Passing the Final FRCA Dr James Shorthouse

This is it.....

2008-06-22T12:39:00.002+01:00

Well, nearly seven months have passed, and it all comes down to eighty minutes or so tomorrow. I've reached the stage today where I am not really able to do much more. Shortly, I'll be heading off to London to stare at the hotel walls for a few hours and follow the usual pre-exam routine of trying to read stuff but not really achieving much.

I've usually found that having done the exam, everything I've read would have made no difference anyway, but I'm still holding onto my earlier piece of advice re: keep reading.

Best of luck to everyone taking the exam this week - I'd like to think that if we've put the work in and done the viva practice, we deserve to pass this marathon! Thanks to all who've left messages of support on this blog: nice to know that there are others sharing the pain. Looking forward to a pint or two tomorrow afternoon in the Square Pig - come and find me, I'm easy to spot: tall with red hair!!

Stir Crazy

2008-06-20T11:38:00.002+01:00

Does the below sound familiar?

-Frantically trying to read a whole textbook in one day?
-Random A-Z hopping?
-Reading the same sentence six times and then wondering what you have just read?
-Panicking because of failure to retain the new clotting cascade?

Enough is enough and, whilst going completely mad on my own in the house trying to achieve the above may seem like the only way forward, I have to try and preserve some sort of sanity and order. So, here is the well-meaning plan for the next two and a half days:

-Concentrate on some clinical viva stuff for the rest of today and part of tomorrow. To break it up, I will do some "light-hearted" revision of ECGs and X-Rays/scans.

-Tomorrow, I will look at topical stuff: this includes guidelines (found earlier in the blog), resuscitation algorithms (you never know - would be embarassing to stumble here!), and a quick scan at the Bricker SAQ book. I will break this up with some more "light-hearted" diagram drawing practice from both the A-Z and my notes.

-This leaves Sunday free: I will go through the RCOA guide (both old and new - received two days ago by post), as colleagues have had vivas straight from this guide in the past. I will also re-re-re-re-re-revise some anatomy and probably try and learn how to draw inhalational agents, including their SVPs etc. I'll probably read through this blog as well just for good measure!

The Final Countdown

2008-06-17T11:00:00.002+01:00

We're nearly there! Anyone done any A-Z chasing (see previous posting re: flipping through the holy book of Anaesthesia from topic to topic? - Guilty as charged!! My rollercoaster week continues - some days I feel I am going to nail this exam. I'm going to walk in and from the start be confident, articulate, and present my text-book knowledge in a concise, yet structured manner. Other times, I look blankly at my viverer, my mouth dry, and my brain even drier - a feeling of hopelessness overwhelming. I have discovered a new phrase: "The £680 answer - an answer so disorganised or dangerous that it will precipitate a return to the College when the leaves are brown!!

I've been pretty lucky and had a lot of viva practice. I've also had a lot of excellent advice from both Consultants and Registrars alike:

There is a famous quote:

"The harder I work, the luckier I get" by Samuel Goldwyn (or Gary Player!).

You often hear of people coming out of an exam, complaining about being asked 'xyz'. There are also people who when dissecting the exam, reveal some extraordinary questions asked, but having answered them without breaking a sweat: "Amazing, I read it just two days ago!"

The moral of this story (and one of the best pieces of advice given to me this week) is: keep reading and reading right to the bitter end. A random topic may come up for you!

Another phrase which keeps repeating itself is: "You already have the knowledge to pass this section" How many people have said that to you? Really irritating isn't it when you have forgotten the Alveolar Gas Equation for the fifth time!? A large proportion of your answer is structure. The temptation when answering a question that you know something about, is to spew forth everything at once. Another piece of excellent advice I was given, is to imagine that the structure of your answer is analogous to a tree. Do not aim for the fruit immediately - start with the trunk (or definition) and a few main branches thereafter (classify). The examiner will guide you towards which piece of fruit to pick and digest upon!!

E.g. Propofol is an anaesthetic agent which is used for induction of anaesthesia, causing a drop in blood pressure and decreased pharyngeal reflexes.......etc.

OR

Propofol is an intravenous agent used for induction and maintenance of anaesthesia, sedation in ICU, and for the control of status epilepticus. It's chemical name is........

Exaggerated example I know, but it illustrates the point.

This week is all about keeping the mental attitude and trying to stay sane - to pass this exam, you do not need to know every little detail. You need to be strong and structured on the basics, and you need to be clinically safe: when asked during a clinical scenario, say what YOU would do because it's probably what you do most days without thinking.

Annual Leave

2008-06-07T15:57:00.002+01:00

I have one more shift on ICU between now and the D-day of Monday 23rd June. My now familiar hotel booking at the Park Inn Hotel (see previous posting for link) in Russell Square has been made!

I've deliberately combined post-nights time-off, study leave, and annual leave to give me this block of flexibility. My plans are to try and keep to a routine of some catch-up reading in the mornings, travel to the hospital at lunchtime and hunt down consultants/SRs for viva practice followed by our formal viva practice for 90 minutes in the early evening.

More tips:
-No wild gesticulations - hands clasped under the table - don't fiddle with the pencil.
-Don't dig a hole - if you don't know, say so.
-Don't mention something you can't talk about.
-Don't say: "You would intubate....etc" It apparantly annoys examiners -they will not be doing anything apart from marking. Say: "I would intubate..." or "The patient requires intubation"
-Don't use abbreviations or colloquialisms. You need to sound professional.
-Be able to draw all line diagrams from the A to Z.

Frustration

2008-05-28T13:04:00.002+01:00

We had a tutorial on paediatric fluid prescribing/administration the other day which was extremely useful, but it reminded me of how I'd managed to miss out on providing the guidelines pre-SAQ paper that were issued by the NPSA on fluid management of paediatric patients. I thought I'd covered all of them in a previous entry, and it was typical that the one that escaped came up in the SAQ paper. So, apologies for the tardiness but here they are:

Reducing the risk of hyponatraemia when administering intravenous infusions to children NPSA March 2007

-Since 2000, there have been four child deaths following neurological injury from hospital-acquired hyponatraemia reported in the UK.

Recommendations
-Remove 0.18% NaCl with glucose 4% from stocks & general use in areas treating children.
-Produce local clinical guidelines for the fluid management of paediatric patients.
-Provide adequate supervision and training for all staff involced in the prescribing, monitoring, and administering of IV fluids for children.
-Review & improve design of existing drug prescription/fluid balance charts.
-Promote reporting of hospital-acquired hyponatraemia incidents

Resuscitation: intravascular volume depletion should be managed with 0.9% NaCl boluses
Deficit: estimate fluid deficit & replace as 0.9% NaCl with 5% dextrose or 0.9% NaCl over a minimum of 24hrs
Maintenance: do not use 0.18% NaCl with glucose 4%

The majority of children may be managed with 0.45% NaCl with 5% glucose (or 2.5% glucose)

So there - I've outed my demon!

There are also some new relevant NICE guidelines:

-April 2008: Management of Inadvertent Perioperative Hypothermia
-March 2008: Prophylaxis against Infective Endocarditis

The Home Straight

2008-05-24T16:04:00.002+01:00

Well, the last month has been agonizing. So difficult to motivate one's self to get viva practice with the unthinkeable potential that it might all be in vain. I am pleased to say that so far my extremely public humiliation has not occurred and that I passed the written SAQ/MCQ paper. I'm absolutely delighted and it has given me the emphasis and boost to keep going for these last couple of weeks.
Congratulations to everyone who has passed (including my esteemed colleagues whom I work with - all eight of us passed).

So, the hard work begins again. Our hospital very kindly runs a nightly viva session for 90 minutes, where consultants and senior registrars put us through our paces in true exam style. It has been intimidating (five seconds of silence can stretch to eternity!), frustrating (I really did know the Alveolar Gas Equation but could not reproduce it), and sometimes just hilarious (yesterday I tried to convince a cardiothoracic anaesthetist that I would perform a fibreoptic intubation somehow combined with RSI - thanks to my guru Dr B who suggested I would attempt it nasally as well!!). The eight of us have formed an excellent bond and friendship during preparation for this exam which has been most welcome.

