Exam Intelligence

As PassingTheFinal pointed out, one of the questions done badly in the April 2008 paper was one of the questions the college felt was answered badly.  The question was:

A 4 year old (20 kg) is admitted with acute appendicitis and is scheduled for urgent surgery. She has
been vomiting for 2 days, is pyrexial, has a tachycardia of 170 bpm and prolonged capillary refill.
a) Describe the perioperative fluid management of this case using intravenous crystalloids. (60%)
b) Outline the complications that can occur with inappropriate intravenous crystalloid therapy. (30%)

There were several publications last year which prompted that particular question, we suspect.  The first of these was the National Patient Safety Agency report into use of intravenous fluids in paediatric practice, specifically it was Reducing the risk of hyponatraemia when administering intravenous infusions to children.

Their advice essentially boils down to NOT using 0.18% NaCl with 4% glucose except in specialist areas, using 0.9% NaCl for resuscitation, and maintenance with 0.45% NaCl + 5% glucose or 0.45% NaCl + 2.5% glucose, bearing in mind these are hypotonic solutions.  Hypotonic solutions should definitely not be used in children at risk of developing hyponatraemia.  More info in the link above!

Another publication that will have prompted this is the Association of Paediatric Anaesthetists of Great Britatin and Ireland’s Consensus Guideline on Perioperative Fluid Management in Children from September last year.  These are worth reading, if only to realise that consensus is not always easy to reach, and for some of the insights it offers!

Anaesthesia journal published an editorial in Volume 62 Issue 4 , Pages 322 - 324 (April 2007) about the guidelines.

An older article can be found in the CEACCP from the British Journal of Anaesthesia: Cunliffe M. Fluid and Electrolyte Management in Children. 2003; 3:1-4. (You will need a password for this, which you can arrange through the Royal College if you don’t already have one.  To do this, email your college reference number and your name to subs@rcoa.ac.uk with a request to get access to CEACCP and BJA online.)

Hope that is useful….

(Did you enjoy the Quick Pasta Sauce? Here’s the follow-on recipe! - Ed.)

You’ll need:

• Pasta leftovers.
• A couple of sausages cooked and chopped up or a tin of tuna, or you could even add some bacon which has been grilled and cut up into pieces.
• If you are a veggie, then you can chop up a courgette or an aubergine and use that.
• Some cream - double or single will be fine
• Bread crumbs. I keep the bits of the crusty bread that are becoming a bit dry and put them in the food processor to make bread crumbs and this will keep in an airtight bag for ages in the store cupboard. If you aren’t sad enough to want to do this then you can either hand crumble some bread or use a food processor to make instant breadcrumbs.
• Half a handful of grated Parmesan or a full handful of cheddar cheese.
• Fresh or dried herbs. I suggest parsley and basil as it will parody what you have in the pasta sauce already.
• Olive oil

Principle/ Method

1. In a bowl, combine the finely chopped herbs, breadcrumbs and the cheese.
   
2. Add a tablespoonful of the olive oil. Mix it all together.
3. In a shallowish oven proof dish, hand mix the cold pasta, cooked sausages and or cooked bacon, veg or fish. Add some of the cream to loosen it all up a bit and spread it evenly around the dish. You’ll need to select a dish that’s appropriate for the amount of pasta you have left over obviously!
4. Spread the crumb mixture over the pasta layer.
5. Cook in a 160- 180°C preheated oven until the breadcrumb layer is turning golden brown. (takes about 20 mins depending on your oven and the freshness of the breadcrumbs!) The fresher they are, the more moisture it will have and the longer it will take to brown!
6. Serve with a nice green salad.

Buon appetito!

more cat pictures

Rumours have reached our ears that there are some trainees looking around for a book to help them through the first few months of anaesthetic training.

Well, we have just the thing: How to Survive in Anaesthesia: A Guide for Trainees

This is the latest edition of a popular novice anaesthetists’ guide book to be published. It contains three sections, titled Nuts and Bolts, Crises and Complications and Passing the Gas.  Each of these contains a number of chapters, some of which outline, amongst other things, the basics of evaluation, control and management of the airway, venous access, ventilators, monitoring, cardiac arrest, anaphylaxis, anaesthetic mishaps, anaesthesia for different types of procedure, and post-op analgesia.

For someone starting from scratch, this is the ideal book.

Click on the link above, or the image below to be taken to Amazon.

This is a great quick sauce made from real tomatoes and herbs (fresh is best, but dried will do if that’s all that you have available). You can add some meat or even a tin of tuna to it if you like, or have it as a vegetarian dish. This should be enough for two but If you double the amount then you can make a pasta bake the next day with the left overs - I’ll tell you how in a following recipe.

You’ll need:

• 4 medium tomatoes (or a handful of cherry tomatoes)
  
• Some white wine (or veg or chicken stock) or failing that; tap water!
• 1 small clove of garlic
• If possible, fresh basil and flat leaf parsley
• 1 fresh chili. (If you can’t get this use a dried one or chili flakes or chili powder… or even a bit of chili sauce!) Add less if you don’t want it too hot.
• 1 teaspoon of sugar (To help the medicine go down? I’m sorry, I couldn’t resist - Ed.)
• Salt and pepper
• Olive oil
• Parmesan cheese. Here I really wouldn’t recommend using the dried stuff from the container - I think you are better off without it!
• Pasta of your choice. I don’t know how much pasta you like to eat or what type you are using so enough for two people.
  

Principle/Method

1. Put your pasta on to boil. Keep an eye on it while you make the sauce. If it’s ready before the sauce don’t worry, drain it, run it under cold water and let it rest on the side for a bit. If you are using fresh pasta, don’t bother putting it in the boiling water until the sauce is made as it usually only takes about 4 mins to cook anyway!
2. Crush or finely chop the clove of garlic and start to gently fry it in the olive oil over a low heat in a saucepan.
3. Roughly chop the tomatoes into chunks and add it to the hot oil. You can now turn the heat to a medium level.
4. Add a glass of the liquid (the wine or the stock or the water)
   
5. Let it bubble and stir occasionally.
6. Add the teaspoon of the sugar and the chili and then add some seasoning. Don’t worry if it doesn’t taste too rich yet, it will develop flavour as it concentrates down. Be careful not to add too much salt before the sauce has reduced or it will taste too salty in the final sauce.
7. Allow the sauce to reduce to at least half what it originally was.  It will thicken as it does this.
8. When you’re happy with the thickness and seasoning, grate a little parmesan into it and roughly tear or chop a handful of the fresh herbs and stir it all into the sauce and turn the heat off.
9. Add your sauce to the drained pasta (or your drained pasta to the sauce - whichever has more room in the pan) and mix it together.
10. Serve it with some more parmesan grated over the top.
    

Buon appetito!

(PS: For the eagle eyed person who spotted chili spelled with one L and thought it was incorrect…it can in fact be spelled both ways!)