Multiple choice questions
1
Anaesthesia for carotid surgery
Which of the below are true regarding the neurological monitoring techniques during carotid endarterectomy?
- A.
Stump pressure monitoring following clamping measures the pressure in common carotid which relates to pressure across Circle of Willis from contralateral circulation
- B.
Continuous EEG monitoring has a high sensitivity and specificity especially in subcortical ischaemia
- C.
Near infrared spectroscopy (NIRS) may miss parietal lobe ischaemia as monitor sensors are placed frontal
- D.
With the transcranial doppler (TCD) monitoring an acoustic window may not be found in about 10–20% of patients
- E.
Somatosensory evoked potentials (SSEPs) are generally reliable with general anaesthesia using volatile agents
2
Applied cardiovascular physiology
Which of the following are true regarding the valsalva manoeuvre?
- A.
It is defined as a forced expiration against a closed glottis following a full inspiration, at a pressure of 40 mmHg, held for 10 seconds.
- B.
There is a fall in intrathoracic pressure due to expulsion of blood from thoracic vessels during Phase I
- C.
There is a fall in heart rate during phase IV
- D.
A square wave response is seen in patients with constrictive pericarditis
- E.
There is a hypertensive response in phase II
3
The perioperative management of frailty in patients presenting for vascular surgery
Which of the following are true regarding the assessment of frailty and its significance in vascular surgical patients?
- A.
The electronic frailty index (eFI) is not diagnostic and should be used as a risk stratification tool
- B.
There is emerging evidence for clinical effectiveness of comprehensive Geriatric Assessment (CGA) tool in elective and emergency perioperative settings
- C.
Sarcopenia is highly prevalent in vascular surgical patients, with a particularly high prevalence of 25% in patients with peripheral arterial disease (PAD)
- D.
There is strong evidence that targeted nutritional conditioning improves outcomes in vascular surgical patients
- E.
Edmonton frailty scale is of limited value as it needs to be validated yet in vascular patients
Single best answer
4
A 62-year-old male presents to the emergency department of a district general hospital with severe back pain He is known to have a 4.8 cm infra-renal aortic aneurysm. His blood pressure is 100/60 mm hg and his GCS is 15. He has a pulsatile abdominal mass. Which of the following is true regarding the immediate management of this patient?
- A.
He should be intubated and transferred to maintain stability
- B.
An urgent CT angiogram is recommended to confirm the diagnosis
- C.
Blood pressure should be managed to keep the systolic below 90 mm hg
- D.
An immediate transfer to the nearest tertiary centre should be planned
- E.
His 30-day mortality may be much lower with endovascular repair compared to the open repair
5
A 58-year-old gentleman is pre-assessed for elective repair of a 5.2 cm infra renal aneurysm via endovascular technique. He is a smoker and hypertensive and has a horse shoe kidney. His usual medications include Ramipril and Aspirin. Which of the following are true regarding his risk assessment and peri-operative outcomes?
- A.
His outcome is better with an open repair than endovascular repair (EVAR) because of solitary kidney
- B.
Prehabilitation may be recommended to reduce peri-operative pulmonary complications
- C.
Aspirin needs to be discontinued a week prior to surgery
- D.
Pre-operative non-invasive myocardial stress test should be performed to assess cardiac risk
- E.
NICE doesn’t recommend a particular mode of anaesthesia in the elective setting
Answers
1. Correct Answers: C, D
2. Correct Answers: A, C, D
3. Correct Answers: A, B, C
4. Correct Answer: D
A suspected ruptured abdominal aortic aneurysm (rAAA) patient should ideally be brought directly to a specialist hospital, however if they are initially taken to a different hospital first, before transfer to the specialist centre, the mortality benefits of centralization should outweigh the negative effects of a small delay of up to an hour.
Symptoms of rAAA include abdominal pain, back pack pain, sweating, agitation and collapse. Clinical signs of rAAA include pallor, hypotension, tachycardia, a pulsatile abdominal mass and signs of acute lower limb ischaemia.
As per the Royal college of Emergency Medicine (RCEM) Best practice guidelines, clinical diagnosis of rAAA should be considered in:
- –
Patients >50 years with acute onset of abdominal/back pain AND hypotension
- –
Patients with a known AAA, with symptoms of either abdominal/back pain OR hypotension/collapse
Initial resuscitation during this period should achieve an alert patient & the overall aim is to avoid hypotension (associated with increased mortality) and avoid hypertension (could disrupt clot formation, targeting a systolic blood pressure 90–120 mmHg). Transfer should occur <30 minutes of diagnosis.
Patients should not be anaesthetized for transfer or imaging as the associated loss of tone and sympathetic drive can result in irreversible cardiovascular collapse.
In the context of rAAA, open aneurysm repair (OAR) and endovascular aneurysm repair (EVAR) were compared in the IMPROVE randomized control trial. The 30-day and 90-day mortality was similar in patients undergoing either EVAR or OAR. At 3 years, EVAR offered a survival advantage (42% vs 54% mortality for OAR) and a gain in quality adjusted life years over OAR.
5. Correct Answer: E
In March 2020 NICE published guidelines and made recommendations that stipulate surgeons and health systems. One of the recommendations is to consider EVAR for people with unruptured AAAs who meet the criteria and who have abdominal co-pathology, such as a hostile abdomen, horseshoe kidney, stoma or other considerations, specific to and discussed with the person, that may make EVAR the preferred option.
Lifestyle modifications such as smoking cessation, even if surgery is imminent, has benefits, and advice on exercise and nutrition is also recommended. A Cochrane review of RCTs comparing the impact of preoperative exercise interventions versus usual care in people having AAA repair was unable to ascertain whether prehabilitation reduced 30-day mortality, pulmonary complications, re-intervention rates or post-operative bleeding. It may however, reduce cardiac and renal complications.
Pharmacologically, statins and aspirin are recommended for high-risk vascular patients undergoing major vascular surgery and can be continued perioperatively.
All patients should have an ECG to exclude arrhythmias or ischaemia and FBC and U&E to identify anaemia or renal impairment, respectively. If raised, baseline troponin and BNP can indicate increased risk. Valvular heart disease, heart failure, raised BNP or ECG abnormalities should prompt a trans-thoracic echocardiogram. Those with 2 risk factors and poor functional capacity should have a non-invasive myocardial stress test.
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