It's time to talk......and talk. You need to pester consultants and senior registrars and get them to viva you - at least twice a day. You need to be selfish with your time and if your list is not fruitful then excuse yourself and find somewhere that is.

Practice your technique of talking about drugs; I use the setup from Sasada & Smith:

-Uses
-Chemical
-Main Action
-Mode of Action
-Routes of Administration/Dose
-Effects (CVS, Resp etc)
-Toxicity/Side Effects
-Kinetics (ADME)
-Other

You need to be adept at reading and presenting ECGs (a notable area of weakness by candidates in recent exams as stated by the College itself). You need to be able to identify common problems on X-rays and CT scans e.g. CT head.

Similar to the SAQs, you need to be uptodate with current topics and guidelines (see previous postings).
Additions include:
-Recent advances in thoughts about IHD in non-cardiac surgery including dual antiplatelet therapy and stents
-POISE Beta-Blocker RCT (www.thelancet.com May 2008)
-Updated Surviving Sepsis Campaign (Intensive Care Medicine 2008 34:17-60)

Also, keep up to date with BJA/Anaesthesia Review Articles and, of course, the beloved CEACCP articles.

AND DON'T FORGET BASIC SCIENCES!!

Structure

2008-05-02T11:31:00.003+01:00

Many thanks to one of my consultants this week for providing me with a beautiful structure to answer any clinical question. I'm sure he won't mind me sharing it:

Preoperative
-History
-Examination
-Investigations (Observations, Bloods, ABGs, ECG, CXR, Other X-rays, Echo, PFTs etc)
-Pre-medication
-Preparation
-Consent

Intraoperative
-Check (machine/equipment, patient)
-Monitoring (AAGBI minimum standards)
-Oxygen
-Venous Access
-Emergency Drugs/Equipment
-Drugs
-Skilled Assistance
-Resuscitation equipment

-Induction
-Maintenance
-Emergence

Postoperative
-Disposal (Recovery, HDU/ITU, ward)
-Oxygen
-Analgesia
-Antiemesis
-IV Fluids
-DVT prophylaxis

The beauty is that you could know nothing about the actual surgery, but by mentioning all of the above in the correct order, you'll probably pass!

Verbal Diarrhoea

2008-05-02T11:18:00.002+01:00

I really thought I knew about U/S and the Doppler Effect - I could have written a short answer question on it. But when someone said to me this week: "Tell me about the Doppler effect", odd words and incomplete sentences came out of my mouth in the wrong order. Then I confused myself and then my brain-to-mouth interface stopped working altogether.

This precisely demonstrates the need to practice speaking and being viva'd. You may know a subject inside out, but it is the ability to convey this information clearly and succinctly in an ordered manner to the examiners which is a lot harder than it would appear.

My aim this week has been to get a viva a day from the consultant I have been working with. I've not done badly, especially on Wednesday when I was doing plastics (8hr TRAM flap) - I got three vivas! You need the consultants (or registrars) to be harsh on you - to really push you - and that's what they did. At times I felt like a real amateur (not like someone ready to be admitted as a Fellow to the RCOA) - I was nervous, I forgot basic knowledge and my clinical answers were unstructured. But I learnt a lot!

The topics I have been viva'd on this week include:
-Haemorrhage / Hypovolaemia
-Emergency cricothyroidotomy
-Nausea & Vomiting
-Temperature Management
-Subarachnoid Haemorrhage / Anaesthesia in Angio Suite
-Alveolar Gas Equation / ABGs from severe asthmatic
-Doppler / U/S
-SI Units
-PDPH/Epidural Blood Patch
-PET

Phew!

2008-04-28T13:31:00.002+01:00

I've deliberately not written anything for about a week to try and forget about the written exam last week.
It was an exhausting day, but I'm really glad it's done for now. I thought that with a couple of exceptions, the SAQ paper was reasonable - it could have been a lot worse. The MCQ paper was an absolute nightmare - more about that later.

SAQ
1) Thoracic paravertebral space: either you know it or you don't. Despite having performed a couple of these blocks in early SHO-days, I couldn't recall the anatomy as I hadn't revised it - simple as that. I tried to make it up as best I could. The indications and complications were fairly generic answers for all nerve blocks.

2) CEMACH - one of my predicted questions came up, so the risk factors and causes of death were hopefully recalled verbatim. The next bit about Early Warning Scoring Systems was the usual lists of stuff making up PAR scoring/APACHE or whichever system is used.

3) Air Embolism - standard question seen before in similar guise in Bricker. I think there was a review article in Anaesthesiology about this subject.

4) 4yo appendicitis, dehydrated - fluid management. This question was about paediatric fluid management with specific reference, I think, to NPSA guidelines on avoiding hyponatraemia in children post-operatively. I thought that the NPSA website was a bit of a nightmare to navigate around, and had not found these guidelines pre-written paper. So, consequently had not read them, so probably missed out some quite important points - typical the only bloody guideline I do miss comes up!!

5) Pre-oxygenation. The lucky people who went on the Booker Course and did this question almost verbatim up there will be happy with this one

6) Complex Regional Pain Syndrome. As for 5) I'm afraid - congrats to Dr Booker!

7) Rocuronium - the 'topical' question. Fortunately I used to have a boss who was fascinated with Sugammadex, so was at least able to give a basic description of this. Unfortunately, I had a complete blank about neostigmine and was only able to write some pretty basic stuff about it - c'est la vie.

8) Asthma/Acute Bronchospasm - waffling plus some standard clinical emergency management.

9) Elective paeds - child not cooperating. The first part of the question about decreasing pre-op anxiety was a chance to be very touchy-feely etc. The second part was much less structured, and perhaps was touching upon consent in paediatric patients ?Gillick competency. I don't think I answered the second bit very well, but hopefully did enough on the first bit.

10) AAA - emergency. So much to write, too little time. A recent CEACCP article on exactly this topic.

11) Needlestick injuries. Very unusually for the College they have repeated a question from just six months ago - I assume it was done fairly badly last time out.

12) Acute Pancreatitis - again repeated from six months ago. So much to write, too little time.

MCQs
I honestly don't know what to say about the MCQ section. I normally go through the paper fairly quickly to start with, just answering the stems that I definitely know. By the time I got to Q.45 and a lot of stems were unanswered, I started to get that feeling of desperation. You know, six months of hard work, thousands of practice MCQs - utterly pointless in trying to do this exam!!
I recognised a few questions from the college book. There were also a few questions from Elfituri & Arthurs MCQs (which incidentally I would have tried to do more questions from had there not been so many dreadful errors in it). But the rest of them......

There were obviously quite a few new questions, as the exam had to be halted numerous times to make corrections for the paper.

The only consolation was the fact that everyone else found it exactly the same!

So, onto viva practice - A senior registrar has grilled me today on the exam he got. Subjects include: phaeochromocytoma, pacemakers, N2O cylinders, tetanus, foetal circulation, and adverse drug reactions.

Last minute

2008-04-21T11:18:00.002+01:00

Well, I'm off to London shortly to spend an uncomfortable 18 hours or so waiting to get this little test out of the way!
I hate the weekend before the exam - there is a lot of frantic reading done, which is completely pointless as I'm sure none of it goes in. My gastrointestinal autonomic system is doing its usual pre-exam malfunction and I can never eat properly! I hope I echo many other people's thoughts out there.
The problem is that you tend to concentrate on all the stuff you think you don't know or have forgotten, rather than the considerable bulk of material that you have managed to assimilate into your completely overloaded brain!

My advice, for what it's worth at this late stage, is:

-Try not to panic - part of this exam is keeping a cool head. Remember what you need to pass - usually 12/20 on each question (sometimes lower, sometimes higher) to get a '2', and minimum 6 1+'s and 6 2's to pass the SAQ paper.
-Get nice pens, plus a spare or two
-Arrive early & bring photo ID as told.
-Read the questions (properly).
-Write nicely and space answers out - make it easy for the examiner! 10% of marks can be gained here!
-Don't overrun on questions
-Eat and sleep well tonight!
-Look through RCOA MCQs
-Look through some guidelines/protocols/past papers.

