypovolaemia and fuid
overload will be poorly tolerated. Use fuids or diuretics carefully.
• A high aferload (that increases myocardial work and reduces cardiac
output) or an excessively low aferload (that compromises coronary
perfusion or end-organ perfusion) will be poorly tolerated. Avoid
both of these situations.
• Beware of anaesthetic agents that cause myocardial depression
and drugs that cause either a signifcant increase in systemic
vascular resistance or tachycardia (e.g. ketamine), or those that can
precipitously drop SVR and compromise coronary perfusion (e.g.
propofol). Depth of anaesthesia monitors should be considered to
assist with agent titration and mitigate the cardiovascular efects of
excessively deep anaesthesia.
• Inotropic support may be required, depending on the degree of
ventricular impairment. A systemic infammatory response from
the surgery may also precipitate a degree of vasoplegia-induced
hypotension, which may need vasopressor support. Note that pure
vasopressor or high alpha-mediated vasoconstriction, leading to a
high aferload, may be poorly tolerated if the aferload is increased
without complementary inotropic support. Tis highlights the utility
of considering cardiac output monitoring or intraoperative/bedside
echo to optimise vasoactive support.
• Avoid excessive PEEP or high airway ventilatory pressures that would
compromise ventricular flling.
• Beware of fuid shifs, insensible fuid loss, and blood loss during the
laparotomy, as these will efect the above.
• Maintain normothermia.
• If blood products are administered, ensure Ca2+ is maintained/
replaced (as Ca2+ is chelated by citrated blood products). A low Ca2+
level will be negatively inotropic, which will be poorly tolerated in
this instance.
Postoperative
• Close monitoring and supportive treatment in cardiac intensive care.

40
 Cardiothoracic Surgery

BIBLIOGRAPHY
Davies MR & Cousins J. Cardiomyopathy and anaesthesia. Continuing
Education in Anaesthesia, Critical Care & Pain. 2009; 9 (6): 189–193.
Elliott P, Andersson B, Arbustini E et al. Classifcation of cardiomyopathies:
a position statement from the European society of cardiology working
group on myocardial and peri-cardial diseases. European Heart Journal.
2008; 29: 270–276.
Ibrahim IR & Sharma V. Cardiomyopathy and anaesthesia. BJA Education
2017; 17 (11): 363–369.

CASE: ONE-LUNG VENTILATION

A 72-year-old male patient is listed for a right upper lobectomy for lung
malignancy. He is a smoker and is on ramipril for hypertension. He weighs
71 kg.

What are the indications for one-lung ventilation?

Absolute
• When a healthy lung needs to be isolated from the contralateral side
afected by any pathological process (air, blood and pus) e.g. lung
abscess and pulmonary haemorrhage.
• To facilitate ventilation e.g. bronchopleural fstula.
• To allow for washout of a single lung e.g. cystic fbrosis.
Relative
• Surgical access e.g. pneumonectomy/lobectomy, oesophageal surgery,
and aortic surgery.

How can one-lung ventilation be achieved?

• Double-lumen tube.
• Bronchial blocker.
• Endobronchial intubation of a normal endotracheal tube.

How do right and lef-sided double-lumen tubes difer?

• Both right- and lef-sided double lumen tubes have separate tracheal
and bronchial aspects.
• However, right-sided double-lumen tubes have a Murphy’s eye in the
bronchial lumen due to the anatomy of the right upper lobe.

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 Clinical Cases for the FRCA

What size double-lumen tube would you choose for this patient?
• Te patient’s height is the most accurate predictor for the size of the
double-lumen tube used:
• Less than 155 cm: 35 French.
• 155–165 cm: 37 French.
• 165–175 cm: 39 French.
• More than 175 cm: 41 French.
• Te size of the tube required can also be estimated based on direct
measurements of the major bronchi on CT scans.

How would you intubate this patient with a double-lumen tube?

Induction
• Preparation for the anaesthetic includes patient consent; a team brief
and completion of the WHO checklist; drawing up of routine and
emergency drugs; insertion of intravenous access and placement of
AAGBI monitoring.
• Given the patient’s comorbidities and the major procedure, an arterial
line should be inserted with vasopressor agents primed and attached
to the patient for use during induction (anticipating cardiovascular
instability secondary to anaesthetic agents).
• A senior thoracic anaesthetist and trained assistant should be present.
• Cardiostable induction of anaesthesia with doses of propofol and
fentanyl slowly titrated to efect and rocuronium.
Intubation
• Ensure that a lef-sided, appropriately sized double-lumen tube has
been checked and lubricated appropriately, with the stylet inserted.
• Use a videolaryngoscope to view the vocal cords.
• Insert the tube through the glottis and remove the stylet to prevent
injury. Rotate the tube 90 degrees anticlockwise. Advance the tube
until 29–30 cm (28–29 cm in women) and resistance is felt.
• Connect to the anaesthetic circuit.
Verifcation of tube position
• Infate the tracheal cuf and ventilate. Bilateral chest rise should be
noted, with breath sounds bilaterally on auscultation.
• Clamp and disconnect the tracheal lumen, infate the bronchial cuf
and auscultate to ensure lef-sided ventilation only.

Note that the cuf should only be infated 1 mL at a time up to 3 mL, beyond which
the risk of ischaemic injury to the bronchial mucosa increases exponentially. If
a leak is still heard afer 3 mL is inserted, the bronchial lumen is likely in the
trachea.
• Unclamp and reconnect the tracheal lumen and recommence
bilateral lung ventilation.

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 Cardiothoracic Surgery

• Te double-lumen tube position should always be confrmed using a

fbreoptic bronchoscope following clinical checks.

What are the advantages of using a bronchial blocker over a double-lumen

tube?
• Can be used in paediatric patients (bigger range of sizes).
• Can be used in patients with single-lumen endotracheal tube in situ
e.g. patients on the intensive care unit, where exchange of tubes is not
desirable due to potentially difcult or swollen airways, with a high
risk of aspiration of gastric contents.
• Decreased risk of airway injury e.g. nerve damage and palsy.
• Less challenging insertion in certain patient groups e.g. patients
with poor mouth opening, tracheostomy patients, and laryngectomy
stoma patients.

What are the causes of hypoxia during one-lung ventilation?

• Te main cause of hypoxia during one-lung ventilation is secondary
to movement of the double-lumen tube. Other equipment-related
causes include failure of oxygen delivery and anaesthetic circuit
disconnection or blockage.
• Increased airway pressures can also cause hypoxia secondary to
bronchospasm, pneumothorax, coughing or anaphylaxis.
• Shunt.

Te patient desaturates to 82% during the procedure. How do you

proceed?
• Ensure that the patient is on 100% oxygen.
• Inform the surgeons and theatre team, and call for help.
• Equipment check: oxygen supply, ventilator and circuit.
• Check the position of the double-lumen tube.
• Maintain adequate cardiac output with fuid, vasopressors and
inotropes if required.
• Suction the dependent lung.
• Apply CPAP to the non-dependent lung (however, this minimises the
surgical view, so may not be possible). Apnoeic oxygenation could
also be used at this stage e.g. low-fow oxygen via a suction catheter.
• Recruitment manoeuvres and increase PEEP to the dependent lung,
with lower tidal volumes. Given the patient’s medical history, aim for
sats of 88%–92% (PO2 of 8 kPa).
• Surgeons to clamp pulmonary artery.
• Two-lung ventilation/consider abandoning procedure if severe
hypoxia continues.

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BIBLIOGRAPHY
Ashok V & Francis J. A practical approach to adult one-lung ventilation. BJA
Education. 2018; 18 (3): 69–74.
Lohser J & Slinger P. Lung injury afer one-lung ventilation. A review of the
pathophysiologic mechanisms afecting the ventilated and collapsed lung.
Anaesthesia & Analgesia. 2015; 121 (2): 302–318.

CASE: LOBECTOMY FOR LUNG

MALIGNANCY
A 69-year-old male patient is listed for a lung lobectomy for malignancy.
He has a history of ischaemic heart disease, COPD and a hiatus hernia. He
stopped smoking last year, having been a smoker for 38 years. You are asked
to review him in the preoperative assessment clinic.

Which factors determine whether a patient is suitable for a lung

lobectomy?
• Informed consent for the procedure (given the risks of the procedure
and postoperative complications).
• Te tumour should be a non-small cell malignancy (either
adenocarcinoma or squamous cell).
• Te tumour must be deemed resectable following surgical assessment.
• Te patient must be assessed as suitable for general anaesthetic.
• Te patient’s postoperative predicted ventilatory capacity, gas exchange
and CPET results should be within acceptable limits.
• Patients with severe right-sided cardiac failure should be excluded from
surgery as a lobectomy causes a permanent increase in pulmonary
vascular resistance and thus further severe right ventricular strain.

What are the important aspects in the history of this patient prior to
surgery?
• Tis is high-risk surgery in a patient with an increased likelihood
of perioperative morbidity and mortality. A thorough preoperative
history, examination and investigations are key to determine whether
the beneft of surgery outweighs the potential risks.
• Respiratory history: history of COPD and malignancy including
recent symptoms, hospital admissions and infections. Pulmonary
function tests and CPET are now routine in the majority of patients
presenting for this surgery.
• Cardiovascular history: thorough history of symptoms suggestive of
worsening cardiac disease or failure e.g. shortness of breath, chest

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 Cardiothoracic Surgery

pain and ankle swelling. Patient should be risk stratifed based on

history and further assessed using relevant investigations.
• Nutritional status: recent decrease in body mass index and extreme
weight loss can lead to increased perioperative complications and
suggest disease spread. Notably, an albumin level of <30 g/L is
associated with poor outcomes in this surgery.
• Other comorbidities, social history and anaesthetic history including
airway assessment.

What are the indications for pulmonary function testing?

• Diagnosis of diseases in symptomatic patients.
• Assessing the progress of a condition or its response to treatment.
• In preoperative risk assessment for pulmonary or non-pulmonary
surgery.
• For disease prognostication purposes.

How can pulmonary function be assessed in this patient?

• Oxygen saturations at rest and during exercise.
• Arterial blood gas for baseline oxygenation values.
• Peak expiratory fow rate using a fow meter – mainly used in diagnosis
and monitoring of obstructive disease processes.
• Spirometry – giving values of FEV1 and FVC.
• Transfer factor – assesses the gas difusion capacity of the alveoli.
• Ventilation/perfusion scanning.
• Shuttle walk test/6 minute walk test.
• Cardiopulmonary exercise testing.

Tis patient requires a right upper and middle lobe lobectomy. How can
his lung function postoperatively be predicted?
• Te total number of lung segments is 19. Te right upper lobe
has three segments, and the right middle lobe has two segments.
Terefore following his procedure, this patient will have 14/19
segments remaining.
• Te patient’s postoperative FEV1 and FVC values can be estimated by
multiplying the preoperative values by 14/19. Tis can also be done
for transfer factor.

When would cardiopulmonary exercise testing be considered?

• Te British Toracic Society has produced an algorithm that aids in
decision making for preoperative investigations.
• If the patient has an FEV1 value of <1.5L (lobectomy) or <2L
(pneumonectomy), they should be referred for spirometry and
transfer factor testing.

45
 Clinical Cases for the FRCA

• If the patient’s predicted postoperative values for FEV1 and transfer

factor are <40%, they should be referred for cardiopulmonary exercise
testing. Patients with a VO2 max value of <15 mL/kg/minute are con-
sidered high risk for surgery.

BIBLIOGRAPHY
Gould G & Pearce A. Assessment of suitability for lung resection. Continuing
Education in Anaesthesia, Critical Care & Pain. 2006; 6 (3): 97–100.

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3
AIRWAY MANAGEMENT

CASE: OBSTRUCTIVE SLEEP APNOEA

A 43-year-old male patient presents to the preoperative assessment clinic
prior to day case inguinal hernia surgery. He is a smoker and has a BMI
of 47. You are asked to review this patient as his blood pressure is 174/96.

What are your anaesthetic concerns regarding this patient?

• Tis patient has a raised BMI. Concerns include: an increased incidence
of a difcult airway; the need for additional anaesthetic and surgical
equipment, stafng and time perioperatively; and the physiological
consequences and comorbidities secondary to his obesity.
• Probable untreated hypertension in a high-risk patient.
• Tere is a high likelihood of undiagnosed (and hence untreated)
obstructive sleep apnoea (OSA).
• Te patient is a smoker. Te physiological and pathological
consequences of smoking cause an increased risk of a difcult airway
and challenging ventilation; higher incidence of infection; and poor
wound healing postoperatively.
• Te need for postoperative high dependency or intensive care should
be considered early. Tis patient may not be a good candidate for day
case surgery.

What is OSA syndrome?

• OSA is a condition where complete or partial airway obstruction during
periods of sleep leads to a decrease in airfow and subsequent desaturation.
• OSA syndrome is defned as a confrmed diagnosis of OSA together
with increased daytime somnolence.
• OSA is thought to afect up to 1.5 million adults in the UK, with up to
85% of these being undiagnosed and therefore untreated.

What measures are involved in sleep studies?

• Sleep studies (polysomnography) can be used as an objective
assessment of the presence and degree of OSA. Measurements include:
• ECG.
• EEG.
• Oxygen saturations.
• Airfow.
• Eye movements.
• Electromyography.
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 Clinical Cases for the FRCA

What is a hypopnoea?
• A hypopnoea is defned as more than 30% reduction in airfow lasting
for longer than 10 seconds, with at least a 4% decrease in oxygen
saturations.

What are the risk factors for the development of OSA?

Anatomical
• Increased neck circumference (>40 cm).
• Enlarged tonsils/adenoids/tongue.
• Craniofacial abnormalities.
Comorbidities
• High BMI (>35).
• Hypertension.
• Diabetes mellitus.
• Asthma.
• Neuromuscular disorders.
Other
• Male.
• Age (40–70 years old).
• Family history.
• Smoker.
• Alcohol excess.
• Pregnancy.
• Low physical activity levels.

What are the key considerations in your anaesthetic plan for this patient?
Preoperative
• Tis is a complex patient with numerous comorbidities presenting
for non-urgent surgery, so the procedure should be delayed until the
patient has been reviewed by the relevant teams:
• GP review for a potential new diagnosis of and treatment for
hypertension.
• Assess for possible OSA (using the STOP-BANG screening tool)
and refer for sleep studies. If a diagnosis of OSA is made, the
patient should undergo at least 3 months of home CPAP prior to
consideration for surgery.
• Smoking cessation advice and encouragement.
• Weight loss advice and encouragement.
• Encourage an increase in physical activity through exercise regimes.
• When surgery is reconsidered for this patient, a complex and thorough
preoperative anaesthetic history, examination and appropriate
investigations are required once the above have been completed, with

48
 Airway Management

a focus on the airway and cardiovascular system. Tis may include an

ECG, echo and CPET.
Intraoperative
• Avoid sedative premedication.
• Prepare for a difcult airway/intubation with an airway plan,
appropriate equipment and adequate senior support.
• Ensure that there is a plan for failed intubation and/or oxygenation.
• Prioritise non-opioid base analgesia during the perioperative period.
• Use regional anaesthesia where possible (for both analgesia and
anaesthesia).
Postoperative
• If a general anaesthetic is used, consider extubating the patient onto
his own CPAP machine with a prolonged stay in recovery, with
continuous sats monitoring and supplemental oxygen.
• Consider high dependency care postoperatively.

What are the potential complications associated with OSA?

• Cardiovascular: hypertension, arrhythmias, myocardial infarction
and right-sided cardiac failure.
• Poor cognitive function and mood disorders.
• Impaired glucose tolerance/type II diabetes mellitus.
• Sexual dysfunction.

BIBLIOGRAPHY
Martinez G & Faber P. Obstructive sleep apnoea. Continuing Education in
Anaesthesia, Critical Care & Pain. 2011; 11 (1): 5–8.

CASE: RHEUMATOID ARTHRITIS

A 45-year-old female is undergoing an extended hemi-colectomy for bowel
cancer. She has a history of rheumatoid arthritis but is otherwise well.

What is rheumatoid arthritis?

• Rheumatoid arthritis is a chronic, infammatory autoimmune
polyarthropathy.
• It is both systemic and symmetrical, and causes tenosynovitis, loss of
cartilage and bony erosions.

What are the airway concerns in a patient with rheumatoid arthritis?

• Atlanto-axial instability/subluxation (anterior ± posterior).
• Subaxial subluxation.

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 Clinical Cases for the FRCA

• Cervical spine ankylosis.

• Cricoarytenoid joint dysfunction.
• Temporomandibular joint dysfunction.

How would you assess this patient’s airway?

Te patient’s airway should be assessed with a thorough history, examination
and the appropriate investigations.
History
• Note any previous history or documentation of a difcult airway or
intubation.
• Take a detailed medical history, focusing on the symptoms specifc to
rheumatoid arthritis:
• Neck pain/upper limb paraesthesia, suggestive of atlanto-axial
instability. Airway manipulation in these patients can lead to
paralysis or death.
• Neck stifness (increasing the risk of a difcult airway).
• Dyspnoea/hoarse voice, which may suggest laryngeal involvement.
• Ask the patient about any dental work and review their dental hygiene.
Examination
• A general examination may reveal risk factors for a difcult airway,
including a raised BMI, obvious anatomical deformities and a
receding jaw.
• Check the patient’s mouth opening as it may be limited if she has
temporomandibular joint dysfunction.
• Examine neck fexion/extension.
• Carry out specifc airway tests:
• Mandibular protrusion: the inability to protrude the lower incisors
anterior to the upper incisors is associated with an increased risk
of difcult laryngoscopy.
• Mallampati: assesses the visibility of the uvula with maximal
mouth opening.
• Tyromental distance: <6 cm from the thyroid cartilage to the
mandible with the neck in extension is suggestive of difcult
laryngoscopy.
• Sternomental distance: <12.5 cm from the sternal notch to the tip
of the mandible with the neck in extension is suggestive of difcult
laryngoscopy.
• Wilson score: uses fve elements (BMI, buck teeth, jaw movement,
neck movement and receding mandible) to predict the likelihood
of a difcult intubation.
A combination of the above should be used to assess the difculty of the patient’s
airway, as the sensitivity and specifcity of each test alone is not high enough to
make an accurate prediction.

50
 Airway Management

Investigations
• An X-ray of the cervical spine should be considered in patients
with rheumatoid arthritis to assess for atlanto-axial involvement,
particularly if the disease is longstanding or if the patient has
symptoms such as pain or paraesthesia.
• MRI scan to follow if indicated.
• Nasendoscopy can be considered in patients with suspected laryngeal
involvement.

What is the Wilson score?

• Te Wilson score is used to assess the likelihood of a difcult
intubation and constitutes fve factors:
• BMI.
• Neck movement.
• Jaw movement.
• Protruding teeth.
• Receding mandible.
• Each factor is given a score out of 2 (where 2 denotes an abnormality)
and a total score of more than 1 suggests a difcult intubation may
be likely.
• A score of >1 identifes 75% of difcult patients with a false positive
rate of 12%.

What are the options for a patient who has been identifed as high risk for
extubation perioperatively?
Te Difcult Airway Society extubation algorithm gives four options for patients
that are high risk.
• Extubate the patient when they are fully awake.
• Postpone extubation and transfer the patient to the intensive care
unit.
• Perform a tracheostomy for a defnitive airway.
• Advanced airway techniques, including exchanging the endotracheal
tube for a laryngeal mask airway; using a remifentanil infusion while
extubating; or using an airway exchange catheter in case the patient
needs re-intubation rapidly.

BIBLIOGRAPHY
Crawley SM & Dalton AJ. Predicting the difcult airway. BJA Education. 2015;
15 (5): 253–257.
Fombon F & Tompson JP. Anaesthesia for the adult patient with rheumatoid
arthritis. BJA Education. 2006; 6 (6): 235–239.

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CASE: ACUTE AIRWAY OBSTRUCTION

You are asked to review a 63-year-old male patient in recovery for sudden
difculty in breathing and neck swelling. He has a history of atrial
fbrillation, ischaemic heart disease and type II diabetes mellitus. He has
just undergone a prolonged laparotomy for small bowel obstruction, for
which he had a central venous catheter placed.

What is your initial management of this patient?

• Tis is an anaesthetic emergency and needs to be dealt with
immediately.
• Te patient should be reviewed urgently in recovery. Senior
anaesthetic help should be sought and the difcult airway trolley
should be present at the bedside.
• Conduct a rapid airway assessment to determine the cause of the
patient’s dyspnoea. Apply 100% high-fow oxygen via a non-rebreathe
mask and transfer the patient to a place of safety if possible (closest
empty theatre).
• Escalate the case rapidly to the duty anaesthetic consultant or a senior
registrar.
• Take a prompt medical and anaesthetic history from the anaesthetic
chart:
• Note the history of atrial fbrillation: this patient may be on an
anticoagulant.

Te neck swelling is rapidly expanding. What are the options for airway
management in this patient?
Te history and examination fndings suggest that the cause of dyspnoea may be
secondary to haematoma formation in the neck afer placement of the central
venous catheter. Both the ENT and vascular teams should be involved early.
Intubation
• Te frst line plan for this patient should be to secure the airway
with an endotracheal tube as he is in danger of imminent airway
obstruction. He may need a smaller tube size than expected due to
the expanding neck swelling. Options for intubation are:
• Intravenous induction with direct or videolaryngoscopy.
• Gas induction with direct or videolaryngoscopy.
• Asleep fbreoptic intubation.
• Awake fbreoptic intubation.

Tracheostomy/front of neck access

• In a patient with a rapidly expanding neck haematoma, this would be
extremely difcult and should only be done in an emergency as part
of “plan D”, or by a specialist (ENT surgeon).
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 Airway Management

Whichever of the above methods are chosen for intubation, the ENT surgeons
should be scrubbed and ready to do a tracheostomy (if time allows).

What are the concerns with an awake fbreoptic intubation in this patient?
• Limited time/expertise: Given the urgent nature of the scenario,
there may not be adequate time or expertise to ensure a safe and
skilled approach, including the time required for satisfactory airway
topicalisation.
• Te airway anatomy may be distorted by the neck swelling, making
the technique more challenging.
• Te procedure is unlikely to be well tolerated by a patient in respiratory
distress and may cause total airway obstruction.
• Te use of sedation may increase the risk of complete loss of the
airway.

What diferent types of videolaryngoscopes are available for use?

• Standard blade: Tis is a conventional blade with a camera, so it can
also be used for direct laryngoscopy.
• Angulated blade: Tis requires the use of a stylet as the blade is more
curved.
• Channelled: Tis uses mirrors and lenses, so the user has to look
through the scope directly rather than at a screen.

What are the potential complications associated with endotracheal

intubation?
Early
• Misplaced tube (oesophageal/endobronchial).
• Dental/oral damage.
• Laryngeal trauma.
• Haemorrhage.
• Vocal cord haematoma.
• Airway oedema.
Late
• Tracheal stenosis.
• Laryngeal nerve damage/palsy.

BIBLIOGRAPHY
Batuwitage B & Charters P. Postoperative management of the difcult airway.
BJA Education. 2017; 17 (7): 235–241.

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CASE: LARYNGECTOMY
A 56-year-old male patient is undergoing an elective laryngectomy for
malignancy.

What added information would you like prior to proceeding with this case?
Patient factors
• An anaesthetic history focusing on known cardiovascular and
respiratory comorbidities, previous anaesthetics and the airway.
• Patients with laryngeal cancer ofen have a history of smoking
or alcohol excess, which will cause perioperative anaesthetic and
surgical challenges.
• Te patient may be malnourished due to a decreased appetite or pain
in the oropharyngeal area, necessitating dietician involvement.
• Anaemia may be present due to blood loss, chronic disease or
secondary to the patient’s comorbidities and should be treated
prior to surgery.
• Information should be sought about completed treatment
(chemotherapy/radiotherapy), which may have implications for
airway manipulation and management. Intubation of a patient who
has undergone radiotherapy to the airway necessitates a precise
airway plan, discussed with the surgical team.
• Specifc information about the tumour: patient symptoms and
progression, and investigations (CT/MRI/nasendoscopy) suggesting
encroachment on local structures:
• Changes in voice/hoarseness.
• Stridor/dyspnoea.
• Shortness of breath when lying fat.

Surgical factors
• Details about the extent of malignant spread and the expected
procedure: whether it is a partial or total laryngectomy, including the
possibility of neck dissection or free fap reconstruction.

What is a stridor?
• A stridor is a harsh inspiratory breath sound produced due to partial
upper airway obstruction.

What is your plan for induction of anaesthesia in this patient?

• Ensure patient consent, a completed WHO checklist, AAGBI
monitoring, the difcult airway trolley present, a consultant
anaesthetist and trained anaesthetic assistant, and emergency drugs
drawn up. Further monitoring may include an arterial line, a central
line and a catheter to monitor urine output.
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 Airway Management

• Tis patient should be anaesthetised in theatre with the surgeons

present and scrubbed, if the anaesthetic assessment deems that the
patient may be difcult to intubate or ventilate.
• Te airway plan should be discussed with the multidisciplinary team
at the team brief, with preparation for what will be done in the event
of a failed intubation.
• Te plan for induction will depend on the specifc patient history,
examination and investigations. If very high risk for a difcult
intubation, a preoperative awake tracheostomy should be done.
However, the usual technique in this patient involves:
• Preoperative assessment of the neck and landmark identifcation
(ultrasound can be used to mark the cricothyroid membrane).
• Preoxygenation with high fow nasal oxygen.
• An intravenous induction with a sufcient dose of a muscle
relaxant (rocuronium can be used with the correct dose of
sugammadex drawn up if considered necessary).
What is THRIVE?
• “THRIVE” stands for transnasal humidifed rapid insufation
ventilatory exchange.
• It is a technique that involves high fow humidifed oxygen delivered
via nasal specs (up to 70 L/minute).
• It uses apnoeic oxygenation. Maintenance of a patent airway allows
gas exchange at a cellular level.
• Te high fow of oxygen prevents entrainment of room air and
generates a positive end expiratory pressure (PEEP) that prevents
atelectasis and airway collapse.
Te surgery is completed successfully and the patient is discharged home.
Tree months later, he presents to the emergency department with shortness
of breath and difculty breathing. What is your initial management?
• Tis is an anaesthetic emergency.
• Call for urgent senior anaesthetic and ENT help.
• Conduct a rapid assessment of the airway to assess the efort and
efcacy of breathing via the stoma.
• Apply 100% oxygen using a Water’s circuit and an appropriately sized
mask for the patient’s stoma.
• Assess the stoma to determine its patency by passing a suction
catheter through.
• Ventilate the patient via his stoma while awaiting expert help.

BIBLIOGRAPHY
Stephens M & Montgomery J. Management of elective laryngectomy. BJA
Education. 2017; 17 (9): 306–311.

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4
CRITICAL INCIDENTS

CASE: DRUG OVERDOSE

A 24-year-old female is admitted to the emergency department with a
suspected drug overdose. You are asked to review her due to a drop in her
conscious level.

What is your initial management for this patient?

• Review the patient immediately.
• Assess the patient for risk to clinical staf with a “hands-of” handover,
to consider any concerns that may necessitate the use of personal
protective equipment.
• Carry out an ABCDE assessment focusing on the patient’s airway,
which may need urgent intervention if impaired consciousness has
led to the inability to maintain adequate ventilation.
• Ensure a thorough history is taken from the paramedics and/or
a friend/relative to ascertain the potential ingested substances.
• Use specifc and supportive treatment as indicated and refer to the relevant
teams once she is stable e.g. medicine, intensive care, and psychiatry.

Based on the collateral history, it is estimated that she has ingested

~14 units of alcohol, an unknown quantity of diazepam and 16 g of
paracetamol. How do you proceed?
Initial treatment
• Initial management of this patient depends on the fndings from the
ABCDE assessment but should include:
• Stabilisation including considering a defnitive airway if appropriate.
• Examination to assess for alternative pathology (including trauma)
causing an altered conscious level.
• Treatment of specifc symptoms e.g. vomiting.
• Treatment of the paracetamol overdose according to local
guidelines.

Investigations
• Continuous bedside monitoring of this patient in a safe location (e.g.
the emergency department resuscitation bay) is essential, as well as
initial baseline blood tests to include:
• Full blood count.
• Urea and electrolytes.
• Liver function tests.
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 Clinical Cases for the FRCA

• Clotting.
• Lactate and blood gas.
• Paracetamol and salicylate levels (4 hours post ingestion).
• Full screen to rule out overdose of other agents. Consider retention
of toxicology samples for medico-legal purposes.
Further management
• Full medical and drug history.
• Escalation to intensive care if appropriate.

What is the role of activated charcoal in drug overdoses?

• Activated charcoal can be used in cases of drug overdose as it binds to
agents and prevents them from being absorbed in the gastrointestinal
tract.
• It should be given within an hour of drug ingestion but can be
considered with drugs that are of slow or modifed release formations,
including the use of additional doses.
• Care should be taken in patients with reduced conscious levels as
there is a risk of pulmonary aspiration.

How would you treat the paracetamol overdose?

• Supportive therapy is key.
• Specifc treatment is with an intravenous infusion of N-acetylcysteine
dosed according to weight. Local guidelines dictate timing and
further investigations; however, it should be noted that this patient
has ingested a signifcant amount of paracetamol and is at high risk
for acute liver failure.

How would you manage the diazepam overdose?

• Treatment for benzodiazepine overdose is largely supportive.
• Te specifc antidote is fumazenil, a benzodiazepine receptor
antagonist, but administration of this is not recommended initially
due to the potential for harmful side efects including arrhythmias
and seizures.

What are the criteria for consideration of a liver transplant due to acute
liver failure secondary to a paracetamol overdose?
• Te King’s College Hospital criteria are:
• pH <7.3.
• Grade 3/4 encephalopathy.
• Serum creatinine >300 μmol/L.
• INR >6.5 (or prothrombin time >100 seconds).

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BIBLIOGRAPHY
Ward C & Sair M. Oral poisoning: an update. Continuing Education in
Anaesthesia, Critical Care & Pain. 2010; 10 (1): 6–11.

CASE: AWARENESS UNDER GENERAL

ANAESTHESIA
You are the anaesthetist on-call for labour ward and are asked to
anaesthetise a 34-year-old parturient for a category 1 Caesarean section for
a fetal bradycardia, which is still present on arrival to theatre. Te patient
is otherwise well, has no allergies, is appropriately starved and has good
mouth opening with a Mallampati score of 2. Her BMI is 24.

What is your plan for induction of anaesthesia?

• Tis is an emergency, and time is of the essence. Te patient should
be assessed quickly to facilitate a rapid transfer to theatre, focusing on
comorbidities, previous anaesthetics and the airway. Te discussion
should include an explanation and consent for a general anaesthetic
and the associated risks.
• Ensure availability of the difcult airway trolley, resus trolley and
emergency drugs.
• Apply AAGBI monitoring, complete the WHO checklist and
pre-medicate with sodium citrate.
• Use a specifc obstetric general anaesthetic checklist.
• Ensure appropriate positioning of the patient and pre-oxygenate for
3 minutes, targeting ETO2 >85%. Continue to pre-oxygenate until the
antiseptic skin preparation and surgical drapes have been applied and
the obstetrician is scrubbed and ready to operate.
• Carry out a rapid sequence induction with cricoid pressure and
suction on and readily available.
• Te choice of drugs should refect experience and local practice but
follows the principle that the drugs should have a rapid onset and
ofset. Tiopentone and propofol are both commonly used, with
suxamethonium as the muscle relaxant.
• Intubate and ventilate the patient with oxygen/air mix, nitrous oxide
and sevofurane.

Te procedure is completed with no complications. Two hours later

you are asked to review the patient due to her being “awake during the
operation”. How do you proceed?

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 Clinical Cases for the FRCA

An incident of accidental awareness is likely to be very traumatic for the patient.

It should be taken very seriously, and in this case the patient should be reviewed
immediately with a senior anaesthetist present.
• Review the anaesthetic chart prior to seeing the patient.
• Respond promptly and sympathetically in the presence of a senior
midwife and the anaesthetic consultant on labour ward. Te
discussion should include a frank apology to the patient as well as an
explanation.
• Take a detailed history from the patient about what she recalls
including specifc feelings, words or actions. Ask specifcally about
pain.
• Ofer counselling and a further discussion with consultant
anaesthetist at the earliest given opportunity.
• Te conversation should be carefully documented and co-signed by
those present.
• Te patient should be followed up in an anaesthetic clinic.
• Tis should be reported as a serious untoward event and should be
escalated according to local protocols.

What is the incidence of awareness in patients undergoing an obstetric

procedure?
• 1:670 according to NAP 5.

How do you account for the increased incidence of accidental awareness

under general anaesthesia (AAGA) in obstetric patients?
Obstetric patients are subject to a large number of risks for AAGA, which pertain
to the patient group, the type of anaesthetic they need, the nature of the surgery
and the human factors involved.
Patient factors
• Female.
• Younger age group.
• Raised BMI.
• Higher risk of a difcult airway.
• Anxious patient.
Anaesthetic factors
• Use of rapid sequence induction.
• Use of a muscle relaxant.
Surgical factors
• Emergency surgery.
• Excessive anaesthesia may be hazardous to the fetus, which may lead
to the anaesthetist giving too low a dose of anaesthetic drugs.

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 Critical Incidents

• Some obstetric operations are performed in actively bleeding patients,

therefore too low a dose of anaesthetic agent may be given with the
intent of avoiding haemodynamic instability.
Human factors
• High stakes situation can be stressful and make drug errors more
likely.
• Obstetric units are ofen stafed by junior anaesthetists out of hours,
and relative inexperience may make drug errors more likely.
• Lack of familiarity of drugs used in obstetrics e.g. thiopentone.

What questions form the modifed Brice questionnaire for assessing

patients who may have experienced awareness under anaesthesia?
• What is the last thing you remember happening before you went to
sleep?
• What is the frst thing you remember on waking?
• Did you have any dreams while asleep?
• What was the worst thing about your operation?
• What was the next worst?

How can the depth of anaesthesia be monitored?

Clinical signs
• Dilated pupils.
• Sweating, lacrimation.
• Movement (unless muscle relaxants are used).
• Tachycardia and hypertension.
Specifc monitoring
• Bispectral index (most commonly used).
• EEG monitoring.
• Auditory evoked potentials.
• Lower oesophageal contractility.

BIBLIOGRAPHY
Goddard N & Smith D. Unintended awareness and monitoring of depth of
anaesthesia. Continuing Education in Anaesthesia, Critical Care & Pain.
2013; 13 (6): 213–217.

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5
DAY SURGERY

CASE: CHILD FOR DAY CASE SURGERY

A 6-year-old child is listed for day case adenoidectomy on your ENT list.

How is day case surgery defned in the UK?

• Te patient is admitted and discharged on the same day, with day
surgery as the intended management (AAGBI).

What are the age limits for paediatric patients undergoing day case
surgery?
• All hospitals should have individualised guidelines based upon their
available facilities, equipment and staf training and experience, as
well as the child’s comorbidities.
• Tertiary centres may adopt a lower limit of 44–46 weeks post-
menstrual age (gestational plus chronological age).
• For ex-preterm infants, the limit is usually 60 weeks post-menstrual
age if they are medically ft.

What are the benefts of day case surgery in paediatric patients?

• Decreased cost to the hospital and parents.
• Separation of day case patient pathways and duration of hospital stay,
reducing the nosocomial infection risk (CP, CF, GDD) and transfer of
infections from certain patient populations (classically multi-drug-
resistant Pseudomonas in patients with cystic fbrosis).
• Reduced starvation time and less reliance on intravenous fuids.
• Reduced risk of cancellation (if an overnight bed is not required).
• Day surgery lends itself to protocols; protocolised day care pathways
improve patient care and safety.
• Decreased child and parental anxiety.
• Less disruption for the child, particularly if they are of school age.

You review the child preoperatively. His mother says that he has had a
runny nose for the last 2 days. How do you proceed?
Certain factors may preclude proceeding with surgery today, which can be
determined by a thorough history, examination and basic investigations.

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 Clinical Cases for the FRCA

History
• A full medical and anaesthetic history should be taken:
• If the child has a history of asthma or obstructive sleep apnoea,
this needs to be explored further to assess the risks and benefts of
day case surgery.
• Ask about the child’s susceptibility to a runny nose: is this
“normal” for the child?
• A history of the coryzal illness should be taken, focusing
particularly on:
• Te presence of a fever or productive cough.
• Loss of appetite, fatigue or feeling generally unwell.
• Parental concern (should not be underestimated).
Examination
• Chest auscultation: the presence of crackles or wheeze in a child is a
worrying sign.
• Child looking generally unwell: listless, drowsy or dehydrated.
Investigations
• Basic observations should be done to assess for signs of infection or
sepsis (fever, tachycardia, hypotension, tachypnoea).
Te decision to either proceed with or cancel surgery would depend upon a
combination of the above factors and surgical considerations (e.g. type of surgery
– ENT). If there were any concerns the patient should be discussed with the
anaesthetic and paediatric consultants.

Aside from the runny nose, the child has had no other symptoms and their
observations are normal. You proceed with induction of anaesthesia and
secure the airway with a laryngeal mask airway. As the surgeon begins
operating you notice an inspiratory stridor. What is your immediate
management?
• Alert the theatre team and surgeons and ask them to stop surgery
immediately and remove any stimulus.
• Call for help early.
• Carry out an immediate assessment of the airway to include oxygen
saturations, end tidal carbon dioxide, laryngeal mask airway position
and adequacy of ventilation.
• Switch to the bag function if not self-ventilating and increase the
inspired oxygen concentration to 100%.
• Gently attempt to manually ventilate the patient to assess airway
patency and auscultate the chest.
• Tis patient may have developed laryngospasm. Te following
treatment should be carried out quickly and efciently:
• Apply CPAP.
• Consider simple airway manoeuvres e.g. jaw thrust.

