A 56 year old woman is undergoing an elective laparoscopy for gallstones. Other than gallstones, she has always been fit and well and has never had an operation in the past. Her preoperative checks are unremarkable. She is induced with propofol, fentanyl and rocuronium, and the anaesthetic is maintained with sevoflurane. 

The initial stages of the operation go smoothly; however, thirty minutes after the anaesthetic induction, she develops muscle rigidity, a heart rate of 148 and a temperature of 40.8°C.

An arterial blood gas shows: 

• FiO₂ 60%
• pH 7.18 (normal 7.35 – 7.45)
• pCO₂ 11.1 kPa (normal 4.6 – 6.4)
• pO₂ 10.3 kPa (normal 11.0 – 14.4)
• Potassium 6.0 mmol/L (normal 3.5 – 5.3)

Given the likely diagnosis, which of the following will be used as part of the management?

A 31 year old pregnant woman has been in established labour for 16 hours. She is gravida 1, para 0, and is 40+5 weeks gestation. She has been using gas and air up to this point but is now getting tired and struggling with the pain of contractions. On examination, she is 5cm dilated. She would like to discuss an epidural to help manage the pain but is concerned about the risks to the baby. 

The anaesthetist comes to discuss an epidural with her and her partner. He warns her that an epidural is known to increase the probability of one outcome. Which outcome is this?

A 40 year old woman is brought to A&E by her partner with fever, back pain, vomiting and loss of appetite. She started with symptoms of a lower urinary tract infection one week ago and was prescribed trimethoprim four days ago by her GP. Her symptoms got progressively worse. In addition, back pain and fever started two days ago. Her partner cannot remember when she last passed urine. She was previously fit and well.

On examination, she is lethargic and looks unwell. She has left-sided renal angle tenderness. Her chest sounds clear, with equal air entry, and her heart sounds are normal on auscultation. She has cold peripheries.

Blood pressure: 72/45. Heart rate: 126. Respiratory rate: 28. Oxygen saturations: 96% on room air. Temperature: 38.9°C. Capillary refill time 5 seconds.

A catheter is inserted and drains 30ml of dark urine. Dipstick results show nitrites +, leukocytes +++, blood ++ and ketones ++.

Her ECG shows sinus tachycardia.

Shortly after arrival at A&E, she has input from the A&E consultant, medical registrar and anaesthetics registrar. Bloods and blood cultures are taken, and the results are awaited. She is given broad-spectrum IV antibiotics, oxygen and repeated boluses of 500ml of Hartmann’s solution. The decision is made to admit her to the intensive care unit. The anaesthetics registrar inserts a central line. 

After 1.5 litres of Hartmann’s solution, her central venous pressure, measured via the central line, is 10 mmHg (normal range 8 – 12 mmHg). Despite this, her blood pressure remains 75/46, with a mean arterial pressure of 56 mmHg. 

What is the next step in managing her blood pressure?

A 45 year old man is involved in a road traffic accident while riding his motorcycle, resulting in a comminuted fracture of his left tibia and fibula. He is admitted to hospital and added to the theatre list for the following morning, to have an open reduction and internal fixation (ORIF) procedure. The anaesthetist reviews him prior to the operation. All the preoperative checks are completed, and a general anaesthetic is planned. Other than a BMI of 36, there are no concerns regarding the anaesthetic.

The patient is brought into the anaesthetic room. He is pre-oxygenated with 100% oxygen. Propofol is given as the induction agent, along with atracurium and fentanyl. 

The anaesthetist has unexpected difficulty intubating the patient. She is not able to properly visualise the airway with the laryngoscope. Three attempts at intubation fail, including with an alternative laryngoscope blade, the use of a bougie and external laryngeal manipulation. 

What is the most appropriate next step?

A 42 year old woman is seen in the pain clinic for chronic unexplained pain. She has experienced pain in most of her body for the past two years. The specific location of the pain is difficult to establish and can change. It mostly occurs in her limbs. She frequently gets headaches. She describes the pain as “agonising” and reports that at times it is 10/10 in severity. She has been reviewed by a rheumatologist and neurologist, who arranged several investigations but were unable to establish a cause for the pain. She has tried paracetamol, ibuprofen and codeine. She thinks ibuprofen may have helped a little for a short time but found paracetamol and codeine inadequate. 

The pain specialist discusses a diagnosis of chronic primary pain and explores factors that may be contributing to the pain. She is referred for cognitive behavioural therapy. She asks what the next step would be with regard to pain medication. 

Which of the following is most appropriate to consider?