-Have some luck !

All the best
James

Psychological imbalance

2008-04-17T10:48:00.003+01:00

Is it psychologically acceptable to swear at a computer screen?
During QBase I reckon it is. I am ploughing my way through QBase 2 at present on the computer - it feels marginally less like doing work if you're clicking a mouse every so often. But the MCQs can be so frustrating. They contradict answers in different MCQ books and unfortunately a small proportion of questions are out of date. But, the standard is reasonably high and the more the merrier etc etc. I've been getting between 42-49% on QBase 2 - which allowing for stupid errors (often!) and not reading the question/stems properly (occasionally!), I think, is OK. I'm sure some of you will be feeling smug on reading this if you're getting higher marks - so this portion was to make you feel better!!!

Well, I've just come off two of the most hideous night shifts on Neuro ITU ever. That'll learn me for taking in books to read/MCQs to do. It reminds me of a week of nights as a surgery house officer where our first three nights were so quiet. So, on the third night my SHO at the time decided to bring in his Playstation for the mess......the rest is history - Tits Up!!!!

Four and a half days to go - so how best to make use of the time?
-I'm still trying to get through as many MCQs as I can - in fact I wish I'd spent more time on them earlier as I may not finish all the books I have. I generally try and do at least two papers a day (usually take about 2 hours to do each), one first thing in the morning and then one later when I'm really tired, exactly like the real thing!!
-Today, I'm concentrating on sexy topics, review articles, guidelines etc, and hopefully if there's time, to finish going through some physics.
-I think the time has come to stop trying to learn new things now, so over the next few days I shall be rereading all the SAQs I have done from the Mersey Course, College papers, and SAQ textbooks (especially Bricker and Dashfield & Murphy).
-Over the past few months, I have been transferring some of my Basic Science notes from Primary into the Bricker Basic Science Viva Book, hopefuly leaving myself with one definitive but concise Basic Science text for both this written part and any future vivas (fingers crossed). I'll also try and go through as much of that as I can in the next few days.

I'm going to buy some really nice pens that are comfortable to write with - preferably ones that I don't have to press too hard onto the paper with. Hand cramp 90 minutes into the SAQs would not be desirable.

I have pledged not to take part in the dangerous pre-exam sport that is A-Z word-chasing. This involves reading a topic in A-Z, then seeing a bold word highlighted in the text that you have forgotten about, and going to that entry, and so on. It wastes a lot of time, and induces sphincter-loosening panic (?sympathetic or parasympathetic).

I am taking the exam in Central London but live about half an hour outside. Rush hour trains or traffic i.e. M4 are not conducive to good mental preparation. Therefore, a four star hotel overnight and a good breakfast, for me, is a prerequisite. So I've booked a nice room at the Park Inn Hotel on Southampton Row about ten minutes walk from the Exam hotel.

Nice!!

Exhaustion

2008-04-12T14:23:00.003+01:00

I've just returned back from the European City of Culture 2008 where I attended the Booker course. I am shattered!
It was really encouraging to speak to a number of people who actually read this blog - thanks for your support and please leave comments and your advice/tips etc.

About the course:
I still reiterate that I think these courses are so valuable in preparing you for this type of exam. I found it pretty tough-going, but it has completely fulfilled it's purpose i.e. enforced writing of a range of SAQs under time pressure (I think we did 44 SAQs altogether including one full 12 question paper), some even more time-pressured MCQs (not easy standard either). The standard of candidate on the course was really high, and I found it quite daunting at the beginning of the week, but as the week progressed there were encouraging signs.
My MCQ marks gradually got better!

My SAQ technique i.e. timing, layout, and handwriting has really improved - mostly thanks to the 'Mersey Method' (unfortunately I don't think it would be fair to divulge it on the www!). There was a couple of sessions where we marked other candidates' SAQ answers - eye-opening the difference between handwriting and layout.

My tips at this point would be:

-MCQs MCQs MCQs (do the college book again the day before!)

-Hone your SAQ technique: make sure you have written a full 12 question paper in 3 hours a) to get your timing right, b) to practice handwriting/layout, c) for stamina!!

-Think of some sexy topics (the exam was set at the beginning of March!)

-Don't forget anatomy (it comes up in all parts of the exam!)

With a little help from my tutor!

2008-04-03T21:12:00.002+01:00

Continuing on the spotter theme.....
I mentioned in a previous entry about the SAQ tutorials I have been attending with some friends, which are run by a consultant we have worked with previously. I cannot understate the value of enforced MCQ practice and group discussion about the answers. At this week's session, we ventured briefly onto the subject of question spotting and our tutor raised a highly valuable point regarding a potential question.
I'm sure he won't mind me passing on his advice: a question on pain in some form or another. Two potential reasons: one, there hasn't been a pain question recently in the SAQs, and secondly (and most importantly), the setting up of the Faculty of Pain Medicine in April 2007 may lead to a request for pain representation within the SAQ questions.

Quick link

2008-03-30T14:51:00.001+01:00

Check out this blog site for more thoughts on how to pass the Final FRCA - glad to see people sharing the pain!!

What next?

2008-03-28T19:03:00.006Z

4 weeks to go.... it's difficult to know at this stage where to focus revision. I've got one more week at work, then I go off to Liverpool for the Booker course and have annual leave etc, two night shifts at work, then more annual leave and then the exam. So, I do have a fair bit of study time available, but what's the best way to utilise it? I need to 'cane it' with MCQs - literally try and do hundreds (maybe into the thousands if possible) - it's the only way, and it's worked before for me. The good thing about MCQs is that they can be done anywhere: in the bath, on public transport on the way to work, even (dare I say it, although couldn't possibly condone it) at work!!

SAQs: I've nearly finished working my way through the Past Papers on the College web-site. Incidentally, the majority of the questions from 1996-2000 can be found in the SAQ textbooks by Bricker, and Dashfield & Murphy, taken verbatim. There are many more SAQs to be answered from the AnaesthesiaUK website (also see one of my previous posts where I categorised all of them).

The RCOA kindly publishes a report on the previous SAQ paper which has some interesting content. Firstly, it would appear that recently, questions done poorly in one year are repeated the following year (but not six months later). Also, they emphasise the inclusion of hot topics. I have taken the liberty of "guestimating" my very own hot topics for the forthcoming exam!!

- CEMACH 2003-2005 - it's just too good an opportunity to miss, surely?

- Obesity in pregnancy was a hot enough topic to make the national news headlines.

- Amniotic Fluid Embolism deaths shot up in this triennium - a lovely little question!!

- POISE (Perioperative Ischaemic Evaluation) study: looks at beta-blocker use in non-cardiac surgery

- CEPEX testing: here and here

- Awareness - trendy topical subject. Has been in the headlines in past couple of months + ironically a Hollywood film is about to be released in the UK.

- Mental Capacity Act - has come into force in late 2007

- Association of Anaesthetists Guidelines in 2007
-LA toxicity +/- Intralipid use
-Malignant Hyperthermia treatment (already used in a question and answered well, so unlikely to come up)
-Perioperative Management of the Morbidly Obese Patient - THIS IS FAIR GAME FOR THIS YEAR!!
-Standards of monitoring during anaesthesia & recovery

- NICE Guidelines (2007-8)
-Venous Thromboembolism: April 2007
-Acutely Ill patients in hospital: July 2007
-Head Injury: September 2007
-Intrapartum Care: September 2007
-Ultrasound Guidance in locating the Epidural Space: January 2008

-New Ideas
-Advances on clotting pathways
-Sickle cell anaemia

I also think that it is prudent to read through review article from the big journals for the last year i.e Jan 2007 - Feb 2008. Bold highlighted articles are those which lend themselves to SAQs!

