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MS Surgery Exam Q37 61
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What's Inside (25 Questions, Q37-61)

The PDF covers all questions from your image, organized into 4 colour-coded sections:

Section A: Shock & Sepsis (Q37-41)

Q	Topic
37	SIRS criteria (classic 4 + Sepsis-3/qSOFA update)
38	Pathogenesis of sepsis-induced hypotension + Surviving Sepsis Hour-1 Bundle
39	Distributive shock - types, haemodynamics, management
40	Biomarkers of sepsis - full table (PCT, CRP, Lactate, IL-6, Presepsin)
41	Haemorrhagic shock - ATLS Class I-IV table + DCR management

Section B: Blood Coagulation (Q42-44)

Q	Topic
42	Physiology of coagulation (cell-based model + classic cascade table)
43	Coagulation disorders + DIC (full diagnosis/management table)
44	Trauma coagulopathy - Lethal Triad, ROTEM, DCR, TXA

Section C: Blood Transfusion (Q45-54)

Q	Topic
45	Blood component separation - full product table
46	Blood substitutes + stored blood changes
47	Assessment of blood loss (clinical + quantitative)
48	Allogeneic transfusion - full SHOT complications table
49	Autologous transfusion - 4 types + advantages
50	Massive transfusion - definition + Massive Haemorrhage Protocol
51	PRP applications in surgical practice
52	Complications of blood transfusion (INCH mnemonic)
53	Blood products + plasma expanders for polytrauma
54	TRALI - mechanism + TRALI vs TACO comparison table

Section D: Anaesthesia & Critical Care (Q55-61)

Q	Topic
55	Local anaesthetics - full drug table + advances + LAST toxicity
56	Regional anaesthesia - types + Spinal vs Epidural comparison
57	Epidural anaesthesia - technique + complications
58	Incentive spirometry - mechanism + technique
59	Cardiac arrest during surgery - 4H/4T + ALS algorithm
60	Post-op pain management - WHO ladder + multimodal drug table
61	Invasive vs non-invasive post-op analgesia techniques

Each answer is formatted for a 15-minute exam write-up with key scoring tables, bulleted mechanisms, and clinical mnemonics from Bailey & Love's 28th Edition.

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Here are all 25 answers in clean readable format:

MS GENERAL SURGERY EXAM ANSWERS (Q37–61)

Bailey & Love's 28th Edition | ~15 min per answer

SECTION A: SHOCK & SEPSIS

Q37. Criteria of SIRS (2013, 2021)

Definition: SIRS = Systemic Inflammatory Response Syndrome - a non-specific clinical response to a severe insult (infectious or non-infectious).

Diagnostic Criteria - ANY 2 of the following 4:

Parameter	Abnormal Value
Temperature	> 38°C OR < 36°C
Heart Rate	> 90 bpm
Respiratory Rate	> 20/min OR PaCO₂ < 4.3 kPa
WBC	> 12,000/mm³ OR < 4,000/mm³ OR > 10% bands

Sepsis-3 Update (2016, tested 2021):

Sepsis = life-threatening organ dysfunction from dysregulated host response to infection
Organ dysfunction = SOFA score increase ≥ 2
Septic shock = Sepsis + vasopressor + lactate > 2 mmol/L despite fluids
qSOFA (bedside): RR ≥ 22, altered mentation, SBP ≤ 100 → 2 of 3 = suspect sepsis

Progression: SIRS → Sepsis → Severe Sepsis → Septic Shock → MODS

[Bailey & Love Ch.2 | Sepsis-3, JAMA 2016]

Q38. Pathogenesis of Sepsis-Induced Hypotension (2014)

Mechanism chain: Infection → TLR/PRR activation → NF-κB → Cytokine storm (TNF-α, IL-1β, IL-6) → Cardiovascular collapse

