for case 7 **and this only works on the BNF, not medicines complete** you could search pancreatitis and (metformin or amoxicillin or etc..) should help guide towards the top 2 drugs
Comments Q. Great video, but I'd argue that the decision RE: anticoagulants is actually much more to do with the surgeon and the haematologists/cardiologists who will likely have originally prescribed them, rather than anaesthetics. Often of course, there is just a protocol that just gets followed by whoever is doing the pre-op screening. A. Hi there, Thank you for your comment. The BNF specifically makes reference to the anaesthetist and surgeon assessing the risks and jointly deciding what to do with anticoagulation. You are correct however advice would also be sought from the original prescriber Q. For case one do you omit losartan the day of the surgery or the day before the surgery? On the BNF it says to omit it 24 hours before the surgery. A. Hi there, Thanks for your question! The other drugs in the answers you can safely continue to take which leaves losartan as the only option. It is not uncommon to stop the losartan on the morning of surgery. In theory, if you take your dose the day before (usually in the morning) then 24 hours would have passed by the time patients go for surgery the following morning (does this make sense?). It is down to the anaesthetist ultimately what they want to do and will depend on what the patient is on the losartan for as well. I hope this helps! Do get back in touch if you have any more questions. Q. With Case 12 do we not need to treat this as an infected exacerbation and give AB as well? A. Hi there, thanks for your question! Indeed, the patient has a fever and left sided crackles and productive of green phlegm so I agree on commencing Abx as well, however Azithromycin is not usually the choice of Abx for an acute exacerbation of COPD (NICE lists Amoxicillin, clarithromycin or doxycycline as first line (or guided by most recent culture sensitivities)). Therefore in the answer options you have, I would say D is more appropriate. Don't worry. These are just questions we have made up ourselves to get you thinking, the PSA questions will have been checked multiple times to ensure there is no ambiguity in the answer options. Q. Some people say that the interactions checker on medicines complete is blocked during PSA exam. Is this true? A. Hey, thanks for your query. As far as I’m aware, you won’t be able to access Stockley’s interaction checker as this is not part of the BNF. However the BNF itself has an interactions checker which, as it is part of the BNF, I can’t imagine will be blocked (unless this is a new concept). I would recommend querying this with your University (and asking them to query with PSA as they will have a definitive answer). I suspect you are confusing Stockley’s interactions and BNF interactions but best to double check. Q. Hi, for case 3 (the MG patient), how would we determine whether we were supposed to go to the corticosteroid replacement section instead of convert the 15mg prednisolone dose to IV hydrocortisone using the conversion table in the glucocorticoid therapy treatment summary? Doing the latter gives a dose of 60mg. This would be the dose equivalent of hydrocortisone for how much prednisolone she is taking, but is more than the 25-50mg suggested in the answer you showed. Thank you! Still to be answered
In response to the last Q: The section in Hydrocortisone monograph relating to surgery suggests to give between 25mg - 50mg IV hydrocortisone whilst also commenting on the patient's oral regime. For example, if patient was undergoing minor surgery, then it suggests "Initially 25-50 mg, to be administered at induction of surgery, the patient's usual oral corticosteroid dose is recommenced after surgery" For moderate to major surgery it suggests "Initially 25-50 mg, to be administered at induction of surgery (following usual oral corticosteroid dose on the morning of surgery), followed by (by intravenous injection) 25-50 mg 3 times a day for 24 hours after moderate surgery and for 48-72 hours after major surgery." Therefore, instead of converting the patient's dose, specifically in relation to surgery, you would do the abovementioned and also administer the patient's oral medicines as described above. In reality, if the patient is unable to take by mouth after surgery (vomiting / in ITU etc, then it would be sensible to convert the oral dose after surgery to IV as well). Hope this helps! KR, MTB
Hey Anastasia, Thank you for your question. This could indeed be an infective exacerbation. Azithromycin is used in CAP however there is no indication in the drug monograph specifically for COPD. NICE guidance recommends first line amoxicillin, doxycycline or clarithromycin. We hope this helps! KR, MTB
Hi Emad, Thanks for your query! There are a wide range of things you can give for VTE. Different trusts prefer different options so there are many correct alternatives. LWMH can be used for VTE prophylaxis and also for treatment of VTE. Let us know if you have any more questions! KR, MTB
So to add, I put NaCl 0.18% + Glucose 4% with additive of 40mmol potassium chloride (which is the 0.13%), 1000ml with a rate of 125ml/hr for 8hrs - this information i found on medicinal forms when searching 'potassium chloride with glucose and sodium chloride'