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 Day Surgery

• Deepen anaesthesia by increasing the concentration of inhalational

agent and/or administering a bolus of propofol appropriate to the
patient’s weight.
• Remove the laryngeal mask airway and apply CPAP using the
facemask if the above measures do not show any improvement.
• Ask the anaesthetic assistant to prepare the airway trolley for
intubation.
• If the patient further deteriorates despite the above interventions,
administer a weight-appropriate dose of suxamethonium to
induce muscle relaxation and facilitate intubation with a correctly
sized endotracheal tube.
• Consider passing an orogastric or nasogastric tube to defate the
stomach following intubation.
• Reassess the chest, focusing on the risk of atelectasis and
secretions, which may require re-infation and passage of a
suction catheter.
• If the symptoms have resolved and an adequate, safe airway is in
situ, consider restarting surgery.

BIBLIOGRAPHY
Bailey R et al. On behalf of the Association of Anaesthetics and the British
Association of Day Surgery. Guidelines for day-case surgery 2019.
Anaesthesia. 2019; 74 (6): 778–792.

CASE: LAPAROSCOPIC SURGERY

A 63-year-old female patient is undergoing a day case laparoscopic
cholecystectomy.

What are the benefts of minimally invasive surgery?

• Reduced length of hospital stay:
• Lower risk of hospital-acquired infections.
• Reduced cost to the hospital.
• Increased efciency and patient throughput.
• Decreased risk of complications e.g. postoperative pulmonary
complications and venous thromboembolism.
• Smaller wound size means less local tissue damage and reduced pain.
• Improved cosmesis.

Are there any contraindications to minimally invasive abdominal

surgery?

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 Clinical Cases for the FRCA

Tere are no absolute contraindications, but caution is advised in the following

situations.
• Severe right-sided or biventricular cardiac failure: Te increased
intra-abdominal pressure leads to an increase in systemic vascular
resistance, which in turn could cause a decrease in the patient’s
cardiac output.
• Extreme hypovolaemic shock: Te reduction in cardiac output may
lead to severe cardiovascular instability and cardiac arrest.
• Poor surgical access.

What is your analgesic plan for this patient?

• Preoperative: 1 g paracetamol and 400 mg ibuprofen orally if not
contraindicated.
• Intraoperative: fentanyl boluses titrated to efect and local anaesthetic
infltration.
• Postoperative: fentanyl/morphine boluses in recovery titrated to efect;
regular oral paracetamol and ibuprofen; oral tramadol if required for
rescue analgesia; and an appropriate oral dose of morphine sulphate
prior to discharge.

Te procedure is completed with no complications and the patient is

transferred to recovery. Half an hour later you are asked to review her
due to ongoing vomiting. What is your management?
• Carry out an assessment of the patient in recovery including
observations and a review of the medication that the patient has
received.
• Ensure adequate hydration (likely intravenous fuids if unable to
tolerate oral).
• Reassure the patient and assess her nausea and pain.
• Consider further anti-emetic agents with multi-modal receptor
targets and adequate management of their pain.

What are the complications of postoperative nausea and vomiting?

• Increased length of stay in recovery and/or hospital.
• Unplanned hospital admission in day case patients.
• Dehydration and electrolyte imbalance.
• Aspiration of gastric contents.
• Wound dehiscence.
• Boerhaave syndrome (very rare).

What are the criteria that should be met prior to discharge following day
case surgery?
Medical factors
• Haemodynamically stable, awake, oriented and mobile.

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 Day Surgery

• Able to eat and drink.

• Minimal or controlled nausea and pain.
• Wound site checked.
Social factors
• Accompanied by appropriate adult for next 24 hours.
• Access to a telephone.
• Adequate housing conditions and access to analgesia.
• Live within 30 minutes of a hospital with appropriate facilities.

BIBLIOGRAPHY
Carey BM, Jones CN & Fawcett WJ. Anaesthesia for minimally invasive
abdominal and pelvic surgery. BJA Education. 2019; 19 (8): 254–260.

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6
GENERAL, UROLOGICAL AND
GYNAECOLOGICAL SURGERY

CASE: APPENDICITIS
A 42-year-old male patient is undergoing an emergency procedure for
appendicitis. He is a smoker and a type 1 diabetic.

What added information would you like when approaching this case?
Patient factors
• A detailed anaesthetic history focusing on previous anaesthetics,
known comorbidities and an airway assessment.
• Specifc diabetic history: when it was diagnosed, the patient’s
compliance with treatment, and any micro and macro-vascular
complications suggesting poor diabetic control. Te patient’s normal
blood sugar level, and the levels at which they feel unwell, can also
indicate their compliance.
• Smoking history: pack years; when the patient last smoked;
any history of asthma/COPD; previous infections and hospital
admissions; ICU admissions; and current chest symptoms e.g.
sputum production, cough.
• Te patient’s starvation status, baseline observations, and relevant
investigations should also be noted.
Surgical factors
• Te urgency of surgery, the availability of the surgeon and theatre
team, and the proposed surgery and approach.

Te patient has a heart rate of 121 and a temperature of 39.2°C. He has a

blood glucose level of 27 mmol/L with ketones present in his urine. Te
surgeons would like to operate as soon as possible. How do you proceed?
Tis is a sick, septic patient with signs of diabetic ketoacidosis, who needs urgent
multidisciplinary management prior to anaesthesia and surgery. Immediate
management should include the aspects listed below.
• Senior help with an ABCDE approach.
• Large bore IV access, 100% oxygen with a non-rebreathe mask and a
fuid bolus.
• Early consideration of ICU team input.
• Investigations: FBC, U+E, blood culture, ABG and ketones.

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 Clinical Cases for the FRCA

• Treatment for suspected diabetic ketoacidosis:

• Fixed rate insulin infusion (0.1 U/kg/hour).
• 0.9% sodium chloride fuid boluses with potassium replacement
when appropriate.
• Commence a 10% dextrose infusion when blood glucose levels fall
below 14 mmol/L.
• Monitor potassium and ketones carefully.
• Treat the underlying cause (likely appendicitis): proceed to theatre
while continuing resuscitation.

In general, what are the risk factors for surgical-site infections?

Patient factors
• Comorbidities: diabetes mellitus, raised BMI, smoker, malnutrition,
poor immune function.
• Smoker.
• Older age.
Surgical factors
• Length of the procedure (increased risk with a longer duration).
• Site and type of surgery.
• Soiling of the surgical wound.
• Surgical technique.
• Emergency surgery.

In this case, how can the risk of developing a postoperative surgical-site

infection be reduced?
Preoperative
• Optimal blood glucose control.
Intraoperative
• Antibiotic prophylaxis within 30 minutes of induction, prior to
wound incision.
• Appropriate antibiotics for the type of surgery – skin commensals
and bowel contents.
• Perioperative haemostasis, optimal oxygenation, cardiovascular
stability and normothermia.
• Asepsis of the theatre environment and surgical technique.
Postoperative
• Further antibiotics as indicated (ofen directed by the surgical team)
e.g. if abdominal soiling is present.
• Good blood sugar control: consider a variable rate insulin infusion
until the patient is eating and drinking when ketoacidosis is resolved.
• Keep the wound clean and dry.
• Ensure early mobilisation postoperatively.

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 General, Urological & Gynaecological Surgery

Te surgeon informs you that the appendix has ruptured and the
patient has four-quadrant peritonitis. Te procedure is converted into a
laparotomy. What is your approach to pain management in this patient?
Tis patient requires a stepwise, multi-modal approach to analgesia.
• Regular paracetamol (IV until absorbing).
• NSAIDs unless contraindicated (note the patient’s renal function).
• Opioids: intraoperative fentanyl boluses, postoperative oral morphine.
• Patient controlled analgesia if oral route is not suitable (fentanyl/
morphine).
• Intraoperative adjuncts e.g. magnesium and ketamine bolus.
• Regional anaesthesia e.g. rectus sheath catheters.

BIBLIOGRAPHY
Giford C et al. Preventing postoperative infection: the anaesthetist’s role.
Continuing Education in Anaesthesia, Critical Care & Pain. 2011; 11 (5):
151–156.

CASE: MINIMALLY INVASIVE

OESOPHAGECTOMY
A 54-year-old male patient is undergoing a minimally invasive
oesophagectomy (MIO) for malignancy. He is being reviewed in the
preoperative assessment clinic.

What are the risk factors for the development of oesophageal

adenocarcinoma?
• Smoking.
• Alcohol intake.
• Male.
• Poor diet.
• History of refux or Barrett’s oesophagus.
• Family history.

What aspects of this patient’s preoperative assessment are key prior to his
procedure?
• Assessment of comorbidities: Patients with oesophageal malignancy
typically have a number of comorbidities, attributed to smoking or
alcohol excess. A thorough assessment of both cardiovascular and
respiratory systems is essential, as well as relevant investigations such
as an echocardiogram, CPET, and lung function tests.

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 Clinical Cases for the FRCA

• Nutrition: Alcohol excess, cancer cachexia and anorexia due

to treatment or dysphagia may all cause malnutrition in these
patients, so assessment and nutrition supplementation are key in the
perioperative period.
• Preoperative optimisation: Patients should be prepared
psychologically and physically for a major procedure, the recovery
period, and the risks associated with it. Local hospital programmes
can facilitate a holistic and multidisciplinary approach using surgery
schools and prehabilitation programmes. Smoking cessation in par-
ticular should be encouraged.

What are the challenges associated with anaesthetising this patient for
his procedure?
Tis is a long procedure with a high risk of surgical complications in a
premorbidly unft patient.
• Abdominal and thoracic surgical insults.
• Potential requirement for one-lung ventilation depending upon the
surgical approach.
• Pneumoperitoneum and thoracoscopic insufation with the potential
physiological implications.
• High risk for postoperative complications including venous
thromboembolism, infection, anastomotic leak and arrhythmias.
• High analgesic requirements during the perioperative period with the
associated side efects of medication.

What complications of pneumoperitoneum are more likely in patients

during a MIO?
• As well as the known systemic physiological implications of
pneumoperitoneum, due to creation of a passage between the
peritoneum and the thoracic cavity, this patient is particularly at risk of:
• Surgical emphysema.
• Pneumothorax/tension pneumothorax.
• Capnothorax.
• Hypercapnia.
• Hypotension due to reduced venous return and capno-
pneumomediastinum.
• Arrhythmias due to capno-pneumomediastinum and surgical
irritation of the myocardium.
• A surgical chest drain is inserted electively in the perioperative period
to mitigate the risks.

What is your plan for analgesia in this patient?

Preoperative
• Consideration of a thoracic epidural inserted into the patient awake.

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 General, Urological & Gynaecological Surgery

• Paracetamol 1 g orally.
• Gabapentin 300–600 mg orally.
Intraoperative
• Intravenous paracetamol.
• Intravenous fentanyl.
• Non-opioid-based analgesic agents: consider magnesium and a
ketamine bolus or infusion.
• Placement and loading of a paravertebral catheter on the operative side.
Postoperative
• Toracic epidural infusion.
• Paravertebral catheter local anaesthetic infusion.
• Patient controlled analgesia with fentanyl/morphine.
• Regular paracetamol.

What are the benefts of an epidural catheter infusion in this patient?

• Good pain control during the perioperative period.
• Decreased stress response to surgery.
• Reduced opioid requirement with fewer respiratory and
gastrointestinal side efects as a result.
• Decreased incidence of postoperative pulmonary complications.
• Lower risk of postoperative myocardial ischaemia and venous
thromboembolism.
• Allows early mobilisation reducing chest complications and risk of
VTE.

BIBLIOGRAPHY
Howells P, Bieker M & Yeung J. Oesophageal cancer and the anaesthetist.
BJA Education. 2017; 17 (2): 68–73.

CASE: LIVER TRANSPLANT

A 56-year-old male patient is undergoing a liver transplant. You are asked to
review him on the ward prior to anaesthetising him.

What are the indications for a liver transplant?

• Te decision for a liver transplant is made by a multidisciplinary team
using the UKELD (UK Model for End Stage Liver Disease) score. Tis
is calculated using the patient’s serum bilirubin, creatinine, sodium
and INR. Te score is a predictor of morbidity and mortality and is
used in the prioritisation of organs.

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 Clinical Cases for the FRCA

• Common indications for a liver transplant are:

• Liver cirrhosis (viral, alcoholic and autoimmune).
• Malignancy.
• Acute liver failure (including due to overdose).
• Metabolic conditions e.g. Wilson’s disease.
• Failed previous transplant.

What key features in this patient’s history would you like to determine
with regards to his chronic liver disease?
• Te cause and duration of his liver disease.
• Conditions related to the cause of the liver disease e.g. alcohol-
induced cardiomyopathy.
• Te presence of any systemic complications of chronic liver disease,
including:
• Portal hypertension.
• Splenomegaly.
• Gastric/oesophageal varices.
• Ischaemic heart disease/cardiomyopathy.
• Hepatopulmonary syndrome.
• Hepatorenal syndrome.
• Anaemia.
• Hepatic encephalopathy.

What is platypnea-orthodeoxia syndrome?

• Tis is a collection of symptoms that can occur secondary to
hepatopulmonary syndrome, where the patient experiences shortness
of breath and desaturation when moving from a lying to a sitting
position.
• Tis is due to intrapulmonary arteriovenous shunting and ventilation/
perfusion mismatch.

What investigations should be considered when working up a patient for

a liver transplant?
• Blood tests including:
• Full blood count (to check for anaemia and thrombocytopaenia).
• Clotting assessment including both in vitro and laboratory (with
thromboelastography).
• Renal function (to assess for hepatorenal syndrome and
electrolyte disturbances due to chronic water retention).
• Cardiac testing: ECG, echo.
• Pulmonary function tests.
• CPET for dynamic cardiorespiratory function.
• Imaging: ultrasound, abdominal MRI if there is a surgical indication.
• Psychological evaluation.

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 General, Urological & Gynaecological Surgery

What dose adjustments for drugs during the anaesthetic should be

considered for this patient?
• Propofol: Te dose should be decreased due to the increased risk of
severe hypotension on induction.
• Volatile anaesthetic agents: Titrate the dose carefully due to the
depressant efect on the cardiovascular system. Depth of anaesthesia
monitoring may be helpful. Minimal hepatic excretion with desfurane
and faster wake-up may be benefcial.
• Neuromuscular blocking agents: Tis patient may need an increased
initial dose due to the increased volume of distribution/decreased
protein binding in patients with chronic liver disease but care with
rocuronium (hepatic excretion), which may accumulate.
• Opioids: Doses should be titrated carefully due to the risk of
accumulation. Shorter acting agents are recommended.

What are the perioperative anaesthetic concerns when anaesthetising a

patient for a liver transplant?
• Tis is a high-risk comorbid patient for a prolonged major abdominal
procedure.
• Risk of signifcant preoperative metabolic, clotting, renal and fuid
imbalance.
• Risk of major haemorrhage due to pre-existing clotting abnormalities
and a highly vascular organ.
• High incidence of metabolic acidosis and severe electrolyte disturbance
during the anhepatic phase causing severe cardiovascular instability.

What are the potential postoperative complications in this patient?

Early
• Haemorrhage.
• Acute graf rejection.
• Hepatic vein/artery thrombosis.
• Sepsis.
• Renal failure.
Late
• Infection.
• Graf rejection.
• Side efects of immunosuppressant agents.
• Liver failure due to recurrence of the initial disease.

BIBLIOGRAPHY
Kashimutt S & Kotze A. Anaesthesia for liver transplantation. BJA Education.
2017; 17 (1): 35–40.

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7
HEAD, NECK, MAXILLO-FACIAL
AND DENTAL SURGERY

CASE: LASER SURGERY

A 71-year-old male patient is undergoing laser surgery for excision of a
laryngeal lesion. He is a smoker with severe COPD and has previously had a
myocardial infarction that required stenting.

What are the principles behind laser surgery?

• “LASER” stands for light amplifcation by the stimulated emission of
radiation. It uses a focused beam of light at a particular wavelength in
order to heat and destroy specifc tissues.
• Laser light is particularly efective as it is monochromatic, coherent
and collimated, with high-density emission of particles over a small
area.
• It consists of three basic elements: a laser medium, a high-energy
source, and a mirror-containing tube or space.

Can you give some examples of medical laser types?

• Carbon dioxide (10,600 nm) – used for heating, cutting and
coagulation of tissues. Commonly used in airway surgery.
• Argon (500 nm) – the energy generated causes disruption of molecular
bonds. Commonly used in retinal surgery and for the treatment of
birthmarks.
• Nd:YAG (1064 nm) – causes tissue ablation. Used for the treatment of
gastrointestinal bleeds and tattoo removal.

What are the concerns associated with anaesthetising this patient?

Patient factors
• Tis is a high-risk patient with signifcant cardiovascular and
respiratory comorbidities. He will require a thorough preoperative
assessment with the relevant further investigations as directed by
clinical examination e.g. ECG, echo, lung function tests and/or CPET.
He may also need to stop his anti-platelet medication perioperatively,
which increases the risk of stent occlusion.
• Te laryngeal lesion suggests a potential for malignancy in this
patient, and its associated complications e.g. malnutrition and the
side efects of adjuvant treatment.
• Te lesion may present with an increased risk of a difcult airway.

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Surgical factors
• Laryngeal surgery: surgical preference may necessitate a
microlaryngeal tube or tubeless feld, with the challenges associated
with adequate oxygenation and ventilation.
• Laser surgery: poses risks to the patient and staf involved, hence
adequate preparation and discussions are required preoperatively.

Te surgeon would prefer a tubeless feld for this procedure. What are the
options for oxygenation and ventilation intraoperatively?
• Manual jet ventilation (Manujet or Sanders injector).
• High-frequency jet ventilation.
• High fow oxygen delivery via nasal cannulae (THRIVE).

Te above techniques are commonly used in conjunction with a TIVA-based

anaesthetic. Ideally, an oxygen concentration of <30% should be used in laser
surgery to minimise the risk of an airway fre developing.

What are the complications of high-frequency jet ventilation?

• Barotrauma.
• Pneumothorax.
• Subcutaneous emphysema.
• Airway injury due to dry gas e.g. damage to epithelial cells,
infammation and oedema.
• Hypercarbia.
• Poor ventilation and hypoxaemia.
• Aspiration.

What safety aspects need to be considered with regard to laser surgery?

Patient factors
• Use a specifc laser-resistant endotracheal tube (if required) with
saline-flled cufs.
• Ensure eye protection for the patient specifc to the laser wavelength
in use.
• Avoid nitrous oxide and aim for inspired oxygen concentration
<30%.
• Avoid fammable skin prep.
Stafng factors
• Ensure the presence of a designated laser safety ofcer.
• Keep the theatre locked and marked clearly when laser is in use.
• Ensure eye protection for the staf specifc to the laser wavelength
in use.
• Ensure matt surfaces to prevent refection of laser light.
• Ensure the minimum amount of staf required is in theatre.
• Regular staf training and servicing of equipment.

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 Head, Neck, Maxillo-Facial and Dental

How would you manage an airway fre during laser surgery?

• Tis is a surgical and anaesthetic emergency.
• Alert the theatre team immediately, call for help and turn of the laser
light.
• Stop oxygenating/ventilating the patient and remove the endotracheal
tube if present.
• Flood the surgical feld with water.
• Commence ventilation with 100% oxygen via a bag valve mask or re-
intubate at this point.
• Reassess the airway (rigid bronchoscopy) and formulate a plan for
further management, which may require intensive care and/or an
emergency tracheostomy.

BIBLIOGRAPHY
Pearson KL & McGuire BE. Anaesthesia for laryngo-tracheal surgery, including
tubeless feld techniques. BJA Education. 2017; 17 (7): 242–248.

CASE: DENTAL ABSCESS

You are reviewing a 32-year-old male patient, who has been listed for
emergency incision and drainage of a dental abscess. He is a smoker and has
learning difculties.

What are your key concerns in the anaesthetic management of this patient?
• Concerns with regard to the dental abscess:
• Possible difcult airway.
• Local or systemic sepsis may afect the patient’s haemodynamic
stability under a general anaesthetic.
• Potential for poor dentition secondary to smoking increases the
risk of a difcult airway.
• Smoker: Te patient is likely to have a reactive airway when
anaesthetised, as well as the physiological efects of nicotine, carbon
monoxide and other toxins contained within cigarettes.
• Learning difculties: He may present as a challenging patient with
limited compliance for treatment and possible consent issues.

What are the increased risks associated with smokers in the perioperative
period?
• Increased incidence of adverse respiratory events including
laryngospasm, bronchospasm, aspiration of gastric contents, type I
respiratory failure and pulmonary oedema.

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 Clinical Cases for the FRCA

• Increased risk of postoperative pulmonary complications e.g.

atelectasis, pneumonia.
• Increased risk of postoperative cardiac events.
• Higher incidence of sepsis and poor wound healing postoperatively.
• Overall increase in duration of hospital stay, morbidity and mortality.

What are the complications of an untreated dental abscess?

• Dental cyst.
• Ludwig’s angina.
• Mediastinitis.
• Maxillary sinusitis.
• Complete airway obstruction.
• Orbital cellulitis.
• Cavernous sinus thrombosis.
• Osteomyelitis.
• Systemic sepsis/shock.

How would you assess this patient’s airway?

In this case, patient assessment may be challenging due to the history of learning
difculties, and should ideally be done with a specialist nurse/carer or family
member present to facilitate patient reassurance, and also for a collateral history
if required.
History
• Duration of symptoms and speed of progression.
• Changes in speech.
• Difculty swallowing, eating and breathing.
Examination
• Observations and general appearance for signs of respiratory distress
e.g. stridor, hypoxia, drooling.
• Specifc airway assessment:
• Mouth opening.
• Mallampati score.
• Jaw protrusion.
• Neck extension.
• Ability to protrude tongue.
Te patient is calm but becomes distressed on examination due to pain. He
is able to open his mouth to 1 fnger width, and neck extension is also limited
due to severe discomfort.

What is your plan for induction of anaesthesia in this patient?

Tere is no right answer to this question – be able to justify and explain your
answer, ensuring that it is a safe approach for induction. Tere are a number
of choices listed below for revision; however, the examiners ofen want you to

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 Head, Neck, Maxillo-Facial and Dental

pick one and describe how you would carry it out, rather than give the various
options.
• A multidisciplinary team discussion regarding the concerns about the
patient is essential. He is at high risk of a difcult airway. A focused
discussion with the senior surgeon and anaesthetic consultant should
be undertaken to establish the plan for securing the airway, and the
plan in the event of a failed intubation.
• Options for anaesthesia include:
• Intravenous induction with muscle relaxation.
• Gas induction.
• Rapid sequence induction.
• Awake/asleep fbreoptic intubation.
• Awake tracheostomy.
• Te main concern in this patient is trismus, which may not relax on
induction of anaesthesia. Te patient appeared calm and compliant
during pre-assessment, so an awake fbreoptic intubation would be a
sensible choice of induction, with sedation.
• However, if the severity of learning difculties is greater (and therefore
an awake intubation would be more challenging), it is important to
question whether mask ventilation is likely to be easy or difcult. In this
case, the plan for intubation could be an attempt with videolaryngoscopy,
followed by an asleep fbreoptic intubation as plan B.
Technique
• Ensure AAGBI monitoring is attached, the difcult airway trolley is
present, and the resus trolley and emergency drugs are readily available.
• Have two senior anaesthetists present, a trained assistant and
surgeons present and scrubbed in theatre.
• Ensure early oxygenation with high fow nasal oxygen delivery and
appropriate positioning of the patient (head-up).
• Give sedation with remifentanil (target-controlled infusion titrated to
efect) controlled by a third anaesthetist.
• Topicalise the airway being mindful of the maximum doses of local
anaesthetic for the patient’s weight.
• Perform the fbreoptic intubation and confrm endotracheal tube
placement prior to induction of anaesthesia.

BIBLIOGRAPHY
Carrick MA, Robson JM & Tomas C. Smoking and anaesthesia. BJA Education.
2019; 19 (1): 1–6.
Morosan M, Parbhoo A & Curry N. Anaesthesia and common oral and
maxillo-facial emergencies. Continuing Education in Anaesthesia, Critical
Care & Pain. 2012; 12 (5): 257–262.

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8
MANAGEMENT OF RESPIRATORY
AND CARDIAC ARREST

CASE: COLLAPSE IN A PREGNANT PATIENT

A 35-year-old female patient has collapsed on labour ward. She is 39 weeks
pregnant and has been induced for reduced foetal movements. She has an
epidural catheter in situ.

What are the causes of collapse in a pregnant patient?

Medical causes
• Intracranial haemorrhage.
• Aortic dissection.
• Cardiac causes: arrhythmias, cardiomyopathy and myocardial
ischaemia/infarct.
• Respiratory causes: acute asthma attack and pulmonary embolus.
• Hypoglycaemia.
• Sepsis.
• Drug toxicity.
Obstetric causes
• Eclampsia.
• Amniotic fuid embolus.
• Haemorrhage.
Anaesthetic causes (commonest causes of arrest in pregnancy)
• Anaphylaxis.
• Local anaesthetic toxicity.
• High or total epidural blockade.

How would you manage this patient?

Tis is an anaesthetic and obstetric emergency that requires urgent and
immediate management.
• Request immediate senior help with an anaesthetic and obstetric
emergency or cardiac arrest call to include senior registrars/
consultants, the labour ward ODP, the midwife in charge and the
neonatal team.
• Rapid assessment of the patient: If there are no signs of life, commence
the ALS protocol. If the patient is breathing and has a pulse, carry
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 Clinical Cases for the FRCA

out an urgent ABCDE assessment to establish the likely cause of the

collapse.
• Stop the epidural infusion if running and check the last known rate
and concentration of the infusion.
• Key treatment early on includes:
• Manual uterine displacement (or lef lateral tilt if this is not possible).
• 100% oxygen via a non-rebreathe mask.
• Large bore IV access and a crystalloid fuid bolus.
• Immediate specifc treatment if the likely cause is identifed.
• Consideration of fetal condition if the mother has not arrested.
• Consideration of the partner if present.

How does the ALS protocol difer in pregnant patients?

Te key diferences are listed below and focus on restoring the mother’s circulation.
• Manual displacement of the uterus in pregnant patients while
ensuring adequate chest compressions.
• A peri-mortem caesarean section within 5 minutes of the cardiac arrest.
• Consideration of specifc obstetric causes of arrest (“BEAUCHOPS”):
• Bleeding.
• Embolism.
• Anaesthetic causes.
• Uterine atony.
• Cardiac.
• Hypertension.
• Other – 4Hs and 4Ts.
• Placental abruption.
• Sepsis.
• Human factors: heightened emotions and anxiety/stress levels.

What is the incidence of amniotic fuid embolism?

• Approximately fve in every 100,000 pregnancies.
• However, this varies due to the difculty in accurate diagnosis.

What are the risk factors for development of an amniotic fuid embolus?
• It is thought that there may be an increased risk with the following:
• Induction of labour.
• Use of oxytocin.
• Assisted/operative delivery.
• Maternal age >35 years old.
• Multiple pregnancy.
• Eclampsia.
• Placental abnormalities (praevia or abruption).
However, no risk factors have been clinically proven.

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 Management of Respiratory & Cardiac Arrest

What is the pathophysiology of an amniotic fuid embolism developing?

• Te presence of amniotic fuid or fetal cells (squames, hair and vernix)
in the maternal circulation leads to either or both of the theories
mentioned below.
• “Mechanical” theory: blockage of the pulmonary vessels by the
fetal cells.
• “Immune-mediated” response: an abnormal activation of the
maternal immune system in response to the presence of foreign
cells, causing an anaphylactoid response.

How is a diagnosis of amniotic fuid embolism made?

• Amniotic fuid embolus is a diagnosis of exclusion, where maternal
collapse occurs together with:
• Fetal compromise.
• Cardiac arrest, instability or arrhythmias.
• Coagulopathy or DIC.
• Major obstetric haemorrhage.
• Seizures.
• Dyspnoea.

Te patient undergoes two cycles of chest compressions and a peri-

mortem caesarean section is carried out. An initial diagnosis of amniotic
fuid embolus is made. ROSC is obtained, and the patient is taken to
theatre where closure of the abdomen takes place. What are the next steps
in the management of this patient?

Patient management
• Bleeding is likely. Consider early use of uterotonics, uterine packing
and a hysterectomy if necessary. Regular monitoring of clotting
(including fbrinogen levels and thromboelastography) can be used to
direct the administration of blood products.
• Multidisciplinary management and transfer of the patient to intensive
care once stable.
• Initiate supportive care based on the patient’s physiological
abnormalities including lung protective ventilation and inotropes or
vasopressors to maintain cardiovascular stability.
• Counselling and discussion with the patient and their family about
events.

Staf management
• “Hot” and “cold” debriefng of staf and counselling or further
training where appropriate.
• Escalation to supervisors within the appropriate teams.
• Document and report the case to UKOSS.

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 Clinical Cases for the FRCA

BIBLIOGRAPHY
Beckett VA et al. CAPS study: incidence, management and outcomes of cardiac
arrest in pregnancy in the UK: a prospective, descriptive study. BJOG.
2017; 124 (9): 1374–1381.
Metodiev Y et al. Amniotic fuid embolism. BJA Education. 2018; 18 (8):
234–238.

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9
NON-THEATRE

CASE: ELECTROCONVULSIVE THERAPY

A 48-year-old female patient is undergoing a course of electroconvulsive
therapy (ECT) under general anaesthesia. She has a history of hypertension,
for which she takes amlodipine, and asthma, for which she takes salbutamol
as required. Te procedure is taking place in the mental health building,
which is located on a diferent site to the main hospital.

What are the indications for ECT?

• Drug resistant or life-threatening depression and mania.
• Acute catatonic state.
• Schizophrenia.
• Rarely: Parkinson’s disease, neuroleptic malignant syndrome and
delirium.

How is ECT carried out?

• Induction of an electrical current across the brain via two electrodes
(either unilateral or bilateral).
• Tis gives rise to a tonic-clonic seizure lasting for up to 2 minutes.
• It uses a current of 0.5A, with energy of 30–45 J lasting ~1 second.
• It is administered twice a week for up to 4 weeks.

What are your main concerns when anaesthetising this patient?

Patient factors
• Tere may be a lack of capacity to consent for the procedure.
• Te patient may be a poor historian due to her psychiatric illness.
• Tere is potential for decreased compliance with treatment for her
comorbidities.
• Te patient may be on medication for her psychiatric condition that
interacts with the anaesthetic agents used.
Anaesthetic factors
• A bite block is commonly used when anaesthetising a patient for ECT,
which may be challenging if the patient has a difcult airway, poor
dental hygiene or active refux.
• Tere are concerns associated with remote site anaesthesia including
the risks to the patient and staf.

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 Clinical Cases for the FRCA

Procedural factors
• Te patient’s comorbidities may afect her suitability for ECT due to
the physiological changes that take place during the procedure.
• Te physiological systemic changes caused by ECT may lead to fur-
ther complications in the post-procedural period.

What are the contraindications for ECT?

Absolute
• Patient refusal if he/she has capacity (this is complex and should be
discussed closely with their parent team).
Relative
• Myocardial infarction or cerebrovascular accident during the last
3 months.
• Cardiac failure.
• Glaucoma.
• Untreated deep vein thrombosis.
• Severe osteoporosis or an unstable fracture.
• Raised intracranial pressure.
• Presence of electrical implantable devices (modern devices may be
safe).

What are the specifc issues with managing a patient in a remote site?
• Te potential lack of appropriate stafng e.g. ODP, senior or emer-
gency help.
• A lack of familiar or appropriate monitoring and equipment.
• Te remote site may not have an adequate recovery area.

What are the anaesthetic goals when anaesthetising a patient for ECT?
• Induction of anaesthesia with muscle relaxation and a rapid onset and
ofset.
• Minimise the efects of anaesthesia on the seizure threshold (in par-
ticular raising the threshold).
• Decrease the risk of potential complications associated with both
ECT and general anaesthesia.

What are the main risks and complications associated with ECT?
Te risks associated with ECT can be classifed according to the systems that are
afected.
• Airway: laryngospasm, aspiration, dental damage (minimised with
the use of a bite block).
• Cardiovascular: bradycardias/asystole and myocardial infarction due
to the sympathetic surge that takes place afer the initial parasympa-
thetic response.

88
 Non-theatre

• Neurological: memory defcits, confusion, prolonged seizure activity,

intracranial haemorrhage.
• Muscular: myalgia, weakness.

Te patient has been brought into the anaesthetic room and the WHO
checklist is being done. However, she is now refusing to go ahead with the
treatment. How do you proceed?
• Do not proceed with the general anaesthetic.
• Discuss the case with the attending psychiatrist and consultant
anaesthetist on duty.
• Assessment of capacity is essential; if the patient is found to have
capacity, this treatment cannot be given against her will.
• A second opinion needs to be sought. Te treatment needs to be
deemed life-saving or necessary to be given if the patient refuses
treatment.
• However, emergency treatment can be given without consent or a sec-
ond opinion.

BIBLIOGRAPHY
Uppal V et al. Anaesthesia for electroconvulsive therapy. Continuing Education
in Anaesthesia, Critical Care & Pain. 2010; 10 (6): 192–196.

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10
ORTHOPAEDIC SURGERY

CASE: TOURNIQUET USE DURING

ORTHOPAEDIC SURGERY
A 29-year-old male patient is undergoing urgent orthopaedic surgery to
his distal upper limb for tendon damage due to trauma. He has a history of
sickle cell disease, but no other medical conditions. Te surgeons require the
use of a tourniquet.

What are the indications for tourniquet use?

• To provide a bloodless, clear surgical feld for distal limb procedures
and decrease the risk of perioperative bleeding.
• For intravenous regional anaesthesia (Bier’s block).
• In pre-hospital medicine for patients with a catastrophic major
haemorrhage.
• Intravenous regional sympathectomy in the management of complex
regional pain syndromes.
• Isolated limb perfusion in the management of localised malignancy.

What are the systemic efects of tourniquet use in limb surgery?

Cardiovascular
• Overall increase in systemic vascular resistance afer tourniquet
application.
• Increased efective blood volume in the central circulation with a rise
in the central venous and systemic arterial pressures seen as a result.
• An increase in heart rate and blood pressure is seen afer 30–60
minutes which persists until defation of the tourniquet. Tis
phenomenon is referred to as “tourniquet pain”.
Respiratory
• No efect on tourniquet infation.
• Tourniquet defation causes a sudden increase in end tidal carbon
dioxide due to the release of end products of metabolism in the blood
distal to the tourniquet.
Neurological
• No systemic efects with infation, but on defation the increased PaCO2
leads to an increase in cerebral blood fow through vasodilation.
• A conduction block is seen in both motor and sensory nerves local to
the tourniquet, which is reversed on tourniquet defation.
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 Clinical Cases for the FRCA

Haematological
• Tourniquet infation leads to a hypercoagulable state secondary to
platelet aggregation, although the relationship between coagulation
and tourniquet use is complicated and there may be a short period of
increased thrombolytic activity on tourniquet defation.
Other
• An increase in temperature is seen afer infation as heat is conserved
in a smaller space, which is reversed on tourniquet defation due to
mixing of blood in the two compartments.
• Afer 1–2 hours of limb ischaemia, there is a modest increase in
arterial plasma potassium and lactate concentrations afer tourniquet
release.
• Local ischaemic changes and anaerobic metabolism in muscular cells
also take place following a period of tourniquet infation.

What is post-tourniquet syndrome?

• Post-tourniquet syndrome occurs in patients who have had a
prolonged tourniquet time. It is the most common morbidity
associated with tourniquet use.
• It is caused by a combined efect of muscle ischaemia, oedema and
microvascular congestion.
• Symptoms include limb stifness, generalised weakness and
numbness, which is subjective. Paralysis is not a feature. Te limb
may be swollen and pale.
• It can last from days to weeks, and is thought to occur due to the
efects of localised oedema and ischaemic changes that take place due
to prolonged tourniquet infation.

What are the concerns with tourniquet use in this patient? How do you
proceed?
• Sickle cell disease is a genetic haemoglobinopathy that causes
deformation and sickling of red blood cells under conditions such as
hypoxia and stress. Tis is likely to occur in the residual blood distal
to the infated tourniquet.
• Tere is no absolute contraindication to the use of tourniquets in
patients with sickle cell disease. A senior-led multidisciplinary
discussion should be undertaken where the risk of complications
relating to tourniquet use should be weighed against the benefts of
reduced blood loss and improved operating conditions.

Te surgeons proceed with surgery using a tourniquet. How can this

patient be optimised during the perioperative period?
Patients with sickle cell disease are complex to manage perioperatively. Tey
may have pathology in multiple body systems including congestive cardiac

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 Orthopaedic Surgery

failure, pulmonary hypertension, strokes and chronic kidney disease. Tey

may sufer from chronic pain and intolerance to opioid analgesia. Tey may be
severely anaemic. As a result, optimisation will be dependent on the course of the
disease. As this operation is urgent, optimisation will be time-limited. Te focus
should be on preventing their haemoglobin sickling and causing a vaso-occlusive
crisis.
Preoperative
• Maintain adequate hydration through intravenous and oral fuids
with minimal fasting.
• Preoperative chest physiotherapy and pulmonary function testing
may be indicated in patients with associated lung disease.
• Investigations should include haemoglobin and a group and save
(with a cross match if severely anaemic).
• Discussions with haematology regarding transfusion may be required
as management is complicated. A guiding principle is to reduce the
concentration of HbS and achieve adequate haemoglobin for oxygen
delivery, while avoiding the sequelae of over-transfusion.
Intraoperative
• Maintenance of optimal conditions including oxygenation and
normocapnia. An arterial line may be necessary.
• Strict temperature monitoring and control.
• Optimisation of analgesia with multimodal techniques.
• Minimise tourniquet time and use the lowest acceptable infation
pressure.
• Consider regional anaesthesia. Te vasodilation may reduce the risk
of a vaso-occlusive crisis postoperatively and also reduce reliance on
opioid analgesia in a patient that may be tolerant.
Postoperative
• Close monitoring on a high dependency unit.
• Continue adequate oxygenation, warming, analgesia and hydration.
• Appropriate venous thromboembolism prophylaxis.