Key steps:

iNOS upregulation → excess Nitric Oxide → profound vasodilation → ↓ SVR
Endothelial injury → capillary leak → intravascular hypovolaemia
TNF-α + IL-1β → myocardial depression
Relative adrenal insufficiency in prolonged sepsis
Mitochondrial dysfunction → cellular dysoxia

Haemodynamic profile:

Parameter	Early (Warm)	Late (Cold)
Cardiac Output	↑ High	↓ Low
SVR	↓ Low	↓↓ Very Low
Mixed venous O₂	High	Low

Management - Surviving Sepsis Hour-1 Bundle:

Measure lactate (re-measure if > 2 mmol/L)
Blood cultures × 2 before antibiotics
Broad-spectrum antibiotics within 1 hour
30 mL/kg IV Hartmann's for hypotension or lactate ≥ 4
Vasopressor if MAP < 65 mmHg → Noradrenaline (1st line)

[Bailey & Love Ch.2 | Surviving Sepsis 2021]

Q39. Distributive Shock (2014)

Definition: Maldistribution of blood flow due to pathological vasodilation → high CO + low SVR → tissue hypoperfusion despite adequate volume.

Types:

Septic shock (most common) - NO-mediated vasodilation
Anaphylactic shock - IgE-mediated histamine/leukotriene release
Neurogenic shock - spinal injury T6+ → loss of sympathetic tone + bradycardia
Toxic shock syndrome - superantigen-mediated cytokine storm

Classic haemodynamic profile: ↑ CO | ↓ SVR | ↓ PCWP | ↑ Mixed venous O₂ | Warm extremities

Management:

Septic: Antibiotics + IV fluids + Noradrenaline
Anaphylactic: IM Adrenaline 0.5 mg (1:1000) + IV fluids + steroids + antihistamines
Neurogenic: IV fluids + phenylephrine + atropine for bradycardia

[Bailey & Love Ch.2, Table 2.1]

Q40. Biomarkers of Sepsis (2023)

Biomarker	Normal	Sepsis	Role
Procalcitonin (PCT)	< 0.1 ng/mL	> 2 ng/mL	Diagnosis; antibiotic de-escalation
CRP	< 10 mg/L	> 100 mg/L	Diagnosis & monitoring
Lactate	< 2 mmol/L	> 2 mmol/L	Tissue hypoxia; prognosis
IL-6	Low	> 1000 pg/mL	Early sepsis marker
Presepsin (sCD14-ST)	< 300 pg/mL	Elevated	Early macrophage activation
sTREM-1	Low	Elevated	Amplifies inflammatory signal
Blood cultures	Sterile	Growth	Gold standard - definitive

Procalcitonin key points:

Rises 2-4h after bacterial infection (faster than CRP)
Does NOT rise in viral infection or autoimmune disease
PCT-guided therapy reduces antibiotic duration by ~3 days
PCT < 0.5 ng/mL = consider stopping antibiotics

[Bailey & Love Ch.2 | Sepsis-3 2016]

Q41. Pathophysiology and Management of Haemorrhagic Shock

ATLS Classification:

Class	Blood Loss	% BV	HR	BP	Urine mL/h	CNS
I	< 750 mL	< 15%	< 100	Normal	> 30	Normal
II	750-1500	15-30%	100-120	Normal	20-30	Anxious
III	1500-2000	30-40%	120-140	↓	5-20	Confused
IV	> 2000 mL	> 40%	> 140	↓↓	< 5	Lethargic

Pathophysiology:

↓ Volume → ↓ Preload → ↓ CO → ↓ MAP
Compensatory: ↑ HR, ↑ SVR, ADH, RAAS activation
Prolonged: Lethal Triad = Hypothermia + Acidosis + Coagulopathy

Damage Control Resuscitation:

Stop the bleeding - PRIMARY goal
Permissive hypotension: MAP 50-65 mmHg until surgical control
Haemostatic resuscitation: pRBC : FFP : Platelets = 1:1:1
Tranexamic acid 1g IV within 3 hours (CRASH-2 trial)
Warm fluids + warming blanket
Calcium replacement; limit crystalloids