Dear Harmony, Thank you for your query. We have used 0.9% NaCl (with addition of either 20mmol or 40mmol potassium) as this is what we have seen in practice. If you look at question 3 in Paper 2 of PSA practice assessment (which you should all have access to) you will note that they too have used 0.9% NaCl (with potassium) as their maintenance fluid --> this doesn't mean it is the only answer, I would imagine there are multiple other fluid bases that are used, we have merely taught from what we have seen in our own practice. Please supplement our teaching with your own learning/ experiences also :) I hope this helps. Please do get back in touch if you have any further questions. KR, MTB
Dear CMed, Thanks for your query! Unfortunately you do need a subscription. Some students are able to access it via Shibboleth if their University organisation is listed and has access. Otherwise you should be granted access to medicines complete 2 weeks prior to your exam date which you should be able to access via the PSA website platform. Hope this helps! KR, MTB :)
Hey there, Thank you for your query, you are quite right, pancreatitis is also listed in the s/e for morphine - the only thing I can think of why this was the least favourable option is that the morphine monograph states "pancreatitis exacerbated" (ie making an existing pancreatitis worse) whereas the other two monographs state "pancreatitis acute". However I agree it is somewhat misleading. Please be assured the questions in the exam will have gone through lots of reviews so that they are not ambiguous so try not to worry :) Best of luck for your exams, KR, MTB
Hi. For case 3, would you not use 'steroid sick day rules', meaning you would double 30mg pred to 60mg OD, which converts to 1.2g worth of hydrocortisone as IV? as 5mg pred is equivalent to 20mg hydrocortisone
Dear Mohit, Thank you for your query. You are correct, in sick day rules usually the patient's steroid regime is doubled during acute illness / admission to hospital. This question however is specifically referring to the peri operative anaesthetic needs for surgery (ie dose given intravenously at induction of surgery), continued intravenously for a set length of time depending on the severity of surgery. We hope this answers your question. KR MTB
Dr Sophie Schofield you were incredibly amazing, thank you
for case 7
**and this only works on the BNF, not medicines complete**
you could search pancreatitis and (metformin or amoxicillin or etc..)
should help guide towards the top 2 drugs
Comments
Q. Great video, but I'd argue that the decision RE: anticoagulants is actually much more to do with the surgeon and the haematologists/cardiologists who will likely have originally prescribed them, rather than anaesthetics. Often of course, there is just a protocol that just gets followed by whoever is doing the pre-op screening.
A. Hi there,
Thank you for your comment.
The BNF specifically makes reference to the anaesthetist and surgeon assessing the risks and jointly deciding what to do with anticoagulation. You are correct however advice would also be sought from the original prescriber
Q. For case one do you omit losartan the day of the surgery or the day before the surgery? On the BNF it says to omit it 24 hours before the surgery.
A. Hi there,
Thanks for your question! The other drugs in the answers you can safely continue to take which leaves losartan as the only option. It is not uncommon to stop the losartan on the morning of surgery. In theory, if you take your dose the day before (usually in the morning) then 24 hours would have passed by the time patients go for surgery the following morning (does this make sense?). It is down to the anaesthetist ultimately what they want to do and will depend on what the patient is on the losartan for as well. I hope this helps! Do get back in touch if you have any more questions.
Q. With Case 12 do we not need to treat this as an infected exacerbation and give AB as well?
A. Hi there,
thanks for your question! Indeed, the patient has a fever and left sided crackles and productive of green phlegm so I agree on commencing Abx as well, however Azithromycin is not usually the choice of Abx for an acute exacerbation of COPD (NICE lists Amoxicillin, clarithromycin or doxycycline as first line (or guided by most recent culture sensitivities)). Therefore in the answer options you have, I would say D is more appropriate. Don't worry. These are just questions we have made up ourselves to get you thinking, the PSA questions will have been checked multiple times to ensure there is no ambiguity in the answer options.
Q. Some people say that the interactions checker on medicines complete is blocked during PSA exam. Is this true?
A. Hey, thanks for your query. As far as I’m aware, you won’t be able to access Stockley’s interaction checker as this is not part of the BNF. However the BNF itself has an interactions checker which, as it is part of the BNF, I can’t imagine will be blocked (unless this is a new concept). I would recommend querying this with your University (and asking them to query with PSA as they will have a definitive answer). I suspect you are confusing Stockley’s interactions and BNF interactions but best to double check.
Q. Hi, for case 3 (the MG patient), how would we determine whether we were supposed to go to the corticosteroid replacement section instead of convert the 15mg prednisolone dose to IV hydrocortisone using the conversion table in the glucocorticoid therapy treatment summary? Doing the latter gives a dose of 60mg. This would be the dose equivalent of hydrocortisone for how much prednisolone she is taking, but is more than the 25-50mg suggested in the answer you showed. Thank you!