BIBLIOGRAPHY
Deloughry JL & Grifths R. Arterial tourniquets. Continuing Education in
Anaesthesia, Critical Care & Pain. 2009; 9 (2): 56–60.
Kam PCA, Kavanaugh R & Yoong FFY. Te arterial tourniquet:
pathophysiological consequences and anaesthetic implications.
Anaesthesia. 2001; 56 (6): 534–545.
Wilson M, Forsyth P & Whiteside J. Haemoglobinopathy and sickle cell
disease. Continuing Education in Anaesthesia, Critical Care & Pain. 2010;
10 (1): 24–28.

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CASE: REVISION HIP SURGERY

A 76-year-old gentleman is undergoing revision of a total hip replacement
due to loosening of his primary replacement and pain. He has a history of
hypertension, for which he takes captopril, mild aortic stenosis, a hiatus
hernia and is a smoker.

What are the key concerns in the management of this patient?

Surgical
• Compared to primary hip surgery, revision surgery increases the
risks of the following:
• Intraoperative complication rate, which includes perforation of
the femur and intraoperative fracture.
• Increased operative time, blood loss and surgical complexity.
• Postoperative infection.
• Poor wound healing.
• Venous thromboembolism.
Anaesthetic
• Prolonged surgical time leads to an increased risk to the patient due to:
• Prolonged mechanical ventilation if a general anaesthetic is used
and increased incidence of postoperative pulmonary complications.
• Higher risk for perioperative hypothermia.

Patient
• Advanced age, smoking status and comorbidities may compound
some of the risks mentioned above.

What are the risk factors for the development of a postoperative joint
infection?
Patient factors
• Diabetes mellitus.
• High BMI.
• Smoker.
• Malnutrition.
• Immune suppression.
• Pre-existing infection relating to:
• Te overlying skin (e.g. cellulitis).
• Te joint prosthesis.
• An unrelated cause contributing to a bacteraemia (e.g. UTI/
pneumonia).
Surgical factors
• Prolonged procedure.
• Lack of laminar fow ventilation.
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 Orthopaedic Surgery

• Postoperative haemorrhage.
• Catheter insertion.

How can this patient be optimised prior to surgery?

Tis optimisation process should start with a thorough preoperative history,
examination and review of recent investigations to explore the relevant
comorbidities. Tis will guide further investigation and identify correctable
pathology to treat. Te interventions most pertinent to this patient include the
following.
• Encourage the patient to stop smoking and engage in local services.
• Refer for lung function tests if the patient is a long-term smoker to
determine the presence and extent of lung disease.
• Review a 12-lead ECG and recent echocardiogram to determine the
severity of aortic stenosis and associated cardiac pathology.
• Ensure that the patient’s blood pressure is appropriately treated with
targets that take into account the aortic valve pressure gradient.
• Investigate and correct common treatable pathology including:
• Anaemia.
• Electrolyte imbalance.
• Blood sugar control in diabetes.
• Coagulopathy.
• Sign-post to weight loss services if applicable to the patient.
• MRSA/MSSA decolonisation.
• Provide preoperative nutritional supplements.
• Educate the patient through local services to encourage adequate
nutrition, exercise and reduced alcohol intake (prehabilitation).

How would you anaesthetise this patient?

Tere is no right answer to this question – just be able to justify your answer as
each technique has risks and benefts that should be taken into account when
making your decision.
Preoperative
• Preoperative management should focus on identifying risk factors as
identifed above.
• Te patient should have a valid group and save or have blood cross-
matched if the risk of bleeding is sufciently high. Tey should be
consented for blood transfusion.
• Te supervising consultant anaesthetist should be informed of the
case due to the potential complications that may arise.
• Premedication, for example, with paracetamol, ranitidine and
metoclopramide. Te patient’s normal dose of captopril should be
omitted for 48 hours.
• Ensure availability of a higher care bed, according to the local
protocols.

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 Clinical Cases for the FRCA

• Ensure AAGBI monitoring, resus equipment, difcult airway trolley

and emergency drugs are readily available.
Intraoperative
General anaesthesia is indicated if this operation is likely to be prolonged or have
a high potential for haemorrhage. If the operation is likely to be shorter with a
lower bleeding risk (e.g. a straightforward acetabular cup revision compared to
an operation where both components are loosened and uncemented in osteolytic
bone), then a spinal anaesthetic or combined spinal-epidural could be considered.
However, this is very dependent on local experience/expertise, so communication
with the surgeon is vital.
Without the beneft of an echocardiogram to quantify the aortic stenosis, and
without specifc reassurance from the surgical team about the nature of the
operation, the most appropriate choice of anaesthetic for this case would be to
perform a general anaesthetic. Te hiatus hernia demands a rapid sequence
induction. As the procedure has the potential to be long, choose maintenance
drugs with a quicker ofset such as propofol or sevofurane. A particular
challenge for this anaesthetic will be to reduce blood loss and maintain stable
haemodynamics.
• Insert at least one large bore intravenous cannula.
• Site invasive blood pressure monitoring if blood loss is likely to be
excessive, or if there is evidence of moderate/severe aortic stenosis.
• Proactive management of blood pressure using crystalloid fuids, a
vasopressor such as metaraminol and targeted blood products.
• Administer tranexamic acid.
• Actively warm the patient.
• Discuss intraoperative cell salvage with the surgical team.
• Discuss the timing of antibiotics with the surgeon as swabs may need
to be taken to send to microbiology prior to administration.
• Analgesia should be multi-modal. A nerve block, such as a fascia
iliaca block, should be considered to help with postoperative pain.
Postoperative
• Close monitoring on a suitable ward, with a low threshold for critical
care admission if there is signifcant blood loss.
• Continue adequate oxygenation, warming, analgesia and hydration.
• Appropriate venous thromboembolism (mechanical and chemical).

What are the options for analgesia in this patient?

• Simple analgesia: paracetamol. NSAIDs are contraindicated in this
case due to the patient’s age, hypertension, ACE inhibitor and bleeding
risk, which together would increase the risk of an acute kidney injury.
• Opioid-based analgesia: intravenous morphine/fentanyl
perioperatively; oxycodone, oramorph and tramadol postoperatively.
Patient-controlled analgesia (PCA) may be necessary postoperatively.

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 Orthopaedic Surgery

• Opioid sparing agents such as ketamine, lidocaine infusion,

magnesium and gabapentin.
• Regional anaesthesia: Te choice will depend on the surgical approach
and anaesthetic expertise. Options include a fascia iliaca block, a
pericapsular nerve group (PENG) block, local anaesthetic feld block
or a wound catheter.
• Neuraxial anaesthesia: single shot spinal (with intrathecal opioids)
and lumbar epidural infusion/patient-controlled epidural analgesia.

BIBLIOGRAPHY
AAGBI. Safety guideline: reducing the risk from cemented hemiarthroplasty
for hip fracture. Anaesthesia. 2015; 70: 623–626.

CASE: SCOLIOSIS SURGERY

A 13-year-old male patient is undergoing spinal surgery for correction of
his scoliosis.

What is scoliosis?
• Scoliosis is a condition defned by lateral curvature of the spine with
varying degrees of rotation. Tere may be associated deformity of the
rib cage.
• Scoliosis involves other body systems, principally the respiratory and
cardiovascular systems.

What are the potential causes of scoliosis in this patient?

• Idiopathic (about 70% of patients).
• Congenital.
• Secondary to neuromuscular disorders e.g. cerebral palsy, muscular
dystrophy.

What are the complications and implications for anaesthesia in patients

with an uncorrected scoliosis?
Airway
• Airway difculties may occur where the scoliosis involves the upper
thoracic or cervical spine.
• Devices such as halo traction may make intubation more challenging.
Respiratory
• Restrictive lung disease and poor pulmonary function due to limited
lung and diaphragmatic movement. Tis may result in alveolar

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hypoventilation, ventilation-perfusion mismatch, increased dead-

space and a reduced total lung capacity.
• In patients with neuromuscular disorders, patients may also have
further respiratory muscle dysfunction.
• Te respiratory complications outlined above necessitate a thorough
history, examination and appropriate investigations preoperatively
(including pulmonary function tests) to assess the disease severity
and the ability of the patient to tolerate a general anaesthetic. Patients
may require preoperative chest physiotherapy.
• Patients with increased curvature and more signifcant pulmonary
sequelae are likely to need a longer period of ventilation
postoperatively.
• Long-term restrictive lung dysfunction may lead to a chronic type II
respiratory failure and right-sided cardiac disease.
Cardiac
• Te primary cause of cardiac dysfunction in scoliosis patients occurs
secondary to severe lung disease, but patients with congenital or
neuromuscular disorders may also present with structural cardiac
defects or cardiomyopathies.
• Severe curvature may distort the mediastinum causing a restrictive
pericarditis, impaired ventricular flling and a fxed cardiac output
state.
• Te preoperative anaesthetic assessment should include a detailed
cardiac history and examination, and further investigations as directed
by the initial fndings.
Other
• Patients with scoliosis secondary to congenital or neuromuscular
disorders may also have signifcant comorbidities including cognitive
dysfunction, learning difculties, generalised muscular spasticity or
atrophy, and bowel dysfunction. Tese need to be considered when
formulating the anaesthetic plan.

Te patient in question has idiopathic scoliosis, mild restrictive lung

disease and no signs of right-sided cardiac failure. What are your key
concerns when anaesthetising this patient?
• Positioning: Tis depends on whether a posterior or anterior
approach is used. In the posterior approach, the prone position will
be employed, requiring satisfactory patient padding and support to
prevent pressure sores. A reinforced endotracheal tube will need to
be correctly checked and secured, and the eyes should also be well
protected with padding and goggles. With an anterior approach, the
patient will be supine with the spinae accessed via a thoracotomy.
• Blood loss: Anaemia should be corrected prior to surgery. Tere is a
known risk of major haemorrhage in spinal surgery, so tranexamic

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 Orthopaedic Surgery

acid and cell salvage are routinely used. Large bore intravenous
access should be easily accessible. Increases in intra-abdominal pressure
should be minimised due to the risk of epidural vein engorgement
contributing to additional blood loss.
• Intraoperative monitoring: AAGBI monitoring should be in place
together with invasive blood pressure, central venous pressure and
cardiac output monitoring. EEG monitoring should be used where a
TIVA anaesthetic technique is employed. Specialist nerve monitoring
is also essential to identify and prevent damage to the spinal cord –
both somatosensory and motor-evoked potentials are commonly
performed.
• Duration of surgery: Prolonged procedural time means that
temperature monitoring and warming are essential, particularly
given the risk of blood loss and patient exposure.

How do anaesthetic agents afect neuromuscular monitoring?

• Volatile agents (at >0.5 MAC) afect both somatosensory and motor-
evoked potentials.
• Neuromuscular blocking agents afect motor-evoked potentials.
• Propofol had a dose-dependent increase in efect on motor-evoked
potentials.
• Opioid agents have no efect on either somatosensory or motor-
evoked potentials.

What is the wake-up test?

• Te wake-up test involves lightening anaesthesia to the point at which
the patient is able to respond to commands, and this procedure is
done afer spinal rod placement to ensure that nerve function has
been preserved.
• It is not routine, particularly with the use of neuromuscular
monitoring.

BIBLIOGRAPHY
Kulkarni AH, Ambareesha M. Scoliosis and anaesthetic considerations. Indian
Journal of Anaesthesia. 2007; 51: 486–495.
Nowicki, RWA. Anaesthesia for major spinal surgery. Continuing Education in
Anaesthesia, Critical Care & Pain. 2014; 14 (4): 147–152.

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PERIOPERATIVE MEDICINE

CASE: DIABETES MELLITUS

A 35-year-old female patient has been listed for an urgent laparoscopic
cholecystectomy for ascending cholangitis. She has a history of type I
diabetes mellitus but no other medical problems. She has a heart rate of 128,
a blood pressure of 83/67 and has been vomiting.

What are your key concerns when assessing this patient on the ward?
• Observations indicate that she may be severely dehydrated and/or septic
so will need urgent assessment and resuscitation prior to an anaesthetic.
• Diabetic ketoacidosis may also be present which requires investigation
and rapid intervention.
• Te history of vomiting increases the aspiration risk at induction
(necessitating a rapid sequence induction).
• Te patient is a type I diabetic and will need a thorough medical
history including the duration, treatment and blood glucose control
as well as any associated micro or macro-vascular complications.
• Given the history of cholangitis and vomiting, she may require an
intravenous insulin and dextrose infusion perioperatively.

Why is this patient at higher risk of complications during the

perioperative period?
• Perioperative sepsis is an indicator for increased morbidity, mortality
and postoperative complications.
• Any micro or macro-vascular complications of diabetes, particularly
cardiac or renal comorbidities, increase the risk of both medical and
surgical complications during the perioperative period.
• Tis patient is at high risk of hyper or hypoglycaemia due to the lack
of oral intake, infection and iatrogenic causes, such as incorrect or
unsuitable insulin prescribing or administration.
• Patients with pre-existing poor glucose control or inappropriate
perioperative glucose control are at higher risk of surgical-site
infections and poor wound healing.
• Patients with diabetes are more prone to electrolyte imbalance,
particularly if being treated for diabetic ketoacidosis.

When you see the patient on the ward, her blood glucose level is
32 mmol/L. How do you proceed?

DOI: 10.1201/9781003156604-11 101

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Initial approach
• Rapid ABCDE assessment and escalation to senior surgical and
medical teams and intensive care if appropriate.
• Ensure large-bore intravenous access.
• Early investigations should include an arterial blood gas (with
lactate), blood ketone level, full set of baseline bloods, septic screen
and bedside observations.
• Multidisciplinary discussion regarding urgency of surgery and
treatment of likely diabetic ketoacidosis.

Initial treatment
• Apply 100% oxygen via a non-rebreathe mask.
• Recognition and treatment of suspected sepsis should focus on the
“sepsis six”:
• Intravenous antibiotics.
• Fluid resuscitation.
• Urinary catheter.
• Blood cultures.
• Lactate.
• Oxygen.
• Follow the local guidelines for management of diabetic ketoacidosis,
to include:
• Fixed rate insulin infusion (0.1 U/kg/hour).
• Resuscitative fuids – regimen of 0.9% sodium chloride
(± potassium chloride). Te patient may need several litres of fuid
and should be continually reassessed.
• 10% dextrose (or similar) should be considered when the capillary
blood glucose level has decreased to a suitable level.
• Capillary blood glucose and ketones should be monitored frequently.
• Strict fuid balance charting.
• Treatment of the underlying cause is essential but should be discussed
with seniors owing to the complex nature of this case. Postoperative
high dependency or intensive care and early assessment by the
inpatient diabetic team should be considered.

Te patient undergoes a laparoscopic cholecystectomy the following day.

What is your plan for postoperative analgesia?
• Intravenous fentanyl boluses in recovery titrated to efect.
• Regular postoperative co-codamol with tramadol as rescue analgesia.
• Judicious use of NSAIDs due to risk of acute kidney injury.
• Buccal prochlorperazine.
• Opioid sparing agents if possible to minimise gastrointestinal side
efects and return the patient to oral intake and their regular insulin
therapy soon as possible.

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BIBLIOGRAPHY
Levy N, Penfold NW & Dhatariya K. Perioperative management of the patient
with diabetes requiring surgery. BJA Education. 2017; 17 (4): 129–136.

CASE: SCLERODERMA
A 45-year-old female is listed for an urgent fxation of her ankle on
the trauma list. She has a history of scleroderma and has never had an
anaesthetic. You are asked to review her prior to her procedure.

What is scleroderma?
• Autoimmune, multi-system disease that is caused by an increase in
collagen production.
• Typically occurs in females between the age of 30 and 50 years.
• Can be either limited or difuse with various efects on physiological
systems.
• “CREST” syndrome is limited: calcinosis, Raynaud’s, oesophageal
dysmotility, sclerodactyly and telangiectasia.
• Difuse scleroderma:
• Pulmonary: interstitial fbrosis and pulmonary hypertension.
• Cardiac: pericarditis and pericardial efusion.
• Renal: glomerulosclerosis.
• Gastrointestinal: dysmotility and malabsorption.
• Musculoskeletal: joint contractures and arthritis.

What are the main concerns when anaesthetising this patient?

Airway
• Tis patient is high risk for a difcult airway due to facial deformity
and contractures in severe disease. A suitable plan should be made
given fndings of a thorough airway assessment.
• Increased potential for aspiration due to refux secondary to
oesophageal dysmotility that should be incorporated into the airway
plan.
Respiratory
• Interstitial fbrosis and restrictive lung disease could make ventilation
challenging.
• Pulmonary hypertension increases the risk of perioperative
morbidity and mortality.
Cardiovascular
• Cardiac involvement can include hypertension, lef-sided cardiac
failure, arrhythmias and pulmonary hypertension. Careful assessment

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with a low threshold for investigations and discussion with the

multidisciplinary team are key when pre-assessing this patient.
• Susceptible to vasospasm if hypothermic. Meticulous temperature
monitoring and warming are essential.
General
• Joint contractures can lead to difcult patient positioning. Consider
positioning the patient in the correct surgical position while awake so
as not to move them once anaesthetised.
• Venous access may be challenging due to scleroderma skin changes.
• Regional anaesthesia may be favourable but challenging due to
musculoskeletal degeneration.
• Consider postoperative high dependency or intensive care due to
challenging management in a high-risk patient.
• Potential for drug interactions if the patient is on regular treatment.

Te patient takes 10 mg prednisolone daily. How should this be managed

during the perioperative period?
• Due to the risk of adrenal insufciency, steroid replacement is necessary:
• 100 mg intravenous hydrocortisone at induction followed by an
infusion of 200 mg hydrocortisone over 24 hours.
• Continue the hydrocortisone infusion postoperatively if the
patient remains nil by mouth.
• When the patient resumes eating and drinking, give a double dose
of hydrocortisone (or equivalent) for up to a week afer surgery.

Te patient states that she has been feeling increasingly short of breath
during the last few weeks. How do you proceed?
• Torough history focusing on the patient’s associated symptoms
including chest pain, limitations on daily activity, ankle swelling,
syncope, fatigue and triggers.
• Patient examination (cardiovascular and respiratory).
• Ensure a low threshold for investigations due to the risk of bilateral
cardiac involvement and pulmonary hypertension, to include:
• ECG (essential).
• Echo.
• Chest X-ray.
• Early discussion with multidisciplinary team regarding the timing
of surgery, the implications of the patient’s comorbidities on surgery
and an anaesthetic, and perioperative management. Senior clinician
involvement is essential due to complexity of this patient.

Surgery is delayed and the patient’s echocardiogram shows raised

pulmonary arterial pressures. What are the physiological goals when
anaesthetising a patient with pulmonary hypertension?

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• Avoid increases in pulmonary vascular resistance through prevention

of hypoxia, hypercapnia, hypothermia, acidosis and pain.
• Maintain coronary perfusion pressures by monitoring and preserving
cardiac output and systemic vascular resistance. Blood loss should be
corrected rapidly.
• Minimise arrhythmias and maintain normal heart rate and regularity.
• Ensure close and invasive monitoring of blood pressure and cardiac
output.

What is your choice for induction of anaesthesia in this patient?

Clearly, this is a very high-risk patient that requires senior support and a careful
multidisciplinary plan as discussed above. Your plan should be safe and well
thought out.
• Te options for anaesthesia include both general and regional
techniques. Given the patient’s cardiovascular and respiratory
comorbidities, a regional technique is favourable, though may be
challenging secondary to the musculoskeletal complications of disease.
• Ensure patient consent, AAGBI monitoring (with intra-arterial
blood pressure monitoring), resus equipment, difcult airway trolley
and emergency drugs readily available, including vasopressor and
inotropic support.
• An experienced senior anaesthetist should be present.
• Ensure careful patient positioning and padding of pressure points.
• Carry out a regional anaesthetic technique: a spinal with a popliteal
nerve block/catheter.

BIBLIOGRAPHY
Bell A, Tattersall R, Wenham T. Rheumatological conditions in critical care.
BJA Education. 2016; 16 (12): 427–433.
Woodcock et al. Perioperative management of glucocorticoids. Anaesthesia.
2020; 75: 654–663.

CASE: ANAEMIA
A 61-year-old female is undergoing major abdominal surgery for ovarian
malignancy. She has a history of rheumatoid arthritis but is otherwise well. Her
preoperative assessment blood test results show a haemoglobin level of 9.0g/dL.

How do we defne anaemia clinically?

• Te World Health Organisation has classifed anaemia as having a
haemoglobin level of <13.0 g/dL (males) and 12.0 g/dL (non-pregnant
females).

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What are the common causes of anaemia?

• Macrocytic anaemia (MCV >96 f):
• Vitamin B12/folate defciency.
• Alcoholic liver disease.
• Drugs e.g. phenytoin.
• Myelodysplasia.
• Normocytic anaemia (normal MCV):
• Acute haemorrhage.
• Anaemia of chronic disease.
• Chronic renal failure.
• Pregnancy.
• Hypothyroidism.
• Microcytic anaemia (MCV <80 f):
• Iron defciency.
• Talassaemia.
• Sideroblastic anaemia.
Likely causes of anaemia in the above patient are anaemia of chronic disease
(rheumatoid arthritis); possible chronic internal haemorrhage due to malignancy,
and side efects of drugs used in the management of both conditions.

What are the risks associated with anaemia during the perioperative
period?
• Increased duration of hospital stay.
• Higher incidence of postoperative intensive care requirement.
• Increased postoperative complications e.g. venous thromboembolism,
wound infections and sepsis.
• Increased likelihood of need for perioperative blood transfusion, and
subsequent risks.
• Overall increase in morbidity and mortality.

What is meant by the term “blood management”?

• Identifcation and multidisciplinary assessment of patients at risk of
perioperative anaemia.
• Strategy that encompasses guidelines and measures that can be used
to manage these patients optimally before, during and afer their
procedure.

How can this patient be optimised prior to surgery with regard to her low
haemoglobin?
• Identify likely causes of anaemia through investigations (haematinics
and red cell morphology).
• Consider agents to improve her haemoglobin level:
• Oral or intravenous iron supplementation (if iron-defcient).
• Erythropoietin.

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• Torough medical and drug history to detect modifable risk factors

for bleeding.
• Optimise the patient’s physiological reserve through optimal
nutrition, exercise and lifestyle changes.
• Planning for surgery:
• Senior led care.
• Minimally invasive procedure if possible.
• Strict surgical haemostasis intraoperatively.
• Cell salvage if appropriate.

Te estimated blood loss from the procedure is 800 mL, and the patient’s
postoperative haemoglobin is 7.6 g/dL. She is given one unit of packed red
cells in recovery. Five minutes into the transfusion, she feels hot, sweaty
and generally unwell. How you do proceed?
• Immediate review and early escalation to seniors if appropriate.
• Stop the blood transfusion while undergoing a rapid ABCDE
assessment of the patient to ascertain the cause of her symptoms.
• Check that the packed red cells match the patient’s name and ID band
and blood group as per local guidelines.
• Maintain patency of cannula with crystalloid.
• Consider paracetamol if pyrexial.
• Review of notes and observations since transfer into recovery.
• Contact blood lab/consultant haematologist.
• Return the given blood to the lab.
• Blood tests including full blood count, clotting and group and save.
• Conduct other relevant investigations and escalate to appropriate
individuals based on initial assessment of the patient.
• Potential causes of the patient’s symptoms include:
• Non-haemolytic febrile transfusion reaction.
• Allergic transfusion reaction.
• Haemolytic transfusion reaction.
• Conditions unrelated to transfusion e.g. sepsis, anaphylaxis, and
cardiac event.

BIBLIOGRAPHY
Takrar SV, Clevenger B & Mallett S. Patient blood management and
perioperative anaemia. BJA Education. 2017; 17 (1): 28–34.

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CASE: MAJOR ABDOMINAL SURGERY

A 65-year-old gentleman is being reviewed in the preoperative anaesthetic
clinic prior to admission for a robotic anterior resection for malignancy in
6 weeks. He has a history of hypertension for which he takes captopril and is
a smoker. He has previously had surgery for an inguinal hernia.

What do you understand by the term “prehabilitation”?

• An evidenced-based approach targeting high-risk patients, which
encompasses medical and lifestyle changes to increase a patient’s
physiological reserve preoperatively.
• Te goal is to decrease the risk of postoperative complications and
enhance the quality of recovery postoperatively, particularly afer a
major operation.

How would you counsel this patient prior to his procedure?

Prehabilitation
• Enrol the patient onto a local multidisciplinary prehabilitation
programme and explain the importance of improvements that can
be made; use surgery/malignancy as a “teachable moment” for the
patient to make lifestyle changes.
• Explain the importance of nutrition and refer to the dietician if
appropriate; the patient may have a poor diet due to malignancy, side
efects of medication or pre-existing medical conditions.
• Smoking and alcohol cessation can have a dramatic efect on
perioperative risk, and counselling should be ofered to the patient
for both if appropriate.
• Physical exercise is key preoperatively to increase perioperative
physiological reserve.
• Psychologist input may help manage these interventions and ofer
tools for mood assessment throughout.
Risk
• Te risks of major surgery and anaesthesia should be discussed with
the patient, including the specifc risks associated with particular
procedures and the potential postoperative complications and
expected recovery timeline.
• Risk stratifcation can be carried out using a number of diferent
tools to quantify probabilities for the patient but not used as the sole
method of explanation.
Perioperative anaesthetic management
• Options for anaesthesia and analgesia should be discussed with
the patient, as well as techniques that may be used to minimise the
perioperative risk.
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• Tis includes optimisation of physiological parameters, a multimodal

analgesia regimen, early postoperative mobilisation and physiotherapy
and senior led care.

How can this patient’s risk be quantifed preoperatively?

Scoring systems
• ASA (American Society of Anaesthesiologists).
• Lee’s Revised Cardiac Index (assesses risk of cardiac complications
afer a non-cardiac procedure).
• POSSUM score (Physiological and Operative Severity Score for the
enumeration of Mortality and Morbidity).
• SORT (Surgical outcome risk tool).
Functional assessment
• CPET.

How can this patient’s CPET results be used to direct perioperative

management?
• Preoperative risk quantifcation and stratifcation using an
assessment of cardiac and pulmonary function in unison.
• To facilitate shared decision making between the patient and
multidisciplinary team.
• To establish a focus for prehabilitation and medical optimisation.
• To allow direction of intraoperative management based on risk.

BIBLIOGRAPHY
Banugo P & Amoako D. Prehabilitation. BJA Education. 2017; 17 (2): 401–405.
Stones J & Yates D. Clinical risk assessment tools in anaesthesia. BJA Education.
2019; 19 (2): 47–53.

CASE: VASCULAR ACCESS SURGERY

A 59-year-old female patient is listed for creation of an arterio-venous
fstula for pre-emptive renal replacement therapy. She has a history of
hypertension, type 2 diabetes mellitus and a raised BMI.

What are the most common causes of chronic kidney disease?

• Diabetes mellitus.
• Glomerulonephritides.
• Pyelonephritis.
• Chronic hypertension.

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• Polycystic kidney disease.

• Renal vascular disease.

What are the options for renal replacement therapy in patients with
end-stage renal failure?
• Continuous ambulatory peritoneal dialysis.
• Haemodialysis.
• Renal transplant.

What is disequilibrium syndrome?

• Disequilibrium syndrome is a collection of symptoms that may occur
in new haemodialysis patients, including headache, visual changes,
nausea and vomiting, confusion, agitation, seizures and coma.
• It is thought to occur due to rapid changes in serum urea and
electrolyte levels, which may lead to cerebral oedema and rapid signs
of neurological changes.
• New dialysis patients should be carefully assessed and monitored,
and their treatment protocols increased gradually to avoid the
development of disequilibrium syndrome.

You are asked to review this patient prior to her procedure. What are the
key aspects in her history that will determine perioperative management?
Renal disease
• Te duration and any previous treatment should be determined,
including any earlier procedures for renal replacement therapy. If the
patient has had a renal transplant, her immunosuppressant status should
be noted and discussed with the renal team prior to her anaesthetic.
• Te cause of the patient’s renal disease should be established as it may
impact on care during the perioperative period.
Comorbidities
• A history of hypertension may predispose the patient to ischaemic
heart disease or peripheral vascular disease. A thorough cardiac
history should be taken including any ischaemic events or symptoms
suggestive of cardiac failure.
• Given the history of type 2 diabetes mellitus and end-stage renal
failure, both micro- and macro-vascular complications are likely.
Tese should be explored, together with current compliance with
treatment and blood sugar control.
• Te patient’s weight will have both physiological and practical
implications during the perioperative period, due to the associated
comorbidities, anaesthetic procedural challenges and the risk of
postoperative complications.
• Renal dysfunction will predispose her to electrolyte imbalance,
clotting dysfunction and a normocytic chronic anaemia that will
need to be checked prior to an anaesthetic.

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Drug history
• Anti-hypertensive medications such as ACE inhibitors may need to
be stopped prior to her procedure to minimise the risk of signifcant
perioperative hypotension.
• Hypoglycaemic agents may need regimens tailored during the
perioperative period.
• Immunosuppressive agents should be continued.

How would you anaesthetise this patient?

Tere is no right answer to this question – be able to justify and explain your
answer, ensuring that it is a safe approach for induction.
• Ensure AAGBI monitoring, resus equipment, difcult airway trolley
and emergency drugs are readily available.
• Given the patient’s comorbidities and the type of surgery, a regional
anaesthetic would minimise the risks associated with a general
anaesthetic. In addition, a nerve block is ofen favoured by the
surgeons due to its vasodilatory efects improving fstula patency
during the perioperative period.
• A regional nerve block also avoids the challenges of agent choice and
dosage for anaesthesia and analgesia, which need to be modifed in
patients with end-stage renal failure.
• Sedation can also be ofered to the patient, carefully titrated to avoid
the risk of respiratory depression and airway obstruction.

You carry out an axillary nerve block. 40 minutes into the procedure, the
patient is complaining of discomfort. How do you proceed?
• Alert the surgeons and ask them to stop as soon as feasible.
• Determine the location and type (e.g. pain and pressure) of discomfort.
• If the discomfort is felt in the arm, ask the surgeons to inject local
anaesthetic at the site of discomfort.
• Administer intravenous analgesia, cautious of respiratory depression
with opiates.
• If discomfort persists at all stages, ofer a general anaesthetic; risks
to be discussed with the patient and a senior alerted for help with
induction if necessary.
• Document actions and assess the patient in recovery and on the ward
following their procedure.

BIBLIOGRAPHY
Bradley T, Teare T & Milner Q. Anaesthetic management of patients requiring
vascular access surgery for renal dialysis. BJA Education. 2017; 17 (8):
269–274.

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CASE: NECK OF FEMUR FRACTURE

An 83-year-old female has been admitted with a proximal femoral fracture
and has been listed for an urgent hemi-arthroplasty on the trauma list. She
has a history of hypertension and previous breast cancer. She was confused
in the emergency department.

What are the key concerns for the perioperative management of this
patient?
Tis is a frail, elderly patient with a signifcant bony injury and a high risk of
perioperative mortality, which increases signifcantly with the length of delay to
surgical repair.
Comorbidities
• Cardiac history: Te patient has a history of hypertension, which
requires further investigation due to the possibility of ischaemic heart
disease or previous cardiac events. If treated with ACE inhibitors,
these should be stopped as soon as possible prior to surgery to avoid
the risk of signifcant perioperative hypotension but should not be a
reason to delay surgery.
• History of breast cancer creates the possibility of a pathological
fracture, particularly if recently diagnosed.
• Confusion in the emergency department could indicate a diagnosis
of either delirium or dementia, both of which should be managed
accordingly during the perioperative period. Capacity to consent for
the procedure will need consideration.
Frailty
• Multidisciplinary/specialist orthogeriatric team should do a frailty
assessment as it increases the risk of perioperative complications.
• Cause of fracture should be determined – falls can indicate frailty
and underlying conditions should be identifed and managed
appropriately to reduce falls risk.
Neck of femur fracture
• High-risk procedure in high-risk patient; local or national guidelines
should direct patient care.
• Surgery should take place within 48 hours of admission into hospital,
unless patient presents with reversible and time critical conditions e.g.
severe anaemia, electrolyte disturbance and uncontrolled diabetes.
• Multidisciplinary, senior perioperative management is key for safe
and optimal management of this patient.
Anaesthetic management
• A thorough preoperative history, examination and investigations are
crucial but should not delay surgery within the required time.
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• Anaesthetic technique should be directed by patient assessment and

importantly management should focus on minimising physiological
disturbances during the perioperative period.
• Neuraxial blockade should be used where appropriate with calculated
risk/beneft balance for an individual patient.
• Te evidence supporting regional over general anaesthesia is limited,
but dictates careful and judicious use of any anaesthetic or analgesic
agents. However, there is an overall increase in mortality with the use of
heavy sedation/general anaesthesia together with a regional technique.
Analgesia
• A multimodal approach to analgesia is key in patients with a proximal
hip fracture, avoiding the use of NSAIDs and high doses of opioid-
based medications.
• Regional techniques should be used where appropriate but should not
limit physiotherapy postoperatively.

What is frailty?
• Frailty is described as a group of symptoms that suggest a decline
in systemic physiological reserve and function. Typical features of
frailty include:
• Loss of muscle mass (sarcopenia).
• Generalised weakness.
• Slow gait.
• Decreased activity levels.

How can frailty be assessed?

Tere are a number of frailty scoring systems that can be used, for example:
• Rockwood Frailty Index – detailed scoring system including assessment
of comorbidities, mental health, cognition and functional status.
• Edmonton Frail Scale – patients are scored based on their medication,
balance, mobility and cognition.
• Clinical Frailty Scale – patients are scored based on their
comorbidities and vulnerability.

What are the challenges associated with pain management in elderly

patients?
• Assessment of pain difcult due to:
• Cognitive impairment.
• Visual/hearing impairment.
• Speech impairment.
• Concomitant pain due to pre-existing comorbidities.
• Limited options for analgesia due to side efects or efects on
physiological systems.
• Variable compliance with medication.

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BIBLIOGRAPHY
Grifths R & Mehta M. Frailty and anaesthesia: what we need to know.
Continuing Education in Anaesthesia, Critical Care & Pain. 2014; 14 (6):
273–277.
National Institute for Health and Care Excellence. Management of hip frac-
tures in adults CG124. June 2011, updated May 2017.

CASE: CARCINOID
A 61-year-old male patient is undergoing abdominal surgery for removal of
a carcinoid tumour.

What is a carcinoid tumour?

• A neuroendocrine tumour that arises from enterochromafn cells.
• Classifed according to their location based on the embryonic gut
origins:
• Foregut – lungs, bronchus and stomach.
• Midgut – small intestine, appendix and proximal colon.
• Hindgut – distal colon and rectum.
• Hormone secreting tumours; the majority of tumours produce and
secrete serotonin. However, the efects of excess hormones do not
usually manifest as they are metabolised in the liver prior to entering
the circulation.

What is carcinoid syndrome?

• Occurs in approximately 25% of patients with a carcinoid tumour.
• In asymptomatic patients, the vasoactive substances produced by the
localised gut tumours are metabolised in the liver, so there are no
systemic symptoms.
• If the carcinoid tumour metastasizes to the liver and rest of the body,
the vasoactive substances such as serotonin and histamine enter the
bloodstream to produce the stereotypical systemic carcinoid symptoms:
• Flushing.
• Diarrhoea.
• Lacrimation.
• Rhinorrhoea.

How would you assess this patient prior to his procedure?

History
• A full and thorough medical history is necessary, focusing on the potential
implications of the carcinoid tumour on the patient’s bodily systems.

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• Te history should also include a routine medical and anaesthetic

history with details about regular medications, social history, allergies
and airway.
• Disease complications can include:
• Cardiovascular: right-sided cardiac disease.
• Respiratory: wheeze and bronchospasm.
• Gastrointestinal: diarrhoea (leading to dehydration and
electrolyte disturbance).
• Skin: fushing.
• General: malnutrition, cachexia.
Examination and investigations
• Tese should be directed by fndings from the patient history and
previous appointments and should include:
• Baseline blood tests including full blood count (anaemia),
electrolytes, liver function tests and clotting.
• Chest X-ray.
• ECG and echo to rule out right-sided cardiac involvement.

What are the anaesthetic goals for management of this patient?

• Provide a smooth perioperative course for major abdominal surgery
including analgesia.
• Minimise the systemic complications of vasoactive mediator release
during tumour handling.
• Avoid the use of anaesthetic agents that may exacerbate carcinoid
symptoms or cause a carcinoid crisis e.g. morphine/atracurium
causing histamine release.