Endpoints: Lactate < 2 | Base excess > -6 | Urine > 0.5 mL/kg/h

[Bailey & Love Ch.2 | CRASH-2 | ATLS 10th Ed]

SECTION B: BLOOD COAGULATION

Q42. Physiology of Blood Coagulation and Its Importance in Surgery (2024)

Primary Haemostasis:

Injury → vascular spasm → platelet adhesion (vWF to collagen via GPIb)
Platelet activation: ADP, TXA₂, serotonin release
GPIIb/IIIa binds fibrinogen → platelet plug

Secondary Haemostasis - Cell-Based Model:

Initiation: TF + FVIIa → FXa + FIXa → small thrombin burst
Amplification: thrombin activates FV, FVIII, FXI, platelets
Propagation: tenase + prothrombinase → large thrombin burst → fibrin clot

Classic Cascade:

Pathway	Factors	Test
Intrinsic	XII→XI→IX→X	APTT
Extrinsic	VII→X	PT/INR
Common	X→Thrombin→Fibrin	Both

Fibrinolysis: tPA → plasminogen → plasmin → cleaves fibrin → FDPs/D-dimers

Surgical importance:

Pre-op: PT, APTT, platelets, bleeding time
Intra-op: diathermy, ligature, topical agents (Surgicel, Gelfoam)
Post-op: DVT prophylaxis (LMWH + TED stockings) vs bleeding risk
Drugs: Warfarin (blocks II,VII,IX,X) | Aspirin (COX-1) | NOACs

[Bailey & Love Ch.4 & Ch.2]

Q43. Coagulation Disorders and Their Management

Disorder	Defect	PT	APTT	Plt	Treatment
Haemophilia A	Factor VIII ↓	N	↑	N	Factor VIII conc / DDAVP
Haemophilia B	Factor IX ↓	N	↑	N	Factor IX concentrate
vWD	vWF ↓	N	↑/N	N/↓	DDAVP / cryoprecipitate
DIC	All factors consumed	↑	↑	↓	Treat cause + FFP + cryo + plt
Liver disease	↓ factor synthesis	↑	↑	↓	Vit K, FFP, platelets
Warfarin OD	Vit K factors ↓	↑	N/↑	N	Vit K + 4-factor PCC
ITP	Anti-platelet Ab	N	N	↓	Steroids, IVIG, splenectomy

DIC key points:

Triggers: sepsis, trauma, obstetric emergencies, malignancy
Lab: ↑PT, ↑APTT, ↓Fibrinogen, ↓Platelets, ↑D-dimer
Management: TREAT THE CAUSE + FFP + cryoprecipitate + platelets

[Bailey & Love Ch.4]

Q44. Coagulopathy in Trauma Patients (2021)

Acute Traumatic Coagulopathy (ATC):

Occurs within minutes in up to 25% of trauma patients
4-fold increase in mortality
Mechanism: shock + tissue injury → protein C activation → anticoagulation + hyperfibrinolysis

Lethal Triad:

Component	Effect	Critical Threshold
Hypothermia	Impairs enzymatic coagulation	< 34°C
Acidosis	Inhibits thrombin + platelet function	pH < 7.2
Haemodilution	Dilutes clotting factors & platelets	> 10 units pRBC

Assessment:

ROTEM/TEG - bedside viscoelastic testing - gold standard
Conventional: PT, APTT, fibrinogen, platelet count, D-dimer

Damage Control Resuscitation:

1:1:1 pRBC:FFP:Platelets (PROPPR trial)
TXA 1g IV within 3 hours (CRASH-2)
Cryoprecipitate if fibrinogen < 1.5 g/L
Calcium replacement
Damage Control Surgery: temporary pack → close → return for definitive repair
Avoid excess crystalloid

[Bailey & Love Ch.2 | PROPPR Trial | CRASH-2]