BJA: here & here

Jan Fentanyl patch vs post-op pain

Feb Statins in sepsis

Mar Neuromuscular monitoring

Apr Blood flow & ventilation in the lung / percussion pacing

May CA stents in non-cardiac surgery

Jun Diastolic heart failure

Jul Neuro ++! The whole post-grad issue is neuroanaesthesia/NICU reviews

Aug Carotid endarterectomy

Sept Perioperative platelet Rx

Oct Sciatica & epidural injections / contrast-induced nephropathy

Nov Cardioprotection with remote ischaemic preconditioning

Dec Gabapentin

Jan Sedation & Regional anaesthesia

Feb Prone position / epidural analgesia vs periph NB for knee surgery

Anaesthesia

Feb Simulators

Mar Temp. epicardial pacing part 1

Apr Temp. epicardial pacing part 2

May Systemic complications post-head injury

Jul Propofol-infusion syndrome

Oct Interpleural block part 1

Nov Interpleural block part 2 / new thrombotic agents & neuraxial anaesthesia for major orthopaedic surgery

Dec Remifentanil

Jan Oesophageal Doppler in abdominal surgery / Statins for non-cardiac surgery part1

Feb Statins for non-cardiac surgery part 2 / cardiac output monitoring

Happy Reading!!

Misery

2008-03-23T11:25:00.002Z

Happy Easter to anyone who is reading this!!
Most of my posts have been pretty positive, and from a couple of the comments it sounds like some people are finding it difficult to get down to work -this is to make you feel better!

I feel utterly fed-up, miserable and bored today. I just cannot bring myself to work. I have just had annual leave for the last week, and have not done badly (apart from Thursday/Friday where I went to a wedding) trying to plough through SAQ from the College website. But I woke up this morning and felt totally lethargic and distracted. I'm sitting at my desk with papers in front of me but no desire at all to tackle them, and with the attraction of so many other inane activities seeming much more appealing!
After such a nice break post-Primary, I had forgotten the utter misery that exam revision is. The only consolation is that I am starting to feel a little cleverer!!

Sixth Gear

2008-03-18T09:00:00.002Z

I've just finished nights and now have a full week off - the first day (yesterday) has already gone and I didn't work because I was too knackered and the body-clock was all over the shop. There are five and a half days of studying stretched out ahead of me, broken up nicely in the middle by an extremely posh wedding of a friend in London, for which I'm also playing the piano during reception drinks. I'm aiming to try and complete two SAQ papers per day, in addition to some MCQ practice. It's a tall order as I've only been managing one recently per day - I am very easily distracted!! But the time has come to be more serious and strictly time myself doing these papers. I also have my weekly tutorial tomorrow night where we'll go through a paper written last week and marked! Unfortunately, I was quite tired during last week's tutorial and wrote the wrong paper and dutifully sent it off to be marked. No big deal, but it undelines a rather important point of listening to and following instructions properly!!!
Thankfully due to some careful study/annual leave planning, I now only have 12 shifts left to work between now and the exam, giving me quite a lot of spare study time. I'm going to bloody need it all !!!

Progress

2008-03-09T10:07:00.002Z

I've not had a chance to update this blog for a couple of weeks - mainly for positive reasons. My work ethic has changed and I've moved up a gear or two now. I find as the exam looms, I start putting more and more pressure on myself to work, and it drives me to put the hours in. The motivation comes from imagining that feeling of seeing your number up on the board in the College telling you that you've passed: I don't want it any other way! Don't get me wrong, I still feel like there's too much to do in too little time, but its now about playing the game.

There's no way around the MCQ paper: you have to practice and practice and get into it's mindset (sounds very psychological I know!). I think it's vital to complete all the College MCQs as there is a high chance that a couple will appear in the exam - free marks if they do. I've almost finished the 240 MCQs in the College book, and am averaging between 40-50% which I'm encouraged by at this stage.

The SAQ paper is all about structure: it is possible to pass a question without intimate details e.g. "How would you anaesthetise XYZ......?". Now, you may not know much about paediatric craniofacial surgery, or even seen it.......BUT you can answer the question. Write down what you would actually do: start with an introduction - shared airway, other potential congenital abnormalities, paediatric anaesthetics blah blah. The preop, periop, postop. Then you would go and see patients, rapport, consent, history, exam, investigations, +/- premed. Emergency equipment & drugs, skilled assistance, venous access, O2, monitoring (AAGBI), senior help, induction - drugs (+doses in mg/kg NOT actual doses) & airway, maintenance, analgesia, post-op etc. I know its a simplified version, but if there is a system which is the same for any question, you will not miss anything out......and you will pass the question. It is all about demonstrating to the examiner that you are structured, organized, and above all you are SAFE!

I've been working my way through the past SAQ papers published on the RCOA website. Interestingly enough, in recent years, there have been two questions repeated almost identically the year after. I believe in October 2005, there was a question about a 15yo having surgery for idiopathic scoliosis, repeated in October 2006. Same for NIBP measurements in May 2006 and May 2007. Obviously, I'm not advocating question spotting as a substitute for the work, but there is definite benefit from having been through these recent papers!

Further to my previous posting on review articles and SAQs, I think the value lies in trying to have a look at review articles from the previous 2 years prior to exam setting. Which means, for this April sitting, essentially all of the articles of 2006/2007, and possible the beginning of 2008. No mean feat! There are a lot of them! Reasoning behind this method of madness, confirmed to me again yesterday whilst going through October 2006 paper. There is a question on Awareness during GA, and in November 2005 there was a lovely review article published in CEACCP on......yes, it was Awareness.

PS/ don't forget to look at your basic sciences for the SAQs/MCQs as well. In May 2007, there is a question on Microshock, and the NIBP question.

Advances

2008-02-25T16:53:00.002Z

In response to a comment on the last posting: the podcasts can be found on the itunes store if you search for: Anatomy & Physiology Advanced and also for thegascast.

I received a phonecall today informaing me that I had been bumped up from the reserved list for the Mersey Booker course to actually having a place now on the course which is a complete bonus (albeit an expensive one). There's nothing like forced MCQs/SAQs and lectures to focus one's mind!!

I did my first SAQ paper today from the Royal College past papers. It wasn't strictly timed and I had to give up on a couple of questions but at least it's a start. I found that I could offer a reasonable amount of quantity but I need to structure the answers better; hopefully this will improve with practice!

A colleague has presented me with an excellent suggestion which was recommended to him by a previously successful candidate. I fully recommend following this principle. From today onwards we will email each other SAQs, write an answer within 15 minutes and email it back to be marked by the other. By gradually building up the number of questions done, the practice should increase exponentially. The answers can also be done during a lunch break at work.

I've also been invited to an informal SAQ evening tutorial session every Monday where possible with three other colleagues. A consultant anaesthetist is heading up the tutorial, and previous paper's answers & structures are marked and discussed. Again, if not already done, I would recommend this strategy of exam practice.

Something else which came to my attention over the weekend whilst on call on the Neuro ITU, and also during a lecture last week from a previous finals examiner, was the subject of paper setting and journals. It has been stated that a few of the SAQs are taken from review articles and journal publications over the previous couple of years. The main journals to keep an eye out for, I believe, are: BJA (including CEACCP & Bulletins), Anaesthesia (including the supplements), Anaesthesiology, and Critical Care Medicine.

The fear

2008-02-19T21:01:00.002Z

I officially today got what is universally known as "the fear". No precipitating factors really; we had a teaching session with a practice SAQ and I struggled to organise and structure my questions. My colleagues always appear to have much more confident and well-organised answers. I know and hope this is just my own insecurities leaking out but I really need to concentrate on understanding what the question is asking and structure accordingly. I had that feeling today of running out of time - where there appears to be so much still to do with not a lot of space to accommodate it all.