During tumour resection the patient’s blood pressure falls to 64/23 and
you notice increased airway pressures. How do you proceed?
• Initial management is to alert the theatre team, call for senior help
and apply 100% oxygen.
• Rapid ABCDE assessment to form a diferential diagnosis. Consider
the likelihood of a carcinoid crisis and treat early if probable.
• Intravenous bolus of 20 μg octreotide, followed by further boluses
titrated to efect. Small doses of phenylephrine or vasopressin can
also be considered if resistant to the initial treatment.
• Fluid bolus and close monitoring of cardiac output.
• Consider concomitant efects of potential large blood loss.

BIBLIOGRAPHY
Powell B, Al Mukhtar A & Mills GH. Carcinoid: the disease and its implications
for anaesthesia. Continuing Education in Anaesthesia, Critical Care &
Pain. 2011; 11 (1): 9–13.

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CASE: POSTOPERATIVE NERVE INJURY

You are asked to review a 41-year-old male patient in the anaesthetic clinic
who presents with lef arm weakness and numbness. He underwent lef
shoulder surgery 1 week ago with an interscalene nerve block and a general
anaesthetic. He is otherwise well.

What are the potential causes of this patient’s symptoms?

Anaesthetic
• Direct damage due to regional anaesthetic needling.
• Intraneural injection of local anaesthetic solution.
• Haematoma caused by needling.
• Perioperative hypotension (unlikely cause of local symptoms).
Surgical
• Direct nerve or tissue damage due to surgical procedure or retractors.
• Pathology secondary to surgery, such as haematoma formation.
• Poor perioperative positioning/padding.
Other
• Cerebrovascular event (localised).
• Local nerve ischaemia secondary to haematoma formation.
• Exacerbation of pre-existing comorbidities e.g. carpal tunnel syndrome.

How would you assess this patient in clinic?

Te purpose of assessing the patient is to identify a treatable cause, guide
management and document how the neurological defcit progresses.
• Take a full history of the patient’s symptoms including the duration,
variation in symptoms over time, exacerbating or relieving factors
and associated symptoms, as well as a medical and social history.
• Examine and document the current sensory and motor defcit.
Attempt to localise symptoms to a particular nerve root or bundle in
order to aid diagnosis. Examine the site of needling and operation;
this may reveal a haematoma.
• Review the anaesthetic chart, operation note and postoperative
observations chart.
• Discuss the patient with an anaesthetic consultant and the relevant
surgical team following the initial assessment to determine the likely
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cause, any relevant investigations that should be done and how the
patient should be managed, including an apology and the appropriate
escalation if likely iatrogenic.
• Consider a referral to neurology if appropriate, and follow up.

What are the risk factors associated with perioperative nerve injuries?
Patient factors
• Comorbidities e.g. hypertension, peripheral vascular disease,
diabetes mellitus, multiple sclerosis.
• Smoking.
• Anatomical variation in local structures.
Anaesthetic factors
• Performing the block under general anaesthetic.
• Haemodynamic instability secondary to hypotension, hypovolaemia,
hypoxia or hypothermia.
• Inexperience.
Surgical factors
• Type of surgery: neurosurgery, cardiac, abdominal and orthopaedic
surgical procedures.

How can peripheral nerve injuries be classifed?

Te Seddon classifcation can be used to classify nerve injuries.
• Neuropraxia – damage to the myelin sheath only.
• Axonotmesis – damage to myelin sheath and axons.
• Neurotmesis – damage to myelin sheath, axons and nerve itself.

What investigations may aid in the diagnosis of this patient’s symptoms?

• Electromyography.
• Nerve conduction studies.
• Magnetic resonance imaging.
• Ultrasound.

How can the risk of peripheral nerve injuries be minimised in patients

undergoing shoulder surgery?
• Torough medical history preoperatively to detect high-risk patients.
• Avoidance of perioperative haemodynamic instability.
• If a regional technique is used, several strategies can be employed to
reduce the risk of peripheral nerve injuries:
• Use of ultrasound with in-plane needling, ensuring that the
needle shaf and tip are always visible.
• A regional nerve block can be carried out in awake patients, so
they are able to identify paraesthesia or pain during the procedure.
• Use of a peripheral nerve stimulator.

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• Adequate patient padding and neutral positioning, including

limitation of excess movement at the shoulder joint, where the
brachial plexus is at risk.
• Using alternative techniques to regional anaesthesia (although the
benefts of a block must be considered as well as the risks when
making an anaesthetic plan).

BIBLIOGRAPHY
Lalkhen AG & Bhatia K. Perioperative peripheral nerve injuries. Continuing
Education in Anaesthesia, Critical Care & Pain. 2012; 12 (1): 38–42.
O’Flaherty D, McCartney CJL & Ng SC. Nerve injury afer peripheral nerve
blockade – current understanding and guidelines. BJA Education. 2018;
18 (12): 384–390.

CASE: CAUDAL ANAESTHESIA

A 2-year-old male patient is undergoing hypospadias repair surgery. You are
asked to review him prior to his procedure.

What are the key aspects in the preoperative assessment for this patient?
History
• Tis is a young child, so the history will be taken from the parent/
guardian. It is important to engage the child and put them at their ease.
• Birth history, vaccinations and a family history of anaesthetic
problems should be emphasised.
• Infections are common in children and a reason to delay surgery. Ask
about coryzal symptoms, fevers and contact with unwell individuals.
Examination
• Examinations may need to be pragmatic depending on the
cooperation of the child.
• Airway assessment.
• Review observations, in particular the child’s temperature.
• Check that the patient has been recently weighed.
Investigations
• No specifc investigations should be required unless indicated by the
patient’s medical history.

What are the benefts of caudal anaesthesia?

• Excellent analgesia during the perioperative period.
• Safe and straightforward procedure.

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• Avoidance of side efects of opioid-based analgesia.

• Caudal catheters can be used for prolonged blockade if appropriate.
• Minimal haemodynamic instability.

How would you perform a caudal block in this patient?

• Ensure access to a checked anaesthetic machine, trained assistant and
full resuscitative capabilities.
Prior to the procedure
• Obtain consent from the parents.
• Apply AAGBI monitoring.
• Perform a general anaesthetic.
• Position the patient: lef lateral with knees fexed to chest.
• Full asepsis using a hat, mask, sterile gloves, sterile drapes and
chlorhexidine 0.5% spray.
• Calculate the correct dose/volume of local anaesthesia based on
the patient’s weight and the Armitage formula (0.5 mL/kg 0.25%
bupivacaine for a sacro-lumbar block).
During the procedure
• Identify the sacral hiatus – forms an equilateral triangle with the
posterior superior iliac spines.
• Insert a 22G cannula in a cranial direction through the sacral hiatus
until a “click” is felt to indicate passage through the sacrococcygeal
membrane.
• Advance the cannula and remove the needle.
• Allow the cannula to drain under gravity looking for blood or
CSF drips.
• Aspirate the cannula again looking for blood or CSF.
• If no blood or CSF is seen, inject the local anaesthetic solution.
• Palpate the skin over the sacrum during injection. Tis will detect a
cannula incorrectly positioned in the subcutaneous tissue.
Postoperative
• Warn the nurses and parents that the patient may have weak/numb
legs and an unsteady gait.

How can the duration of the block be prolonged?

• Higher concentration or volume of local anaesthetic (ensuring the
maximum safe dose is not exceeded).
• Use of a caudal catheter to enable additional local anaesthesia to be
administered.
• Many diferent drugs have been added to the local anaesthetic
in caudal blocks, including fentanyl, clonidine and ketamine.
Te ketamine must be a preservative free preparation to avoid
neurotoxicity.

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What are the complications associated with caudal analgesia?

• Block failure.
• Leg weakness.
• Urinary retention (although unlikely to be an issue as the patient
would be catheterised intraoperatively).
• Intravenous injection and local anaesthetic toxicity.
• Dural puncture/intrathecal injection.
• Epidural haematoma/abscess.

BIBLIOGRAPHY
Patel D. Epidural analgesia for children. Continuing Education in Anaesthesia,
Critical Care & Pain. 2006; 6 (2): 63–66.

CASE: WRONG-SIDED BLOCK

A 35-year-old male patient is undergoing rotator cuf repair surgery afer
sustaining an injury while playing cricket. He is otherwise well, has no
allergies, and has never had an anaesthetic before.

What are the options for anaesthetising this patient?

• General anaesthetic.
• General and regional anaesthetic combined.
• Regional anaesthesia awake or with sedation.

What are the advantages of regional anaesthesia alone in patients under-

going shoulder surgery?
Tere is no consensus in surgeons or anaesthetists in the place for awake shoulder
surgery under regional anaesthesia and how it compares to combined regional
and general anaesthesia. Te provision of this service is dependent on a team
that are engaged and provide it regularly. Tere are some patients where it will
be the safest option.
Regional anaesthesia
• Represents an additional choice to the patient.
• Provides excellent pain control during and afer surgery.
• Allows for a shorter duration of surgery/inpatient stay.
• Avoids the side efects of opioid-based analgesic agents e.g. nausea,
vomiting and constipation.
• Avoids the side efects and complications of general anaesthetic
e.g. airway compromise, dental damage, postoperative pulmonary
complications and hypotension.

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• Allows patients to eat and drink straight afer surgery.

• Facilitates a rapid turnover of patients, improving efciency and
decreasing costs for hospital.

How would you anaesthetise this patient?

Tere is no right answer to this question, as long as you are safe. However, given
the direction of the questions, a regional approach would be a good answer!
Preoperative
• Perform a standard anaesthetic assessment. Tere is nothing in the
history above that suggests signifcant pathology to investigate.
• Consent to the technique explaining the benefts, risks and potential
complications.
• Apply full monitoring as per the AAGBI minimum monitoring
standards.
Interscalene regional block
• Position the patient supine, head up and neck rotated to contralateral
side.
• Ensure full asepsis, including a hat, mask, sterile gloves and
chlorhexidine 0.5% spray.
• Using a linear ultrasound probe, identify the brachial plexus at the
level of the subclavian artery and follow it in a cephalad direction until
the C5-C7 nerves can be identifed travelling as a discrete bundle.
• “Stop before you block” moment: Confrm the correct block on the
correct side for the correct patient.
• Inject local anaesthetic into the skin.
• Using an in-plane approach, inject a sufcient volume of bupivacaine
to surround the nerves (10–15 mL 0.5% bupivacaine should be
sufcient) using a 50 mm echogenic block needle.
• Assessment of patient following regional block to ensure no
complications.

What is meant by an “in-plane” approach?

• Te needle is inserted into the skin at the lateral aspect of the
ultrasound probe, ensuring that the needle tip and shaf are both
visible throughout the procedure.

What are the potential complications associated with an interscalene block?

• Block failure.
• Phrenic nerve blockade.
• Horner’s syndrome.
• Recurrent laryngeal nerve blockade and hoarse voice.
• Nerve injury.
• Prolonged weakness/numbness.

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• Local anaesthetic toxicity.

• Wrong-sided block.

You perform the interscalene block and review the patient 5 minutes
later. Unfortunately, the block was performed on the incorrect side. What
are the factors that may contribute to a wrong-sided block being done?
Surgical
• Surgical mark on the incorrect side.
• Consent form indicating the incorrect side.
Anaesthetic technique
• Block performed afer induction of general anaesthesia.
Situational factors
• Prolonged period between the WHO checklist and regional block.
• Surgical mark not visible while the block is being done.
• Inexperienced anaesthetist.
• Failure to perform a “stop before you block” moment.
• Human error due to distractions, time pressure, fatigue, stress or
anxiety.

How would you manage this incident?

Since 2018, a wrong-sided block has been classifed as a “never event”, and as such
is going to cause a great deal of anxiety to the patient and the practitioner. It will
also derail the operating list. It should be managed with honesty and humility.
• Declare the mistake to the patient, anaesthetic assistant, anaesthetic
and surgical consultants and theatre team.
• Apologise to the patient. Ensure that they are kept safe e.g. monitored
if they have had any sedative medication, or woken up safely if they
have had a general anaesthetic.
• Discuss with a senior anaesthetist and the theatre team regarding how
to proceed; almost certainly the operation will have to be postponed.
• Document conversations with the patient and team.
• It may be appropriate for another anaesthetist to take over the case/list.
• Discuss with supervisor and medicolegal team if appropriate.
• Report the wrong-sided block as a critical incident according to local
protocols.
• Discuss the issue with educational supervisor/college tutor as to
whether further support or training is needed.

BIBLIOGRAPHY
Hewson DW, Oldman M & Bedforth NM. Regional anaesthesia for shoulder
surgery. BJA Education. 2019; 19 (4): 98–104.

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CASE: RIB FRACTURES

A 79-year-old male patient is admitted to the emergency department afer
a fall. He has a history of ischaemic heart disease and prostate cancer but
is normally well and mobile. What is your initial management?
A fall could be minor or very serious depending on the context, cause and
mechanism. Without further information, assume it is a major trauma as it is
better to be overprepared than under.
• Te patient needs to be assessed with a full “hands-of” handover
to the trauma team unless there is catastrophic bleeding or a life-
threatening event.
• A primary survey should be performed to include treatment of each
body system as indicated. It would follow an ABCDE approach.
• A trauma CT scan is the priority in order to determine the location of
injuries and further interventions required.
• Transfer of patient to appropriate location: ward, intensive care unit
or theatre for further treatment and management.

Te patient is alert and gives a history of tripping over his cat at home
onto the tiled kitchen foor. He is complaining of pain in his right chest.
What are your concerns?
• Cause of the fall – likely mechanical, but other factors should be
investigated e.g. syncope.
• Duration of his chest pain; if prior to the fall, the pain could indicate
a myocardial ischaemic event; if following the fall, it could suggest a
pneumothorax and/or rib fractures.
• Other injuries due to the fall.

A trauma CT scan shows four right-sided rib fractures and no other

internal injuries. Which ribs are most commonly fractured?
• Ribs 1–3 tend to be protected by the clavicle and shoulder joint, so
usually require a high-impact force to be fractured.
• Ribs 4–10 are most commonly fractured.
• Ribs 11 and 12 are less likely to be fractured, as they are relatively
fexible.

What are the priorities in the management of this patient?

Rib fractures are associated with serious lung complications and a high mortality.
Mortality increases with age, number of rib fractures, fail chest and lung contusion.
Te priority here is risk mitigation, which can be achieved in several diferent ways.
Analgesia
• Multimodal analgesia should be administered, including simple
analgesia, opioids and other adjuncts such as lidocaine patches and
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gabapentin. Regional anaesthesia may be especially helpful where the

above measures are insufcient to allow coughing, deep breathing or
physiotherapy.
• Early aggressive regional anaesthesia has been shown to reduce
mortality, with the best evidence base for thoracic epidurals and
paravertebral blocks. However, other chest wall blocks are becoming
popular and are used on many units.
• Local guidelines or rib fracture pathways should ensure a stepwise
approach to analgesia.
Assessment
• A multidisciplinary approach is vital for efective management of
elderly patients with rib fractures, including review by appropriate
medical teams, orthogeriatricians, physiotherapy, senior nursing
staf, anaesthetists and the acute pain team.
• History: Should focus on comorbidities, falls, frailty and medications
(particularly the use of blood thinners).
• Examination: Look for signs of fail chest, contusions and other
lung pathology. A full respiratory examination should be conducted
to assess the efect of the injury on the patient’s oxygenation and
ventilation.
• Investigations: Depending on the situation, it may be useful to take
blood for an arterial blood gas, full blood count, urea and electrolytes
and a clotting screen.
Location
• Given the high mortality, this patient should be managed on a high
dependency unit.
Ventilation
• Te patient is at high risk of atelectasis, pneumonia and
respiratory failure due to hypoventilation and a poor cough secondary
to pain.
• Initially, the patient should be prescribed supplementary oxygen with
nasal cannulae or a facemask to maintain adequate saturations.
• High fow nasal cannulae or non-invasive ventilatory techniques
should be considered if the above is not efective and the patient
becomes hypoxic or hypercapnic.
• Early respiratory physiotherapy is key, focusing on techniques such as
deep breathing and coughing, and incentive spirometry.

What regional techniques can be considered in this patient?

• Serratus anterior block/catheter.
• Paravertebral block/catheter.
• Erector spinae plane block/catheter.
• Toracic epidural.

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What are the benefts of a paravertebral catheter compared to a thoracic

epidural in this patient?
• Analgesia from a paravertebral catheter is equally efective as a
thoracic epidural.
• Avoids the side efects and risks associated with epidurals e.g. dural
puncture, sympathetic blockade and urinary retention (particularly
in a patient with prostate cancer).
• A paravertebral block is easier to perform with ultrasound guidance.
• Te patient can remain mobile, which may decrease the risk of other
complications e.g. venous thromboembolism.

BIBLIOGRAPHY
Williams A, Bigham C & Marchbank A. Anaesthetic and surgical management
of rib fractures. BJA Education. 2020; 20 (10): 332–340.

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13
SEDATION

CASE: DENTAL EXTRACTION

A 26-year-old female patient is undergoing extraction of two wisdom teeth
under sedation. She is otherwise well and has no allergies.

What is conscious sedation?

• Conscious sedation can also be described as moderate sedation.
• It is a “drug-induced depression of consciousness”.
• Verbal contact is maintained throughout the procedure using either
verbal commands or light touch.
• Te patient remains spontaneously ventilating, haemodynamically
stable and is able to maintain their airway without any interventions
such as airway manoeuvres or adjuncts.

What are the key issues when pre-assessing this patient for her procedure?
• Te patient should be carefully assessed to confrm her suitability for
conscious sedation, with a focus on the airway, cardiovascular and
respiratory systems, and body mass index. Relative contraindications
to sedation include:
• Morbid obesity.
• Severe comorbidities e.g. cardiovascular disease, liver disease,
lung disease.
• Learning difculties.
• Inability to stay still e.g. resting tremor.
• Severe needle phobia.
• A thorough social and psychological assessment is key; the patient
needs to be well informed that she will remain conscious throughout,
and therefore be aware of what is going on around her e.g. drilling
sounds and voices.
• Patients should be fasted as if they were undergoing a general
anaesthetic, in case of the need for airway intervention and induction
of anaesthesia.

When carrying out conscious sedation, how can the risks to the patient
be minimised?
Choice of agent
• Te choice of drug should be determined by the patient’s
comorbidities, the length of the procedure and the anaesthetist’s
familiarity with the agent.
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• Ideally, only one drug should be used throughout the procedure to

decrease the efect of synergism and augmentation of side efects such
as respiratory depression when agents are used in combination.

Location
• Dental procedures are ofen carried out in remote locations, and
the anaesthetist should ensure that they are familiar with both the
routine and emergency equipment and drugs, and how to escalate
should assistance be required in an emergency.
• An appropriate recovery area should be available prior to the patient’s
discharge.

Personnel
• Te clinician carrying out the procedure should not be in charge of
sedating the patient concurrently.
• Adequate numbers of trained staf are required including recovery
nurses and an anaesthetic assistant.

Monitoring
• AAGBI monitoring should be used, to include pulse oximetry, cardiac
monitoring and non-invasive blood pressure monitoring. End tidal
carbon dioxide can be used to monitor ventilation.
• Clinical signs such as the response to verbal and tactile communication
should be used, and a trained anaesthetist should be present
throughout the whole procedure.

During the procedure, the dental surgeon alerts you to a sudden increase
in the volume of blood in the suction and in the patient’s mouth. Te
patient starts coughing and her saturations decrease to 87%. What is your
immediate management?
Tis is an anaesthetic emergency, and should be dealt with quickly and safely.
• Alert the theatre team immediately. Tis is an anaesthetic emergency,
likely aspiration of blood.
• Call for urgent senior help and ask for the airway trolley.
• Suction any excess blood in the patient’s airway and place her in a
head down, lef lateral position.
• Ventilate the patient using a facemask with 100% oxygen.
• Cricoid pressure can be applied if the patient is not vomiting.
• If there is no improvement, or the patient continues to deteriorate,
intubate and ventilate the patient. Suction the airway using a suction
catheter prior to positive pressure ventilation.
• Order an urgent chest x-ray and consider chest physiotherapy/
bronchoscopy if there is any evidence of consolidation on imaging or
chest auscultation.

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• Further management should be directed by the patient’s observations

and clinical examination, but there should be a low threshold for
critical care input.

BIBLIOGRAPHY
Blayney MR. Procedural sedation for adult patients: an overview. Continuing
Education in Anaesthesia, Critical Care & Pain. 2012; 12 (4): 176–180.

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14
TRAUMA AND STABILISATION

CASE: MAJOR TRAUMA

A 23-year-old male cyclist is admitted to the emergency department
following a road trafc collision with a car travelling at 50 mph on a dual
carriageway.

How is major trauma defned?

• Te Injury Severity Score (ISS) is used to defne major trauma, with a
score of more than 15 suggesting major trauma.
• To calculate the ISS, the body is divided into six regions, and injuries
in each area are scored on a scale of 1 (minor injury) to 6 (not
survivable).
• Te three highest scores are squared and added together to give the
fnal result.

How would you approach this patient?

• A patient with major trauma is usually taken directly to a major
trauma centre, where a trauma team should be assembled in the
emergency department and briefed prior to the patient arriving, for
rapid assessment and treatment.
• A “hands-of” handover to the trauma team should be done if the
patient does not require any immediate life-saving treatment.
• A primary survey should be carried out by multiple medics on the
team to identify any life-threatening injuries. Tis should be fed back
to the trauma team leader.
• Te priority is to reduce the time from the injury to defnitive care, so
only absolutely necessary interventions should be performed, such as
securing the airway and gaining adequate intravenous access.
• If the patient is stable, a trauma CT (head to pelvis) should be
performed to guide further management.
• Te patient should be transferred to an appropriate location for
defnitive or supportive treatment e.g. theatres, intensive care unit,
trauma ward.

On examination, the patient has oxygen saturations of 90%, and paradoxical

breathing is noted. He is tender to palpation on the right side of his chest,
which is bruised. His arterial blood gas demonstrates a type 1 respiratory
failure.

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What are the potential causes for these fndings?

Respiratory
• Pneumothorax.
• Haemothorax.
• Pulmonary contusion.
• Diaphragmatic rupture.
• Tracheal/bronchial rupture.
Cardiovascular
• Cardiac tamponade.
• Damage to the thoracic aorta.
• Cardiac contusion.
Musculoskeletal
• Flail chest.
• Sternal fracture.

What are the strategies available for minimising blood loss in this patient?
Management of catastrophic bleeding should be the priority, using the following
measures.
• Stop the bleed following the haemostatic ladder: direct compression of
the wound; application of a compression dressing; and packing with
haemostatic agents. If the above measures fail, consider a tourniquet.
Limb immobilisation and pelvic binding should be considered if
internal bleeding is suspected. For cavity haemorrhage (e.g. abdominal
bleeding), early damage control surgery may be necessary, aimed
at controlling the bleeding rather than physiological restoration
of function. If appropriate and available, consider interventional
radiology.
• Replace the volume that has been lost: rapid blood transfusion using an
appropriate device (e.g. Level 1 infuser or Belmont) through a suitable
large bore intravenous line. Bedside clotting testing (e.g. TEG) should
be used to guide further transfusion.
• Facilitate clotting: tranexamic acid, active warming and calcium.

Te arterial gas shows a blood glucose level of 14.9 mmol/L. Why might
this be?
• Te patient has undergone major trauma, leading to activation of the
stress response.
• Increased plasma catecholamine and glucocorticoid levels secondary
to the stress response facilitate gluconeogenesis and glycogenolysis,
causing the plasma glucose levels to increase.

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Te patient desaturates to 84% and his blood pressure drops to 65/43.

Tere are no breath sounds on the right and his trachea is deviated to the
lef. How do you proceed?
• Tis is likely a tension pneumothorax, which is a life-threatening
emergency.
• Alert the multidisciplinary trauma team immediately.
• Te urgent treatment is a thoracostomy performed in the 4th or 5th
intercostal space in the mid-axillary line. Following decompression, a
chest drain will be required.
• Decompression of the pneumothorax will likely restore the patient’s
normal physiology. However, if the patient deteriorates further, a
careful plan is required prior to intubation and ventilation taking the
following into account:
• Te patient is currently haemodynamically unstable, and both
induction and positive pressure ventilation may lead to a cardiac
arrest.
• Surgical decompression can be done during induction, which
requires appropriate preparation.
• Continuous reassessment of the patient is necessary. Intubation
should be considered prior to a transfer to prevent a challenging
emergency intubation during the transfer. However, it might be
safer to continue resuscitative measures frst to reduce further
cardiovascular collapse on induction.

BIBLIOGRAPHY
Sengupta S & Shirley P. Trauma anaesthesia and critical care: the post trauma
network era. Continuing Education in Anaesthesia, Critical Care & Pain.
2014; 14 (1): 32–37.

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15
INTENSIVE CARE MEDICINE

CASE: PANCREATITIS
A 42-year-old male patient is admitted to intensive care with severe pancreatitis.
He has a history of hypertension, chronic back pain and alcohol excess.

How is a diagnosis of severe pancreatitis made?

• A diagnosis of pancreatitis requires two of the following three criteria
to be fulflled:
1. Severe epigastric abdominal pain consistent with a diagnosis of
pancreatitis.
2. An increase in serum lipase or amylase at least three times the
upper limit of normal.
3. CT abdominal scan fndings suggestive of pancreatitis.
• Severe pancreatitis suggests the presence of organ failure or local
complications for more than 48 hours, and ofen requires management
on a high dependency or intensive care unit for supportive therapy.

What causes Cullen’s sign?

• Cullen’s sign is seen as darkened discolouration and oedema
surrounding the umbilicus.
• It is caused by retroperitoneal haemorrhage tracking through
subcutaneous fat and abdominal planes.

How would you manage this patient on admission to intensive care?

• Take a detailed handover from the parent team including any
investigations and treatment.
• Carry out an ABCDE assessment to establish the need for time-critical
interventions and escalation of care environment, in consultation
with seniors as appropriate.
• Take a thorough medical and social history, examine the patient and
ensure appropriate baseline investigations are done including an
arterial blood gas, renal function and markers of infection.
• Management of this patient will be largely supportive and should
include:
• High fow oxygen and further ventilatory support if indicated.
• Fluid resuscitation due to ongoing insensible losses and
intravascular volume depletion.
• Blood pressure support with vasopressors if required.
• Early enteral feeding and ulcer prophylaxis.

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• Correction of electrolyte disturbances and blood glucose control.

• Analgesia for patient comfort and to minimise the efect of
abdominal pathology on ventilation.
• Consider administering agents to prevent alcohol withdrawal given
the patient’s history (chlordiazepoxide is commonly used).

What are the complications in patients with severe acute pancreatitis?

Local complications
• Pancreatic/local fat necrosis.
• Haemorrhagic pancreatitis.
• Pancreatic pseudocyst formation.
• Pancreatic abscess.
Systemic complications
• Pleural efusion.
• Systemic thromboses e.g. portal vein/splenic vein thrombosis.
• Major abdominal haemorrhage.
• Intra-abdominal hypertension/abdominal compartment syndrome.
• Malnutrition.
• Diabetes mellitus.
• Prolonged stay on intensive care and associated risks.
• Overall increase in morbidity and mortality.

Te patient deteriorates and requires intubation and ventilation. A week

later, his repeat CT scan shows fndings suggestive of pancreatic necrosis.
How should he be managed?
• Continue supportive treatment as above.
• Ensure multidisciplinary involvement of the surgical team to
ascertain the best course of management.
• Consider parenteral nutrition if not absorbing enteral feeds.
• Any surgical intervention should be delayed until 3–4 weeks afer
the initial diagnosis due to the increased risk of mortality with early
surgery.
• If indicated (for management of suspected infected necrosis or
abscess) opt for minimally invasive techniques initially if appropriate
e.g. percutaneous drainage.
• Administer antibiotics only if there is suggestion of infective necrosis
(liaising with microbiology).

What are the long-term consequences of a prolonged stay in intensive

care?
• Weakness and loss of muscle mass.
• Sleep disturbance.
• Cognitive dysfunction/decline.
• Anxiety/depression.

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 Intensive Care Medicine

• Long-term pathology: chronic kidney disease, heart failure,

pulmonary fbrosis.
• Complications of prolonged intubation/tracheostomy e.g. phrenic
nerve weakness and tracheal stenosis.
• Chronic pain.
• Chronic pressure sores.

BIBLIOGRAPHY
MacGoey P, Dickson EJ & Puxty K. Management of the patient with acute
pancreatitis. BJA Education. 2019; 19 (8): 240–245.

CASE: SEPSIS
You are asked to review a 36-year-old female patient in the emergency
department who has presented with lethargy and feeling generally unwell.
Her partner says she has been confused and feverish. Her oxygen saturations
on air are 95%, her respiratory rate is 29, her heart rate is 122 and her blood
pressure is 83/52.

What are the priorities in the management of this patient?

Tis is a sick patient who needs immediate assessment and treatment.
Assessment
• Carry out a rapid ABCDE assessment including a focused history and
examination, treating any pathophysiology concurrently.
• Recognise the relevant indicators of sepsis and form a diferential
diagnosis based on the patient assessment to direct investigations.
• Escalate to senior medical and critical care teams as appropriate.
Investigations
• Attach continuous bedside monitoring and consider early invasive
blood pressure monitoring (but this should not delay treatment).
• Do a urine dipstick and culture if appropriate.
• Order a portable chest X-ray (to take place in the emergency department).
• Blood tests should include a full blood count, urea and electrolytes,
clotting and blood cultures. A venous or arterial blood gas should be
done as soon as possible (note the lactate).
Treatment
• Titrated supplementary oxygen therapy.
• Fluid resuscitation through large bore intravenous access. Start with
30 mL/kg crystalloid initially, but the patient may need several litres
and should be reassessed following each bolus/infusion.

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• Broad-spectrum intravenous antibiotics according to the local

guidelines and suspicion of the likely source.
• Catheterise and strict monitoring of fuid balance.
• Consider vasopressor agents early if not fuid responsive.
• Refer and transfer to critical care if appropriate.

What are the qSOFA criteria?

• Te quick Sequential Organ Failure Assessment scoring system uses
three criteria to assess the risk of morbidity and mortality in patients
with sepsis:
1. Respiratory rate ≥22.
2. Altered mental status.
3. Systolic blood pressure <100 mmHg.
• Each criterion receives a score of 1, and a score of 2 or more indicates
an increased risk of mortality and a prolonged critical care stay.

What is the defnition of sepsis?

• A life-threatening organ dysfunction due to a dysregulated host
response to infection (2016 3rd International Consensus).

What are the physiological targets in the early management of sepsis?

• Mean arterial pressure >65 mmHg.
• Lactate <4 mmol/L with lactate clearance.
• Individualised approach to cardiovascular system manipulation:
adequate fuid resuscitation and assessment of cardiac function to
determine whether inotropic agents are required.

Te patient requires vasopressors to maintain her systolic blood pressure,

and she is admitted to intensive care where she is intubated. How can the
risk of ventilator-associated pneumonia be decreased?
• Te measures within the ventilator care bundle aim to lower the risk of
a patient developing a ventilator-associated pneumonia, and include:
• A daily sedation hold.
• Elevation of the head of the bed.
• Regular monitoring of endotracheal tube cuf pressures.
• Sub-glottic suction of secretions.
• Excellent hand hygiene when handling airway equipment.
• Use of closed circuits.

BIBLIOGRAPHY
Gunasekera P & Gratrix A. Ventilator-associated pneumonia. BJA Education.
2016; 16 (6): 198–202.

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Nunnally ME. Sepsis for the anaesthetist. British Journal of Anaesthesia. 2016;
117 (S3): iii44–iii51.
Rhodes A, Evans LE, Alhazzani W et al. Surviving sepsis campaign:
international guidelines for management of sepsis and septic shock: 2016.
Intensive Care Medicine. 2017; 43: 304–377.

CASE: PATIENT CARE FOLLOWING A

CARDIAC ARREST
A 49-year-old male patient is admitted following a cardiac arrest in the
community. He underwent three cycles of CPR and shocks for a VF rhythm.
Te post-ROSC ECG demonstrates widespread ST segment elevation. He is
intubated and ventilated and admitted to intensive care following cardiac
catheterisation, during which a clot was removed from the lef anterior
descending coronary artery.

What are the key aspects for post-resuscitation care in this patient?
• Take a full collateral history and carry out a systematic examination.
Update the family and determine the general wishes of the patient,
including advanced statements or directives.
• Continue treatment for the likely cause of the cardiac arrest
(myocardial infarction) with close cardiology team involvement,
including appropriate medication as directed.
• Optimise ventilatory and haemodynamic strategies with appropriate
monitoring to ensure favourable physiology to minimise secondary
brain injury and cardiac work.
• Ensure neuroprotective measures including treatment of pyrexia
and seizures and blood glucose control. Targeted temperature
management should be discussed.
• Consider further investigations when the patient is stable e.g. CT
head, EEG and echo.

How is targeted temperature management carried out?

• Ensure continuous core body temperature monitoring e.g.
oesophageal temperature probe.
• Te patient should be well sedated and can be paralysed to prevent
shivering and other involuntary movements.
• Surface cooling measures e.g. ice packs, wet towels or specifc
proprietary devices.
• Specialised intravascular systems can be used to monitor and fnely
control core temperature.

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What is the “post-resuscitation” syndrome?

• Te post-resuscitation syndrome consists of four elements that
contribute to further pathological responses afer cardiac arrest:
1. Secondary brain injury.
2. Cardiac dysfunction/stunning.
3. Systemic ischaemia and reperfusion injury.
4. Continuation of the pathological process that triggered arrest.

Te patient remains intubated and ventilated for 2 days. How should

prognostication take place?
• Neurological prognostication should take place at least 72 hours
following the cardiac arrest to allow for targeted temperature
management to take place, and for potential reversibility of ongoing
pathological processes.
• Prior to prognostication, restoration of normal physiology should be
attempted as best as possible to allow for an accurate diagnosis.
Clinical examination
• Sedation hold with regular neurological assessment including GCS.
• Poor prognostic indicators include: absence of ocular refexes
(pupillary, corneal blink), absent/abnormal motor response and
ongoing seizure activity.
Investigations
• CT head looking for indicators of hypoxic brain injury.
• EEG – burst suppression and seizure activity are negative prognostic
indicators.
• Somatosensory evoked potentials (specifcally N20s).
• Blood markers of tissue damage e.g. neuron-specifc enolase
levels >33 μg/L on days 1–3 are strongly associated with a poor
outcome.

If you are asked further about somatosensory-evoked potentials, it should be

noted that:
• Bilaterally absent short latency peaks (N20 peaks) have a 100%
predictive value for poor outcome (death/severe disability) with a false
positive rate of nearly 0% and narrow confdence intervals.
• SSEP is the most reliable test to predict poor outcomes in this patient
group but does not predict good outcomes.
• Te pre-test probability for poor outcome is essential; use the test only
for patients who remain unconscious following a hypoxic ischaemic
insult. Te test has been validated for use as early as 24 hours afer a
cardiac arrest.
• SSEP testing is not afected by sedatives, analgesics, paralysing agents
or metabolic insults.

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Te CT scan suggests widespread ischaemia efects likely representing

severe hypoxic brain injury in this context. What criteria need to be met
before brainstem death testing can take place?
• No likely reversible cause of apnoea e.g. biochemical/metabolic
causes, residual sedatives or neuromuscular blockade, hypothermia.
• Stable physiology prior to undertaking the tests.
• Testing should be performed by two doctors familiar with the process,
fully registered with the General Medical Council for at least 5 years,
with at least one consultant.
• Tere should be an identifed precipitating cause of brainstem death.

How is the apnoea test carried out?

• Pre-oxygenate the patient with 100% oxygen.
• Disconnect the ventilator and oxygenate the patient through a
catheter in the trachea (5 L/minutes).
• Observe the patient for signs of respiratory efort for 5 minutes.
• Ensure a rise in PaCO2 by >0.5 kPa, from a starting baseline of
PaCO2 >6 kPa and pH <7.4.

BIBLIOGRAPHY
Academy of Medical Royal Colleges. A code of practice for the diagnosis and
confrmation of death. 2008. Available online at www.aomrc.org.uk.
Jackson MJ & Mockridge AS. Prognostication of patients afer cardio-
pulmonary resuscitation. BJA Education. 2018; 18 (4): 109–115.

CASE: MALNUTRITION
A 43-year-old male patient is admitted to intensive care following an
emergency laparotomy for a ruptured infected appendix. He is a smoker and
drinks 40 units of alcohol a day. He is intubated and ventilated.

Why is this patient at high risk of malnutrition?

• Likely abdominal sepsis with poor oral intake prior to his recent
illness.
• Major abdominal surgery is associated with a postoperative ileus.
• Tis is a high-risk patient that has had a major procedure and will
likely need a prolonged stay in intensive care and hospital.
• Alcohol excess suggests possible poor long-term nutritional status
and possible chronic liver disease (causing decreased absorption of
essential nutrients).

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What are the systemic complications associated with malnutrition?

• Overall increase in morbidity and mortality.
• Decreased muscle mass, leading to poor mobility and increased risk
of venous thromboembolism.
• Low respiratory drive and function associated with respiratory failure
and pneumonia.
• Increased time on the ventilator and difcult weaning.
• Poor wound healing and increased risk of wound infection.
• Refeeding syndrome.

What are the standard daily nutritional requirements for a 70 kg adult?

Energy 2500–3000 calories (25 kcal/kg)

Nitrogen 7–14 g
Glucose 210 g
Lipid 140 g
Sodium 70–140 mmol
Potassium 50–100 mmol
Calcium 10 mmol
Magnesium 10 mmol
Phosphate 10 mmol

What is your plan for nutrition in this patient?