SECTION C: BLOOD TRANSFUSION

Q45. Blood Component Separation and Their Role in Surgery (2016, 2017)

Component	Contents	Storage	Surgical Indication
pRBC	RBCs, minimal plasma	4°C, 35-42 days	Anaemia, haemorrhage (Hb < 7)
FFP	All clotting factors	-30°C, 1 year	DIC, massive transfusion, warfarin reversal
Platelets	Platelets in plasma	22°C agitated, 5-7 days	Plt < 50k pre-op; < 10k prophylactic
Cryoprecipitate	FVIII, vWF, Fibrinogen, FXIII	-30°C, 1 year	Haemophilia A, vWD, DIC, TIC
Albumin	Colloid protein	Room temp	Hypoalbuminaemia, SBP
Factor Concentrates	Specific factors	Varied	Haemophilia, PCC for warfarin reversal

Leucodepletion (universal UK since 1999): prevents FNHTR, CMV, vCJD, HLA alloimmunisation

Irradiation: prevents TA-GvHD in immunocompromised patients

[Bailey & Love Ch.4]

Q46. Blood Substitutes and Changes in Stored Blood (2011, 2023)

Storage Lesion:

Change	Clinical Effect
↓ 2,3-DPG	Left shift O₂ curve → impaired O₂ release to tissues
↑ K⁺	RBC lysis → hyperkalaemia → arrhythmias
↓ pH	CO₂ + lactate accumulation → acidosis
↓ Factor V, VIII	Labile factors degrade (only retained in FFP)
↑ Citrate	Chelates Ca²⁺ → hypocalcaemia in massive transfusion
↑ Microaggregates	Microthrombi formation

Blood Substitutes:

HBOCs (e.g. Hemopure): polymerised Hb, carries O₂, no crossmatch needed
Perfluorocarbons (PFCs): dissolve O₂, require high FiO₂
Limitations: vasoconstriction, short half-life, NOT yet in routine clinical use
Future: recombinant Hb, nano-RBCs, universal donor RBCs

[Bailey & Love Ch.4]

Q47. Assessment of Blood Loss in a Surgical Patient (2021)

A. Clinical:

Vital signs: HR, BP, RR, capillary refill > 2 sec, urine output
ATLS Classes I-IV (see Q41)
Shock Index = HR/SBP | Normal 0.5-0.7 | > 1.0 = significant haemorrhage

B. Investigations:

FBC: Hb (note: early haemorrhage Hb may be falsely normal)
ABG: Lactate, Base deficit (> -6 = significant shock)
Coagulation: PT, APTT, fibrinogen
Group & Save / Crossmatch

C. Quantitative methods:

Swab weighing (1 g = 1 mL blood)
Suction canister measurement
EBL formula = EBV × (initial Hct - final Hct) / initial Hct
EBV: 70 mL/kg adult | 80-85 mL/kg child

[Bailey & Love Ch.2 & Ch.4]

Q48. Classification, Indications and Complications of Allogeneic Blood Transfusion (2025)

Definition: Transfusion of blood from another individual.

Indications:

Hb < 7 g/dL (< 8 in cardiac disease); Class III/IV haemorrhage
Platelets < 10 × 10⁹/L (prophylactic) or < 50 × 10⁹/L (pre-operative)
FFP if PT/APTT > 1.5× normal; Cryo if fibrinogen < 1.5 g/L

Pre-Transfusion Checks: ABO/Rh typing | Crossmatch | Bedside ID (2 identifiers) | Consent

Complications (SHOT Classification):

Reaction	Mechanism	Management
Acute haemolytic	ABO incompatibility	STOP, fluids, frusemide, FFP
FNHTR	WBC antibodies	Paracetamol, slow rate
Anaphylaxis	IgA deficiency	Adrenaline, steroids, antihistamines
TACO	Volume overload	Diuretics, O₂, upright position
TRALI	Anti-HLA/HNA antibodies	O₂, ventilatory support, ICU
Septic shock	Bacterial contamination	Blood cultures, IV antibiotics
TA-GvHD	Donor T-cells attack host	Irradiation (PREVENTION only)
Iron overload	Repeated transfusion	Desferrioxamine

[Bailey & Love Ch.4 | SHOT Annual Report]

Q49. Autologous Blood Transfusion - Types and Advantages (2021, 2022)

Definition: Collection and re-infusion of patient's own blood.