A 33 year old man is brought into hospital by ambulance with a cough, thick green sputum, fever and shortness of breath. He is accompanied by his partner, who gives the history, as the patient is breathless and drowsy. Initially, he thought he had a viral illness and tried to cope at home, but continued to get worse. This afternoon his partner found him confused and breathless when returning from work and called an ambulance. He was previously well and takes no regular medications. He has smoked 10 cigarettes a day for the past 10 years.

On examination, there are bilateral crackles throughout the chest. No murmurs or additional heart sounds are heard on auscultation. He is confused and drowsy. There is no peripheral oedema. He has cyanosis of his lips. 

Blood pressure: 86/50. Heart rate: 134. Respiratory rate: 34. Oxygen saturations: 89% on 10L/minute oxygen through a non-rebreather mask. Temperature: 39.2°C. GCS 12.

A chest x-ray shows diffuse bilateral infiltrates in the lung fields.

He is started on treatment for sepsis and community-acquired pneumonia. He is sedated, intubated and ventilated and admitted to the intensive care unit. 

In addition to sepsis and community-acquired pneumonia, what is the most likely explanation for his condition?

A 64 year old man is brought to A&E by ambulance with acute onset chest pain, dizziness and confusion. He has a past medical history of hypertension and raised cholesterol. He is prescribed amlodipine and atorvastatin but rarely takes his medication. 

On examination, he is confused. No murmurs or additional heart sounds are heard on auscultation. He has cold peripheries and a weak pulse.

Blood pressure: 83/46. Heart rate: 53. Respiratory rate: 26. Oxygen saturations: 97% on 2L/min via nasal cannula. Temperature: 36.6°C. GCS 13.

His ECG shows ST elevation in leads II, III and aVF. 

He is given aspirin and prasugrel. The cardiology registrar is contacted and arranges urgent primary percutaneous coronary intervention.

Which of the following is also indicated as part of the initial management?

A 78 year old woman is brought to A&E by ambulance with a fever, confusion and right-sided leg pain. She is accompanied by her son, who last saw her five days ago when she seemed well. He had not heard from her since, and when visiting, he found her confused in her armchair. He is not sure how long she had been there or whether she had been eating and drinking. He is unsure what medical conditions she has and what medications she takes.

On examination, she is confused, lethargic and looks unwell. The skin below the knee and around the ankle on her right leg is red, hot, tense and tender. She has bibasal crackles on auscultation of her chest. Her pulse is irregularly irregular, and she has an ejection systolic murmur on auscultation. She has cool peripheries.

Blood pressure: 87/46. Heart rate: 112. Respiratory rate: 28. Oxygen saturations: 96% on room air. Temperature: 39.2°C. Capillary refill time 5 seconds. GCS 13.

Her arterial blood gas shows:

• pH 7.23 (normal 7.35 – 7.45)
• pCO₂ 4.4 kPa (normal 4.6 – 6.4)
• pO₂ 11.1 kPa (normal 11.0 – 14.4)
• HCO₃ 10.6 (normal 22 – 28 mmol/L)
• Lactate 4.3 mmol/L

What is the interpretation of this arterial blood gas?

A 53 year old man presented to A&E with chest pain. He was diagnosed with an ST-elevation myocardial infarction. Whilst in A&E, he went into cardiac arrest secondary to ventricular fibrillation. He received cardiopulmonary resuscitation and defibrillation and regained spontaneous circulation. He was intubated and admitted to the intensive care unit. Once haemodynamically stable, he underwent primary PCI, which identified an occlusion to his left anterior descending artery. This was treated with angioplasty and stenting. 

Whilst in the intensive care unit, he developed heart failure, acute kidney injury, ventilator-associated pneumonia and a catheter-associated urinary tract infection. After 25 days of mechanical ventilation, he was stable, and the decision was made to start weaning him off mechanical ventilation. Unfortunately, it proved difficult to wean him off mechanical ventilation. He is noted to have weakness, reduce tone and wasting of the proximal muscles.

What is the most likely explanation for his difficulty weaning and muscle weakness?

A 64 year old man is admitted to hospital with muscle pain in all limbs, nausea, lethargy, confusion, reduced urine output and dark brown urine. The day before, he participated in a half marathon. Before the half marathon, the most exercise he had done was a 3-mile walk. He ran half a mile on a separate occasion. 

Further assessment revealed a severe acute kidney injury, elevated creatine kinase and hyperkalaemia. His urine dipstick was positive for blood. 

The intensive care team reviewed him, and arrangements were made for admission to the intensive care unit for haemodialysis. 

Which of the following is most likely to be inserted?