Antibiotic stewardship in critical care 1. Regarding antimicrobial stewardship: (a). Antibiotic guidelines in critical care reduce the hospital length of stay. (b). Inappropriate antibiotic use leads to the emergence of resistance. (c). Antibiotic dosing has little effect on antimicrobial resistance. (d). De-escalation of antibiotics should be considered 48 72 h after their introduction. (e). An antibiotic stewardship programme leads to a reduction in antimicrobial resistance 2. Regarding antimicrobial stewardship: (a). Prolonged courses of antibiotics have been shown to increase the incidence of microbial resistance to these drugs. (b). Switching from an intravenous to the oral route reduces resistance patterns. (c). Computer-assisted support does not improve antimicrobial prescribing. (d). Formulary restriction has been shown to improve resistance patterns. (e). Real-time polymerase reaction (PCR) technology alone improves mortality 3. Time-dependent antimicrobials include: (a). Ciprofloxacin. (b). Imipenem. (c). Penicillin V. (d). Metronidazole. (e). Gentamicin. 4. Regarding the pharmacokinetics and pharmacodynamics of antimicrobials: (a). Glycopeptides exhibit both concentration- and time-dependent killing. (b). With time-dependent antibiotics, the extent of microbe killing remains unchanged regardless of the dose. (c). With concentration-dependent antibiotics, the extent of microbe killing is dependent on the antibiotic concentration. (d). Antibiotics that rely primarily on concentration-dependent killing require administration by continuous infusion. (e). Concentrations greater than or equal to the minimum inhibitory concentration (MIC) for all antibiotics are required to suppress bacterial growth Management of acute upper GI bleeding 1. A 67-year-old British man is brought to the emergency department with a history of haematemesis and melaena. He has no relevant previous medical or drug history, works as a builder, is a non-smoker and drinks 60 units of alcohol per week. In relation to the upper gastrointestinal bleeding (UGIB): (a). Variceal bleeding is the most likely cause. (b). Peptic ulcer disease is the commonest cause of bleeding in high-income communities. (c). Variceal bleeding is the commonest cause of bleeding in Egypt and India. (d). The bleeding will have originated distal to the ligament of Treitz. (e). His predicted mortality attributable to this illness is higher than that of an inpatient who develops UGIB. 2. Initial observations and investigations for the same 67-year-old patient were as follows: Glasgow Coma Scale score 15, heart rate 112 beats min 1, blood pressure 98/54 mm Hg. Blood results (normal ranges in brackets): sodium 142 (135 145) mmol litre 1, potassium 4.1 (3.5 5.0) mmol litre 1, urea 10.1 (1.7 8.3) mmol litre 1, creatinine 95 (49 92) µmol litre 1. Haemoglobin concentration 115 (115 155) g litre 1, white blood cell count 9.6 (4 11) 10 9 litre 1, platelet count 234 (150 400) 10 9 litre 1. Liver function tests were normal. 1 BJA Education Volume 17 Number 4 2017 Published by Oxford University Press on behalf of the British Journal of Anaesthesia 2017
At endoscopy the patient was found to have a duodenal ulcer with adherent clot and an actively bleeding vessel injected. The following are appropriate statements concerning the use of upper gastrointestinal bleeding (UGIB) scoring systems: (a). Now that endoscopy has been performed, initial scoring should take place. (b). The scores were devised to assess quality outcomes. (c). The scores are used for research purposes only. (d). This patient s predicted mortality in the event of a rebleed is >50%. (e). The Glasgow Blatchford score is 12. 3. In a patient presenting with suspected acute variceal upper gastrointestinal bleeding: (a). The patient s haemoglobin concentration should be maintained above 70 g litre 1. (b). Terlipressin is continued until β-blockers are established. (c). 3. A repeat oesophagogastroduodenoscopy (OGD) is indicated 24 h later. (d). Patients with further bleeding after initial OGD should be referred for surgical management. (e). Referral for transjugular intrahepatic portosystemic shunt (TIPS) should be considered in patients with Child Pugh class B liver cirrhosis presenting with variceal bleeding, once the patient has been stabilized. 