Types:

Pre-operative autologous donation (PAD): collect 2-4 weeks before elective surgery
Acute normovolaemic haemodilution (ANH): remove blood at start, replace with crystalloid, re-infuse at end
Intra-operative cell salvage (ICS): suction field blood → wash → re-infuse (cardiac, vascular, orthopaedic)
Post-operative drainage salvage: collect drain blood, filter, re-infuse within 6 hours

Advantages:

Eliminates alloimmunisation, infection risk, TRALI, TA-GvHD
Reduces allogeneic demand
Fresh, 2,3-DPG replete blood (cell salvage)
Acceptable to Jehovah's Witnesses (cell salvage)

Contraindications for cell salvage:

Malignant field (relative) | Bowel contamination | Amniotic fluid (relative)

[Bailey & Love Ch.4]

Q50. Massive Blood Transfusion - Definition, Complications, Management (2022)

Definition (any one):

≥ 10 units pRBC in 24 hours
Replacement of entire blood volume in 24 hours
4 units pRBC in 1 hour with anticipated continued need

Complications:

Dilutional coagulopathy (↓ factors, ↓ platelets)
Hypocalcaemia (citrate chelates Ca²⁺) → myocardial depression
Hyperkalaemia → arrhythmias
Hypothermia → enzyme inhibition
Metabolic acidosis
TACO, TRALI

Massive Haemorrhage Protocol (MHP):

Activate MHP - alert haematology, blood bank, consultant
Empiric 1:1:1 pRBC:FFP:Platelets (do NOT wait for labs)
Tranexamic acid 1g IV stat + 1g over 8h
Calcium gluconate 10 mL 10% IV after every 4 units pRBC
Warm blood via in-line warmer (target > 37°C)
ROTEM/TEG-guided product use
Cryoprecipitate if fibrinogen < 1.5 g/L (target > 2 g/L)
rFVIIa (NovoSeven) as last resort

[Bailey & Love Ch.4 | PROPPR Trial | CRASH-2]

Q51. Applications of Platelet-Rich Plasma (PRP) in Surgical Practice (2021)

Preparation: Autologous blood centrifuged → platelet conc 5-10× baseline (> 1 million/µL)

Growth Factors: PDGF, TGF-β, VEGF, EGF, IGF → healing, angiogenesis, collagen synthesis

Surgical Applications:

Orthopaedics: cartilage repair, tendinopathy, bone graft enhancement
Plastic surgery: wound healing, scar management, skin graft take
Maxillofacial: dental implants, jaw reconstruction, sinus lifts
Colorectal: perianal fistula treatment
Cardiothoracic: sternal wound healing post-sternotomy

Evidence: Good for knee osteoarthritis and chronic wounds; evolving for other uses (Level IIb-III)

[Bailey & Love Ch.4]

Q52. Complications of Blood Transfusion

Mnemonic - INCH:

Immune: haemolytic (ABO), FNHTR, urticaria, anaphylaxis, TRALI, TA-GvHD, alloimmunisation
Infective: HIV (1:2.5M), Hep C (1:1.5M), Hep B (1:220,000), CMV, malaria, vCJD, bacterial
Non-immune: TACO, air embolism, hypothermia, dilutional coagulopathy
Chemical/metabolic: hyperkalaemia, hypocalcaemia, iron overload (> 20 units)

Most dangerous - Acute Haemolytic Reaction (ABO mismatch):

Intravascular haemolysis → DIC → ARF → death
First sign: "feeling of impending doom" / loin pain / haemoglobinuria
Action: STOP transfusion immediately, maintain IV access, send unit + patient sample to lab

[Bailey & Love Ch.4]

Q53. Blood Products, Plasma Expanders for Polytrauma Shock; Complications of Transfusion

Blood products: See Q45 and Q48.