Assessment
• Tis patient is at high risk of malnutrition and refeeding syndrome
given his surgical and social history, therefore an urgent dietician
assessment is needed to determine the best regimen.
• Te patient should be examined for signs of malnutrition e.g. body
mass index, muscle mass, dentition, skin and hair health.
• Investigations should include regular electrolytes to monitor for signs
of refeeding syndrome. A low serum creatinine refects low muscle
mass, and low urea is ofen associated with prolonged malnutrition.
• Carry out a multidisciplinary discussion with the surgical team to
ensure an appropriate method of feeding is instigated.
Treatment
• Insert a nasogastric tube and check for correct positioning according
to recognised standard clinical guidelines as advised by NICE.
• Estimate the appropriate feed composition based on the patient’s
weight.
• Ensure an appropriately restricted dose of feed initially to minimise
the risk of refeeding syndrome.
• Monitor the patient for signs of malabsorption and consider
interventions as necessary.

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Two days afer enteral feeding is started, the patient has high aspirate
volumes. How would you manage this?
• Review the patient and documentation of aspirate volumes since the
feed was started. Discuss the regimen options with the dietician and
a senior intensivist. Enteral feeding may still be continued, perhaps at
a lower rate depending on the gastric residual volumes.
• Consider pharmacological prokinetic agents e.g. metoclopramide
and erythromycin.
• Review the position of the nasogastric tube and consider nasojejunal
positioning.
• Consider parenteral nutrition if the above measures fail.

What are the complications of parenteral nutrition?

Line-related complications
• Infection.
• Bleeding/haematoma.
• Pneumothorax.
• Trombosis.
Feed-related complications
• Electrolyte disturbances.
• Refeeding syndrome.
• Fluid overload.
• Poor blood glucose control.
• Stress ulcers.

How can the risk of stress ulcers be minimised?

• Pharmacological agents e.g. histamine receptor antagonists, proton pump
inhibitors, sucralfate (rarely used due to difculty in administration).
• Nasogastric (enteral) feeding.
• Optimal oxygenation.

BIBLIOGRAPHY
Chowdhury R & Lobaz S. Nutrition in critical care. BJA Education. 2019; 19 (3):
90–95.

CASE: ABDOMINAL COMPARTMENT

SYNDROME
You are asked to review a 64-year-old male patient who was admitted to the
intensive care unit 1 day ago following an emergency laparotomy for excision

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of ischaemic bowel. He has a BMI of 42 and has a history of hypertension.

He remains intubated and ventilated, is oliguric, and is now demonstrating
worsening acidosis on his arterial blood gas.
What are the potential causes of deterioration in this patient?
• Sepsis.
• Fluid imbalance/hypovolaemia.
• Low cardiac output state/hypotension.
• Acute kidney injury.
• Electrolyte/metabolic disturbance.
• Raised intra-abdominal pressure.
What is abdominal compartment syndrome?
• A sustained increased in intra-abdominal pressure above 20 mmHg,
with consequent signs and symptoms of organ dysfunction.
Normal intra-abdominal pressure is ~5 mmHg, and intra-abdominal
hypertension is defned as a pressure above 12 mmHg.
What are the risk factors for the development of abdominal compartment
syndrome?
Poor abdominal wall compliance
• Lung pathologies causing increased thoracic pressure.
• Major abdominal surgery.
• Prone positioning.
Increased abdominal content
• Ileus.
• Severe ascites.
• Pneumoperitoneum (iatrogenic/pathological).
• Pancreatitis (due to local complications e.g. pseudocyst formation or
indirectly secondary to fuid resuscitation/ileus).
• Intra-abdominal bleeding (abdominal aortic aneurysm, trauma,
retroperitoneal haematoma).
Fluid and electrolyte imbalance
• Burns.
• Trauma.
• Metabolic disturbances.
• Persistent hypotension.
• Hypothermia.
• Massive transfusion.
• Deranged clotting.
• Severe sepsis/shock.
Patient factors
• Age.
• Raised BMI (particularly central obesity pattern).
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How can this patient’s intra-abdominal pressure be measured?

Intra-vesical measurement
• Ensure the patient is catheterised and supine. Drain the catheter fully
and clamp.
• Connect the patient’s catheter to a 3-way tap and a pressure
transducer (zeroed).
• Inject 20–25 mL of 0.9% sodium chloride into the bladder and
measure the pressure at the end of expiration.

Te patient’s intra-abdominal pressure consistently measures above

25 mmHg. What are the potential systemic complications?
• Decreased cardiac output, venous return and contractility through
cardiac compression.
• A further drop in abdominal perfusion pressure, causing:
• Ischaemic bowel.
• Acute liver injury.
• Difculty ventilating due to poor pulmonary compliance and
increased thoracic pressure.
• Acute kidney injury secondary to poor perfusion and obstruction of
the venous supply and ureters.
• Increased length of intubation/ventilation and stay on intensive care,
with its associated risks.
• Overall increase in morbidity and mortality.

How would you manage this patient?

Assessment
• ABCDE assessment focusing on the risk factors/causes of raised
intra-abdominal pressure.
• Serial monitoring of intra-abdominal pressure.
• Cardiac output assessment/monitoring to optimise fuid resuscitation
and the use of vasoactive substances.
• Consider the need for diagnostic imaging.
Treatment
• Largely supportive, ensuring optimal positioning (reverse
Trendelenburg), ventilation, feeding and fuid balance of patient.
• Consider nasogastric and fatus tubes to decompress if appropriate.
• Ensure adequate sedation and paralysis to prevent increases in
pressure due to ventilator dysynchrony or coughing.
• Adjust the cardiovascular physiology to optimise abdominal
perfusion pressure and fow.
• Consider renal replacement therapy if indicated.
• Multidisciplinary discussion with the surgical team to assess the
risks and benefts of a decompression laparostomy, which should be
considered in patients with intraperitoneal fuid, abscess or blood.

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BIBLIOGRAPHY
Kirkpatrick AW et al. Intra-abdominal hypertension and the abdominal
compartment syndrome: updated consensus guidelines from the World
Society of the Abdominal Compartment Syndrome. Intensive Care
Medicine. 2013; 39: 1190–1206.
Berry N & Fletcher S. Abdominal compartment syndrome. Continuing
Education in Anaesthesia, Critical Care & Pain. 2012; 12 (3): 110–117.

CASE: ACUTE RESPIRATORY DISTRESS

SYNDROME
A 76-year-old gentleman was admitted to the intensive care unit 4 days ago
with shortness of breath secondary to a right lower lobe pneumonia. He was
intubated and ventilated. He has a history of COPD, ischaemic heart disease
and a hiatus hernia. You are asked to review this patient due to worsening
type 2 respiratory failure.

What are the potential causes of his deterioration?

Equipment factors
• Inappropriate ventilator settings.
• Malpositioned endotracheal tube.
• Blocked endotracheal tube or circuit.
Disease factors
• New ventilator-associated/aspiration pneumonia.
• Sepsis.
• Over-sedated patient.
• Acute respiratory distress syndrome (ARDS).

How is ARDS diagnosed?

• Te 2012 Berlin defnition can be used, which includes four criteria
that need to be met for a diagnosis of ARDS to be made:
• Acute onset of symptoms (within 1 week of physiological insult or
trauma).
• Bilateral pulmonary infltrates (on chest X-ray or CT).
• Hypoxia with PEEP of at least 5 cm H2O.
• Symptoms not explained by cardiac failure.
• ARDS can be defned as mild, moderate or severe depending on the
degree of hypoxia. Tis is calculated using the PaO2/FiO2 ratio:
• Mild: PaO2/FiO2 ≤39.9 kPa.
• Moderate: PaO2/FiO2 ≤26.6 kPa.
• Severe: PaO2/FiO2 ≤13.3 kPa.

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What are the common causes for the development of ARDS?

Pulmonary
• Pneumonia.
• Pulmonary contusion.
• Airway burns/smoke inhalation.
• Vasculitis.
• Drowning.
Extra-pulmonary
• Sepsis.
• Massive blood transfusion.
• Polytrauma.
• Pancreatitis.
• Burns.
• Toxins.

Te patient assessment suggests a diagnosis of ARDS. What is your initial

approach to management?
• Ensure lung protective ventilatory strategies, to include:
• Tidal volume ≤6 mL/kg.
• Plateau pressures <30 cm H2O.
• PEEP >5 cm H2O.
• Respiratory rate 20–30.
• Permissive hypercapnia (raised PaCO2 if the pH >7.2).
• Titrated oxygen targets.
• Supportive management:
• Identify and treat the underlying cause.
• Consider neuromuscular blockade.
• Elevate the head of the bed.
• Judicious use of fuids.
• If the above measures do not demonstrate improvement, consider:
• Prone position ventilation.
• Extracorporeal membrane oxygenation.

What are the common complications associated with placing patients in

the prone position on intensive care?
• Pressure sores/ulcers.
• Facial oedema.
• Haemodynamic instability.
• Ocular oedema or injury.
• Nerve damage.
• Accidental removal of endotracheal tube and intravenous lines.
• Difculty maintaining renal replacement therapy access.

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BIBLIOGRAPHY
McCormack V & Tolhurst-Cleaver S. Acute respiratory distress syndrome.
BJA Education. 2017; 17 (5): 161–165.

CASE: UPPER GI BLEED

You are asked to review a 46-year-old male patient in the emergency
department who presented with a major upper gastrointestinal bleed. He
has a history of alcoholic liver disease.

What is your initial management for this patient?

• Carry out an immediate ABCDE assessment and resuscitation as
appropriate, including continuous monitoring and 100% oxygen with
a non-rebreathe mask. Tis should include an airway assessment to
gauge the need for intubation.
• Insert at least two large bore intravenous cannulae and administer
fuid boluses as appropriate.
• Activate the major haemorrhage protocol to ensure readily available
blood products, and that haematology, porters and the medical team
are aware of the patient.
• Take bloods including clotting and cross match. Carry out bedside
testing if possible (Haemocue, TEG).
• A focused history and examination of the patient may determine the
cause and severity of the bleed:
• Medical history.
• Drug history.
• Previous GI bleeds.
• Peripheral stigmata of chronic liver disease.
• Discuss the patient with the gastroenterologists and theatre team
regarding endoscopy as soon as he is stable.
• Consider pharmacological therapy:
• Terlipressin (given the potential for a variceal bleed).
• Reverse anticoagulants if appropriate e.g. vitamin K, prothrombin
complex, protamine (if inpatient on heparin).
• Tranexamic acid.
• Proton pump inhibitor infusion.
• Administer antibiotics if endoscopy intervention includes variceal
banding.

What are the indications for intubation in this patient?

• Severe bleeding leading to airway compromise.
• Severe haemodynamic instability.
• Hepatic encephalopathy/confusion and poor compliance of treatment.

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• Need for endoscopic intervention.

• Cardiac arrest.
What are the common causes of upper GI bleeds?
• Ulcers (oesophageal, gastric, duodenal): drug causes (NSAIDs),
infective (H. pylori) and stress.
• Oesophageal/gastric varices secondary to portal hypertension.
• Mallory-Weiss tear.
• Malignancy.
• Post-surgical.
How can the risk of re-bleeding and death be predicted in this patient?
• Te Rockall score can be used to assess the risk of mortality and
further episodes of bleeding in this patient. It uses fve categories,
each of which are given a score from 0 to 3:
• Age.
• Presence of shock (heart rate and systolic blood pressure).
• Comorbidities.
• Diagnosis.
• Endoscopy fndings.
• A score of >7 suggests a 35% risk of mortality, which is increased if the
patient has another episode of bleeding.
Te patient is having ongoing episodes of haematemesis, and he requires
transfer to theatre for an urgent endoscopy. He has a history of varices.
What are the treatment options for this patient?
• Endoscopic variceal band ligation (1st line).
• Endoscopic variceal sclerotherapy.
• Balloon tamponade if the above measures fail.
• Transjugular intrahepatic portosystemic shunt (semi-elective,
following stabilisation with balloon tamponade).
What are the risk factors for the development of stress ulcers in patients
on intensive care?
• Invasive ventilation.
• Severe shock states.
• Deranged clotting.
• Patient with severe burns.
• Neurological trauma e.g. traumatic brain or spinal injuries.
• Pre-existing gastrointestinal ulcers.

BIBLIOGRAPHY
Elsayed IA, Battu PK & Irving S. Management of acute upper GI bleeding.
BJA Education. 2017; 17 (4): 117–123.

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CASE: ACUTE CONFUSION

You are asked to review a 68-year-old gentleman who was admitted to
intensive care 3 days ago following an emergency laparotomy for small bowel
obstruction. He has a history of hypertension, diverticular disease and is a
smoker. He is confused and trying to climb out of his bed.

What are the potential causes of confusion in this patient?

• Pre-existing comorbidities e.g. dementia.
• Alcohol ± nicotine withdrawal.
• Electrolyte disturbances.
• Infection.
• Hypoglycaemia.
• Hypoxaemia.
• Encephalopathy (hepatic, uraemic, sepsis).
• Drug side efects (anaesthetic/sedatives).
• Postoperative cognitive decline.
• Cerebrovascular event.

What is delirium?
• An acute disturbance of consciousness and altered cognitive state
that may demonstrate a fuctuating course over a short period of time.
• Delirium can be hyperactive, hypoactive or mixed.

What are the risk factors for the development of delirium in this patient?
Patient factors
• Increased age.
• History of hypertension.
• Smoker.
• May have visual or hearing impairment due to his age.
Illness factors
• Potential for electrolyte or metabolic disturbance postoperatively.
• Possible pyrexia or sepsis.
• Postoperative anaemia.
• Side efects of medication.
• Poor sleep as inpatient.
• Decreased mobility in hospital.
• Pain.
How would you assess and treat this patient?
Assessment
• Carry out a rapid initial assessment to determine whether the patient
or staf is at risk; if so, an urgent intervention may be required to
prevent injury.
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 Intensive Care Medicine

• Te CAM-ICU scoring system (confusion assessment method for

ICU) can be used to assess the patient. Tis includes the following
aspects:
1. Determining whether the confusion is acute or fuctuating.
2. Assessing patient inattention.
3. Establishing conscious level.
4. Assessing for presence of disorganised thoughts.
For a patient to be CAM-ICU positive (and therefore have a diagnosis of delirium),
the frst two criteria must be met, together with either the 3rd or 4th criterion.
Treatment
• Avoidance of, and minimising risk factors for delirium. Measures can
include:
• Daily sedation hold.
• Drug chart review.
• Treat infection or metabolic disturbances if present.
• Ofer hearing or visual aids if appropriate.
• Aim for optimal diurnal sleep-wake cycle.
• Physiotherapy.
• If the above measures fail, pharmacological agents can be considered:
• 1st line: haloperidol.
• 2nd line (or if haloperidol contraindicated): olanzapine.
Note that benzodiazepines should be avoided in these patients.

What are the complications in this patient should his delirium remain
untreated?
• Overall increase in morbidity and mortality.
• Increased length of hospital stay/duration on intensive care.
• Increased risk of infection.
• Cognitive decline (long-term).

BIBLIOGRAPHY
King J & Gratrix A. Delirium in intensive care. Continuing Education in
Anaesthesia, Critical Care & Pain. 2009; 9 (5): 144–147.

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16
OBSTETRICS

CASE: POSTPARTUM HEADACHE

A 32-year-old female presents 2 days postpartum with a headache. She has a
body mass index of 40 but no other medical conditions. She had an epidural
inserted during labour and a forceps delivery with no complications.

What are the possible causes of a headache in this patient?

Obstetric causes
• Hypertensive disorders of pregnancy.
• Lactation headache/hormonal changes in oestrogen and
progesterone levels.
• Post-dural puncture headache.
• Cerebral vein thrombosis, haematoma or infarct.
Non-obstetric causes
• Common causes: dehydration, tension headache or migraine.
• Infective: meningitis/encephalitis/sinusitis.
• Cerebrovascular: haemorrhage, haematoma, infarct or thrombosis.
• Malignancy.
• Illicit drug use.
• Domestic violence.

How would you manage this patient initially?

• An ABCDE assessment of this patient should be carried out to include
a history and neurological examination to determine the cause and
rule out any sinister pathology.
• Ensure multidisciplinary team management to involve the
appropriate individuals.
• Monitoring, observations and investigations should be done as
directed by the initial assessment.

What is posterior reversible leucoencephalopathy syndrome?

• A syndrome is characterised by headache, seizures, altered mental
state and visual loss with vasogenic oedema of the white matter
afecting the posterior occipital and parietal lobes of the brain. It was
frst diagnosed in 1996.
• Te pathophysiology of PRES is not fully understood, but it is thought
to be due to the efects of hypertension on the posterior circulation in
DOI: 10.1201/9781003156604-16 153
 Clinical Cases for the FRCA

the brain. Disruption of auto-regulation and local cellular damage are

thought to play a part, leading to cerebral oedema.
• In pregnancy, PRES is a rare but serious complication of eclampsia,
and management is largely supportive while the underlying cause is
treated.
• Diagnosis is by MRI.
• Tere is a 15% risk of mortality or permanent nerve injury.
• Treatment is with blood pressure control, anticonvulsants and renal
replacement therapy if required.

What are the typical fndings in the history and examination of a patient
with a post-dural puncture headache?
History
• A dural puncture may have been identifed at the time of the
procedure (although in ~40% of PDPH following an epidural, the
dural puncture was not recognised at the time of insertion).
• May be associated with multiple or difcult epidural insertion
attempts, and with a low or high BMI.
• Commonly, the headache is fronto-occipital, worse on sitting or
standing and improves when lying down (although in 5% of cases
there is no postural element).
• Tinnitus, mufed, photophobia and neck stifness hearing may be
present.
Examination
• Nerve palsies (most commonly VIth and VIIIth cranial nerves).
• In equivocal cases, circumferential squeezing of the abdominal
may alleviate the headache (caval compression causes expansion of
epidural venous circulation, which in term compresses the dural sac,
producing an increase in CSF pressure and temporary alleviation of
the headache).
Investigations
• Observations and baseline blood tests are usually normal.

What is the initial management of a patient with a PDPH?

• Conservative management should be attempted initially, to include:
• Hydration (ideally oral).
• Analgesia (paracetamol and ibuprofen are safe in breastfeeding).
• Bed-rest is no longer recommended; patients should mobilise as
they feel able.
• Monitoring and assessment either at home or on the postnatal ward.
• If the above measures fail to work, an epidural blood patch should be
considered. If tinnitus or other cranial nerve palsies develop, a blood
patch should be encouraged.

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You are asked to insert an epidural for a patient in labour ward while on
call, and note clear fuid profusely leaking from the Tuohy needle. What
your immediate management?
In cases of known dural punctures, the immediate management of the patient
depends on a number of diferent factors including the experience of the
anaesthetist, the stafng on labour ward and the status of the patient.
Intrathecal catheter insertion
• Te epidural catheter can be inserted into the intrathecal space and
top-ups administered by an anaesthetist only, with no infusions
attached.
• Te catheter must be very clearly labelled and handed over to the
senior midwifery and anaesthetic teams.
• Expect tachyphylaxis as labour progresses.
• Tis technique is likely to achieve good analgesia initially, but there is
an increased risk of analgesic failure because of a lack of familiarity
among the anaesthetic and midwifery staf, and the catheter may also
be pulled out of the intrathecal space.
Re-do epidural
• Te epidural can be re-attempted at a diferent space, ideally by a
second anaesthetist if the frst insertion was particularly challenging,
or if the initial anaesthetist feels stressed or tired.
• Te patient should be closely monitored by the anaesthetic team
due to the potential risk of intrathecal administration of drugs via
the initial puncture site. High blocks when topping up for an operative
procedure are relatively common. Top-up cautiously.
• Always make sure that the dural puncture is carefully
documented. Again inform the patient, and the midwifery and
anaesthetic teams.

BIBLIOGRAPHY
Russell R et al. Treatment of obstetric post-dural puncture headache. Part 2:
epidural blood patch. International Journal of Obstetric Anaesthesia.
2019; 38: 104–118.
Sabharwal A & Stocks GM. Postpartum headache: diagnosis and management.
Continuing Education in Anaesthesia, Critical Care & Pain 2011; 11 (5):
181–185.

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CASE: MAJOR OBSTETRIC HAEMORRHAGE

You are asked to review a 25-year-old patient who has just delivered in the
birthing suite and is now actively bleeding following an initial estimated
1.2 L blood loss.

What is the defnition of a “major obstetric haemorrhage”?

• Tere is no universally accepted defnition, but it is ofen classifed
according to one of the following markers:
• Blood loss >1.5 L.
• A drop in haemoglobin of >4 g/dL.
• >4 units of blood required for transfusion.

What are the causes of obstetric haemorrhage?

Antepartum
• Placental abruption (one third of cases).
• Placenta praevia (one third of cases).
• Other causes e.g. uterine rupture (one third of cases).
Postpartum (“Four Ts”)
• Tone – uterine atony.
• Trauma.
• Tissue – retained products/placenta.
• Trombin – coagulopathic state.

How would you manage this patient?

Tis patient is actively bleeding and approaching the threshold for a major
obstetric haemorrhage, hence she needs urgent assessment and intervention.
Commonly several diferent teams are working to resuscitate while simultaneously
controlling ongoing blood loss. Te suggested management is listed below.
• Put out a major obstetric haemorrhage emergency call to include
obstetric, anaesthetic and midwifery teams, blood bank and porters.
Alert the consultant anaesthetist early if concerned, or according to
local protocols.
• Carry out an urgent ABCDE assessment, apply 100% oxygen via a
non-rebreathe mask and insert large bore intravenous access (at least
2 16G).
• Administer crystalloid fuid boluses until blood is available, and
send urgent blood samples for full blood count, clotting (including
fbronectin) and cross-match. Serial haemocue or blood gases can
be done to obtain values for haemoglobin/lactate/calcium. Bedside
measurement of clotting should be performed if available. Consider
blood products afer 2L of crystalloid has been given.

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• Administer warmed blood and blood products early using a rapid

infuser and liaise with haematology in the case of ongoing major
obstetric haemorrhage. Give FFP, cryoprecipitate and/or fbrinogen
if indicated. Remember that FFP does not elevate fbrinogen very
efectively (the concentration of fbrinogen in FFP is ofen <2 g/L).
Fibrinogen is ofen low following major placental abruptions and
amniotic fuid embolism.
• O-negative blood can be given if cross-matched blood is not available.
• Consider medical and surgical intervention early to treat the
underlying cause of the bleeding, and further management of patient
should be done on the high dependency or intensive care unit.

What pharmacological agents can be used in the management of massive

obstetric haemorrhage?
• Tranexamic acid IV (1 g )over 10 minutes followed by an infusion if
indicated.
• Calcium chloride (10 mL, 10%), but the dose can be directed by serial
blood gas results.
• Uterotonic agents (if uterine atony is the cause):
• Oxytocin 5U IV followed by infusion of 40U over 4 hours.
• Ergometrine 500 mcg intramuscular (or slow IV over 15 minutes).
• Carboprost 250 mcg intramuscular (every 15 minutes to a
maximum of 2 mg).
• Misoprostol 1 mg rectally.

Te obstetric registrar suspects partially retained placenta as the cause

of haemorrhage and wants to take the patient to theatre. What are the
concerns with regional anaesthesia in this patient?
• Regional anaesthesia in a hypovolaemic patient can lead to severe
cardiovascular instability due to sympathetic blockade causing
vasodilation.
• Coagulopathy following major obstetric haemorrhage can increase
the risk of epidural haematoma if neuraxial blockade is attempted.

What are the goals in the treatment of this patient?

• Te goal in this patient is to gain control of the bleeding and ensure
normal physiology, using the following indicators:
• Mean arterial pressure >70 mmHg.
• Urine output >0.5 mL/kg/hour.
• Haematocrit >0.3.
• Platelets >100 × 109 L−1.
• Fibrinogen >2 g/L.
• Ionized calcium >1.
• Temperature >36°C.

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What are the options for surgical intervention in this patient?

• Evacuation of the uterus.
• Bimanual compression and uterine massage.
• Insertion of an intrauterine balloon (e.g. Bakri balloon).
• Internal iliac artery ligation.
• Uterine compression suture if the abdomen is open.
• Interventional radiology (arterial embolisation).
• Hysterectomy – last resort, and if possible, requires two consultant
obstetricians should concur that hysterectomy is needed. However, it
should not be delayed if bleeding is immediately life threatening and
a second consultant is unavailable.

BIBLIOGRAPHY
Plaat F & Shonfeld A. Major obstetric haemorrhage. BJA Education. 2015;
15 (4): 190–193.

CASE: NON-OBSTETRIC SURGERY IN A

PREGNANT PATIENT
A 26-year-old female is booked onto the emergency theatre list for drainage
of a perianal abscess. She is 30 weeks pregnant.

What added information would you like prior to proceeding with this case?
A multidisciplinary approach should be taken in the care of this patient to include
surgeons, anaesthetists, obstetricians and the neonatal team due to the increased
maternal and fetal risks associated with surgery during pregnancy.
Anaesthetic factors
• Tis patient should be reviewed and managed by a senior anaesthetist,
conducting a thorough history and examination to determine her
comorbidities and risk factors. In addition, take an obstetric history
including parity, gestation and any complications of pregnancy.
• Te main anaesthetic concerns in this patient are:
• Increased risk of difcult airway and failed intubation.
• Avoidance of fetal distress and hypoxia through maintenance of
maternal physiology.
• Aortocaval compression.
• Risk of premature labour.
• Care to minimise fetal exposure to medications, and in particular,
avoid medications that are known to be harmful to the fetus or
increase the risk of premature labour.
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Surgical factors
• Te patient should be reviewed by a consultant surgeon and the
procedure should be delayed if it is not necessary, while recognising
that untreated maternal infection can be harmful to the fetus and that
fetal wellbeing is ultimately linked to maternal wellbeing.
• If surgery is essential, it should be performed by a senior surgical
team.
Obstetric factors
• Te obstetric team should be aware that this patient is undergoing
surgery, and a consultant obstetrician should be informed.
• If appropriate, perioperative fetal monitoring should be conducted
by a senior midwife. Most commonly, this means assessing fetal
wellbeing by listening to the fetal heart rate pre- and post procedure.
Very occasionally the CTG may be monitored intraoperatively, but
it is difcult to interpret if the fetus has also been anaesthetised by
the anaesthetic drugs administered to the mother. If intraoperative
monitoring is used, a plan should be made of the appropriate course
of action if an abnormal CTG is detected. Tis may vary from simply
checking that maternal physiology is optimised, to proceeding to
immediate caesarean delivery. If the latter is considered, then all the
appropriate teams and equipment must be immediately to hand.
• Consideration of steroids for fetal lung maturation in case of premature
labour, and the likelihood of delivery is considered to be high.

If a general anaesthetic is used, the standard for airway control would be

tracheal intubation. What factors increase the risk of a difcult airway in
this patient?
• Anatomical: increased breast tissue, airway oedema, and lef lateral
positioning leading to an altered view with laryngoscopy.
• Physiological: decreased functional residual capacity and increased
oxygen demand, allowing less time for intubation prior to desaturation.
• Human factors: increased stress and anxiety, limited experience
managing obstetric patients under general anaesthesia.

How would you conduct the induction of anaesthesia this patient?

• Ensure emergency drugs and equipment checked including the
difcult airway trolley, attach AAGBI monitoring, machine check
and patient consent/WHO checklist complete.
• Preparation for rapid sequence induction: trained assistant; senior
support; discussion of the airway plan including the plan in the
event of a failed intubation; cricoid pressure; suction switched on and
accessible; antacid prophylaxis; and appropriate positioning of the
patient (head up with lef lateral tilt).
• Consider using a videolaryngoscope frst-line.

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• Pre-oxygenation with 100% for 3 minutes targeting an end tidal

oxygen concentration of >85%.
• Induction of anaesthesia with propofol (1.5–2 mg/kg) and
suxamethonium (2 mg/kg), with cricoid pressure. Consider an opiate
at induction (1–2 mcg/kg fentanyl, or equivalent); the opiate does
not pose a risk to the fetus as delivery is not expected, and the risk
of a hypertensive response to laryngoscopy is increased in pregnant
women, particularly if hypertensive diseases of pregnancy are present.
• Tracheal intubation of the patient with an appropriately sized
endotracheal tube (OAA/DAS guidelines recommend a size 7.0 mm
ETT as the default for pregnant women); confrmation of placement
and maintenance of anaesthesia with sevofurane/oxygen/air mixture.

In the case of a failed intubation, what factors would favour proceeding

with this particular surgery rather than waking the patient up?
• Te Difcult Airway Society has produced a specifc obstetric
intubation guideline and algorithm that guides the anaesthetist in
this situation.
• Factors that would encourage waking the patient include:
• No maternal or fetal compromise.
• Junior anaesthetist.
• Very high BMI.
• Complex or prolonged surgery.
• Patient not fasted.
• Factors that favour proceeding with surgery are:
• Severe maternal or fetal compromise with a threat to life.
• Consultant anaesthetist.
• Successful placement of 2nd generation supraglottic airway device.
• Fasted patient with minimal comorbidities.
• In this particular scenario, in the case of failed intubation, it would
be prudent to follow the difcult airway algorithm, which includes
calling for urgent senior help, attempting supraglottic airway device
insertion and facemask ventilation, and early consideration of waking
the patient.

BIBLIOGRAPHY
Mushambi MC et al. Obstetric anaesthetists’ association and difcult airway
society guidelines for the management of difcult and failed tracheal
intubation in obstetrics. Anaesthesia. 2015; 70: 1286–1306.
Rucklidge M & Hinton C. Difcult and failed intubation in obstetrics.
Continuing Education in Anaesthesia, Critical Care & Pain. 2012; 12 (2):
86–91.

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CASE: HYPOXIA IN A POST-PARTUM PATIENT

A 36-year-old female, who has just delivered, is complaining of dyspnoea.
Her oxygen saturations are 88% on room air.

What are the possible causes for hypoxia in this patient?

Anaesthetic causes
• Opiate overdose (remifentanil, or following a general anaesthetic).
• High neuraxial blockade if epidural in situ.
Obstetric causes
• Major obstetric haemorrhage.
• Pre-eclampsia.
• Peripartum cardiomyopathy.
• Amniotic fuid embolus.
• V/Q mismatch (carboprost).
Other causes
• Pulmonary embolus.
• Sepsis.
• Anaphylaxis.
• Exacerbation of asthma.
• Myocardial infarction.
• Structural cardiac problem (valvular or septal defect).
• Arrhythmias.

What is your initial management for this patient?

• Tis is a medical emergency that requires urgent assessment and
intervention. Initial management for this patient includes:
• Immediate ABCDE assessment prioritising the airway and
breathing to determine the cause of hypoxia and facilitate specifc
treatment.
• 100% oxygen through a non-rebreathe mask and ensuring large
bore intravenous access.
• Urgent senior anaesthetic and obstetric help, with early
consideration of the intensive care team if rapid deterioration.

What are the risk factors for the development of a peripartum

cardiomyopathy?
• Increased maternal age.
• Multiparity.
• Ethnic minority (Nigeria, Haiti).
• Twin pregnancy.
• Chronic or new onset hypertension.
• Prolonged tocolysis.
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What is the pathophysiology in patients with a peripartum

cardiomyopathy?
• Te pathophysiology of peripartum cardiomyopathies is complex,
and is currently based on a “2 hit” model: a genetic predisposition
together with the efect of prolactin.
• Prolactin is broken down into a smaller fragment (16 kDa), which is
thought to exert cardiotoxic efects resulting in apoptosis and death
of cardiac myocytes.
• Primarily patients display symptoms suggestive of lef ventricular
systolic dysfunction leading to biventricular dysfunction and cardiac
failure.
• Te disease cause is thought to be multi-factorial to include immune
or hormone mediated, infammatory and genetic.
• For a diagnosis of peripartum cardiomyopathy to be made, the
specifc criteria are:
1. Cardiac failure at the end of pregnancy or up to fve months afer
delivery.
2. No other likely cause for cardiac failure.
3. New onset of symptoms.
4. Lef ventricular dysfunction.

An urgent echocardiogram shows an ejection fraction of 32%. What are

the next steps in the management of this patient?
• Stabilisation of this patient, referral to the cardiology team and
admission to the coronary care or intensive care unit as appropriate.
• Multidisciplinary team management to include obstetricians, tertiary
cardiology and anaesthetists.
• Medical management of acute cardiac failure using ACE
inhibitors, nitrates, beta blocking agents and diuretics as directed by
specialists.
• Supportive therapy and counselling for the patient and her partner.
• Severe cases may require further specialist intervention including the
use of intra-aortic balloon pumps, cardiac implantable devices and
lef ventricular assist devices.
• Anti-coagulation and/or DVT prophylaxis should be considered.
• Tere is a possible role for bromocriptine in these patients;
small studies currently suggest that suppression of prolactin
production reduces the severity of PPCM and improves the rate of
recovery.

Two years later this patient remains stable on medical therapy. She is keen
to have another baby. How should she be counselled?
• Detailed medical assessment to determine her cardiac and other
comorbidities, in order to evaluate whether the patient would be able
to tolerate the physiological demands of pregnancy.

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• Absolute contraindications to pregnancy include pulmonary

hypertension and severe cardiac failure, which suggest a high risk of
morbidity and mortality.
• Te risks of pregnancy should be explained to the patient based
on her current status. If her ejection fraction has not recovered to
>50%, then the risk of mortality is 25%–50%. If her ejection fraction
has normalised, there is a 20% risk of deteriorating lef ventricular
function during pregnancy.

BIBLIOGRAPHY
Honigberg MC. Peripartum cardiomyopathy. British Medical Journal. 2019;
364: 5287.
Tompson L & Hartsilver E. Peripartum cardiomyopathy. Update in
Anaesthesia. 2016; 31: 55–58.

CASE: PLACENTA PRAEVIA

A 26-year-old female is being seen in the obstetric clinic. Her 20-week
anomaly scan showed placenta praevia.

What is the defnition of placenta praevia?

• In 2014, the American Institute of Ultrasound in Medicine
recommended a change in the defnition to “a condition where the
placenta lies directly over the maternal os on a transabdominal or
transvaginal ultrasound scan”.

What is the defnition of a “low lying placenta”?

• A low lying placenta is defned as a placenta whose lowest edge lies
within 20 mm of the os, afer 16 weeks of pregnancy.

What is the incidence of placenta praevia?

• 1 in 200 pregnancies (but this varies with the defnition).
• Te incidence is increasing in association with the increasing number
of caesarean sections and increased assisted reproductions.

What are the risk factors for the development of placenta praevia?
• Previous caesarean section(s).
• Assisted reproduction.
• Increased maternal age.
• Previous placenta praevia.
• Maternal smoker.

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You are asked to review the patient. She identifes as a Jehovah’s Witness.
What are the key points that you want to discuss with her?
• Ideally, this patient should be reviewed by a consultant anaesthetist in
a quiet room, with no other friends or family members present.
• Establish what the patient knows about her condition and the risks
associated with placenta praevia including major haemorrhage,
hysterectomy and death.
• Establish the patient’s wishes with respect to treatment in hospital,
focusing on the exact blood products she would and would not accept,
to include the use of tranexamic acid and cell salvage.
• Ensure documentation of the exact wishes of the patient in her notes
and in an Advanced Directive that is signed and witnessed.

Te patient is booked in for an elective caesarean section at 38 weeks of

gestation. What can be done to pre-optimise her prior to surgery?
• Regular full blood count and haematinics to allow for enteral or
intravenous iron preoperatively if required.
• Consider the use of erythropoietin preoperatively.
• Document the plan for pregnancy and delivery including surgical
intervention, to include:
• Site of delivery.
• Confrming the patient’s wishes at the time of delivery/bleeding.
• Ensuring a senior obstetric and anaesthetic team.
• Early use of multi-modal uterotonic agents.
• Early consideration of interventional procedures in the case of
major obstetric haemorrhage.
• Early use of anti-fbrinolytic agents.
• Checking the availability of cell salvage and any blood products
that are acceptable to the patient.
• High dependency or intensive care unit postoperatively.

How does cell salvage work?

• Blood is harvested from the surgical feld using a large bore,
low-pressure suction cannula.
• Amniotic fuid can be collected using a separate suction system.
• Te blood anticoagulated to prevent clotting. Tis is usually achieved
with heparin solutions but ACD-A (anticoagulant citrate dextrose)
solutions can also be used.
• If enough blood is collected, it is centrifuged, washed and re-suspended
in saline before being transfused back into the patient.

What are the concerns with the use of cell salvage in obstetric
patients?
• Tere were previously concerns associated with the risk of amniotic
fuid embolism in the use of cell salvage in obstetric patients.

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• Some centres advocate the use of leukocyte depletion flters, but it

is thought that the usual fltration process is efective in removing
amniotic fuid cells from the collected blood.
• Fetal red cells are not distinguished from maternal red cells, so there
is a risk of alloimmunisation and anti-D is likely to be required
for Rhesus negative mothers with a Rhesus positive fetus. Local
guidelines should be adhered to.

BIBLIOGRAPHY
Jauniaux ERM et al. On behalf of the royal college of obstetricians and
gynaecologists. placenta praevia and placenta accreta: diagnosis and
management: green-top guideline No. 27a. BJOG 2018; 126(1): 1–48.
Klein AA et al. Association of anaesthetists guidelines: cell salvage for
peri-operative blood conservation 2018. Anaesthesia. 2019; 73: 1141–1150.

CASE: PREGNANT PATIENT WITH

CARDIAC DISEASE
A 32-year-old lady presents to the maternity day assessment unit with
decreased fetal movements at 36 weeks. She has a history of rheumatic fever.