4. With regard to haemodynamically unstable patients with non-variceal upper gastrointestinal bleeding (UGIB): (a). These patients should be offered proton pump inhibitors (PPIs) before oesophagogastroduodenoscopy (OGD). (b). OGD should be performed within 24 h. (c). Those with rebleeding should be offered interventional radiological techniques or surgical intervention rather than repeat OGD. (d). Tranexamic acid injections should be administered within 3 h to patients who remain unstable after initial attempts at resuscitation. (e). Helicobacter pylori eradication does not confer additional benefit over PPIs Perioperative management of opioidtolerant patients 1. Approximate opioid conversions include: (a). A 100 μg h 1 transdermal fentanyl patch approximates to 400 mg day 1 of oral morphine. (b). Codeine administered orally at 60 mg four times daily (qds) approximates to 4 mg of oral morphine every 4 h. (c). Morphine sulphate (MST) 20 mg administered orally twice daily (bd) approximates to 10 μg h 1 of transdermal buprenorphine. (d). Tramadol 100 mg qds approximates to 20 mg of MST. (e). A patient taking MS 75 mg bd is unable to eat and drink after operation and has a patientcontrolled analgesia device. The background morphine infusion should be 2 mg h 1 of intravenous morphine. 2. Concerning a patient admitted to hospital with worsening back pain and who usually takes strong opioids: (a). The patient also has a history of prostate cancer and the pain is now more widespread and affecting the legs. The most likely diagnosis is opioid-induced hyperalgesia. (b). The patient is feeling unwell after losing a box of tablets and requests more morphine. The most likely diagnosis is opioid addiction. (c). The patient presents asking for more morphine and admits to taking morphine from a friend. The most likely diagnosis is opioid dependency. (d). The patient has been taking a stable dose of morphine for some time and presents with gradual worsening of back pain. The most likely diagnosis is opioid tolerance. (e). The patient develops more widespread pain and presents asking for more morphine. The most likely diagnosis is disease progression. 3. Appropriate statements regarding opioids include: (a). Tolerance to the side-effects of opioids occurs before the occurrence of tolerance to analgesia 2 BJA Education Volume 17 Number 4 2017
(b). Methadone is metabolized in the liver to active metabolites that have an effect at the N- methyl-d-aspartate (NMDA) receptor. (c). Buprenorphine is a partial μ-agonist with a very high opioid receptor affinity, making it an ideal agent for maintenance therapy. (d). Naltrexone is a competitive μ-receptor antagonist used for maintenance therapy in alcoholism and substance abuse disorder. (e). Opioid equianalgesic dose tables are an accurate method for calculating equivalence in opioid-tolerant patients 4. Appropriate statements regarding opioids include: (a). When performing an opioid rotation, it is recommended to reduce the dose by 30 50% because of incomplete cross-tolerance. (b). Continuance of a patient s normal long-acting opioid in the postoperative period would not be recommended if considering the use of morphine patient-controlled analgesia (PCA) after operation. (c). It is recommended that naltrexone be stopped 48 72 h before surgery. (d). After stopping naltrexone for 72 h before operation, patients are likely to need more immediate-release opioid to manage their acute pain than would be expected for opioidnaive patients. (e). Full opioid agonists should be weaned before restarting naltrexone to prevent precipitating opioid withdrawal symptoms Perioperative management of the patient with diabetes requiring emergency surgery 1. A 24-year-old single mother with a 15-year history of well-controlled type 1 diabetes mellitus (T1DM) presents to the emergency department with a painful wrist after a fall. The orthopaedic surgeons recommend internal fixation of a fracture of her distal radius for the simple fracture. Her glycated haemoglobin level (HbA1c) 2 months before attendance was 51 mmol mol 1 (6.8%) [suggested target to facilitate elective surgery <69 mmol