I started some MCQs the other day from MCQs in Anaesthesia by Ganado (see previous post with book listings. The explanations for the answers given in this book are superb - almost like a mini-textbook in itself. The first 20 MCQs I did, I scored 50% and was delighted; falsely so!! The next 20 MCQs scored 35%. As usual with commencement of MCQ practice it can be variable, usually with some confidence-draining scores at the beginning. One of the positive factors I took from the Primary exam was that I know I am a good MCQ guesser. This is an important fact that you should know about yourself when preparing for MCQs. Some people are naturally good guessers; other are not. One way of finding out if you have not already done so is to do a number of MCQs e.g. 25-50. Whilst you are doing them, number each answer from 1-3, where 1 is "I'm positive I know that this is the correct answer"; 2 is "I think this is the correct answer but can't be totally sure"; 3 is "This is a complete guess". Mark the MCQ and count up the number of 1's, 2's, and 3's. If you're getting lots of 2's and especially 3's as correct answers, you are likely to be a good guesser and should probably make more educated guesses in the actual exam, rather than leaving questions out due to the negative marking. Chances are that with this strategy, you will gain a higher mark than if you omitted the question.

Bizarrely, whilst browsing some podcasts on the itunes online store, I found some advanced Anatomy & Physiology tutorials by an American clinician (Dr M Bonner). Rather sceptically, I downloaded them to my Ipod and have been playing them in the car to and from work this past week. Despite a few Americanisms and some dodgy intro and exit music, surprisingly, I have found them quite useful. They do go right back to the beginning in some subjects but to listen passively whilst driving and brushing up on some basic science, I think, has made pretty good use of commuting time.

Getting Serious!

2008-02-10T17:52:00.000Z

I haven't had the chance to write anything for the last four weeks or so due to moving house. We didn't have broadband for the first two weeks and dial-up internet is so painfully slow. I had to take a week off revision for the move and have only just started to build it up again. I'm ploughing through Clinical Anaesthesia/Specialties/Trauma etc which seems to be the largest section for reading in text books. I still haven't really made notes as such, apart from the odd revision card for stuff I can never remember. When I was doing the Primary, I made so many notes yet never ended up using them (I think I still have Parbrook in my note form somewhere). People will probably argue that it is the act of writing the notes which aids the learning; for some this is true. I have found that for me it is repetition of material that works i.e. reading it again and again so it finally sticks.

I have been extremely lucky with my rotation so far at the Huge Teaching Hospital, as I will have had some experience in some of the major specialties by the time the exam is reached i.e. Cardiac, Paediatrics, Obstetrics, Neuroanaesthesia, ICM. Again for me, learning by seeing cases and performing the relevant anaesthesia under expert supervision and teaching has helped me no end, especially when it comes to clinical cases. They also run regular and rather daunting viva sessions in front of your colleagues - yes, I know it makes the exam experience easier, but it still doesn't help when your colleagues realise you have forgotten everything about Malignant Hyperthermia!!

I start my Neuro ICU nights this week, so cannot really estimate how much work will get done as I have a presentation to prepare and an audit to write up as well. My aim is to finish reading Clinical Anaesthesia within the next week and then the dreaded Basic Sciences will make a return! This time I have Bricker's 'The Anaesthesia Science Book' at my disposal so will again divide my time between Physiology, Pharmacology, and Physics/Clinical Measurement using this textbook, referring to my Primary notes/Parbrook/Peck & Hill etc. I'm also starting some MCQ practice this week. There is a tendency to concentrate on the SAQs at the expense of MCQs - I don't find doing MCQs as mentally taxing as the SAQs so at least it will bring some variability into the work now.

Routine

2008-01-15T02:31:00.000Z

I saw a scary thing today. Whilst browsing the AnaesthesiaUK website today, I noticed: 97 days until the Final written. 97 DAYS!! I'm finally getting into a routine whereby reading and revision is becoming the norm even after a full day's work. I've just finished my first read-through of neuroanaesthesia and ICM and plan to move onto pain and then clinical anaesthesia/specialties. I will then re-revise basic sciences etc from the primary. Most of my revision at present is just reading, although I am making the odd notes on stuff that I just can't seem to commit to memory e.g. antibiotics, adrenoreceptors!! For no logical reason at all, other things that I think may come up in the exam in some guise or another include the POISE study of perioperative beta-blockade in CVS patients, ARDS, and CEMACH (as already mentioned). Watch this space!!

Reality

2008-01-05T10:24:00.000Z

Happy New Year - especially to all those taking the exam! (And congratulations & envy to those who have just passed!). With all festivities (including my birthday) over now, the cold reality of what lies ahead is now setting in. Essentially there are four months of revision before the written exam remaining. I don't feel I have done too badly up to now, having completed a first read-through of Cardiothoracics, Paediatrics, Obstetrics, and Neuroanaesthesia. I'm aiming to continue with ITU, clinical specialties, and then Primary/Basic Sciences over the next six weeks or so. Then I will probably start practicing MCQs and SAQs under exam conditions.

Festive cheer

2007-12-19T15:03:00.002Z

Having just finished some obstetric revision, I have a sneaky suspicion that the new CEMACH 2003-2005 report may feature in next years exam in some form or another. Below is a concise summary, the majority of which relates to anaesthesia:

CEMACH 2003-2005 Summary

Definition
-Confidential Enquiries into Maternal Deaths.
-The longest running "Gold Standard" audit in the world. First Report covered 1952-54
-Triennial report published by DOH looking into all maternal deaths in UK

Causes of death:
-Direct: deaths of women while pregnant or within 42 days of termination of pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not accidental or incidental causes.
-Indirect: deaths resulting from previous existing disease, or disease that developed during pregnancy and which was not due to direct obstetric causes, but which was aggravated by the physiological effects of pregnancy.
Late: deaths occurring between 42 days and one year after the end of pregnancy

Changed title from “Why Mothers Die” to “Saving Mothers’ Lives”.

- All maternal deaths: 14 per 100000 maternities (no statistically significant change).

- Direct maternal mortality: slight rise (not statistically significant).

- Lack of decline of maternal mortality: older patient, obesity, comorbidities, migrants, lifestyle.

Commonest direct causes of maternal death
1) Thromboembolism (again)
=2 )pre-eclampsia/sepsis
4) Amniotic fluid embolism
=5) Haemorrhage/early pregnancy

- Increased numbers of: pre-eclampsia, genital tract sepsis/trauma + inexplicable rise in amniotic fluid embolism.
- Decreased haemorrhage/early pregnancy/ectopic.
- Nil of above: statistically significant.

Commonest indirect cause of maternal death
- Cardiac disease (less healthy diets, smoking, alcohol and the growing epidemic of obesity).

Anaesthetics
- 150 cases reviewed: direct or indirect cause of death also having anaesthetic

Direct anaesthetic deaths:
- 6 deaths – (4.5%) 0.28 per 100000 maternities. Same as previous triennium.
- All but one: Caucasian.
- 4/6: obese (2 were morbidly obese: BMI > 35)

Cases
1) Post-op bronchospasm & resp failure: obese asthmatic lady – failed reintubation during recovery post laparascopic surgery for ectopic pregnancy. Irreversible cardiac arrest.

2) Obese lady, early pregnancy, trainee anaesthetist. High-dose opiate given prior to extubation. In recovery developed respiratory difficulties. Inadequate ventilation, bradycardia, cardiac arrest.

3) Morbidly obese asthmatic lady, elective LSCS, spinal anaesthesia. Post-op agitation and SOB. Fatal cardiac arrest on post-op ward with inadequate resuscitation equipment.

4) Low-dose infusion epidural during labour & forceps delivery. PPH + IVI + syntocinon infusions. Grand mal convulsion + VF arrest – unable to resuscitate. Given 150mls 0.1% bupivacaine IV.

5) Lady with pectus excavatum in mid-pregnancy: â foetal movements, fulminant PET, & HELLP. Hypertensive, hyperreflexic, oliguric, & abnormal LFTs – given labetalol, Mg, & hydralazine. For urgent LSCS: RIJ cannulation unsuccessful but subclavian cannulation successful on the second attempt. Cardiac arrest shortly afterwards – large right haemothorax.

6) Obese woman with longstanding renal problems requiring nephrectomy. Had premature labour and delivery. A few weeks later, she was admitted with fever, loin pain, and ileofemoral venous thrombosis. Planned for drainage of septic focus from remaining kidney under U/S guidance. Pt refused LA and suffered an irreversible cardiac arrest during GA.