What are the diferent methods available to monitor fetal wellbeing in

labour?
• Fetal heart rate monitoring by Pinard, doppler, cardiotocography
(CTG) or a fetal scalp electrode.
• Abdominal ultrasound scan to look at fetal growth, amniotic fuid
pocket size, blood fow in the umbilical and/or uterine blood vessels
and/or fetal cerebral blood vessels.
• Fetal blood sampling – fetal scalp blood can give a measure of lactate
and pH.
• Less common – fetal pulse oximetry and electrocardiography.

What features on the CTG suggest an abnormal trace?

Te features can be classifed into reassuring, non-reassuring and abnormal,
and are based around the baseline heart rate (reassuring is 110–160 bpm);
baseline variability (reassuring is 5–25 bpm); and decelerations (reassuring is
either none, early or variable with no concerning characteristics for less than 90
minutes).
• An abnormal trace is indicated by one of the following features:
• Heart rate below 100 or above 180 bpm.

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• Acute bradycardia or a prolonged deceleration lasting for more

than 3 minutes; late decelerations for over 30 minutes; or variable
decelerations with concerning features in over 50% of contractions
for over 30 minutes.
• Poor or increased baseline variability (<5 for 50 minutes or >25
for 25 minutes).
Tis patient’s CTG shows a non-reassuring trace that settles, and the obstetric
team would like to carry out a category 3 caesarean section. When you take a
history from her, she describes feeling more tired and short of breath during
the last week. A pre-pregnancy echo shows mild aortic stenosis.

How do you proceed?

Tis is a complex medical patient that requires input from senior obstetricians
and anaesthetists, and management of the patient in this situation should
include the following.
• A detailed but urgent assessment of the patient including a full history
and examination, focusing on the cardiovascular system as well as
anaesthetic risk and airway assessment.
• Consider an urgent ECG and echo. A clinical decision has to be made
to evaluate the risk to the fetus from delay, compared to the risk to
the mother from incomplete information. Whenever possible, these
investigations should have occurred earlier in the pregnancy.
• Tis patient should ideally have been seen during pregnancy by
a multidisciplinary team for a decision to be made in terms of her
management during and afer labour, when she is at highest risk of
deterioration.
• Early escalation to consultant anaesthetist and obstetrician.

What are the anaesthetic goals in the management of this patient?

• Appropriate senior multidisciplinary care with consultant anaesthetist,
obstetrician and cardiologist (and possibly cardiac surgeon).
• Consideration should be given to the site of delivery including
transfer to a tertiary centre prior to delivery. Occasionally delivery is
undertaken in the cardiac theatres.
• Monitoring to include invasive blood pressure monitoring.
• Consideration should be given to the efect of changes in heart rate,
preload, contractility and aferload, and thus whether fuid loading or
running patients with minimal fuid is appropriate. Tis assessment
can also dictate the type of anaesthetic and the type of uterotonic that
should be used.
• In this case, a general principle would be to keep heart rate low/
normal, maintain contractility and aferload.
• Treat blood loss with blood products early.
• Avoidance of increases in pulmonary vascular resistance and ensure
normothermia, good oxygenation and adequate analgesia.

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How would you induce anaesthesia in this patient?

Both general anaesthesia and controlled neuraxial blockade have been suggested
for use in this patient; the importance lies in maintenance of the anaesthetic goals
listed above.
Prior to anaesthesia
• Invasive monitoring to include AAGBI monitoring as well as arterial
line and central venous access.
• Ensure lef lateral tilt.
• Administer antacid prophylaxis.
• Ensure good and accessible intravenous access.
• Judicious use of fuids and vasopressor agents to maintain blood
pressure.
• Give oxytocin as an infusion only and avoid ergometrine and carboprost.
• Cardiac high dependency or intensive care postoperatively.
General anaesthetic
• Rapid sequence induction with agent of choice titrated to efect.
• Maintenance of anaesthesia using sevofurane and nitrous oxide.
Regional anaesthetic
• Spinal or epidural catheter with careful, slow titration of local
anaesthetic and opioid to efect.

How is a combined spinal-epidural performed?

• Ensure patient consent, intravenous access, and AAGBI monitoring.
• Tere are two main methods of carrying out this procedure:
• “Needle through needle” – the epidural space is located using a
standard Tuohy needle, then a spinal needle is passed through
into the intrathecal space at the same level. Afer the spinal dose
is injected, the spinal needle can be removed and the epidural
catheter inserted and secured as normal.
• “Two space” technique – the spinal injection is performed at a
level above or below the epidural catheter insertion space. Te epi-
dural is usually performed before the spinal.

BIBLIOGRAPHY
Bishop L et al. Adult congenital heart disease and pregnancy. BJA Education.
2018; 18 (1): 23–29.
Burt C & Durbridge J. Management of cardiac disease in pregnancy. Continuing
Education in Anaesthesia, Critical Care & Pain. 2009; 9 (2): 44–47.
Jayasooriya G & Djapardy V. Intrapartum assessment of foetal well-being. BJA
Education. 2017; 17 (12): 406–411.

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CASE: INTRAUTERINE DEATH

A 27-year-old female has been reviewed in the maternity day assessment unit
for decreased fetal movements. An ultrasound scan confrms intrauterine
death at 34 weeks.

What is the incidence of intrauterine death?

• Approximately 5 per 1000 births.
• Approximately 20% of these (1:1000) occur at or near term (>36 weeks
of gestation).
• An early stillbirth occurs between 20 and 27 weeks gestation; a late
stillbirth occurs between 28 and 36 weeks gestation.

What are the main causes of intrauterine death?

Te main causes are secondary to problems with the placenta and/or the umbilical
cord, including abruption and umbilical cord compression.
• Multiple factors can result in poor uterine function, including:
• Pre-eclampsia.
• Systemic lupus erythematous or other causes of hypercoagulability.
• Clotting disorders (haemophilia is high-risk).
• Maternal medical conditions e.g. diabetes, heart disease, thyroid
disease or infection.
• Alcohol, recreational drug use e.g. cocaine and/or smoking.
• Birth defects (25% of stillbirths).
• Infection: either viral or bacterial directly afecting the fetus, or
leading to sepsis in the mother. Common bacteria include group B
streptococcus, E. coli, klebsiella, enterococcus, haemophilus infuenza
and mycoplasma. Rubella, herpes, Lyme disease and malaria are also
well recognised.
• Trauma – can result in uterine injury, rupture, abruption or direct
fetal injury.
• Intrahepatic cholestasis of pregnancy (ICP).
Antenatal causes
• Congenital malformations or infections.
• Maternal diabetes mellitus.
• Pre-eclampsia.
Intrapartum causes
• Maternal sepsis.
• Placental abruption.
• Uterine rupture.
• Excessive frequency of uterine contractions.
• Umbilical cord compression.

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What are the key aspects in the management of this patient?

Supportive
• Care of the patient and partner to be provided by a senior midwife
trained or experienced in intrauterine deaths.
• Te patient should be managed in a room ideally located away from
the main labour ward.
Method of delivery
• Te decision should be made by the senior obstetric team; most
of these patients deliver vaginally but a caesarean section may be
indicated in some cases.
• Attempts should be made to determine the cause of intrauterine
death, as this may afect management of both the current delivery,
and future pregnancies.
Pain management
• Te anaesthetist should be notifed and assess the patient early.
• Te patient can be ofered a variety of modes of analgesia including
oral medication, intravenous agents and neuraxial blockade.
• Te patient should be assessed regularly and care should be taken to
monitor her clotting and markers of infection. Derangements may
preclude neuraxial blockade.
Te patient has a heart rate of 135 and a temperature of 39.6°C. You are
asked to review her urgently. How do you proceed?
Tis patient is showing signs of sepsis and needs urgent management including
a rapid ABCDE assessment and instigation of treatment according to the local
sepsis bundle.
• Immediate review of the patient and early escalation to senior
obstetric and anaesthetic teams.
• Management of the patient should be in a high dependency area or
intensive care if appropriate.
• Ensure large bore intravenous access, fuid resuscitation, anti-pyretic
(paracetamol), and intravenous broad-spectrum antibiotics.
• Monitoring to include basic observations, urine output, full blood
count, clotting and serial lactate levels.

What are the risk factors for the development of sepsis in pregnant patients?
Pregnancy results in an impaired immune response, so pregnant women are all
more vulnerable to infection.
Obstetric
• Procedures during pregnancy e.g. amniocentesis, cervical suture.
• Prolonged labour or rupture of membranes.
• Caesarean section.
• Retained placenta.
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Non-obstetric
• Comorbidities: raised BMI, diabetes mellitus, immunosuppressed state.
• Ethnic minority or poor socioeconomic status.

BIBLIOGRAPHY
Elton RJ & Chaudhari S. Sepsis in obstetrics. BJA Education. 2015; 15 (15):
259–264.

CASE: PREGNANCY-INDUCED
HYPERTENSION
A 31-year-old primiparous female is found to have a blood pressure of
183/96 mmHg at a routine midwife appointment. She is 37 weeks pregnant
and has no other medical conditions.

What is the defnition of pregnancy-induced hypertension?

• Pregnancy-induced hypertension is hypertension (more than
140/90 mmHg) that develops afer 20 weeks of gestation (more than
140/90 mmHg) but with no proteinuria.

How should this patient be managed?

• Full history and examination focusing on cardiovascular history and
risk factors:
• Check whether the patient had pre-existing hypertension.
• Any symptoms of hypertension: headache, changes in vision, dizziness.
• Senior midwife assessment including CTG.
• Urgent medical treatment of severe hypertension according to the
NICE guidelines:
• Admit to hospital.
• Measure blood pressure every 15 minutes until controlled below
160/110 mmHg.
• Blood tests: full blood count, liver function tests, renal function
(U+E) and PCR.
• First-line treatment: labetalol PO (200 mg) or IV (50 mg bolus
followed by infusion).
• Nifedipine or methyldopa can be used if labetalol is inefective or
contraindicated. Do not give sublingual nifedipine as excessively
rapid hypotension may occur and fetal condition may be
compromised.
• Aim for a blood pressure of <135/85 mmHg.

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Te patient’s blood pressure is controlled and she is discharged home on

oral labetalol. Four days later she presents with a severe headache and visual
changes.

What is the defnition of pre-eclampsia?

• Pre-eclampsia is hypertension (>140/90 mmHg) that develops afer
20 weeks of gestation with proteinuria, which is defned as one of:
• 2+ of proteinuria on a standard urine dipstick on two separate
occasions.
• Urine protein: creatinine ratio (PCR) >30 mg/mmol.
• Protein >300 mg in a 24 hour urine collection (rarely done).

What are the risk factors for the development of pre-eclampsia?

• Personal or family history of pre-eclampsia.
• Twin pregnancy.
• Increased maternal age (>40 years).
• Pre-pregnancy raised BMI (>35).
• Maternal comorbidities: diabetes, hypertension, renal disease.

What are the goals in the management of this patient?

• Blood pressure control and strict fuid balance prior to delivery.
• Fetal monitoring (CTG).
• Prevention of progression to eclampsia.
• Close monitoring of the patient with senior obstetric, anaesthetic and
midwifery input and early escalation when appropriate.

What is the indication for treatment with magnesium sulphate?

• Treatment of eclamptic seizures (4 g IV over 10 minutes followed by
an infusion of 1 g/hour for 24 hours).
• Patients with severe symptomatic pre-eclampsia.

Te patient is induced and would like an epidural. How do you proceed?

• Te decision to site an epidural requires a risk-beneft assessment for
the patient. Most individuals will beneft from neuraxial blockade,
not only because of the peripheral vasodilation that occurs but also
because the analgesia achieved will obtund the hypertension that
occurs with contractions.
• Assessment of the patient should include any relative or absolute
contra-indications to epidural placement.
• In this case, if the decision to site an epidural is made, the coagulation
status of the patient should be verifed frst. Care must be taken to
avoid large fuid boluses and to closely monitor the blood pressure
following careful loading of the epidural. Early and judicious use of
vasopressor agents should be used in the event of hypotension.

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What are the risks associated with an epidural?

Common
• Hypotension.
• Increased incidence of instrumental delivery (not if the concentration
of bupivacaine is maintained at 0.1% or below).
• Increased use of uterotonics (oxytocin).
• Increased incidence of maternal pyrexia and therefore antibiotic
administration, but no increase in maternal or fetal infection risk.
• Increased duration of second stage of labour (marginal).
• Local bruising and short-term backache (but not long-term backache).
Rare
• Subdural blockade.
• Dural puncture.
• High or total spinal blockade.
• Local anaesthetic toxicity.
• Nerve damage.
• Epidural abscess.
• Epidural haematoma.

BIBLIOGRAPHY
National Institute for Clinical and Health Excellence guideline. Hypertension
in Pregnancy: Diagnosis and Management. NICE. London. 2019.

CASE: OBESITY IN A PREGNANT PATIENT

A 34-year-old primiparous female is being assessed in the obstetric anaes-
thetic clinic. She has a body mass index of 46 kg/m2.

How is body mass index classifed?

According to the World Health Organization, the classifcation of body mass
index is:

Classifcation BMI
Underweight <18.5
Normal/healthy 18.5–24.9
Overweight 25–29.9
Obese class I 30–34.9
Obese class II 35–39.9
Obese class III 40+

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Although a BMI of 18.5–24.9 is defned as “normal” by the WHO, this has been
re-classifed by the NHS to “healthy” as a higher proportion of the population are
now in the 25–29.9 category, statistically making this “normal”!

What are the risks associated with obesity in pregnancy?

Obstetric risks
• Increased risk of pre-eclampsia.
• Increased incidence of gestational diabetes.
• Increased risk of caesarean birth.
• Higher likelihood of postpartum haemorrhage.
• Overall increase in morbidity and mortality.
• Increased risk of venous thromboembolism.
Neonatal risks
• Assessment of fetal size and presentation more difcult.
• Increased risk of congenital abnormalities.
• Higher chance of stillbirth, premature birth and miscarriage.
Anaesthetic risks
• Difcult intravenous access.
• Increased risk of difcult or failed intubation.
• Increased risk of a dural puncture during epidural insertion.
• Increased risk of failure of neuraxial blockade.
• Increased risk of high or total spinal with both epidural top-up and
spinal anaesthesia for operative procedures.
• Excessive sedation if sleep apnoea present.

What are the risk factors associated with the development of venous
thromboembolism in pregnancy?
Pre-existing risk factors
• History of VTE.
• Known thrombophilia.
• Increasing age (>35 years).
• Raised BMI.
• Smoker.
Obstetric risk factors
• Pre-eclampsia.
• Multiple pregnancy.
• Prolonged labour or caesarean section.
• Major obstetric haemorrhage.
• Preterm or stillbirth.
Transient risk factors
• Non-obstetric surgical procedure.

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• Dehydration.
• Immobility.

How should the above patient be managed in terms of her risk of VTE?
• Te risk of venous thromboembolism should be assessed at her
booking appointment.
• Depending on the risk, this patient may need thromboprophylaxis
during the antenatal period.
• Low molecular weight heparins are the frst-line agent in these patients.

Te patient has been booked for induction of labour due to gestational

diabetes mellitus. What are the important aspects in her management
when she is admitted?
Stafng and equipment
• A senior obstetric, midwifery and anaesthetic team should be
available and alerted when the patient is admitted.
• Extra equipment may be required e.g. bed, chair and retractors.
Specifc anaesthetic management
• Both the anaesthetist and patient should be aware that procedures
might be more challenging, including neuraxial blockade, cannula
insertion and intubation. Te patient should be made aware of the
risks associated with this and help should be facilitated early to
mitigate these.
• Te benefts of an early epidural should be clearly explained to
the patient, including avoidance of a general anaesthetic should a
caesarean section be indicated; allowing adequate time for insertion
and loading; and facilitating easier insertion during the earlier stage
of labour.
• If the patient is on thromboprophylactic agents, these need to be
omitted appropriately in order to facilitate neuraxial blockade.
• Regular antacid prophylaxis should be given in labour, and the patient
should be limited to clear fuid only during labour to decrease the risk
of aspiration should a general anaesthetic be required.
• Recovery afer a general anaesthetic is a high-risk time for both
aspiration and hypoventilation, and the patient should be monitored
closely should this be required.

BIBLIOGRAPHY
Denison FC et al. On behalf of the Royal College of Obstetricians and
gynaecologists. Care of women with obesity in pregnancy: Green top
guideline No 72. 2018; 126 (3): 62–106.

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PAEDIATRICS

CASE: CHILD WITH AIRWAY OBSTRUCTION

A 2-year-old female patient is brought into the emergency department
with difculty breathing. She is otherwise ft and well, has no allergies, was
born at term and has had all her vaccinations. You are asked to review her
urgently.

What are potential causes of respiratory distress in this patient?

• Infective:
• Laryngotracheobronchitis (croup).
• Peritonsillar abscess.
• Bronchiolitis.
• Epiglottitis.
• Bacterial pneumonia.
• Obstructive/non-infective:
• Foreign body obstruction.
• Laryngotracheal malacia.
• Anaphylaxis.
• Malignancy.
• Exacerbation of asthma.
• Pneumothorax.
• Pulmonary oedema.
• Pulmonary infltrates.
• Non-respiratory cause.

How would you assess her airway?

• Carry out a rapid initial ABCDE assessment to identify airway
patency and any imminent risk of complete airway obstruction or
respiratory arrest. Escalate to a consultant anaesthetist/ENT early
and as appropriate.
• If there is no immediate threat to the airway, avoid worsening the
situation by upsetting the child. Consider a quiet room with the child
seated on the parent’s lap and avoid interventions that may cause
distress precipitating total airway obstruction.
History
• Onset and duration, course (step-wise, insidious) of dyspnoea and
other associated symptoms.
• Exacerbating and relieving factors.

DOI: 10.1201/9781003156604-17 175

 Clinical Cases for the FRCA

• Type of delivery, gestation, post-delivery course (oxygen requirement,

NICU, intubation or non-invasive ventilation).
Examination
• General – GCS, rash, activity levels, cough, coryza.
• Chest movement – efort, symmetry, efcacy.
• Signs of respiratory distress – cyanosis, tracheal tug, recession,
grunting, drooling.
• Breath sounds – stridor, stertor, grunting, wheeze, crackles.
Investigations
• Respiratory rate and oxygen saturations.
• Temperature.
• Heart rate and blood pressure.
• Chest X-ray – portable. Do not attempt to move the child from a place
of relative comfort and safety to obtain departmental imaging.
• Treat with oxygen to maintain saturations of 94%–98% as required.

On examination you note stridor and a barking cough. Her oxygen

saturations are 94% but she is alert. What are the likely pathogens
underlying her illness?
• A diagnosis of viral laryngotracheobronchitis, or croup (80% of
presentations of acute stridor in the UK), is likely.
• Te most common cause of this is the parainfuenza virus, but it
can also occur due to human coronavirus, adenovirus infuenza and
respiratory syncytial virus.
• Epiglottitis is less likely as she is up to date with her vaccinations and
this is usually caused by Haemophilus infuenza type B.

What is the initial treatment for this patient?

Treatment for croup is largely supportive. In this patient, the following measures
should be considered.
• Oral dexamethasone (0.15 mg/kg) (should show clinical improvement
within 30 minutes).
• Nebulised budesonide (2 mg) if unable to take oral steroids.
• Nebulised adrenaline (400 mcg/kg) (transient improvement for up to
2 hours).
• Humidifed oxygen through a facemask.
• Early consideration of intubation and ventilation if any signs of
clinical deterioration.

What is the Westley Croup Score?

• Te Westley Croup Score was devised to assess the severity of a child’s
illness based on their GCS, and the presence of cyanosis, recession or
stridor.

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• Te total score denotes a diagnosis of mild, moderate or severe croup

that can direct management.

An hour later you review the patient. She is drowsy and has oxygen
saturations of 86% despite being on high fow oxygen. What is your plan
for airway management?
• Ensure rapid escalation to paediatric and anaesthetic senior teams,
ENT surgeons capable of performing a tracheotomy, and discussion
with the tertiary paediatric unit and transfer teams.
• Preparation for intubation:
• Emergency resuscitation and difcult airway trolleys present.
• Induction and emergency drugs drawn up appropriate to the
patient’s weight.
• Airway equipment – have an appropriately sized cufed oral
endotracheal tube (with smaller tubes readily available as airway
likely swollen).
• Full AAGBI monitoring attached.
• Airway plan:
• Where, when and how should be decided as a multidisciplinary
team based upon the urgency of intubation, ease of safe transfer
to theatres, a thorough airway assessment and the skill mix of the
clinicians.
• Pre-oxygenate the patient using an Ayre’s T-piece with a sensible
level of CPAP to splint the airways.
• Option 1: gas induction with sevofurane in 100% oxygen.
• Option 2: IV induction (e.g. with ketamine) and muscle paralysis
(rocuronium).
Of note: the FRCA curriculum states the potential use of Heliox in this situation.
In practice this is very rarely used. It usually comes as 30:70 oxygen:helium mix
(though this can vary). Benefts of its use are due to its relatively high viscosity
and low density, the Reynold’s number is low, increasing the chance of laminar
fow and therefore reduced turbulence and a reduction in respiratory efort. Te
drawback is that it is hard to source and only 30% oxygen.

BIBLIOGRAPHY
Davies I & Jenkins I. Paediatric airway infections. BJA Education. 2017; 17 (10):
341–345.
Maloney E & Meakin G. Continuing education in anaesthesia. Critical Care &
Pain. 2007; 7 (6): 183–186.

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CASE: EMERGENCE DELIRIUM

You are asked to review 3-year-old male patient in recovery following
insertion of grommets under a general anaesthetic. He is agitated and
restless, and his mother is becomingly increasingly upset by his behaviour.

What are the potential causes of agitation in this patient?

• Pain.
• Hypoxia.
• Hypoglycaemia.
• Residual anaesthetic agent.
• Hunger/thirst.
• Hypothermia.
• Sepsis.
• Need for micturition or defaecation.
• Emergence delirium.

What is your initial management?

• Review the patient in recovery with their anaesthetic chart and a
full set of bedside observations including a blood glucose level and
temperature to identify or rule out treatable causes.
• Reassure the mother and encourage her to try and soothe the child by
holding him on the bed if appropriate.
• Consider location – quiet corner in recovery, familiar faces.
• Ensure adequate analgesia has been given and prescribed
perioperatively.
• Escalate to senior paediatric anaesthetist and/or surgeons if any
specifc concerns.

What is emergence delirium?

• A collection of symptoms that may be displayed in children in the
immediate postoperative period.
• Tis includes disturbances in awareness and interaction with their
environment, increased motor responses and hypersensitivity to light
and sound.
• Behaviours displayed include confusion, thrashing, screaming,
avoiding eye contact and inconsolability.

What are the risk factors for the development of emergence delirium?
Patient factors
• Pre-school age.
• Male.
• Anxiety preoperatively.
• Anxious parent.
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Surgical factors
• Ear, nose and throat surgery.
• Eye surgery.
Anaesthetic factors
• Use of short-acting volatile anaesthetic agents e.g. desfurane and
sevofurane.

How can the risk of developing emergence delirium be decreased?

• Parental and child education preoperatively, including play therapy,
preoperative assessment and familiarisation with anaesthetic
techniques e.g. facemask.
• Consider a total intravenous anaesthetic technique.
• Single dose of propofol (1 mg/kg) at the end of the procedure, prior
to emergence.
• Consider the use of intraoperative pharmacological agents e.g.
midazolam, clonidine, dexmedetomidine, ketamine, fentanyl.

What are the options for reducing preoperative anxiety in children?

Non-pharmacological
• Preoperative parental and child education e.g. videos, leafets,
pre-admission visit, familiarisation with anaesthetic technique e.g.
facemask, cannula.
• Play therapy and discussions with psychologists.
• Distraction e.g. toys, books and familiar videos or music.
• Age appropriate, efective communication with the patient and their
parent.
• Presence of a calm parent at induction.
• Involvement of the child in the anaesthetic e.g. choosing a “favour”
of the anaesthetic mask.
• Adjustment of environment e.g. minimal persons in anaesthetic
room.
• Deep breathing and relaxation tasks if age appropriate.
Pharmacological
• Benzodiazepines e.g. midazolam (oral or buccal).
• Alpha-2 receptor agonists e.g. clonidine.
• NMDA receptor antagonists e.g. ketamine.
• Opioids.

When is the use of sedative premedication not recommended in children?

• Known or predicted difcult airway or intubation.
• Risk of hypoventilation e.g. obstructive sleep apnoea, raised BMI.
• Aspiration risk e.g. emergency surgery/child that has not been starved.
• Reduced conscious level.

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• Sepsis/systemic infection.
• Allergy to anxiolytic medication.

BIBLIOGRAPHY
Heikal S & Stuart G. Anxiolytic premedication for children. BJA Education.
2020; 20 (7): 220–225.
Nair S & Wolf A. Emergence delirium afer paediatric anaesthesia: new
strategies in avoidance and treatment. BJA Education. 2018; 18 (1): 30–33.

CASE: NEONATAL EMERGENCY SURGERY

A 17-day-old baby requires an emergency laparotomy for necrotising
enterocolitis.

What is a neonate?
• A neonate is a child aged from birth to 28 days of life.

What are the indications for emergency abdominal surgery in neonates?

• Necrotising enterocolitis:
• Perforation.
• Failure to respond to non-surgical interventions.
• Small or large bowel perforation.
• Malrotation.
• Gastroschisis.
• Small or large bowel obstruction:
• Hirschsprung’s disease.
• Meckel’s diverticulum.

How should the patient be assessed preoperatively?

Tis is a high-risk patient with an increased likelihood of perioperative
morbidity, mortality and complications. Preoperative assessment should be
carried out by an experienced paediatric anaesthetist and discussed with the
neonatal multidisciplinary team.
History
• Parental history: pregnancy, health conditions, medication and social
history.
• Delivery: type, gestation and complications.
• Birth weight, current weight, and signifcant perinatal events.
• Any known medical conditions.

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• Current physiological status (respiratory/cardiovascular support).

• Treatment so far (non-surgical/surgical) and current medication
including whether the patient received IM vitamin K.
Examination
• Airway: oxygen requirement, signs that may indicate a difcult
intubation.
• Respiratory: oxygen requirement, work of breathing or ventilatory
settings if appropriate.
• Cardiovascular: support, signs of compromise, fuid balance, lines in
situ.
Investigations
• Respiratory and cardiovascular observations.
• Arterial (or capillary) blood gas with recent trends.
• Bloods: full blood count, clotting, urea and electrolytes, glucose and
cross match.
• Chest x-ray to check the endotracheal tube position if intubated and
for signs of infant respiratory distress syndrome.
• Others relevant to the history and clinical fndings such as
echocardiogram or cranial USS.

What is the normal value of haemoglobin at this age?

• Normal neonatal haemoglobin is 17–20 g/dL due to the presence of
foetal haemoglobin, which demonstrates an increased afnity for
oxygen due to a reduced amount of 2,3-DPG.
• Blood volume for a term neonate is 90 mL/kg and small volumes of
blood loss can be signifcant in terms of percentage blood volume lost.
Tere is no consensus on appropriate transfusion triggers and this
decision must be based upon the individual patient.
• By 6 months of age, the foetal haemoglobin will be largely replaced by
adult haemoglobin, leading to a physiological anaemia.

What are the priorities for anaesthetising this patient?

Preoperative
• Personnel: Experienced paediatric anaesthetists, surgeons,
neonatologists and trained theatre staf should be present due to
the high-risk and specialist nature of this surgery. A preoperative
multidisciplinary team brief is essential for careful planning and
preparation of each stage.
• Equipment: Ensure appropriately sized paediatric airway equipment
including a range of endotracheal tube sizes; the paediatric difcult
airway trolley; correctly sized monitoring; devices used for warming
both the patient and any infused fuids; and equipment required for
transfer.

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• Drugs: Both routine and emergency drug doses should be carefully

calculated and drawn up prior to the patient being transferred to
theatre to prevent any errors.
• Location: Surgery may need to be carried out on the neonatal unit
if the patient is too unstable for transfer to theatre, which requires
adequate planning.
Intraoperative
• Four-quadrant aspiration of the nasogastric tube prior to induction.
• Preoxygenation followed by induction using an IV, inhalational or
combined technique, muscle paralysis and tracheal intubation with
controlled lung-protective ventilation.
• Consider invasive blood pressure monitoring and central venous
access based upon risk/beneft for the individual patient.
• Fluids: continue dextrose-containing maintenance fuids and monitor
and replace ongoing losses with isotonic solutions, guided clinically
by cardiovascular status, and bedside investigations. A neonate can
have up to 10 mL/kg/hour evaporative losses with an open abdomen.
Blood products should be considered early.
• Regular monitoring and maintenance of blood glucose and
temperature.
• Intraoperative and postoperative analgesia.

What are the options for analgesia in this patient?

• A multimodal approach should be taken.
• Regular age/weight appropriate intravenous paracetamol.
• IV opioid boluses intraoperatively – dosing dependent on whether the
patient will remain intubated postoperatively as there is a high risk of
apnoeas in this patient.
• Local anaesthetic infltration.
• Regional anaesthesia if appropriate (caudal/epidural) – rarely done
in practice.
• Opioid infusion ± nurse controlled analgesia.

BIBLIOGRAPHY
Chandrashekhar S, Davis L & Challands J. Anaesthesia for neonatal emergency
laparotomy. BJA Education. 2015; 15 (4): 194–198.

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CASE: PYLORIC STENOSIS

An 8-week-old male patient is listed for a pyloromyotomy. He was admitted
to hospital 3 days ago with vomiting and dehydration. You are asked to
review him prior to his procedure.

What is a pyloromyotomy?
• Surgical procedure that is carried out in patients with pyloric stenosis,
a condition caused by hypertrophy of the smooth muscles of the
pylorus, which leads to a functional obstruction of the gastric outlet.
• Te procedure can be performed open or laparoscopically, and
involves dissecting the walls of the pylorus muscle down to the
mucosa to relieve the obstruction.

What are the risk factors for the development of pyloric stenosis?
• Incidence varies from 0.9–5.1 per 1000 live births.
• Overall unknown cause.
• Five times higher incidence in males compared to females.
• Increased risk with frst-born babies, monozygotic twin concordance
suggesting a genetic element, and premature infants.

What are the typical signs and symptoms in a patient with undiagnosed
pyloric stenosis?
• Most commonly present in the frst 4–6 weeks of life.
• Projectile, non-bilious vomiting afer feeding.
• Failure to thrive and poor weight gain.
• Dehydration, drowsiness and failure to engage.
• Palpation of an olive-like mass in the right upper quadrant of the
abdomen.

How would you assess this patient preoperatively?

History
• Parental history: pregnancy, health conditions, medication and social
history.
• Delivery: type, gestation and complications.
• Birth weight, current weight, APGAR scores at birth and events since
birth.
• Any known medical conditions.
• Treatment so far and current medication.
Examination
• Basic cardiovascular, respiratory and airway assessment.
• Fluid balance: the patient needs to be appropriately resuscitated prior
to the procedure.

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Investigations
• Bedside observations to ensure adequate resuscitation and
haemodynamic stability.
• Bloods to include urea and electrolytes and serial gases; babies
commonly present with a hypochloraemic, hypokalaemic metabolic
alkalosis secondary to vomiting and dehydration.
• Ultrasound to confrm the presence of pyloric stenosis.

Why is this patient at increased risk of postoperative apnoeas?

• All babies under 60 weeks gestational age are at higher risk of apnoeas,
and should be nursed in an appropriate setting with working apnoea
monitors available.
• Te vomiting of gastric contents leads to a hypokalaemic,
hypochloraemic metabolic alkalosis and dehydration from water loss.
Te body compensates for this by:
• Excreting bicarbonate in the urine.
• Responding to reduced plasma volume by secreting aldosterone to
favour retention of sodium and water and excretion of potassium
by the kidneys.
• As dehydration progresses, this becomes the priority and hydrogen
ions are excreted by the kidneys in exchange for sodium and water.
• Ventilation is stimulated by an increase in the concentration of
hydrogen ions in cerebrospinal fuid, hence metabolic alkalosis
can lead to respiratory depression.
• Even when the metabolic disturbance in the plasma is corrected, it
can take hours before equilibration with cerebrospinal fuid takes
place. Tis explains the higher risk of apnoea in these patients.

How should induction of anaesthesia take place in this patient?

• Tis is elective surgery – induction should be undertaken afer the
patient is fully resuscitated and;
• pH 7.35–7.45.
• Bicarbonate equal to or under 30 mmol/L (or as per local
guidelines).
• Chloride 95–112 mmol/L.
• Potassium 3.5–5 mmol/L.
• Base excess −4 to −2.5 mmol/L.
• Ensure parental consent, WHO checklist, AAGBI monitoring and
patency of IV access.
• Preparation for the anaesthetic should include an experienced paediatric
anaesthetist, trained assistant, availability of resuscitation/difcult
airway trolleys and appropriate doses of routine and emergency drugs.
• Four-quadrant aspiration of nasogastric tube (should be in situ prior
to induction). Consider an ultrasound of the stomach to ensure full
emptying.

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• Inhalational anaesthetic with sevofurane in 100% oxygen followed

by neuromuscular blockade and intubation with an appropriately
sized endotracheal tube.
• Controlled ventilation, fuids and warming perioperatively.
• Check the blood glucose regularly perioperatively as the patient is in
a starved state and is usually on a maintenance dextrose infusion, so
is at a higher risk of hypo/hyperglycaemic episodes.

What is your plan for analgesia in this patient?

• Postoperative pain is not usually severe.
• Regular paracetamol.
• Cautious intraoperative fentanyl.
• Local anaesthetic infltration or consider regional anaesthesia –
bilateral rectus sheath or transversus abdominis plane blocks.

BIBLIOGRAPHY
Craig R & Deeley A. Anaesthesia for pyloromyotomy. BJA Education. 2018;
18 (6): 173–177.

CASE: INHALED FOREIGN BODY

A 3-year-old male child presents to the emergency department with difculty
in breathing following an episode of coughing while eating breakfast an
hour ago. He is otherwise ft and well, has no allergies, was born at term and
has had all of his vaccinations. You are asked to review him.

What fndings would suggest foreign body obstruction as a cause of his

respiratory distress?
History
• Te patient is commonly aged under 3 years old or orally fxated
(learning difculties/behavioural patterns).
• Sudden onset of symptoms.
• Witnessed episode of choking.
• Symptoms appear following a meal.
• Dry cough since the onset of respiratory distress.
• Lack of systemic symptoms e.g. fever and prodromal illness.
Examination
• Hypoxia.
• Signs of respiratory distress e.g. stridor and tachypnoea.

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• Wheeze.
• Decreased air entry unilaterally.
Investigations
• Chest X-ray: foreign body if radio-opaque, hyperinfation on
expiration and atelectasis.

What is the concern with inhalation of peanuts?

• Peanut oil released from the inhaled nut can lead to bronchial
irritation, chemical pneumonitis and further complications such as
oedema, an empyema or abscess, in contrast to inorganic foreign
bodies.

How would you assess this patient in the emergency department?

• Rapid ABCDE assessment to identify airway patency and any
imminent risk of complete airway obstruction or respiratory arrest.
Escalation to a consultant anaesthetist/ENT early and as appropriate.
• If there is no immediate threat to the airway, avoid worsening the
situation by upsetting the child. Consider a quiet room with child
seated on parent’s lap and attempt to develop a rapport.
• Take a history from the parent including a standard anaesthetic
history in case the child deteriorates/dislodges the foreign body and
you need to get to theatre urgently.
• Examination – the priority is to not upset or cause further distress to
the child. If possible, assess:
• Chest movement – efort, symmetry and efcacy.
• Signs of respiratory distress – cyanosis, tracheal tug, recession and
drooling.
• Breath sounds e.g. stridor and wheeze (classically monophonic
and low in acute obstruction).
• Investigations (if tolerated):
• Respiratory rate and oxygen saturations.
• Heart rate.
• Chest X-ray.

On examination, there is a right-sided wheeze and decreased air entry on

the same side. Te patient’s oxygen saturations are 94% on room air. Te
patient is otherwise alert and comfortable. A chest X-ray demonstrates
evidence of gas trapping on the right. How do you proceed?
• Discuss the plan with a senior paediatric anaesthetist and ENT
surgeons and alert the appropriate theatre team in order to facilitate
the appropriate procedure (likely removal of the foreign body via
bronchoscopy).
• If the patient is stable, removal of the foreign body can be delayed
until he is appropriately fasted.

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• Te patient should be kept in a quiet location, carefully monitored

until transfer to theatre.
• Do not try and attempt intravenous access, upset the child or try to
make them lie down/position them against their will.
• Titrate oxygen to saturations of 94%–98% as tolerated.
• A sign of deterioration can include panic, agitation or loss of
compliance. In such a situation, bedside observations may be
particularly challenging. A change in behaviour should be urgently
assessed by a senior member of the ENT and anaesthetic teams.

How would you anaesthetise this patient?