Still to be answered
In response to the last Q:
The section in Hydrocortisone monograph relating to surgery suggests to give between 25mg - 50mg IV hydrocortisone whilst also commenting on the patient's oral regime.
For example, if patient was undergoing minor surgery, then it suggests "Initially 25-50 mg, to be administered at induction of surgery, the patient's usual oral corticosteroid dose is recommenced after surgery"
For moderate to major surgery it suggests "Initially 25-50 mg, to be administered at induction of surgery (following usual oral corticosteroid dose on the morning of surgery), followed by (by intravenous injection) 25-50 mg 3 times a day for 24 hours after moderate surgery and for 48-72 hours after major surgery."
Therefore, instead of converting the patient's dose, specifically in relation to surgery, you would do the abovementioned and also administer the patient's oral medicines as described above. In reality, if the patient is unable to take by mouth after surgery (vomiting / in ITU etc, then it would be sensible to convert the oral dose after surgery to IV as well).
Hope this helps!
KR,
MTB
For case 12 - Why does the case sound more like an infective exacerbation and would prescribing an antibiotic be wrong?
Hey Anastasia, Thank you for your question.
This could indeed be an infective exacerbation. Azithromycin is used in CAP however there is no indication in the drug monograph specifically for COPD. NICE guidance recommends first line amoxicillin, doxycycline or clarithromycin.
We hope this helps!
KR,
MTB
For VTE if you gave LMWH would that still be correct?
Hi Emad,
Thanks for your query!
There are a wide range of things you can give for VTE. Different trusts prefer different options so there are many correct alternatives.
LWMH can be used for VTE prophylaxis and also for treatment of VTE.
Let us know if you have any more questions!
KR,
MTB
Hi, why for the maintenance fluid prescribing are you prescribing 0.9% NaCl as opposed to 0.18% NaCl which should be used for maintenance?
So to add, I put NaCl 0.18% + Glucose 4% with additive of 40mmol potassium chloride (which is the 0.13%), 1000ml with a rate of 125ml/hr for 8hrs - this information i found on medicinal forms when searching 'potassium chloride with glucose and sodium chloride'
Dear Harmony,
Thank you for your query.
We have used 0.9% NaCl (with addition of either 20mmol or 40mmol potassium) as this is what we have seen in practice. If you look at question 3 in Paper 2 of PSA practice assessment (which you should all have access to) you will note that they too have used 0.9% NaCl (with potassium) as their maintenance fluid --> this doesn't mean it is the only answer, I would imagine there are multiple other fluid bases that are used, we have merely taught from what we have seen in our own practice.
Please supplement our teaching with your own learning/ experiences also :)
I hope this helps.
Please do get back in touch if you have any further questions.
KR,
MTB
Hi how do you access the interactions checker on medicines complete? I’m locked behind a paywall :/
Dear CMed,
Thanks for your query!
Unfortunately you do need a subscription. Some students are able to access it via Shibboleth if their University organisation is listed and has access. Otherwise you should be granted access to medicines complete 2 weeks prior to your exam date which you should be able to access via the PSA website platform.
Hope this helps!
KR,
MTB :)
doesn't morphine as well cause pancreatitis? the frequency for it and GLP-1 is both rare or frequency unknown, so which would I choose
Morphine exacerbates Pancreatitis. Doesn’t cause it
Hey there,
Thank you for your query, you are quite right, pancreatitis is also listed in the s/e for morphine - the only thing I can think of why this was the least favourable option is that the morphine monograph states "pancreatitis exacerbated" (ie making an existing pancreatitis worse) whereas the other two monographs state "pancreatitis acute". However I agree it is somewhat misleading.
Please be assured the questions in the exam will have gone through lots of reviews so that they are not ambiguous so try not to worry :)
Best of luck for your exams,
KR,
MTB
Hi. For case 3, would you not use 'steroid sick day rules', meaning you would double 30mg pred to 60mg OD, which converts to 1.2g worth of hydrocortisone as IV? as 5mg pred is equivalent to 20mg hydrocortisone
Dear Mohit,
Thank you for your query.
You are correct, in sick day rules usually the patient's steroid regime is doubled during acute illness / admission to hospital.
This question however is specifically referring to the peri operative anaesthetic needs for surgery (ie dose given intravenously at induction of surgery), continued intravenously for a set length of time depending on the severity of surgery.
We hope this answers your question.
KR
MTB