Indirect Anaesthetic Deaths

-Further 31 cases where poor perioperative anaesthetic management may have contributed to outcome

- Failure to recognise serious illness

- Poor management of haemorrhage (including syntocinon use): Less than optimum anaesthetic management contributed to many of the 17 maternal deaths from haemorrhage (12 died from PPH).

- Sepsis: Poor anaesthetic management/resuscitation was thought to have contributed to 10 maternal deaths from sepsis (usually failure to appreciate seriousness of maternal condition).

- Pre-eclampsia/eclampsia: 4 women died in relation to poor anaesthetic management (usually related to poor control of systolic blood pressure at time of LSCS/post-operatively)

- Management of obese pregnant women

- Quality of in-house hospital Trust enquiries into serious untoward incidents including maternal deaths: some reports of internal hospital enquiries sent to CEMACH were lacking in insight, improperly conducted, did not include clinicians from relevant specialties, or included clinicians involved directly with the maternal death (potential bias).

Slowly

2007-12-11T13:09:00.000Z

Still not firing on all cylinders yet - motivational issues + obstetric nights! Have managed to finish the paediatric syllabus now, so moving onto obstetrics this week. Below is a paediatric crib sheet which I have copied directly onto my PDA as a useful resource:

Paediatric Crib Sheet

Neonate

-1^st 44wks postconceptual age

-TV = 7ml/kg

-CO = 200ml/kg/min

-Blood vol = 90ml/kg

Infant

-Up to 12 months

-Weight = (Age in months + 9)/2

-TV = 6-8ml/kg

-Blood vol = 85ml/kg

Child

-1-12 years

-Weight = (Age + 4) x 2

-Blood vol = 80ml/kg

-Mean SBP = 90 + (age x 2)

Fluids

-Maintenance: 4ml/kg/hr for 1st 10kg. 2ml/kg/hr for 2nd 10kg. 1ml/kg/hr for subsequent kgs

-4% dextrose/0.18% saline

-Fluid Bolus: 20ml/kg

Equipment

LMA size

1 (0-5kg)-cuff 2-5mls.

1.5 (5-10kg)-5-7mls.

2 (10-20kg)-7-10mls.

2.5 (20-30kg)-12-14mls.

3 (>30kg)-15-20mls.

-Uncuffed until 8-10yrs

ETT size

>2kg = 2.5mm

2-4kg = 3.0mm

Term neonate = 3.5mm

3 months-1yr = 4.0mm

>2yrs = (Age/4) + 4

ETT length

oral (age/2) + 12

nasal (age/2) + 15

-TV= 10mls/kg

-PCV 18-20cmH2O/RR 16-24

-Min FGF 3L

-Insp press = 18-20cmH₂O

-RR = 16-24

Fasting

-Clear fluid 2hrs

-Breast Milk/Formula 4hrs (<12months)

-Solids (& milk) 6hrs

Drugs

-EMLA: 5% lignocaine & 5% prilocaine (45mins)

-Ametop: 4% amethocaine gel (30mins)

-Midazolam 0.1-0.2mg/kg (PO 0.5mg/kg)

-(Flumazenil 5µg/kg incr to 40µg/kg)

-Temazepam 0.5-1mg/kg

-Fentanyl 1-5µg/kg (up to 25µg/kg: cardiac)

-Propofol 2-5mg/kg

-Thiopentone 4-6mg/kg

-(Etomidate 0.3mg/kg (0.1-0.4))

-Ketamine 2mg/kg (5-7mg/kg IM)

-Suxamethonium 2mg/kg

-Atropine 10µg/kg (20µg/kg IM)

-Adrenaline 0.1ml/kg 1:10000 (10µg/kg)

-Atracurium 0.5mg/kg

-Rocuronium 0.6mg/kg

-Vecuronium 0.1mg/kg

-Neo/Glyco 0.02ml/kg

(dilute 1ml w. 4ml saline give 0.1ml/kg).

-Morphine 0.1-0.2mg/kg 4hrly

-Oramorph 0.4mg/kg

(Naloxone 5-10µg/kg)

-Paracetamol 20-30mg/kg loading then 15mg/kg qds

-Diclofenac 1mg/kg tds (max 3mg/kg/day)

-Ibuprofen 5-10mg/kg tds

-Codeine phos 1mg/kg qds

-Cefuroxime 20-30mg/kg tds

-Metronidazole 7.5mg/kg

-Augmentin 25-50mg/kg qds

-Erythromycin 10-25mg/kg

-Cyclizine 1mg/kg

-Dexamethasone 0.15mg/kg

Ondansetron >2yrs 0.1mg/kg

Armitage regime

-0.25% bupivacaine

-Lumbosacral: 0.5ml/kg

-Thoracolumbar: 1ml.kg

-Midthoracic: 1.25ml/kg

Add

-clonidine 1µg/kg,

-diamorphine 30µg/kg,

-PF ketamine 0.5mg/kg,

-PF morphine 50µg/kg

-Wound infiltration 1ml/kg 0.25% bupivacaine

Epidurals

Loading dose:

-0.75ml/kg(lumbar) or 0.5ml/kg(thoracic) of 0.25% bupivacaine

Infusion:

-60ml of 0.125% bupivacaine + 2µg/ml fentanyl

Rate: 0.1-0.4ml/kg/hr

SAQ

2007-12-02T12:59:00.002Z

I have tried to group these into topics as best I can:

General SAQ

Summarise the causes, effects and prevention of aspiration pneumonitis.

What are the indications for performing a tracheostomy? List the complications of tracheostomy

What solutions are available for the restoration of circulating volume in a patient suffering from acute blood loss? Discuss the advantages and disadvantages of each.

What are the causes and management of circulatory collapse at induction of anaesthesia?

Outline the key points in the management of a patient with massive haemorrhage.

Formulate a guideline for the perioperative administration of blood, explaining the reasons for your recommendations.

A General Practitioner has contacted you for advice about a patient who may be susceptible to malignant hyperthermia. Write a letter to the General Practitioner explaining the significance of this condition for the patient and the relatives.

What diagnostic features would lead you to identify malignant hyperthermia during and immediately after anaesthesia of an adolescent presenting for appendicectomy?

What is the pathophysiology of malignant hyperthermia? How would you investigate it?

What factors determine the rate of haemoglobin desaturation during a failed intubation? What can be done to maintain oxygenation in this situation?

How can jugular venous bulb oxygen saturation be measured? What factors cause its value to increase or decrease?

How may coagulation be assessed in the perioperative period?

What is the normal glucocorticoid response to surgery? Outline, with reasons, your perioperative corticosteroid regimens in patients:
a) taking steroids at the time of surgery;
b) who have stopped taking steroids several months previously.

What tests may be done to evaluate the adequacy of pulmonary oxygen transfer? Briefly describe how you would interpret the results.

What nationally based audits in the UK include an examination of anaesthetic practice? Outline the methodology and recommendations of two recent reports.

List the risk factors for venous thromboembolism and classify the current methods of prevention, with examples

Explain the importance of a high airway pressure alarm system during general anaesthesia.

Outline the methods for prophylaxis of venous thromboembolism in routine surgical practice.

A patient who is HIV sero-positive is scheduled to undergo a laparotomy. Discuss the factors determining the risk of transmission to theatre staff. How can this risk be reduced?

What are the indications for a preoperative chest radiograph?

What do you understand by the term critical incident? Following a critical incident, what information should be recorded? What sequence of events should ensue??

Discuss the risks and benefits associated with intermittent positive pressure ventilation through a laryngeal mask airway.

What are the advantages and limitations of the laryngeal mask airway?

What is evidence-based medicine? How would you apply the process to your clinical practice

List the key clinical features, and commonest causative agents, of severe anaphylaxis occurring during general anaesthesia. Outline its management.

Under what circumstances is myoglobin found in the urine? What are the implications of myoglobinuria and how is it managed?