Tere are many diferent techniques for induction of anaesthesia for bronchoscopy,
but the overriding principles are the same: maintenance of patient safety,
oxygenation and anaesthesia. A multidisciplinary approach and good teamwork
with the surgeons is key.
• Ensure parental consent, WHO checklist, AAGBI monitoring and
intravenous access if possible.
• Preparation for anaesthetic should include an experienced paediatric
anaesthetist, trained assistant, availability of resuscitation/difcult
airway trolleys and appropriate doses of routine and emergency drugs.
• Premedication: avoid sedatives, and consider a weight-appropriate
dose of glycopyrrolate to reduce airway secretions.
• ENT surgeons should be scrubbed in theatre.
• Inhalational induction with sevofurane in 100% oxygen, maintaining
spontaneous ventilation to avoid displacing the object further into
the airway and avoid ball-valve trapping.
• Direct laryngoscopy to facilitate spraying of cords (above and below)
with local anaesthetic (lignocaine 4 mg/kg) once deep anaesthesia.
Tere is a high risk of laryngospasm; therefore, IV access should be
ensured.
• Options for maintenance of anaesthesia include:
• Sevofurane in oxygen via the anaesthetic circuit connected to the
side port of the bronchoscope ± remifentanil infusion.
• IV propofol infusion ± remifentanil infusion.
• Dexmedetomidine infusion.
• Continue a high inspired concentration of oxygen and avoid nitrous
oxide to prolong apnoeic time and avoid potential ball-valve gas
expansion.
• Bronchoscopy and instrumentation of the airway are extremely
stimulating and therefore some form of opiate carefully titrated is
usually required.
• Dexamethasone IV can be given intra- and postoperatively to reduce
airway infammation.
• A prolonged period in recovery is sensible and postoperative care in a
suitable nursing environment to closely monitor for airway deterioration.

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• Nebulised adrenaline should be carefully considered; systemic

absorption is low.
• If any airway soiling present, prophylactic antibiotics may be
required.
• Rarely, the patient may require continued postoperative ventilation
and transfer to PICU.

In general, what are the indications for bronchoscopy in paediatric

patients?
To aid diagnosis
• Tracheo-oesophageal fstula.
• Treatment-resistant pneumonia.
• Failure to wean from ventilation.
For therapeutic purposes
• Removal of foreign body.
• Mucous suctioning.
• Balloon dilation of airways.
• LASER surgery.

BIBLIOGRAPHY
Roberts S & Tornington RE. Paediatric bronchoscopy. Continuing Education
in Anaesthesia, Critical Care & Pain. 2005; 5 (2): 41–44.

CASE: POST-TONSILLECTOMY BLEED

You are asked to review a 4-year-old male patient on the paediatric ward,
who had a tonsillectomy 11 hours previously. He is bleeding, and the sur-
geons want to take him back to theatre urgently.

What are the indications for a tonsillectomy in paediatric patients?

• Recurrent/persistent tonsillitis.
• Obstructive sleep apnoea.
• Tonsillar abscess.
• Lymphoma biopsy, or suspicious lump biopsy if unilateral tonsillar
hypertrophy (rare).

Which patients are at higher risk for a post-tonsillectomy bleed?

A primary haemorrhage occurs within 24 hours of the procedure and is usually
due to venous/capillary ooze from failed haemostasis. A secondary haemorrhage

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occurs more than 24 hours from the procedure and is usually due to infection,
most commonly 5–10 days postoperatively.
• Patient factors – male, adults (compared to children), indication for
tonsillectomy (infectious > obstructive).
• Surgical factors – diathermy technique and coblation for secondary
bleed.

What are your main concerns with regards to this patient?

• Tis is a high-risk paediatric patient.
• Medical and surgery emergency with potential hypovolaemic shock
and ongoing blood loss.
• Risk of aspiration from full stomach (swallowed blood and
postoperative oral intake) especially during induction of anaesthesia
and extubation.
• Potential difcult airway and intubation due to local oedema,
swelling and haemorrhage.
• Efect of residual anaesthetic and analgesic drugs prior to a second
emergency general anaesthetic.
• Human factors for child, parents and theatre staf: anxiety/stress.

How would you assess this patient on the ward?

• Carry out a rapid ABCDE assessment to identify the risk of airway
obstruction and the presence of hypovolaemic shock.
• Te volume of blood loss can be difcult to quantify as the patient
swallows it – look for frequent swallowing, blood on pillow,
haemostasis or haemoptysis.
• Urgent escalation to a paediatric anaesthetist/ENT.
• Allow the patient to sit upright and encourage spitting blood out.
• Apply 100% oxygen if it does not cause distress to the child.
• Obtain IV access.
• Start resuscitation if any signs of shock are present.
• Take a history from the parents/paediatric team:
• Events since the procedure.
• Duration of bleeding.
• AMPLE history/review anaesthetic chart.
• Examination:
• General – GCS and signs of active bleeding.
• Airway.
• Focused respiratory and cardiovascular examinations including
peripheral and central pulses, capillary refll and urine output.
• Investigations:
• Respiratory rate and oxygen saturations.
• Heart rate and blood pressure (blood pressure is a less sensitive
parameter due to the ability of paediatric physiology to compensate).
• Temperature.

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• Bloods including haemoglobin, clotting and cross match.

• Bedside haemoglobin if available (haemocue or venous blood gas,
which will give lactate, haemoglobin and mixed oxygen saturations –
<70% is an indicator for increased morbidity and mortality).

On examination the patient has a heart rate of 134 beats/minute, a blood

pressure of 81/53 and a delayed capillary refll time. He is drowsy. How
would you manage this patient?
Resuscitation
• Given the observations and signs of active bleeding, this patient is
in hypovolaemic shock and requires urgent resuscitation prior to
transfer and defnitive management.
• Call for help – paediatric peri-arrest team and activation of the major
haemorrhage protocol.
• Titrate oxygen delivery to saturations of 94%–98%.
• Intravenous access – at least two large bore cannulae (use intraosseous
needle early if unsuccessful).
• Attach continuous monitoring.
• Administer 20 mL/kg fuid boluses of isotonic crystalloid over
5 minutes until blood is available; reassess the heart rate and blood
pressure afer each bolus and repeat if appropriate.
• Cautious suction if severe ongoing bleeding but care as it may disrupt
any formed clots.
Preparation for surgery
• Notify the theatre coordinator urgently in order to facilitate
preparation of surgical and anaesthetic equipment.
• Notifcation of senior anaesthetic and ENT team, if not already
contacted, and coordinate surgical and anaesthetic plans.
Transfer to theatre
• Monitored transfer to theatre once stabilised with anaesthetist and
ENT surgeon present in case of sudden airway obstruction or a major
bleed.

What are the options for induction of anaesthesia in this patient?

• Ensure parental consent, WHO checklist, AAGBI monitoring and
check patency of intravenous access.
• Preparation for anaesthetic should include the presence of an
experienced paediatric anaesthetist, trained assistant, availability
of resuscitation/difcult airway trolleys and appropriate doses of
routine and emergency drugs.
• Specifc equipment should include a large bore nasogastric tube and
two suction devices. Blood and blood products should be present
in theatre. A smaller-sized endotracheal tube than normal may be
required.

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• Anaesthetise the patient in theatre with surgeons present and

scrubbed.
Gas induction
• Inhalational induction with sevofurane in 100% oxygen.
• Maintenance of spontaneous ventilation.
• Induction can be done in the lef lateral position and a slight
head-down position to allow drainage of blood.
• Te ongoing efort of breathing can help the anaesthetist identify the
relevant anatomy if the airway is bloodied due to rhythmic upper
airway movement and bubbles.
Intravenous induction
• Rapid sequence induction with appropriate doses of induction agents,
but care must be taken due to the risk of cardiovascular collapse.
• Appropriate induction agents would be ketamine (1–2 mg/kg) and
rocuronium (1 mg/kg).
• Gentle positive pressure ventilation due to the risk of aspiration.
• Titration of analgesia may be more difcult in paralysed patients,
especially those with OSA.
Other considerations
• Discuss the use of 10 mg/kg tranexamic acid with surgeon – there is
weak evidence in post-tonsillectomy secondary bleeds for its use.
• Torough suctioning of gastric contents to remove swallowed blood
once haemostasis is achieved, using a large bore orogastric tube.
• Rule out a nasopharyngeal clot (and risk of dislodgement with
postoperative airway instrumentation).
• Extubate awake in the lef lateral position.
• A postoperative course of antibiotics, dexamethasone and adrenaline
nebulisers may be required.

BIBLIOGRAPHY
Murto KT et al. Paediatric adenotonsillectomy, part 1: surgical perspectives
relevant to the anaesthetist. BJA Education. 2020; 20 (6): 184–192.
Ravi R & Howell T. Anaesthesia for paediatric ear, nose and throat surgery.
Continuing Education in Anaesthesia, Critical Care & Pain. 2007; 7 (2):
33–37.
Zalan J et al. Paediatric adenotonsillectomy, part 2: considerations for
anaesthesia. BJA Education. 2020; 20 (6): 193–200.

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PAIN MEDICINE

CASE: FIBROMYALGIA
A 45-year-old female presents to the pain clinic with a 4 month history of
widespread body pain. She has a history of asthma, for which she takes
regular inhalers, and depression, for which she takes fuoxetine.

What is pain?
• As defned by the International Association for the Study of Pain
(IASP) in 2020, pain is “an unpleasant sensory or emotional
experience associated with, or resembling that associated with, actual
or potential tissue damage”.

When assessing patients with chronic pain, what are yellow fags?
• Yellow fags are used in patients with pain. Tey indicate the presence
of psychological risk factors for the development of chronic pain.
Tese include:
• Anxiety and/or depression.
• Te patient favours passive treatment e.g. analgesia and ice packs
over active treatment such as physiotherapy.
• Te patient does not carry out usual activities due to fear of
exacerbating the pain.
• Catastrophising of symptoms.

What is fbromyalgia?
• Fibromyalgia is a syndrome characterised by generalised pain and
tenderness, together with non-specifc symptoms such as fatigue and
difculty sleeping.
• Te criteria for a diagnosis of fbromyalgia have been specifed by the
American College of Rheumatology, to include the following three
factors:
1. Widespread pain index (WPI) ≥7 and symptom severity (SS) scale
score ≥5 or WPI 3–6 and SS scale score ≥9 (from a defned scoring
system).
2. Symptoms have been present at a similar level for at least 3 months.
3. Te patient does not have a disorder that would otherwise explain
the pain.

What is allodynia?
• Allodynia is the sensation of pain in response to a non-painful stimulus.

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What is hyperpathia?
• Hyperpathia is an exaggerated painful response to a stimulus, with
an increased threshold for the said response.

What are the risk factors associated with fbromyalgia?

• Tere are no specifc or defned causes for fbromyalgia, but it is
associated with a number of diferent conditions and risk factors,
including:
• Chronic fatigue syndrome.
• Irritable bowel syndrome.
• Interstitial cystitis.
• Temporomandibular joint dysfunction.
• Family history of fbromyalgia.
• Rheumatoid arthritis.
• Systemic lupus erythematosus.
• Anxiety, stress and depression.
• Female gender.

A diagnosis of fbromyalgia is made in this patient afer a thorough

history and examination are carried out. What are the initial treatment
options for her?
Physical
• Physiotherapy.
• Graded exercise therapy.
• Acupuncture.
• TENS.
Psychological
• Cognitive behavioural therapy.
• Pain management programme.
• Acceptance commitment therapy.
Pharmacological
• Antidepressants.
• Simple analgesic agents.
Although they are commonly prescribed, NICE do not recommend the use of
anti-neuropathic agents or opioids in the treatment of fbromyalgia. Tere is also
no evidence for the use of ketamine or lidocaine.

BIBLIOGRAPHY
Dedhia JD & Bone ME. Pain and fbromyalgia. BJA Education. 2009; 9(5):
162–166.

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CASE: CANCER PAIN

A 63-year-old gentleman presents to the pain clinic with severe pain. He has
recently been diagnosed with metastatic pancreatic cancer.

What are the potential causes of pain in this patient?

• Pre-existing comorbidities or chronic pain condition.
• Direct pain from the tumour-causing infammation and oedema of
the surrounding structures.
• Pain due to treatment (side efect of chemotherapy or radiotherapy,
or postoperative pain).
• Pain arising due to complications of the cancer diagnosis e.g.
osteoporosis/bone pain.

What is your approach in the assessment of this patient?

• A biopsychosocial approach should be taken to carefully assess the
patient’s pain.
• A full and thorough history of the patient’s pain is required to
determine the onset, location, type of pain and efect on the patient’s
life. Tis should be followed by the appropriate examinations and
investigations.
• Pain management should be multidisciplinary, taking into account
the prognosis of the patient and the likely causes of his pain. Tis
should include oncologists, surgeons, palliative care and the acute
and chronic pain teams where appropriate.
• Te pain is likely to be exacerbated by psychological factors,
necessitating an empathetic and holistic approach.

Te patient describes severe abdominal and back pain that is worse at

night. What are his analgesic options?
Pharmacological
• Simple analgesia: regular paracetamol and NSAIDs.
• Opioids: modifed release morphine with immediate release agents
for breakthrough pain should be considered early given this patient’s
severe pain and likely terminal diagnosis. Te dose should be
titrated carefully to minimise unpleasant side efects. If the patient
is palliative, these agents can ofen be given through a syringe driver.
• Antidepressants or anti-convulsants if there is a neuropathic element
to pain.
• Steroids can be used successfully in the management of cancer pain
that occurs due to stretching of viscera and local structures. Tese are
ofen also used following radiotherapy.

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• Chemotherapy can lead to a decrease in pain by its direct efect on

tumours.
• If the back pain is due to bony metastases, bisphosphonates may be
used to target these lesions.
Interventional
• Surgery is a potential, but probably unlikely consideration in this
patient due to spread of the disease. However, interventions such as
stenting may help alleviate painful and uncomfortable symptoms.
• Radiotherapy may be used to target bony metastases.
• Targeted nerve destruction – coeliac plexus blockade.
• Intrathecal drug delivery may also be considered.

What are the side efects of opioid-based agents?

• Sedation.
• Constipation.
• Nausea/vomiting.
• Pruritus.
• Urinary retention.
• Respiratory depression.
• Worsening of pain (opioid-induced hyperalgesia).
• Myoclonic jerks at very high levels.

What are the complications associated with a coeliac plexus block?

• Hypotension.
• Diarrhoea.
• Major vessel injury (aorta/vena cava) and catastrophic haemorrhage.
• Intravascular injection/local anaesthetic toxicity.
• Damage to abdominal organs.
• Paralysis.
• Sexual dysfunction.

BIBLIOGRAPHY
Scott-Warren, J & Bhaskar A. Cancer pain management – Part I: General
principles. Continuing Education in Anaesthesia, Critical Care & Pain.
2014; 14 (6): 278–284.
Scott-Warren, J & Bhaskar A. Cancer pain management – Part II: Interventional
techniques. Continuing Education in Anaesthesia, Critical Care & Pain.
2014; 15 (2): 68–72.

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CASE: CHRONIC PAIN

A 53-year-old female is undergoing an abdominal-peritoneal resection
for small bowel cancer. She has a history of hypertension, type 2 diabetes
mellitus and chronic back pain, and is a smoker.

What are the key aspects of her history that you would like to explore
when she attends the preoperative assessment clinic?
• Cardiac history: duration of hypertension, agents required, and
overall control. Explore whether the patient experiences chest
pain, shortness of breath, ankle swelling and any other symptoms
associated with ischaemic heart disease or heart failure.
• Respiratory history: smoking pack-year history (undiagnosed COPD
is a possibility).
• Diabetic history: duration, control and agents including insulin. Te
presence of macro and microvascular complications may indicate a
longstanding history and poor diabetic control.
• Chronic back pain: cause, duration, efect on activities of daily living,
and treatment including non-pharmacological and medication used
to control pain.
• Other comorbidities and drug/social history, allergies and previous
anaesthetic history.
• Concerns and expectations of the patient during the perioperative
period.

Te patient has a 10-year history of back pain that is managed by the

chronic pain clinic. She currently takes regular co-codamol, ibuprofen,
rescue tramadol and wears a buprenorphine patch.

What can be done preoperatively to optimise management of this

patient’s pain during the perioperative period?
• Assessment of the patient’s pain and current management, ideally in
the pain clinic, but the urgency of her surgery may preclude this.
• Determine the total dose of the above agents that the patient takes
on a regular basis as this will need to be continued as a baseline
perioperatively. Discuss the patient’s previous drug history as she
may have tolerated some opioids better than others.
• Explore the efect of the patient’s pain on her activities of daily living
as she may need extra help/a package of care in the postoperative
period when recovering from major surgery.
• Document the above information and discuss with the patient’s
anaesthetic and surgical team where necessary. Establish a
perioperative analgesic plan that should be explained to the patient, so
all questions can be answered and concerns discussed prior to surgery.

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What is your plan for pain management for this patient during the
perioperative period?
Tere is no right answer to this question, but ensure a multimodal approach
to analgesia is taken that includes a range of opioid-sparing techniques. A key
aspect of this is to decide whether to continue or remove the buprenorphine
patch; either option can be chosen, but show that you have thought about the
consequences of both.
Preoperative
• Oral paracetamol (1 g).
• Oral gabapentin (300–600 mg).
• Usual doses of codeine/tramadol, or consider conversion to modifed
release oral oxycodone if tolerated by the patient.
• Remove the buprenorphine patch following a discussion with
the patient. Challenges faced with the presence of the patch in the
perioperative period include:
• Partial antagonism, which may lead to decreased efcacy of full
opioid agonists given during the perioperative period.
• Drug delivery may be unreliable due to the decreased blood
supply to the area (causing a decrease), or increased heat in the
area, increasing drug delivery.
Intraoperative
• Intravenous paracetamol (1 g).
• Intravenous fentanyl boluses titrated to efect.
• Intravenous lidocaine 1 mg/kg bolus followed by infusion of 1 mg/kg/
hour (or according to the local protocol).
• Intravenous magnesium.
• Intravenous ketamine (0.5 mg/kg).
• Regional anaesthesia: spinal anaesthetic with appropriate dose of
diamorphine.
• Intravenous clonidine (1–2 mcg/kg).
Postoperative
• Regular paracetamol (1 g).
• Consider NSAIDs.
• Patient-controlled analgesia with an opioid, usually morphine, but
both fentanyl and oxycodone could also be considered.
• Modifed release oxycodone with immediate release oxycodone as
rescue analgesia.
• Tramadol as required.
• Local anaesthetic wound catheters/rectus sheath blocks, or an epidural.
• Anti-emetics and laxatives as required.
• Early review by the acute pain team and management of the patient
on the intensive care or high dependency unit. Tis patient will need
regular monitoring of her pain using an objective pain scoring system

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and consideration of increased doses or addition of other agents if

her pain is not under control. Te pain is likely to be exacerbated
by surgical trauma, positioning, anxiety and mobility. Early
physiotherapy should be encouraged.

What are common signs of opioid withdrawal?

• Yawning (early sign).
• Myalgia.
• Agitation/anxiety.
• Increased sweating.
• Abdominal pain/cramps.
• Nausea/vomiting/diarrhoea.
• Insomnia.

BIBLIOGRAPHY
Simpson GK & Jackson M. Perioperative management of opioid-tolerant
patients. BJA Education. 2017; 17 (4): 124–128.

CASE: CHRONIC POSTOPERATIVE

SURGICAL PAIN
A 36-year-old female patient is undergoing a right-sided mastectomy
for breast carcinoma. She is a smoker and has a history of anxiety, but is
otherwise well.

What is your plan for perioperative analgesia in this patient?

Tere is no absolute answer to this question – just make sure your answer is
multi-modal and includes simple analgesia as well as more complex agents and
techniques.
Preoperative
• Oral paracetamol (1 g).
• Oral ibuprofen (400 mg).
Intraoperative
• Regional anaesthesia e.g. serratus anterior plane block.
• Intravenous fentanyl boluses titrated to efect.
• Intravenous magnesium (2–4 g).
Postoperative
• Regular paracetamol and ibuprofen (oral).
• Intravenous fentanyl boluses may be required in recovery.

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• Oral morphine.
• Oral tramadol (50–100 mg) for rescue analgesia.
• Early assessment by the pain team/surgical team if the pain does not
settle.

What are the risk factors for the development of chronic postsurgical
pain in this patient?
• Younger age.
• Female.
• History of anxiety.
• Breast surgery (20%–50% incidence).
• Potential prolonged procedure.
• Risk of nerve damage during the procedure.
• Possibility of radiotherapy postoperatively.

Tree months following the initial surgery, this patient presents to the
pain clinic with severe right-sided pain.

What factors might indicate that this patient has developed chronic
postsurgical pain?
• According to the Macrae and Davies defnition, the following factors
would suggest that this patient has developed chronic postsurgical
pain:
• Pain that has developed afer a surgical procedure.
• At least 2 months duration.
• No other cause of pain is likely/other causes have been ruled out.
• Pain that does not pre-date the surgical procedure.

What are the initial management options for this patient?

A biopsychosocial approach to pain management is recommended afer the
initial assessment and diagnosis.
Physical
• Acupuncture.
• Physiotherapy.
Psychological
• Pain management programme.
Pharmacological
• Antidepressant drugs e.g. amitriptyline.
• Anti-convulsants e.g. gabapentin, pregabalin.
• Weak opioids e.g. dihydrocodeine, tramadol.

Te patient is undergoing a breast reconstruction, and is worried about

worsening of her pain. What measures can be taken to reduce this risk?

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• Repeated surgery is a risk factor for the development of chronic

postsurgical pain, but the following interventions have been suggested
to decrease its incidence:
• Perioperative gabapentin.
• Postoperative local anaesthetic wound infusions.
• Regional anaesthesia – paravertebral block.
• Perioperative ketamine infusion.
• Management of patient expectations and psychological strategies.

BIBLIOGRAPHY
Redid D & Curran N. Chronic pain afer surgery: pathophysiology, risk factors
and prevention. Postgraduate Medical Journal. 2014; 90: 222–227.
Searle RD & Simpson KH. Chronic post-surgical pain. Continuing Education
in Anaesthesia, Critical Care & Pain. 2010; 10 (1): 12–14.

CASE: FACIAL PAIN

A 58-year-old female presents with a 3-week history of right sided facial
pain.

What is a neuralgia?
• Neuralgia is pain that is felt in the distribution of one or more nerves.

What are the potential causes of pain in this patient?

• Infective e.g. sinusitis.
• Dental pain e.g. abscess.
• Neuralgia e.g. trigeminal neuralgia, post-herpetic neuralgia.
• Trauma.
• Malignancy.
• Pain radiating from headache e.g. migraine, cluster headache.
• Vascular e.g. temporal arteritis.
• Temporomandibular joint dysfunction.

What are the typical features seen in a patient with trigeminal neuralgia?
• Pain occurs in the distribution of one or more branches of the
trigeminal nerve.
• Te pain is severe and described as shooting, burning or stabbing.
Attacks typically last between seconds to minutes.
• Te pain is ofen triggered by talking, eating or the feeling of wind on
the patient’s face.

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• Te patient is usually asymptomatic in between attacks of pain.

• Trigeminal neuralgia is most common in female patients above the
age of 50.

Are there any risk factors associated with trigeminal neuralgia?

• Risk factors include:
• Pre-existing multiple sclerosis.
• Age.
• Previous cerebrovascular event.
• Hypertension.
• Charcot-Marie-Tooth disease.
• Intracranial malignancy close to the trigeminal nerve.

How would you assess this patient?

History
• Torough history to include comorbidities, drug history and social
history.
• History of the pain focusing on onset, nature of pain and triggers.
• Efect of the pain on activities of daily living.
Examination
• Neurological and cranial nerve examinations.
Investigations
• Basic observations and routine bloods can be used to rule out
infective causes.
• Imaging can be considered if intracranial pathology or malignancy
is suspected.

Based on her history, a diagnosis of trigeminal neuralgia is made. What

are the treatment options for this patient?
Medical
• Pharmacological therapy is the frst line treatment in patients with
trigeminal neuralgia, with carbamazepine as the initial agent of
choice. Oxcarbazepine is second line.
• Other drugs that have been used with varying degrees of success
include gabapentin, pregabalin, lamotrigine and amitriptyline.
Surgical
• Trigeminal neuralgia can be treated with botox, although mainly if
only the ophthalmic branch is afected and in patients where other
interventions may be unsuitable.
• Peripheral nerve blockade – a non-invasive technique using alcohol
or laser therapy for lysis of the trigeminal nerve branch involved.
• Trigeminal ganglion radiofrequency ablation.

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• Microvascular decompression of the trigeminal nerve.

• Gamma knife radiosurgery.

What are the complications associated with microvascular decompression

surgery?
• Recurrence of symptoms.
• Aseptic meningitis.
• Hearing loss on the afected side.
• Visual defects.
• Facial numbness.
• CSF leak.
• Cerebrovascular event.
• Haemorrhage.
• Death.

BIBLIOGRAPHY
Vasappa CK & Kapur S. Trigeminal neuralgia. BJA Education. 2016; 16 (10):
353–356.

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OPHTHALMIC

CASE: PENETRATING EYE INJURY

A 34-year-old gentleman presents to the emergency department following an
injury to his face with a broken glass bottle. He is intoxicated but denies any
comorbidities, allergies and regular medication. He is listed for emergency
surgery due to a penetrating eye injury.

What are your main concerns when assessing this patient?

• Te patient is intoxicated, causing challenges for preoperative
assessment and the perioperative period:
• Potential for an incomplete or inaccurate medical and anaesthetic
history.
• Non-compliance with treatment plans, particularly if a local or
regional anaesthetic technique is used.
• An increased risk of aspiration during induction and extubation
(alcohol may delay gastric emptying).
• Possible lack of capacity to consent to the procedure.
• Potential for additional ingestion of illicit drugs.
• Pharmacological interaction of alcohol with anaesthetic agents.
• Unknown factors e.g. starvation status, previous anaesthetic and
medical history.
• A penetrating eye injury requires careful control of the patient’s
physiology during the perioperative period; consider early escalation
to a consultant anaesthetist.
• Te history raises the possibility of other trauma if he was involved in
an attack. He will need a primary and secondary survey and relevant
investigations if there is evidence of other injuries e.g. bruising and
bleeding.
• Te urgency of surgery requires a multidisciplinary discussion with
surgeons regarding the nature of the injury and potential anaesthetic
risks.

What are the risks of delaying surgery in this patient?

• Infection.
• Endophthalmitis.
• Retinal detachment.
• Vitreous loss.
• Blindness.

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 Clinical Cases for the FRCA

What are the options for anaesthesia in this patient?

• Te options for anaesthesia in a patient with a penetrating eye
injury are:
• General anaesthetic.
• Local anaesthetic ± sedation.
• Regional anaesthetic block ± sedation.

What are the concerns with a regional anaesthetic technique in this

patient?
• Poor compliance due to intoxication, including the inability to remain
still during block insertion and lie fat.
• Lack of a skilled operator to facilitate the regional technique if during
on-call hours.
• Risks of sedation in an intoxicated patient including loss of the airway
and aspiration.
• A regional anaesthetic technique may cause increased intraocular
pressure that may worsen the penetrating eye injury.

How would you anaesthetise this patient?

Given the risks discussed above, it follows that the safest technique is likely to be
a general anaesthetic.
• Ensure patient consent, the presence of a senior anaesthetist and
trained assistant, AAGBI monitoring, and routine and emergency
equipment and drugs readily available, including antihypertensive
medication.
• Consider the location of surgery: Ophthalmic theatres tend to be in
remote locations, so ensure all staf are familiar with the facilities. If
not, carry out the procedure in main theatres afer discussing with
the surgical and theatre teams.
• Te priority is to ensure adequate oxygen delivery to the tissues, while
limiting secondary damage from increased intraocular pressure.
• Te choice of induction agents needs to favour lowering of intraocular
pressure. Avoid ketamine and suxamethonium to reduce the risk
of further damage secondary to transient increases in intraocular
pressure. Coughing, straining and surges in blood pressure should
be minimised.
• Use of a quick-acting opioid and spraying the vocal cords with a local
anaesthetic will help blunt the pressor response to laryngoscopy.
Induction
• Pre-oxygenation with 100% oxygen followed by a rapid sequence
induction with cricoid pressure and appropriate doses of alfentanil,
propofol and rocuronium would be most suitable in this patient.
• Spray the cords with a weight-appropriate dose of local anaesthetic
solution.

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• Secure the airway with an endotracheal tube, followed by ventilation

with oxygen, air and a volatile anaesthetic agent.
• Avoid tying the tube tie tightly due to the risk of increasing intraocular
pressure as a result.

What are the concerns when extubating this patient following his
procedure?
• Transient increases in intraocular pressure can cause further
secondary damage, so coughing and surges in blood pressure should
be avoided.
• In order to minimise the risk of secondary damage during extubation,
consider:
• Extubation while asleep and exchange the endotracheal tube for a
laryngeal mask airway.
• Using a remifentanil infusion while extubating.
• Postponing extubation and transfer the patient to the intensive
care unit.

What are the options for analgesia in this patient?

• Simple analgesia: regular paracetamol and ibuprofen.
• Weak opioids: codeine.
• Strong opioids: oral morphine or tramadol.
• Local and regional anaesthesia.

BIBLIOGRAPHY
Gordon HL. Preoperative assessment in ophthalmic regional anaesthesia.
Continuing Education in Anaesthesia, Critical Care & Pain. 2006; 6 (5):
203–206.

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20
PLASTICS AND BURNS

CASE: BURNS PATIENT

A 39-year-old male patient is admitted to the emergency department afer a
house fre with burns to his chest, back and right arm.

How can you calculate the percentage of burns in this patient, and why is
this important?
• A Lund-Browder chart can be used to calculate the total body surface
area of burns.
• An alternative is to use the “Rule of Nines”:
• Te head, right arm and lef arm each account for 9%.
• Te back, chest, right leg and lef leg each account for 18%.
• Te perineum counts for 1%.
• Te percentage of burns will determine the management of the patient
including the volume required for fuid resuscitation and the location
of defnitive care (e.g. tertiary burns unit for adults with >10% dermal
or full-thickness burns).

How much fuid does this patient require in the frst 24 hours following
the burn?
• Te Parkland formula can be used to determine the fuid requirement
in this patient and is calculated by multiplying the patient weight (kg)
by the percentage burns by 4, to give a volume (mL).
• Half of the fuid should be given in the frst 8 hours afer the burn and
the rest in the following 16 hours.
• Hartmann’s solution is the choice of fuid in burns patients in most
units.

One week following the initial burn, the patient is listed on the emergency
list for wound debridement. What are the anaesthetic concerns for this
patient?
Preoperative
• Te patient’s cardiovascular and respiratory comorbidities may
be exacerbated due to the burn injury, which can pose challenges
for ventilation and maintenance of haemodynamic stability
perioperatively. An assessment of current oxygen requirements and
cardiovascular support will aid in the formulation of an anaesthetic
plan.
DOI: 10.1201/9781003156604-20 209
 Clinical Cases for the FRCA

• Tis patient has been in a house fre, suggesting that airway damage is
possible. An airway assessment will help to determine the likelihood
of a difcult intubation or ventilation.
• Preoperative investigations should be done to check for anaemia,
deranged clotting and renal function.
• Intravenous access is likely to be difcult and limited due to the extent
and location of the burns.
Intraoperative
• Temperature: Patients with high percentage burns increase their
baseline temperature, so need to be managed in a warm environment
with heated blankets. Fluids and blood products should also be warmed.
• Monitoring can be challenging in burns patients, and alternative sites
and means for monitoring may be required.
• Ventilation: Lung protective ventilation is routine, but note that high
airway pressures are common in patients with chest and neck burns.
• Drugs: Suxamethonium should be avoided due to its efect on
extra-junctional receptors.
Postoperative
• Te main postoperative concern is good pain management.
A multimodal approach should be used with the early consideration
of ketamine, neuropathic agents and opioid rotation.

What are the common complications in burns patients?

Immediate complications
• Airway obstruction.
Early complications
• Sepsis.
• Oedema.
• Rhabdomyolysis and renal failure.
• Adult respiratory distress syndrome.
• Venous thromboembolism.
• Malnutrition.
Late complications
• Chronic pain.
• Anxiety and depression.
• Chronic lung disease.

BIBLIOGRAPHY
Bishop S & Maguire S. Anaesthesia and intensive care for major burns. Continuing
Education in Anaesthesia, Critical Care & Pain. 2012; 12 (3): 118–122.

210
 Plastics and Burns

CASE: BREAST RECONSTRUCTION SURGERY

A 41-year-old female patient is undergoing a mastectomy and immediate
autologous breast reconstruction surgery for a localised malignancy. She is
a smoker and has a body mass index of 35, but is otherwise ft and well with
no known allergies.

What are the benefts of using the patient’s own tissues for reconstruction
compared to implants?
• Fewer long-term complications.
• Fewer procedures overall despite a longer initial operation.
• Enhanced aesthetics and higher patient satisfaction.

What are the diferent types of autologous faps?

• Pedicled: Te fap remains attached to the patient during the
procedure via a pedicle and is manipulated into the correct position
to be used for reconstruction e.g. latissimus dorsi fap.
• Free: Te fap is removed from one part of the body and reattached at
a diferent site.

What is the beneft of a DIEP fap over a TRAM fap?

• A deep inferior epigastric perforator (DIEP) fap allows sparing of the
rectus abdominis muscles, which means:
• A decrease in the incidence of postoperative hernias.
• Preservation of the patient’s abdominal strength.
• DIEP faps are therefore preferred over TRAM faps.

What are the risk factors for fap failure in this patient?
• Smoking: Cessation should be encouraged preoperatively due to the
physiological efects of nicotine and carbon monoxide leading to
decreased, poorly oxygenated blood fow to the fap.
• Raised BMI: Weight loss should be advised preoperatively to decrease
the risk of postoperative complications and fap failure.

What are the anaesthetic goals for this procedure?

Te anaesthetic goals are based on maintaining excellent blood fow to the fap
during the perioperative period, which can be targeted according to the Hagen-
Poiseuille equation.
• Maintenance of normothermia through adequate patient warming
and core temperature monitoring.
• Ensure normovolaemia.
• Preservation of high cardiac output with low-normal systemic
vascular resistance.

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 Clinical Cases for the FRCA

• Administer adequate analgesia to decrease the stress response to

surgery.
• Ensure a plasma haematocrit of 30%–35% for optimal blood fow to fap.

What monitoring would you like for this patient during the perioperative
period?
During induction and maintenance:
• Full minimum AAGBI monitoring.
• Core temperature monitoring.
• Invasive blood pressure monitoring.
• Urinary catheter to monitor urine output.
• Cardiac output monitoring.
• Depth of anaesthesia monitoring.
Postoperatively:
• AAGBI monitoring in PACU until awake and stable.
• Flap monitoring: colour, capillary refll, skin turgor, temperature,
bleeding on pinprick and Doppler signal.

What is your plan for postoperative analgesia in this patient?

• Simple analgesia: regular paracetamol and ibuprofen.
• Opioid-based analgesia: oral morphine or morphine/fentanyl PCA if
required.
• Regional anaesthesia: transversus abdominis plane block/catheter.

Te surgeon asks for methylene blue dye to be injected. A few minutes

later you notice a rash on the patient’s chest. Her heart rate is 118 and her
blood pressure is now 74/34. How do you proceed?
Given the history and examination fndings, this may be an anaphylactic
reaction to the methylene blue dye. Tis is an anaesthetic emergency. A rapid
ABCDE assessment should be carried out to determine the cause (and immediate
treatment as appropriate for the fndings) with appropriate early escalation.
• Alert the theatre team immediately.
• Call for urgent senior help.
• Carry out a rapid assessment of the patient and management
according to the anaphylaxis algorithm:
• Apply 100% oxygen.
• Stop injection of the dye if ongoing.
• Elevate the patient’s legs.
• Administer a bolus of adrenaline: 50 μg intravenously with a
250 mL crystalloid fuid bolus. Tis can be repeated as appropriate,
but an infusion should be considered afer three boluses.
• Administer chlorphenamine (10 mg) and hydrocortisone (200 mg)
intravenously when the patient is stable.

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 Plastics and Burns

• Continuous reassessment and escalation to advanced life support

algorithm if the patient deteriorates further. CPR should be
commenced if a cardiac arrest occurs or if the systolic blood
pressure decreases to less than 50 mmHg.
• Ongoing multidisciplinary discussion with the senior surgeon and
a consultant anaesthetist to ascertain the plan for proceeding with
surgery and management, based on the patient’s haemodynamic
stability, the likelihood of fap success and the stage of the procedure.
• Have a low threshold for postoperative management on a higher
dependency or critical care unit.
• Consider mast cell tryptase levels when the patient is stable (ideally
immediately, at 1–2 hours and more than 24 hours afer the reaction).
• Inform the patient and their general practitioner.
• Referral of the patient to the allergy clinic, liaising with the
departmental lead for anaphylaxis.
• Report the reaction to the MHRA via the yellow card pathway.

BIBLIOGRAPHY
Dewachter P & Savic L. Perioperative anaphylaxis: pathophysiology, clinical
presentation and management. BJA Education. 2019; 19 (10): 313–320.
Nimalan N, Branford OA & Stocks G. Anaesthesia for free fap breast
reconstruction. BJA Education. 2016; 16 (5): 162–166.

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21
VASCULAR SURGERY

CASE: ABDOMINAL AORTIC ANEURYSM

A 67-year-old male patient is admitted to the emergency department
following a collapse with severe abdominal and back pain. He has a history
of hypertension, COPD and type II diabetes mellitus. An emergency CT
scan shows a leaking abdominal aortic aneurysm.

What is an abdominal aortic aneurysm?

• A dilated or widened part of the aorta of more than 30 mm within the
abdominal cavity.

What are the risk factors for the development of an abdominal aortic
aneurysm?
• Male gender.
• Increased age (>65 years old).
• Chronic cigarette smoker.
• Comorbidities: ischaemic heart disease, peripheral arterial disease,
hypertension, hyperlipidaemia, COPD, Marfan’s syndrome,
tuberculosis and Takayasu’s disease.
• Positive family history.

How can the risk of a spontaneous rupture be reduced?