mol 1 (8.5%)]. She usually manages her diabetes with a continuous subcutaneous insulin infusion (CSII) pump. The optimal method of managing her diabetes perioperatively includes: (a). Admission to hospital the night before surgery, transfer to a variable-rate intravenous insulin infusion (VRIII), titration of the insulin infusion to maintain a capillary blood glucose (CBG) of 6 10 mmol litre 1 and stopping the VRIII once she is eating and drinking and receiving her normal CSII. (b). Admission to hospital directly from the emergency department and allowing her to manage her own diabetes with her CSII, aiming for a CBG of 6 10 mmol litre 1, aiming to put her first on the emergency list. (c). Admission to hospital on the day of surgery and also ensuring she is operated first on the trauma list. Before admission, ensuring that she is assessed by a specialist who can advise on perioperative management of diabetes. The patient and the specialist agree a management plan involving the perioperative use of the CSII and aiming for a CBG of 6 10 mmol litre 1, whilst nil by mouth. (d). Admission to hospital the night before surgery and transfer to a VRIII, and taking down the VRIII in the anaesthetic room. (e). Admission straight from the emergency department, not allowing further oral intake, and listing her for emergency surgery at some stage. 2. A 75-year-old male weighing 80 kg with poorly controlled type 2 diabetes (HbA1c measured 3 months previously was 77 mmol mol 1 (9.2%) [suggested target to facilitate elective surgery <69 mmol mol 1 (8.5%)], hypertension and chronic renal impairment with an estimated glomerular filtration rate (egfr) of 52 ml min 1.73 m 2 (normal range >90 ml min 1.73 m 2 ) presents to hospital with abdominal pain and vomiting. His normal medication includes metformin 1 g three times per day, gliclazide 160 mg twice daily and ramipril 5 mg twice daily. His capillary blood glucose (CBG) on admission is 15 mmol litre 1 (normal target range 6 10 mmol litre 1 ). He has a contrastenhanced computed tomography (CT) scan and is diagnosed with small-bowel obstruction secondary to a caecal mass. He needs an urgent laparotomy. His perioperative management should involve: 3 BJA Education Volume 17 Number 4 2017
(a). Continuing to manage his diabetes with his usual diabetes medication. (b). Commencing a variable-rate intravenous insulin infusion (VRIII) and only giving fluids to resuscitate his cardiovascular system. (c). Commencing a VRIII and administering 5% dextrose in 0.45% saline with 0.3% potassium chloride at 80 ml h 1 through the same cannula, and giving additional crystalloid fluids with a sodium concentration >131 mmol litre 1 to resuscitate his cardiovascular system through a different cannula. (d). Regular assessment of likely fluid and electrolyte needs from his history, clinical examination, current medications, clinical monitoring and laboratory investigations, including a daily review of concentrations of urea, creatinine and electrolytes and hourly measurement of urine output, and acting accordingly. (e). After operation he should be seen by a diabetes inpatient specialist nurse (DISN). 3. A 75-year-old man weighing 70 kg with wellcontrolled type 2 diabetes mellitus is admitted to hospital in an acute confusional state secondary to a urinary tract infection (UTI). His usual diabetes medication is metformin 500 mg twice daily and gliclazide 80 mg twice daily. He makes a good recovery from his UTI, but whilst in hospital he develops heel ulcers, which subsequently require debridement after several weeks of conservative treatment. Throughout his stay, his glycaemic control and renal function have remained excellent. The following statements are appropriate: (a). On admission he should have been prescribed treatment of hypo- and hyperglycaemia, and the frequency of CBG monitoring should have been specified. (b). The development of the heel ulcer is unlikely to have been preventable. (c). His surgery should be scheduled for him to be first on the operating list (to minimize starvation), and he should not be postponed/delayed. (d). On the day of surgery, he can be managed by manipulation of his oral diabetes medication (continuation of metformin and omission of gliclazide). (e). On the day of surgery, his diabetes is optimally managed with a VRIII and the simultaneously administered fluid should be 5% glucose in 0.45% saline with 0.3% potassium chloride delivered at 83 ml h 1. 