Crystalloids:

Hartmann's/Ringer's lactate - balanced, preferred in trauma
Normal saline - risk of hyperchloraemic acidosis with large volumes
Dextrose - NOT for resuscitation (hypotonic, worsens cerebral oedema)

Colloids:

Human albumin solution (HAS 4-5%): liver failure, SBP
Gelatin (Gelofusine): half-life 2-3h, anaphylaxis risk
AVOID HES/Voluven in sepsis (CHEST trial: ↑ mortality + AKI)

Principles for Polytrauma:

Permissive hypotension (MAP 50-65) until surgical haemostasis
1:1:1 haemostatic resuscitation + TXA early + Calcium + warm fluids
Minimal crystalloid to avoid dilutional coagulopathy

[Bailey & Love Ch.2 & Ch.4 | ATLS 10th Ed]

Q54. TRALI - Definition, Mechanism and Management (2021)

Definition: New acute lung injury within 6 hours of transfusion, with PaO₂/FiO₂ < 300 mmHg, bilateral pulmonary infiltrates on CXR, NO evidence of pre-existing ALI or TACO.

Mechanism - Two-Hit Model:

Hit 1: Patient's condition primes pulmonary neutrophils (surgery, sepsis, trauma)
Hit 2: Donor anti-HLA (class I/II) or anti-HNA antibodies activate primed neutrophils
Neutrophil activation → ROS + proteases → endothelial damage → capillary leak → non-cardiogenic pulmonary oedema
Most implicated: FFP and platelets from multiparous female donors

TRALI vs TACO:

Feature	TRALI	TACO
Mechanism	Non-cardiogenic (Ab-mediated)	Cardiogenic (volume overload)
JVP/CVP	Normal/↓	Elevated
Response to diuretics	No	Yes
BNP	Normal	Elevated
CXR	Bilateral infiltrates, no effusion	Bilateral infiltrates + effusion

Management:

STOP transfusion immediately
High-flow O₂; escalate to CPAP/BiPAP or mechanical ventilation
Lung-protective ventilation (6 mL/kg + PEEP)
NO diuretics (not volume overload)
Report to blood bank and SHOT
Prevention: male-only / nulliparous donors for plasma products

[Bailey & Love Ch.4 | SHOT Report 2023]

SECTION D: ANAESTHESIA & CRITICAL CARE

Q55. Pharmacological Advances in Local Anaesthetics (2015)

Mechanism: Reversibly block voltage-gated Na⁺ channels. Block order: autonomic > sensory > motor.

Agent	Type	Max Dose	Duration	Uses
Lidocaine	Amide	3 mg/kg (7 with adrenaline)	1-2h	Infiltration, IVRA, topical
Bupivacaine	Amide	2 mg/kg	4-8h	Spinal, epidural, PNB
Levobupivacaine	Amide	2.5 mg/kg	4-8h	Safer cardiac profile
Ropivacaine	Amide	3 mg/kg	4-6h	Epidural, less motor block
Prilocaine	Amide	6 mg/kg	2-3h	Bier's block
Cocaine	Ester	1.5 mg/kg topical	1h	ENT topical (vasoconstriction)

Advances:

Liposomal bupivacaine (Exparel): sustained release up to 72h
Ultrasound-guided blocks: greater accuracy, fewer complications
Continuous PNB catheters: improved post-op analgesia
Adjuvants: dexamethasone (prolongs block 4-8h), dexmedetomidine, clonidine
EMLA cream: lidocaine 2.5% + prilocaine 2.5% for venepuncture

LAST (Local Anaesthetic Systemic Toxicity):

CNS: perioral tingling → tinnitus → seizures → coma
Cardiac: arrhythmias → cardiac arrest (bupivacaine worst)
Treatment: STOP, 100% O₂, 20% Intralipid 1.5 mL/kg IV bolus

[Bailey & Love Ch.14]

Q56. Regional Anaesthesia (2006)

Definition: Interruption of nerve conduction over a body region using LA without loss of consciousness.