How may unintended perioperative hypothermia harm patients?
What are the potential causes of delayed resumption of spontaneous ventilation after major intra-abdominal surgery with general anaesthesia? Discuss prevention, diagnosis and management

What are the indications and contraindications for the use of an arterial tourniquet?
What complications may arise from the use of such a tourniquet

What are the anaesthetic problems caused by morbid obesity?

How would you prevent awareness under general anaesthesia?

Under what circumstances should general anaesthesia for elective cases be postponed and why?

What are the causes and management of hypoventilation immediately following anaesthesia?

List the causes and briefly give the management of tachycardia in an adult during general anaesthesia.

What factors do you consider important in selection of day case patients?

How does the presence of aortic stenosis affect the management of anaesthesia?

A houseman informs you that a patient's arterial pressure is raised before surgery; describe your management.

What is the significance of preoperative jaundice?

Surgery

What particular problems may occur during lower abdominal surgery in a patient who suffered a traumatic transection of the spinal cord at C6 four weeks previously? Briefly indicate how you would avoid or prevent the problems you describe.

An 80 year old lady with a sub-capital fractured neck of femur requires surgical fixation. She is found to be in fast atrial fibrillation. What are the important points in the preoperative preparation for anaesthesia in this case?

A patient with a history of obstructive sleep apnoea presents for an elective cholecystectomy. How would you assess the fitness for anaesthesia? What precautions would you take with your anaesthetic management of this patient?

A surgeon is attempting an inguinal herniorrhaphy in a fit obese young man under local anaesthetic infiltration that is proving inadequate and asks for your help. What anaesthetic strategies are available for managing this situation?

A 78 year old male heavy smoker is admitted for laparotomy for his rectal cancer. He is treated with bendrofluazide and atenolol for hypertension (160/90 mmHg on admission). What specific actions would you take to improve the chances of a successful outcome.

VASCULAR

You have been asked to anaesthetise a 60 year old woman for ligation and stripping of varicose veins in one leg. She has a history of ischaemic heart disease. Explain briefly how suitability for her management in a day-case facility is assessed.

An obese 70-year-old man underwent an emergency abdominal aortic aneurysm repair yesterday evening. He is known to be a heavy smoker and is a treated hypertensive. He has been cardiovascularly stable overnight and is responding appropriately. Propofol and morphine infusions are stopped with a view to extubation. Agitation, tachycardia (heart rate 130 bpm) and hypertension develop (250/90 mmHg).
List the factors that could be important in precipitating this response. (40%)
Briefly outline your further management in the ICU of these factors. (60%)

Outline your perioperative management of a patient with a ruptured abdominal aortic aneurysm.

Discuss the principles underlying the anaesthetic management of carotid endarterectomy. What are the risks of carotid endarterectomy? How may the anaesthetist reduce these risks

UROLOGY

A 70 yr old man with chronic obstructive airways disease requires a transurethral resection of the prostate. Outline the advantages and disadvantages of intrathecal block for this patient.

ORTHO

A 20 year old patient, with sickle cell disease, was injured 12 hours ago. He has fractures of the metacarpal bones on his dominant hand. Elective surgical reduction and fixation is planned. Describe your anaesthetic management.

You anaesthetised a sixty-four year old man for removal of a protruding disc C4/5. The patient was found to be quadriplegic in recovery. Discuss the likelihood of this being a consequence of you anaesthetic.

A 70 year old man presents for a total hip replacement. He has no significant past medical history. At the anaesthetic assessment clinic he is noted to have a grade III ejection systolic murmur at the right sternal edge, radiating to his neck.
Describe, with reasons, what investigations should be undertaken on this patient and explain how the results would affect your anaesthetic management.

What are the types of anaesthetic that should be considered for fixation of a compound ankle fracture in a patient who was briefly knocked unconscious at the accident? Outline the advantages and disadvantages of each technique.

What information would you wish to obtain from a patient at your postanaesthetic visit, the day after a total hip replacement?

GYNAE

A sixty-five year old diabetic female is to undergo a total abdominal hysterectomy. She is normally controlled by oral hypoglycaemic drugs. Describe your perioperative management of her blood sugar.

RENAL

What problems are associated with anaesthesia for elective surgery in a patient with dialysis-dependent renal failure?

An otherwise fit patient requires nephrectomy for a large solitary renal tumour.
What surgical factors might influence your conduct of the anaesthetic?

DENTAL

List the likely causes of collapse in the dental chair of a patient undergoing a procedure under local anaesthetic without sedation, with notes on the presenting signs and symptoms. Briefly state what first-aid measures can be undertaken in each case.

What are the risks for patients associated with the administration of general anaesthesia in dental surgery? How may these risks be reduced?

Summarise the perioperative anaesthetic management of a patient who requires plating of his jaw fractured in a fight?

Discuss the principles of the management of a 25 year old patient with Down’s syndrome, who requires multiple dental extractions.

NEURO

What are the pathophysiological insults which exacerbate the primary brain injury following head trauma? How can these effects be prevented or reduced

How would you manage the transfer of a patient to a regional neurosurgical unit for evacuation of an extradural haematoma

A 40-year old man is admitted with an acute head injury. List the indications for intubation, ventilation and referral to a neurosurgical unit.

OTHER

What factors contribute to intravenous drug errors in anaesthetic practice? (40%)
What strategies are available to reduce the incidence of such errors? (60%)

What are the presenting clinical features of infective endocarditis? (40%)
What are the principles that guide the use of antibiotics as prophylaxis against this condition during surgery? (60%)

What is the physiological basis of preoxygenation for anaesthesia? (40%)
Describe a method of preoxygenation and how you would assess its adequacy. (35%)
What are the advantages and disadvantages of preoxygenating a fit adult? (25%)

What perioperative measures can be taken to minimize non-autologous red cell transfusion in a patient undergoing elective surgery

Which patients are at increased risk of infection related to an epidural catheter? (30%)
What symptoms and signs suggest the development of an epidural abscess? (30%)
What investigations would be definitive in initiating further management? (20%)
What should this be? (20%)

List the predisposing factors for aspiration of gastric contents during general anaesthesia. How can the risk of this complication be minimised? How should it be treated?

What are the anaesthetic considerations in a patient with autonomic neuropathy?

Discuss the perioperative management of the blood pressure of a patient undergoing removal of a phaeochromocytoma.

A 60 year old smoker requires non-laser surgery to the vocal cords. Outline the various anaesthetic techniques available, listing advantages and disadvantages of each.

What would make you suspect that a patient had sustained an air embolus during an anaesthetic? How should this situation be managed?

What procedures are associated with venous gas embolism? How can it be detected?
What are the effects of a large venous gas embolus? Describe its management.

List the dangers to the eye of general anaesthesia for elective intraocular operations. How are these prevented?

Outline the problems involved in anaesthetising an intravenous heroin abuser needing urgent surgery for incision of perianal abscess

What are the principles of pain relief after surgery in a drug abuser dependent on opioids?

What are the problems of monitoring anaesthetised patients in the magnetic resonance imaging unit?

What hazards does a patient encounter as a result of being placed in the lithotomy position for surgery? What additional hazards are introduced by then tilting the operating table head-down? Indicate briefly how you attempt to prevent these hazards

Outline the possible complications of anaesthesia with a patient in the prone position.

What are the factors contributing to unplanned awareness during general anaesthesia?

Elderly

Outline the effects of old age upon morbidity and mortality in anaesthesia.

You are asked to anaesthetise an 87 year old lady for diathermy of her bladder tumour on a day case basis. What are the potential problems of this case and how would you manage them?

What factors contribute to postoperative cognitive deficits in elderly surgical patients? How may these risks be minimised?

What are the advantages and disadvantages of day case anaesthesia in patients aged more than 80 years?

What are the important organisational (40%) and clinical (60%) factors which govern the anaesthetic management of patients over 80 years of age

Difficult airway

An adult patient is known to be severely difficult to intubate. Describe a technique of fibreoptic intubation for this case

List the bedside tests available to predict a difficult intubation. Comment on their usefulness.