4. A 45-year-old man with type 1 diabetes mellitus that is managed by multiple-dose insulin injection presents with diabetic ketoacidosis (DKA) secondary to Fournier s gangrene. At a multidisciplinary discussion it is agreed that the patient requires immediate surgery and resuscitation in theatre. Perioperative management of the patient includes: (a). Preoperative resuscitation using intravenous colloids. (b). Perioperative resuscitation with Hartmann s solution with additional potassium chloride added. (c). Use of 0.9% saline with premixed 0.3% potassium chloride as the preferred DKA resuscitation fluid in theatre and the accident and emergency department. (d). Commencing a fixed-rate intravenous insulin infusion (FRIII), but stopping the intravenous insulin pump when the patient arrives in theatre because of the risk of hypoglycaemia. (e). Administration of 20% glucose when the blood glucose falls below 14 mmol litre 1. Patient-reported outcome measures and patient-reported experience measures 1. Patient-reported outcome measures (PROMs): (a). Measure patient-reported experience. (b). Are disease-specific. (c). Measure the patient s perception of their health status. (d). Measure the efficacy of a clinical intervention. (e). Measure clinical effectiveness and safety. 2. Patient-reported experience measures (PREMs): (a). Provide information on the patient s experience during care. (b). Look at the outcomes of patient care. (c). Are satisfaction surveys. (d). Are used as an indicator of quality of care. (e). Measure patient experience. 4 BJA Education Volume 17 Number 4 2017
3. Regarding the collection of patient-reported outcome measures (PROMs) and patient-reported experience measures (PREMs) data: (a). In 2009 the UK Department of Health launched an initiative to measure PROMs for two key surgical interventions: total hip replacements and total knee replacements. (b). PROMs and PREMs are clinical tools not used in research. (c). There is a positive correlation between patient experience and patient outcomes. (d). The EQ-5D questionnaire is disease-specific. (e). Postoperative data are collected immediately. 4. Regarding the use of patient-reported outcome measures (PROMs) and patient-reported experience measures (PREMs) and their limitations: (a). PROMs and PREMs do not provide information regarding the cost-effectiveness of interventions. (b). They provide useful information for physician revalidation. (c). PREMs provide data to streamline and redesign pathways to meet patients expectations. (d). PROMs and PREMs questionnaires are generic and can be used for varied types of data collection. (e). Education programmes are required for PROMs and PREMs. (d). Constipation. (e). Sleep disturbance. 3. Options for managing dopaminergic medication in the perioperative period include: (a). Continuing usual oral medication. (b). Modified-release levodopa with dopamine decarboxylase inhibitor via a nasogastric tube. (c). Dopamine infusion. (d). Transdermal rotigotine. (e). Subcutaneous apomorphine. 4. Strategies to reduce postoperative delirium include: (a). Involvement of the patient s Parkinson s Disease nurse specialist or Parkinson s Disease physician. (b). Routine administration of low-dose haloperidol in those with a history of hallucinations or delusional ideation. (c). Optimally managing pain and hydration, avoiding constipation, sensory impairment and unnecessary immobility. (d). Agreeing a preoperative delirium management plan, including individualized and general nonpharmacological measures. (e). Withholding dopamine agonist medications for around 1 week after operation. Parkinson s disease 1. The following anti-emetics are contraindicated in patients with Parkinson's disease: (a). Prochlorperazine. (b). Domperidone. (c). Droperidol. (d). Metoclopramide. (e). Cyclizine. 2. The following are common clinical features of Parkinson's disease: (a). Dysphasia. (b). Sialorrhoea. (c). Intention tremor. 5 BJA Education Volume 17 Number 4 2017