• Regular surveillance screening to monitor aneurysm growth.
• Smoking cessation.
• Regular exercise and adequate nutrition/weight loss.
• Pharmacological agents: statins, aspirin, beta-blockers and ACE
inhibitors may all play a part in reducing the risk of growth and
rupture.
• Good control of blood pressure and blood glucose levels.
• Elective surgery if the aneurysm measures >5.5cm.

Te vascular team want to take this patient to theatre urgently. What is

your initial management of this patient in the emergency department?
Tis is a life threatening and time critical case that should be addressed
immediately. Te patient should be assessed and moved to theatre without any
delays. It may be appropriate to commence a blood transfusion while transferring
the patient.

DOI: 10.1201/9781003156604-21 215

 Clinical Cases for the FRCA

Assessment
• Immediate ABCDE assessment in the emergency department
focusing on their conscious level and haemodynamic stability. It
might be advisable to accept a lower than normal blood pressure to
minimise further bleeding. Te patient’s GCS should be used as a
guide: the patient should remain verbally responsive.
• Continuous bedside cardiac monitoring should be instigated.
Insertion of lines should not cause any delays and can be done once
the patient has been anaesthetised.
• A rapid history should be taken from the patient or their relative
regarding comorbidities, current medication, allergies and previous
anaesthetics. An airway assessment should also be done.
Treatment
• Insert a minimum of two large bore intravenous cannulae ready for
blood transfusion.
• Consider permissive hypotension. If required, a rapid infusion device
may be used to restore enough of the circulating blood volume
to maintain cerebral perfusion (assessed by GCS as above). Te
patient’s blood pressure itself is not a reliable guide, particularly on
the background of hypertension. Crystalloids should be avoided to
reduce the risk of coagulopathy.
• Administer analgesia: intravenous opioids titrated cautiously.
Other
• Ensure escalation to the senior anaesthetic, surgical and critical care
teams to ensure that the patient receives optimal care; he has a very
high risk of morbidity and mortality.
• Tis patient may be suitable for endovascular repair, which should be
discussed early with an interventional radiologist.
• Early discussion with emergency theatre staf is necessary to facilitate
rapid and efcient transfer and surgical intervention, including
preparation of emergency drugs and equipment e.g. cell salvage,
warming and rapid infuser devices.
• Ensure urgent preparation of blood products; consider major
haemorrhage protocol activation for easy access and monitoring.
• Facilitate patient transfer to theatre with emergency drugs and
equipment.

What is the Hardman index?

• Te Hardman index is a scoring system that can be used to predict the
mortality of a patient with a ruptured abdominal aortic aneurysm.
It takes into account 5 factors:
• Age >76 years.
• Serum creatinine >190 μmol/L.
• Haemoglobin <9 g/dL.

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• Ischaemic changes visible on ECG.

• Loss of consciousness following hospital admission.
• In the revised index, the risk of mortality increases to 21% with one risk
factor, 60% with two risk factors and 78% with three or more risk factors.
Note that SORT and POSSUM are commonly used to assess the risk of
perioperative morbidity and mortality in these patients.

How would you anaesthetise this patient?

• Tis is a high-risk patient with a signifcant likelihood of perioperative
morbidity and mortality. Ideally, at least two senior anaesthetists and
ODPs should be present to ensure optimal care.
• Induction of the patient should take place in theatre with the
surgeons scrubbed, the patient prepped and draped, and emergency
drugs and blood products readily available. Tis is due to the risk of
decompensation on induction of anaesthesia. Clamping the aorta is
likely to be necessary for rapid haemorrhage control.
• Monitoring: full AAGBI monitoring, with equipment for a catheter
and arterial line ready to be placed afer cross clamping, unless the
patient is deemed stable enough to tolerate the delay. Temperature,
cardiac output and central venous pressure monitoring should be
done perioperatively.
• Ensure a minimum of two large bore intravenous access with the
rapid infusion device connected and blood immediately available for
transfusion. A cell saver should be readily available for use.
• Carry out a rapid sequence induction with the appropriate dose of
drugs depending on the patient’s haemodynamic stability. Ketamine,
fentanyl and rocuronium are commonly used. Induction may lead
to signifcant haemodynamic instability due to the side efects of
the anaesthetic agents, positive pressure ventilation and abdominal
muscle relaxation. Maintenance of anaesthesia should be done with a
volatile anaesthetic agent.
• Following cross clamping of the aorta for haemorrhage control,
the patient should be more stable, allowing insertion of auxillary
monitoring to include invasive blood pressure, CVP, BIS and core
temperature. Blood samples (in particular clotting screen/TEG)
should be obtained to guide further treatment, and a normal blood
pressure can be restored at this point.
• Management of coagulation should be done following a discussion
with the surgeons, to balance the risk of bleeding against the
possibility of a clot developing in the aortic graf.
• A nasogastric tube should be inserted due to the likelihood of a
postoperative ileus.
• Te patient should be transferred to intensive care postoperatively for
further monitoring and treatment. It is likely that further stabilisation
will be required prior to extubation.

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 Clinical Cases for the FRCA

BIBLIOGRAPHY
Leonard A & Tompson J. Anaesthesia for ruptured abdominal aortic
aneurysm. Continuing Education in Anaesthesia, Critical Care & Pain.
2008; 8 (1): 11–15.
NICE Guideline: Abdominal Aortic Aneurysm: Diagnosis and Management.
Available online at www.nice.org.uk. 2020.

CASE: CAROTID ENDARTERECTOMY

A 65-year-old male patient is listed for a carotid endarterectomy 8 days
afer a transient ischaemic attack. He is a smoker with moderate COPD and
hypertension and has a hiatus hernia.

What are the indications for a carotid endarterectomy following a

cerebrovascular event?
• Te NICE 2019 guidelines state that stable patients should undergo
urgent imaging to determine the next course of treatment following
a stroke or TIA.
• Two large randomised controlled trials were carried out looking at
the degree of carotid artery stenosis and intervention:
• North American Symptomatic Carotid Endarterectomy Trial
(NASCET) – criteria determined that patients with 50%–99%
stenosis should be considered for surgery.
• European Carotid Surgery Trial (ECST) – criteria suggested that
patients with 70%–99% stenosis should be considered for surgery.
• Te criteria used should be specifed when the decision is made.

What is a carotid endarterectomy?

• A procedure that enables removal of atheromatous plaque from the
carotid artery.
• It involves dissection of the carotid artery following cross clamping
above and below the afected area.

How would you assess this patient preoperatively?

Patients suitable for this procedure beneft from surgery within 2 weeks of the
onset of symptoms. Tis should be balanced against the risks secondary to
comorbidities that could be optimised prior to surgery.
History
• Take a full medical history focusing on cardiovascular and respiratory
comorbidities and the risk factors for an anaesthetic and further
cerebrovascular events.

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• Determine the severity and any current symptoms of COPD,

including the ability to lie fat and remain still for a prolonged
period of time, as a regional anaesthetic technique may be an
option.
• Tese patients are likely to have disease present in other organs;
have a high suspicion for undiagnosed ischaemic heart disease
and renal insufciency.
• Explore any symptoms or further episodes since the primary TIA.
• Take a full drug and social history, including control with existing
agents.
• Ask about previous anaesthetics and airway assessment.

Examination
• Cardiovascular and respiratory examination.
• Airway examination.
• Any neurological defcits due to the previous cerebrovascular event
should be clearly documented to enable accurate postoperative
monitoring.
Investigations
• Note the oxygen saturation at rest and non-invasive blood pressure.
Te patient’s normal blood pressure should be clearly documented.
• Baseline blood tests: full blood count, urea and electrolytes and
clotting.
• Te severity of the patient’s comorbidities may dictate the need
for further investigations such as an echocardiogram, pulmonary
function tests and CPET.

What are the options for cerebral monitoring perioperatively?

• An awake patient enables continuous sensory and motor function
testing throughout the procedure.
• Cerebral oximetry can be used to monitor brain perfusion.
• A transcranial Doppler probe measures blood fow in the middle
cerebral artery.
• Stump pressures can detect cerebral perfusion pressure.
• Electroencephalogram (waveform changes may indicate ischaemia).
• Somatosensory-evoked potentials.
• Near-infrared spectroscopy gives an indication of changes in cerebral
oxygenation.

What is the indication for a shunt?

• Cross clamping of the carotid artery relies on blood fow through the
contralateral carotid artery and Circle of Willis to maintain cerebral
perfusion. Te restriction of fow in that artery may suggest the need
for a shunt.

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 Clinical Cases for the FRCA

• A shunt can be inserted to bypass the area that has been cross-clamped
if there are concerns about poor cerebral perfusion. However, the
benefts of a shunt need to be weighed up against the potential risks
e.g. air embolism and thrombus formation.

What are the options and benefts of a regional anaesthetic technique in

this patient?
• Te options for a regional anaesthetic in this patient are:
• Local infltration (usually inadequate).
• Superfcial cervical plexus block.
• Deep cervical plexus block.
• A combination of the three techniques above (most common).
• Cervical epidural (rarely done in the UK).
• Benefts of a regional technique in this patient are:
• Allows gold standard monitoring of neurological function and
cerebral blood fow perioperatively (assuming awake patient).
• Avoids the risks of a general anaesthetic in a high-risk patient.
• Reduced requirement for a shunt as the patient can be monitored
throughout.
• Shorter recovery time and stay in hospital, leading to reduced
postoperative complications.
• Avoidance of haemodynamic instability secondary to
administration of anaesthetic agents, reducing the risk of further
cerebrovascular events.
It should be noted that the GALA study did not demonstrate a survival beneft
with regional anaesthesia over a general anaesthetic.

What is hyperperfusion syndrome?

• A collection of symptoms that may occur following a carotid
endarterectomy due to a sudden increase in blood fow to that side of
the brain, including an ipsilateral headache and seizures.
• It can lead to focal neurological defcits and intracranial haemorrhage.
• Te patient’s blood pressure must be very closely monitored and
maintained within a defned range to prevent patients developing
hyperperfusion syndrome following this procedure.

BIBLIOGRAPHY
GALA Trial Collaborative Group. General anaesthesia versus local anaesthesia
for carotid surgery (GALA): a multicentre, randomised control trial.
Lancet. 2008; 372 (9656): 2132–2142.
Ladak N & Tompson J. General or local anaesthesia for carotid
endarterectomy? Continuing Education in Anaesthesia, Critical Care &
Pain. 2012; 12 (2): 92–96.

220
INDEX

ABCDE assessment causes 147

abdominal aortic aneurysm 216 defned 146
airway obstruction 175, 186 diagnosis 146
anaphylactic reaction to methylene initial management 147
blue dye 212 intensive care, complications
aneurysm clipping 12 associated with placing patients
appendicitis 69 in prone position 147
collapse, in pregnancy 84 adrenaline 7, 29, 32, 191, 212
diabetes mellitus 102 advanced life support (ALS) protocol, in
drug overdose 57 pregnancy 84
hypoxia in post-partum patient 161 agitation 110, 178, 187, 199
intra-abdominal pressure 145 airway management
major obstetric haemorrhage 156 acute airway obstruction 52–53
pancreatitis 135 laryngectomy 54–55
postpartum headache 153 obstructive sleep apnoea 47–49
post-tonsillectomy bleed 189 rheumatoid arthritis 49–51
sepsis 137 airway obstruction
upper gastrointestinal bleed 148 acute 52–53
abdominal aortic aneurysm 215–217 child with 175–177
anaesthesia 218 complete 175, 186
Hardman index 216–217 partial 47
initial management in emergency alcohol 57
department 215–216 excess 30, 37, 48, 54, 71, 135, 141
risk factors 215 withdrawal, chlordiazepoxide
spontaneous rupture, reduction 215 for 136
abdominal compartment syndrome alfentanil 5, 206
143–145 allodynia 193–194
intra-abdominal pressure 144, 145 American College of Rheumatology 193
management 145 American Society of Anaesthesiologists
risk factors 144 (ASA) 109
abdominal sepsis 141 amiodarone, for tachy-dysrhythmias 32
acceptance commitment therapy 194 amitriptyline, for chronic postoperative
accidental awareness under general surgical pain 200
anaesthesia (AAGA) 60–61 amlodipine 87
ACE inhibitors see angiotensin amniotic fuid embolism
converting enzyme (ACE) diagnosis 85
inhibitors incidence 84
acid–base balance 12, 27 pathophysiology 85
activated charcoal, in drug overdoses 58 risk factors 84
acupuncture anaemia 105–107
chronic postoperative surgical blood management 106
pain 200 causes 106
fbromyalgia 194 defned 105
acute airway obstruction 52–53 patient optimization 106–107
acute respiratory distress syndrome risks associated with 106
(ARDS) 146–148 aneurysm clipping 3–5

221
 Index

angiotensin converting enzyme (ACE) botox, for trigeminal neuralgia 202

inhibitors 4, 96, 111, 112, brady-dysrhythmias, beta-adrenergic
162, 215 drugs for 32
antibiotic prophylaxis 31, 36, 70 breast reconstruction surgery
antidepressants 211–213
abdominal and back pain 195 anaesthetic goals 211–212
chronic postoperative surgical anaphylactic reaction to methylene
pain 200 blue dye, management for
fbromyalgia 194 212–213
anti-diuretic hormone (ADH) 38 autologous faps 211
anti-emesis benefts of patient’s own tissues 211
chronic pain 198 DIEP fap 211
Parkinson’s disease 10 fap failure, risk factors for 211
antimicrobial therapy 7, 39 monitoring during perioperative
aortic stenosis 21, 94–96, 166 period 212
appendicitis 69–71 postoperative analgesia 212
ARDS see acute respiratory distress Brice questionnaire 61
syndrome (ARDS) British Toracic Society 45
argon 77 bronchial blocker 41, 43
ascending cholangitis 101 bronchoscopy, in paediatrics 186–188
asthma, salbutamol for 87 bupivacaine 120, 122, 172
atrial fbrillation 25–26 buprenorphine patch 197, 198
atrial septal defect (ASD) 21 burns 209–210
atrioventricular septal defect (AVSD) 21
autologous faps 211 calcineurin inhibitor 30
autonomic storm 7 calcium chloride, for massive obstetric
awake craniotomy 17–19 haemorrhage 157
anaesthesia 18 cancer pain 195–196
complications 19 analgesic options 195–196
cortical mapping 19 assessment 195
indications 17 causes 195
preparation 18 coeliac plexus block, complications
scalp block 19 of 196
seizure management 19 opioid-based agents, side efects
awake fbreoptic intubation 52, 53, 81 of 196
axillary nerve block 111 captopril 3, 4, 94, 95, 108
axonotmesis 118 carbamazepine, for trigeminal
azathioprine, side efects of 31 neuralgia 202
carbon dioxide 12, 24, 64, 77, 91, 128
back pain 135, 195–197, 215 carboprost, for massive obstetric
benzodiazepines 7, 8, 12, 18, 58, 179 haemorrhage 157
beta-adrenergic drugs, for brady- carcinoid syndrome 114
dysrhythmias 32 carcinoid tumour 114
biopsychosocial approach 195, 200 Cardiac Advanced Life Support
biventricular pacemaker 34 algorithm 28
blood management 106 cardiac arrest
blood pressure 1, 3, 7, 12, 15, 27, 32, 95, intensive care medicine 139–141
96, 105, 137, 138, 170, 171, 189, post-resuscitation care 139
190, 216, 217 prognostication 140
blood sugar 27, 69, 70, 95, 110 targeted temperature
body mass index (BMI) 12, 45, 127, 142, management 139
153, 172 cardiac tamponade 24, 27–28, 132
222
 Index

cardiac transplantation chronic kidney disease 109–110

anaesthetic implications and goals chronic pain 197–199
32–33 chronic postoperative surgical pain
consideration 29–30 199–201
contraindications 30 chronic postsurgical pain 200
long-term consequences 30–31 chronic spinal cord injury 15–17
pacemaker insertion 31 airway and respiratory system 15–16
preoperative assessment 31–32 anaesthesia 16
cardiomyopathy 37–40 assessment 15
anaesthetic management 39–40 cardiovascular system 16
classifcation 37 headache and blurred vision,
defnition 37 management of 16–17
dilated 37–38 neurological system 16
peripartum 161 ciclosporin, side efects of 31
preoperative assessment 38–39 cis-atracurium, for neuromuscular
risk factors 37 blockade 33
signs and symptoms 37–38 Clinical Frailty Scale 113
cardiopulmonary bypass (CPB) 23, 24, 27 clipping 1, 3
cardiopulmonary exercise testing (CPET) clonidine 18, 120, 179, 198
45–46, 49, 71, 74, 77, 109 Clostridium tetani 6
cardiothoracic surgery coagulopathy 28, 39, 95, 157
cardiomyopathy 37–40 co-codamol 102, 197
heart transplant 29–33 codeine, for chronic pain 198
implantable electrical device 34–36 coeliac plexus block, complications
lobectomy for lung malignancy 44–46 associated with 196
mitral valve replacement 25–29 cognitive behavioural therapy 194
one-lung ventilation 41–43 coiling 1, 4
ventricular septal defect 21–24 collapse, in pregnancy
cardiotocography (CTG) 159, 165–166, ALS protocol 84
170, 171 amniotic fuid embolism 84–85
carotid endarterectomy 218–220 causes 83
cerebral monitoring 219 management 83–85
hyperperfusion syndrome 220 confusion, acute 150–151
indications 218 confusion assessment method for ICU
preoperative assessment 218–219 (CAM-ICU) scoring system 151
regional anaesthetic technique 220 congenital cardiac defects 21
shunt, indication for 219–220 conscious sedation 127–128
caudal anaesthesia 119–121 continuous positive airway pressure
caudal block 120 (CPAP) 43, 48, 49, 64, 65, 177
cell salvage 164–165 cortical mapping 19
cerebral oximetry 219 corticosteroids 30, 33
cerebrovascular event 117, 150, 218–220 CPET see cardiopulmonary exercise
chest compressions 28, 84, 85 testing (CPET)
child with airway obstruction 175–177 cross clamping, of carotid artery 219
airway assessment 175–176 croup, treatment for 176
airway management 177 CTG see cardiotocography (CTG)
initial treatment 176 Cullen’s sign 135
respiratory distress, causes of 175
Westley Croup Score 176–177 day case surgery
chlordiazepoxide, for alcohol age limits for paediatric patients 63
withdrawal 136 benefts in paediatric patients 63
chlorphenamine 212 child for 63–65
223
 Index

day case surgery (cont.) anaesthetic concerns 87–88

defned 63 anaesthetic goals 88
discharge criteria 66–67 contraindications 88
laparoscopic surgery 65–67 indications 87
de-airing 27 risks and complications 88–89
decompression, of pneumothorax 133 electrolytes 24, 27, 40, 142
deep inferior epigastric perforator emergence delirium 178–180
(DIEP) fap 211 risk factors 178–179
defbrillation 29 risk minimization 179
defbrillator/pacing pads 36 sedative premedication 179–180
delirium 150 endotracheal intubation,
assessment and treatment 150–151 complications 53
complications 151 enfurane 12
risk factors 150 enteral feeding 135, 143
dental abscess 79–81 epicardial pacing 27
airway assessment 80 epidural anaesthesia 171–172
anaesthesia, induction of 80–81 epidural catheter 73, 83, 155, 167
anaesthetic management 79 epiglottitis 176
untreated, complications of 80 epilepsy 10–12
dental extraction 127–129 agents avoided in patients with 12
dexamethasone anaesthetic concerns 11
for airway infammation 187 assessment 10–11
for croup 176 ergometrine, for massive obstetric
dexmedetomidine 18, 179, 187 haemorrhage 157
diabetes mellitus 101–102 European Carotid Surgery Trial (ECST)
diabetic ketoacidosis 69, 101 218
management 102 European Society of Cardiology (ESC) 37
treatment 70
diazepam overdose 58 facial pain 201–203
difcult airway algorithm 160 fentanyl 5, 66, 96, 120, 200, 217
Difcult Airway Society 160 fetal heart rate monitoring 165
difuse scleroderma 103 fetal wellbeing, in labour 165
dihydrocodeine, for chronic fbromyalgia
postoperative surgical pain 200 initial treatment 194
dilated cardiomyopathy risk factors 194
anaesthetic management 39–40 fap failure 211
cardiac failure 38 fuid resuscitation 135, 137, 138, 144,
preoperative assessment 38–39 145, 169
risk factors for 37 frailty 112, 113, 125
signs and symptoms 37–38 Frank-Starling mechanism 32
disequilibrium syndrome 110
double-lumen tubes gabapentin
bronchial blocker over 43 for chronic pain 198, 200
one-lung ventilation 41–43 for trigeminal neuralgia 202
drug overdose 57–58 gas trapping 186–187
dysrhythmias 23, 32, 34, 40 general anaesthesia
awareness under 59–61
Ebstein’s anomaly 21 electroconvulsive therapy 87–89
Edmonton Frail Scale 113 penetrating eye injury 206–207
ejection fraction 162, 163 revision hip surgery 96
electroconvulsive therapy (ECT) 87–89 Generic Pacemaker Code 35

224
 Index

gestational diabetes mellitus 174 inhaled foreign body 185–188

glycopyrrolate 32, 33, 187 Injury Severity Score (ISS) 131
graded exercise therapy 194 inotropes 27, 28
“in-plane” approach 122
haematemesis 149 intensive care medicine
haemoglobin 16, 27, 93, 105–107, 156, abdominal compartment syndrome
181, 190 143–145
haemophilus infuenza type B 176 acute confusion 150–151
Hardman index 216–217 acute respiratory distress syndrome
Hartmann’s solution 209 146–148
heart transplant 29–33; see also cardiac malnutrition 141–143
transplantation pancreatitis 135–137
heliox 177 patient care following cardiac arrest
high-frequency jet ventilation 78 139–141
hydrocortisone 104, 212 sepsis 137–138
hyperpathia 194 upper GI bleed 148–149
hyperperfusion syndrome 220 International Association for the Study
hypertension of Pain (IASP) 193
amlodipine for 87 International Subarachnoid Aneurysm
captopril for 94 Trial (ISAT) 1
pregnancy-induced 170–172 interscalene block
ramipril for 41 complications 122–123
hypoplastic lef heart syndrome 21 wrong-sided block management 123
hypopnoea 48 intra-abdominal pressure 66, 99,
hypospadias repair surgery 144, 145
caudal anaesthesia 119–120 intrauterine death 168–170
caudal block 120 causes 168
complications associated with caudal incidence 168
analgesia 121 management 169
preoperative assessment 119 intra-vesical measurement 145
hypoxia intubation
during one-lung ventilation 43 acute airway obstruction 52
in post-partum patient 161–163 awake fbreoptic 53
causes 161 endotracheal 53
initial management 161 invasive blood pressure monitoring 36
risk factors 161 isoprenaline 32, 36

ibuprofen 66, 197, 199 Jehovah’s Witness 164

idiopathic scoliosis 98–99
immunosuppression 30, 33 ketamine 97, 120, 217
implantable cardioverter defbrillator
(ICD) 34 laparoscopic appendicectomy 29
implantable electrical device 34–36 laparoscopic cholecystectomy 101–102
indications 34 laparoscopic surgery 65–67
pacemaker ID card 35–36 laparotomy 37, 40, 52, 71, 141, 143,
perioperative care 36 150, 180
permanent pacemaker 34 laryngeal mask airway 18, 51, 64,
preoperative assessment 35 65, 207
implantable loop recorder 34 laryngeal surgery 78
inguinal hernia surgery 47 laryngectomy 43, 54–55
inhalation, of peanuts 186 laryngotracheobronchitis 176

225
 Index

laser surgery 77–79 manual jet ventilation 78

airway fre management 79 methohexitone 12
anaesthetic concerns 77–78 methyldopa 170
high-frequency jet ventilation, metoclopramide 12, 95, 143
complications of 78 microcytic anaemia 106
medical laser types 77 microvascular decompression surgery,
oxygenation and ventilation 78 complications 203
principles 77 minimally invasive oesophagectomy
safety aspects 78 (MIO) 71–73
Lee’s Revised Cardiac Index 109 analgesia 72–73
lidocaine 97, 124, 194, 198 epidural catheter infusion 73
limb surgery, tourniquet use in 91 oesophageal adenocarcinoma, risk
liver transplant 73–75 factors for 71
anaesthetic concerns 74–75 pneumoperitoneum, complications
indications 73–74 of 72
investigations 74 preoperative assessment 71–72
postoperative complications 75 minimally invasive surgery
lobectomy, for lung malignancy 44–46 analgesic plan 66
low lying placenta, defned 163 benefts 65
Lund-Browder chart 209 contraindications 65–66
postoperative nausea and vomiting 66
macrocytic anaemia 106 MIO see minimally invasive
magnesium 71, 73, 97 oesophagectomy (MIO)
magnesium sulphate 171 misoprostol, for massive obstetric
major abdominal surgery 108–109 haemorrhage 157
major obstetric haemorrhage 156–158 mitral stenosis
causes 156 anaesthetic goals 26
defnition 156 atrial fbrillation 25–26
management 156–157 causes of 25
pharmacological agents for 157 classifcation 25
regional anaesthesia 157 preoperative assessment 26
surgical intervention 158 symptoms 25
treatment 157 mitral valve
major trauma normal area 25
approach 131 replacement 25–29
blood glucose level 132 morphine 5, 66, 96, 200
catastrophic bleeding, management mycophenolate, side efects of 31
of 132
defned 131 N-acetylcysteine, for paracetamol
Mallampati score 59, 80 overdose 58
malnutrition 141–143 nasendoscopy 51, 54
enteral feeding 143 nasogastric tube 1, 3, 9, 65, 142, 143, 182,
nutrition plan 142 184, 190, 217
parenteral nutrition, complications Nd:YAG 77
of 143 nebulised adrenaline, for croup 176
risk of 141 nebulised budesonide, for croup 176
standard daily nutritional neck of femur fracture 112–113
requirements 142 neck swelling 52, 53
stress ulcers, risk minimization 143 “needle through needle” technique 167
systemic complications 142 neonatal emergency surgery 180–182
mandibular protrusion 52 anaesthesia 181–182
mannitol 5 analgesia 182
226
 Index

indications 180 opiate overdose 161

normal neonatal haemoglobin 181 opioid-based agents, side efects of 196
preoperative assessment 180–181 opioid withdrawal, signs of 199
neostigmine 33 oramorph 96
neuralgia 201 orthopaedic surgery
neuraxial anaesthesia 97 revision hip surgery 94–97
neuroanaesthesia 2, 4 scoliosis surgery 97–99
neuromuscular blockade, cis-atracurium tourniquet use 91–93
for 33 OSA see obstructive sleep apnoea (OSA)
neuromuscular blocking agents 75 overdose
neuropraxia 118 diazepam 58
neurotmesis 118 opiates 161
nifedipine 17, 170 paracetamol 58
nimodipine, for subarachnoid oxcarbazepine, for trigeminal neuralgia
haemorrhage 1 202
nitrous oxide 5 oxycodone 96, 198
non-obstetric surgery, in pregnancy oxygen 7, 12, 24, 27, 29, 39, 43, 45, 48, 55,
158–160 64, 78, 84, 93, 102, 115, 125,
normocytic anaemia 106 128, 131, 137, 141, 148, 156,
North American Symptomatic Carotid 159–161, 166, 176–177, 181,
Endarterectomy Trial 185–187, 189–191, 206, 212, 219
(NASCET) 218 oxygenation 7, 11, 33, 43, 45, 55, 78, 81,
93, 96, 125, 147, 160, 187, 206
obesity, in pregnancy 172–174 oxytocin, for massive obstetric
obstetric anaesthesia haemorrhage 157
cardiac disease, pregnant patient with
165–167 pacemaker
hypoxia in post-partum patient biventricular 34
161–163 ID card 35–36
intrauterine death 168–170 insertion 31
major obstetric haemorrhage 156–158 permanent 34
non-obstetric surgery in pregnant paediatric anaesthesia
patient 158–160 child with airway obstruction
obesity in pregnant patient 172–174 175–177
placenta praevia 163–165 emergence delirium 178–180
postpartum headache 153–155 inhaled foreign body 185–188
pregnancy-induced hypertension neonatal emergency surgery
170–172 180–182
obstructive sleep apnoea (OSA) 47–49 post-tonsillectomy bleed 188–191
anaesthetic plan 48–49 pyloric stenosis 183–185
complications 49 pain
defned 47 defned 193
polysomnography 47 yellow fags 193
risk factors 48 pain management programme 194, 200
oesophageal adenocarcinoma 71 pain medicine
one-lung ventilation 41–43 cancer pain 195–196
bronchial blocker 43 chronic pain 197–199
double lumen tubes 41–43 chronic postoperative surgical pain
hypoxia 199–201
causes of 43 facial pain 201–203
management 43 fbromyalgia 193–194
indications 41 pancreatic necrosis 136
227
 Index

pancreatitis 135–137 perioperative sepsis 101

acute 136 peripartum cardiomyopathy
Cullen’s sign 135 counselling 162–163
diagnosis 135 ejection fraction 162
intensive care management 135–137 management 162
paracetamol 57, 66, 95, 96 pathophysiology 162
chronic pain 198 risk factors 161
chronic postoperative surgical peripheral nerve blockade 202
pain 199 peripheral nerve injury
overdose, treatment for 58 risk minimization in patients
parainfuenza virus 176 undergoing shoulder surgery
paravertebral catheter 73, 126 118–119
parenteral nutrition, complications Seddon classifcation 118
of 143 permanent pacemaker (PPM) 34
Parkinsonism 8 pethidine 10, 12
Parkinson’s disease Physiological and Operative Severity
analgesia 9 Score for enumeration of
anti-emesis 10 Mortality and Morbidity
medication 9 (POSSUM) score 38, 109
perioperative risks 8–9 physiotherapy
preoperative assessment 9 chronic postoperative surgical
systemic symptoms 9 pain 200
Parkland formula 209 fbromyalgia 194
partial airway obstruction 47, 54 placenta praevia 163–165
patent ductus arteriosus (PDA) 21 cell salvage 164–165
patient care, following cardiac arrest defnition 163
139–141 incidence 163
patient-controlled analgesia (PCA) 96 Jehovah’s Witness 164
penetrating eye injury 205–207 risk factors 163
analgesia, options for 207 plastics 209–213
assessment 205 platypnea-orthodeoxia syndrome 74
extubation 207 pneumoperitoneum, complications of 72
general anaesthesia 206–207 polysomnography 47
local anaesthesia 206 positive end expiratory pressure (PEEP)
regional anaesthetic technique 206 28, 29, 40, 43, 55, 146, 147
risks of delaying surgery 205 post-dural puncture headache
perianal abscess, drainage of (PDPH) 154
anaesthesia, induction of 159–160 posterior fossa surgery 12–14
difcult airway algorithm 160 posterior reversible leucoencephalopathy
failed intubation 160 syndrome 153–154
general anaesthesia 159 postoperative apnoeas 184
multidisciplinary approach 158–159 postoperative joint infection 94–95
tracheal intubation 159 postoperative nerve injury 117–119
pericardium, blood in 28 postpartum headache 153–155
perioperative medicine causes 153
anaemia 105–107 dural puncture management 154–155
carcinoid 114–115 initial management 153–154
diabetes mellitus 101–102 post-resuscitation care 139
major abdominal surgery 108–109 post-resuscitation syndrome 140
neck of femur fracture 112–113 post-tonsillectomy bleed 188–191
scleroderma 103–105 post-tourniquet syndrome 92
vascular access surgery 109–111 prednisolone, side efects of 31
228
 Index

pre-eclampsia re-bleeding 149

defnition 171 regional anaesthesia 97
risk factors 171 carotid endarterectomy 220
pregabalin, for trigeminal neuralgia 200 caudal anaesthesia 119–121
pregnancy major obstetric haemorrhage 157
ALS protocol in 84 penetrating eye injury 206
cardiac disease in 165–167 postoperative nerve injury 117–119
collapse in 83–85 rib fractures 124–126
non-obstetric surgery in 158–160 rotator cuf repair surgery 121–122
obesity in 173 wrong-sided block 121–123
sepsis in 169–170 regional nerve block 10, 111, 118
venous thromboembolism in 173–174 remifentanil 18, 51, 81
pregnancy-induced hypertension 170–172 renal replacement therapy 110
prehabilitation 72, 95, 108, 109 renin-angiotensin-aldosterone
preoperative anxiety, in children system 38
non-pharmacological treatment 179 respiratory and cardiac arrest,
pharmacological treatment 179 management of 83–85
preoperative assessment respiratory distress
cardiac transplantation 31–32 causes of 175
cardiomyopathy 38–39 foreign body obstruction 185
carotid endarterectomy 218–219 revision hip surgery 94–97
hypospadias repair surgery 119 anaesthesia 95–96
implantable electrical device 35 analgesia 96–97
minimally invasive oesophagectomy management 94
71–72 patient optimisation 95
mitral stenosis 26 postoperative joint infection, risk
neonatal emergency surgery 180–181 factors for 94–95
Parkinson’s disease 9 rheumatic heart disease 25
pyloric stenosis 183–184 rheumatoid arthritis 49–51
ventricular septal defect 23–24 airway assessment 49–51
prognostication 45, 140 airway management 51
prolactin 162 Wilson score 51
propofol 4, 18, 59, 75, 206 rib fractures 124–126
pulmonary blood fow 21–24 analgesia 124–125
pulmonary hypertension 22, 23, 26, 30, assessment 125
93, 103, 104, 163 initial management 124
pyloric stenosis 183–185 paravertebral catheter 126
anaesthesia, induction of 184–185 regional techniques 125
analgesic plan 185 risk mitigation 124–125
postoperative apnoeas 184 trauma CT scan 124
preoperative assessment 183–184 ventilation 125
pyloromyotomy 183 Rockall score 149
risk factors 183 Rockwood Frailty Index 113
signs and symptoms 183 rocuronium 33, 75, 206, 217
pyloromyotomy 183 rotator cuf repair surgery
interscalene block
quick Sequential Organ Failure complications 122–123
Assessment (qSOFA) scoring wrong-sided block
system 138 management 123
regional anaesthesia 121–122
ramipril, for hypertension 41 “Rule of Nines” 209
ranitidine 95 runny nose 64
229
 Index

salbutamol, for asthma 87 thiopentone 59, 61

scalp block 5, 19 thoracostomy 133
scleroderma 103–105 THRIVE (transnasal humidifed rapid
scoliosis insufation ventilatory
causes 97 exchange) 55
defned 97 thyromental distance 52
idiopathic 98–99 tonsillectomy 188, 189
surgery total anomalous pulmonary venous
anaesthetic concerns 98–99 drainage (TAPVD) 21
complications and implications for total intravenous anaesthesia (TIVA) 4,
anaesthesia 97–98 5, 78, 99
wake-up test 99 tourniquet defation 91
sedation 127–129 tourniquet infation 91, 92
sepsis tourniquet pain 91
intensive care medicine 137–138 tourniquet use 91–93
in pregnancy 169–170 concerns 92
sickle cell disease 92 indications 91
somatosensory evoked potentials 14, perioperative management 92–93
140, 219 post-tourniquet syndrome 92
spirometry 45, 125 systemic efects in limb surgery 91–92
sternomental distance 52 tracheal intubation 159, 160, 182
STOP-BANG screening tool 48 tracheostomy 51–53
stress ulcers tramadol 12, 96, 197, 198, 200
risk factors, in patients on intensive tranexamic acid, for massive obstetric
care 149 haemorrhage 157
risk minimization 143 transcutaneous electrical nerve
stridor 54, 176 stimulation (TENS) 194
subarachnoid haemorrhage 1–3 transfer factor testing 45
anaesthetic concerns 2 transnasal humidifed rapid insufation
coiling 1 ventilatory exchange
complications 1–2 (THRIVE) 55
management 2–3 transposition of great arteries (TGA) 21
treatment 1 transversus rectus abdominis
surgical outcome risk tool (SORT) 109 myocutaneous (TRAM)
surgical-site infections faps 211
postoperative 70 trauma
risk factors for 70 approach 131
suxamethonium 36, 59, 65, 160, 206, 210 blood glucose level 132
sympathetic stimulation 32, 38 catastrophic bleeding, management
symptom severity (SS) scale score 193 of 132
CT scan 124
tachy-dysrhythmias defned 131
amiodarone for 32 trigeminal ganglion radiofrequency
verapamil for 32 ablation 202
tacrolimus, side efects of 31 trigeminal neuralgia 201–202
tension pneumothorax 133 tumour resection 115
tetanus 6–8 “2 hit” model 162
autonomic storm 7 “two space” technique 167
diagnosis 6
stridor management 7 UKELD (UK Model for End Stage Liver
treatment 6–7 Disease) score 73
therapeutic drug monitoring 30 upper gastrointestinal (GI) bleed 148–149
230
 Index

vascular access surgery 109–111 preoperative assessment 23–24

vascular surgery surgical closure 24
abdominal aortic aneurysm 215–217 symptoms and signs 22
carotid endarterectomy 218–220 ventilation 24
vasopressors 27, 28, 138 ventricular wall tension 38
venous thromboembolism (VTE) verapamil, for tachy-dysrhythmias 32
management 174 videolaryngoscopes 7, 42, 53, 159
in pregnancy 173–174 VSD see ventricular septal defect (VSD)
ventilation
high-frequency jet 78 wake-up test 99
manual jet 78 warfarin, for atrial fbrillation 26
one-lung 41–43 Westley Croup Score 176–177
ventilator-associated pneumonia 138 Widespread pain index (WPI) 193
ventricular fbrillation 28–29 Wilson score 51, 52
ventricular septal defect (VSD) 21–24 World Health Organisation 105
pathophysiology 22–23 wrong-sided block 121–123

231
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