Types:

Central neuraxial: Spinal, Epidural, Caudal
Peripheral nerve blocks: brachial plexus, femoral, sciatic, ankle
IV regional (Bier's block): upper limb surgery
Plexus blocks, field blocks, wound infiltration

Spinal vs Epidural:

Feature	Spinal	Epidural
Space	Subarachnoid (CSF)	Epidural space
Drug volume	Small (2-4 mL)	Large (10-20 mL)
Onset	Fast (2-5 min)	Slow (15-20 min)
Duration	Fixed (2-4h)	Continuous (catheter)
Level	L2/3 or L3/4	Any level
Dural puncture	Yes (intentional)	Accidental = PDPH
Uses	Lower limb, perineal	Labour, post-op analgesia

Advantages over GA:

Avoids airway instrumentation
Better post-op analgesia, ↓ opioid, ↓ PONV
Earlier mobilisation, shorter hospital stay
Preferred in high-risk cardiac/respiratory patients

[Bailey & Love Ch.14]

Q57. Short Note on Epidural Anaesthesia

Anatomy: Space between ligamentum flavum and dura mater (fat, epidural veins, lymphatics). Extends foramen magnum to sacral hiatus.

Technique:

Position: sitting or lateral decubitus
Needle: Tuohy 16-18G, bevel upward
Identification: loss of resistance to saline
Catheter: 3-4 cm into epidural space
Test dose: 3 mL lignocaine 2% + adrenaline (detect intrathecal/intravascular placement)

Drugs: Bupivacaine 0.1-0.5% ± fentanyl/morphine

Low concentration = sensory block (labour)
High concentration = motor + sensory (surgery)

Complications:

PDPH (dural puncture headache): postural, Rx = bed rest, caffeine, blood patch
High spinal: hypotension, bradycardia, respiratory arrest
Hypotension: IV fluids + ephedrine 6 mg IV
Epidural haematoma: back pain → paraplegia → emergency MRI + decompression
Epidural abscess: fever + neuro deficit → MRI + IV antibiotics ± drainage

Uses: Labour analgesia | Major abdominal/thoracic/lower limb surgery | PCE (post-op)

[Bailey & Love Ch.14]

Q58. Incentive Spirometry (2008)

Definition: Respiratory therapy device that encourages slow, deep, sustained inspiratory efforts to prevent/treat atelectasis by providing visual feedback of inspired volume.

Mechanism:

Diaphragmatic breathing → opens collapsed alveoli → ↑ FRC
Sustains flow-volume loop → recruits atelectatic segments

Types:

Volume-oriented (preferred): measures inspired volume (Voldyne) - target > 2500 mL
Flow-oriented: visual balls indicating flow rate

Indications:

Post-operative (especially upper abdominal/thoracic surgery)
COPD, pneumonia, neuromuscular disease, atelectasis
Pre-op conditioning in high-risk patients

Technique: Sit upright → exhale normally → seal lips → inhale slowly and deeply → hold 5-10 seconds → 10 breaths/hour while awake

Benefits: ↓ post-op pneumonia and atelectasis | Improves FVC, FEV₁, SpO₂

[Bailey & Love Ch.14]

Q59. Management of Cardiac Arrest During Surgery (2023)

Reversible Causes - 4Hs and 4Ts:

4H: Hypoxia | Hypovolaemia | Hypo/Hyperkalaemia | Hypothermia
4T: Tension pneumothorax | Tamponade | Thrombosis (PE/MI) | Toxins

Surgical-Specific Causes:

Massive haemorrhage | Vagal reactions | Air embolism
Malignant Hyperthermia (MH) | LAST | Cement implantation syndrome

Immediate Management (ALS Algorithm):

Recognise: unresponsive, no pulse, no normal breathing
Call crash team
CPR: 30:2, 100-120 bpm, 5-6 cm depth
Intubate early (anaesthetist present)
Adrenaline 1 mg IV every 3-5 min
Shockable (VF/pVT): defibrillate 200J biphasic immediately
Amiodarone 300 mg IV after 3rd shock
Non-shockable (PEA/Asystole): CPR + adrenaline + treat reversible causes

Special Situations:

Malignant Hyperthermia: STOP trigger agent, Dantrolene 2.5 mg/kg IV, active cooling
LAST: 20% Intralipid 1.5 mL/kg IV bolus
Tension pneumothorax: needle decompression 2nd ICS MCL → chest drain
Air embolism: left lateral Trendelenburg, aspirate via CVP, 100% O₂

[Bailey & Love Ch.14 | ALS Guidelines 2021]

Q60. Pain Relief in Surgery / Post-Operative Pain Management (2009, 2011)

WHO Analgesic Ladder:

Step 1 (Mild): Paracetamol 1g QDS + NSAIDs (ketorolac, ibuprofen)
Step 2 (Moderate): Weak opioids - codeine, tramadol ± adjuvants
Step 3 (Severe): Strong opioids - morphine, fentanyl, oxycodone

Multimodal Analgesia (gold standard): Paracetamol + NSAID + Regional block + Opioid PRN → reduces opioid consumption

Drug	Mechanism	Dose	Notes
Paracetamol	Central COX inhibition	1g QDS IV/PO	Safe, start ASAP
NSAIDs	COX-1/2 inhibition	Ketorolac 15-30 mg	Caution: renal, GI, bleeding
Morphine	µ opioid receptor	0.1 mg/kg IV titrated	Gold standard severe pain
Fentanyl	µ agonist rapid onset	1-2 mcg/kg IV	Patch for chronic pain
Gabapentin	Ca²⁺ channel (α₂δ)	300 mg TDS	Reduces opioid use
Ketamine	NMDA antagonist	0.1-0.5 mg/kg	Opioid-sparing

Delivery methods:

PCA: IV morphine 1 mg bolus, 5 min lockout - safe, patient autonomy
Epidural (PCE): bupivacaine ± fentanyl - best for thoracic/abdominal surgery
TAP block: somatic pain after abdominal surgery

ERAS principles: Pre-emptive analgesia | Minimal opioids | Early mobilisation

[Bailey & Love Ch.14]

Q61. Invasive and Non-Invasive Techniques of Post-Operative Analgesia (2021)

NON-INVASIVE:

Oral: paracetamol, NSAIDs, opioids, gabapentinoids, ketamine
Transdermal: fentanyl patch (72h), buprenorphine
Inhaled (Entonox): 50% N₂O + 50% O₂ - labour, dressing changes
TENS: gate control theory - mild/moderate pain
Ice/cold therapy: local anti-inflammatory analgesia

INVASIVE:

IV PCA: morphine 1 mg bolus, 5 min lockout
Epidural (PCE): bupivacaine + fentanyl via catheter - gold standard major surgery
Spinal opioids: intrathecal morphine 0.1-0.3 mg - 12-24h analgesia
Peripheral nerve blocks:
- TAP block - abdominal surgery
- Femoral nerve block - hip/knee
- Sciatic nerve block - foot/ankle
- Brachial plexus block - upper limb
- Intercostal block - rib fractures, thoracotomy
- Paravertebral block - mastectomy, thoracic surgery (unilateral)
Continuous wound infusion catheters
Intra-articular injection: bupivacaine (knee arthroscopy)

Monitoring: Pain NRS 0-10 | Sedation score | Respiratory rate | PONV

[Bailey & Love Ch.14]

All 25 answers complete. Source: Bailey & Love's Short Practice of Surgery, 28th Edition, Chapters 2, 4, and 14.

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