What is the role of the laryngeal mask airway in the management of difficult intubation?

ITU

Outline your management of an adult patient brought into the A & E department in status asthmaticus.

A 62 year old man is admitted to the high dependency unit following a laparotomy to relieve a large bowel obstruction. He has a urinary catheter in situ. Two hours later, he has only passed 25 ml of urine. List, with reasons, the likely causes. What is going to be your initial plan of management?

What measurements and derived values can be made from pulmonary artery catheters used in the intensive care unit? Suggest a clinical application for each one.

A patient on the intensive care unit has a mean arterial pressure of 130 mmHg. What drugs might be useful for reducing this to a safe level and what is the mechanism of action of each

List the factors associated with central venous catheter infections and suggest methods to limit such infections

How would you determine the mixed venous oxygen content in the intensive care patient? What is the usefulness of this measurement?

Describe the immediate resuscitation of a patient admitted to A&E following a fall from a 20 ft ladder.

A 27 year old man is admitted with a fracture of the cervical spine at C5/6. There are no other injuries. Describe the management of this patient in the first 48 hours after injury.

List the radiological investigations that are available to help exclude an unstable cervical spine injury in an unconscious, ventilated adult with multiple severe injuries. (25%)
What are the limitations of each technique? (75%)

Describe the criteria and tests for brain stem death. Briefly indicate the neurological basis for each test

Discuss the causes of muscle weakness in a critically ill patient. How would you investigate them

Discuss the ventilatory management of an adult with ARDS. What pathophysiological processes are involved in patients who develop acute respiratory distress syndrome?

A patient is mechanically ventilated for acute lung injury in the ICU. Explain what practical steps you would take to turn the patient from the supine to the prone position. (70%)
List three common acute complications of the prone position. (30%)

A comatose, ventilated patient who has a head injury has an intracranial pressure of 35 mmHg. His CT scan excludes a surgically reversible cause. What immediate steps would you take to assess and treat the patient

You are asked to see a 45 year old man in the Emergency Department who has suffered 30% burns. What factors in the history would suggest that he has suffered a significant inhalational injury? (25%)
What symptoms, signs and results of laboratory tests would confirm your suspicions? (75%)

Describe the diagnosis and immediate assessment of a patient with smoke inhalation injury.

What is disseminated intravascular coagulation. Discuss its management in the critically ill patient.

What are the limitations and risks of intra-arterial pressure monitoring in the critically ill? How may these be minimised

How is ventilator-associated pneumonia (VAP) diagnosed? (20%)
Explain the physical (50%), positional (15%) and pharmacological (15%) strategies that have been
advocated for its prevention?

Discuss methods of applying non-invasive ventilation. What are its uses and benefits?

What is ventilator-induced lung injury? Explain the relative importance of volutrauma and barotrauma. What is the practical importance of ventilator induced lung injury?

Define transfusion related acute lung injury (TRALI). Discuss its pathogenesis, presentation, management and outcome

Describe your technique for insertion of a chest drain.

What forms of ventilatory support are used for patients undergoing mechanical ventilation?
What methods of sedation of patients undergoing mechanical ventilation are available in the intensive care unit (ICU)?
What factors affect the ablility to wean patients from mechanical ventilation?
Describe the criteria and methods to wean such patients from mechanical support.

Discuss the management of a patient admitted to the ICU with: acute severe asthma; severe burns; septicaemia; Guillain Barre.

Discuss the differential diagnosis of stridor in a 3-year-old child.

What information can be measured or derived from a successfully placed multilumen PA catheter?

Describe the alternatives to donor blood transfusion.

Statistics

The plasma concentrations of a drug have been measured in 20 normal patients and in 20 patients with renal failure. What simple statistical tests exist to determine whether these 2 sets of observations differ at the 5% level? What assumptions are inherent in each test which you describe?

What is meta-analysis? Outline the methodology. How are the results usually presented

Acute Pain

What are the advantages and disadvantages of intravenous patient controlled analgesia for postoperative pain control?

What are the advantages and disadvantages of the different ways by which opioids may be administered for postoperative pain?

What methods are available for therapeutic nerve blockade? Explain the mechanism of action for each method

A 60 year old man presents for a hemicolectomy. How may choice of pain management influence recovery from surgery?

Describe the methods of pain relief for total abdominal hysterectomy.

What safety features should be incorporated into a patient controlled analgesia (PCA) system and what is the purpose of each? What instructions would you give to the nursing staff, having set up the PCA?

A 70 year old man is to undergo an above knee amputation. What can be done to relieve any pain he may experience thereafter

What safety features should be incorporated into an intravenous patient controlled analgesia (PCA) system and what is the purpose of each? What instructions would you give the nursing staff, having set up the PCA?

How would you provide optimal pain relief for a 60 year old man undergoing shoulder replacement

What aims and strategies are emphasised in a "Pain Management Programme

Outline the nerve pathways involved in the transmission and perception of a painful stimulus from the foot.

List the indications and contraindications for Transcutaneous Electrical Nerve Stimulation (TENS)? What does the patient need to know when using a TENS machine ?

Describe two assessment tools used for the measurement of acute pain in adults. (30%)
Describe the McGill pain questionnaire used to assess chronic pain. (20%)
Include the strengths and weaknesses of each of the above. (30%)
Why do assessment tools used in acute and chronic pain differ? (20%)

Write short notes on paracetamol.

Chronic Pain

A 60-year old man is referred to you with reflex sympathetic dystrophy following an injury at the elbow 6 months earlier. Outline the treatment.

List, with examples, the causes of neurogenic pain. What symptoms are produced? What treatments are available?

What are the principles of cancer pain management

Describe the features and management of phantom limb pain

A patient presents to the pain clinic with low back pain. List the indicators (‘red flags’) that would alert you to the possibility of serious pathology? In their absence, what is the early management of simple mechanical low back pain?

Write short notes on TENS ... neurolytic agents ... cryoanalgesia.

What are the indications for a coeliac plexus block. Describe one approach and the complications of this technique.

Anatomy/Nerve Blockade

Make a simple drawing, with labels, to show the trachea, main and segmental bronchi.

Make a simple diagram, labelled to show the anatomical structures associated with the right internal jugular vein (including its important relationships). List the complications of cannulation of this vessel, mentioning how each may be avoided. Where should the tip of a left internal jugular line lie and why ? What anatomical abnormalities of this vein can make cannulation hazardous or impossible? Outline the risks associated with cannulation of this vessel and how they can be minimised for hip surgery.

Draw a labelled diagram of the anatomy of the anterior aspect of the wrist. How may this knowledge be used in anaesthetic practice?

Outline your technique for percutaneous tracheostomy, with particular reference to the anatomy involved. List the possible complications of this procedure

Draw a diagram of the lumbar plexus.

Outline the anatomical basis of a ‘3 in 1’ block. Explain why the block may fail to provide reliable analgesia

Describe the anatomy of the inguinal canal and describe a technique for local anaesthesia for herniorrhaphy (excluding extradural/spinal blockade).

Describe the arterial blood supply to the spinal cord. How may it be compromised?

Describe two adjoining mid-lumbar vertebrae. Include the joints, their nerve supply and the ligaments

Describe how you would carry out an axillary brachial plexus block

Draw a labelled diagram of the anatomical relations of the stellate ganglion. How is it blocked and what are the possible complications?

Describe the anatomy of the coeliac plexus. What are the indications for its therapeutic blockade?

Describe the anatomy of the nerves involved for neural conduction blockade at the ankle. Femoral nerve root value. Relation ship of those nerve to the ankle Ankle block performance. Maximum dose. Calculation. Complication

What are the indications for a popliteal fossa block? (10%)
List the nerves that are affected and describe their cutaneous innervation. (35%)
What responses would you get on stimulating these nerves? (25%)
Briefly describe one technique for performing this block. (30%)

List the nerves which supply the eye and its muscles. Briefly describe the relevant function of each nerve. (40%). What specific considerations would you take into account when providing general anaesthesia for adult vitreo-retinal surgery? (60%)

Intercostal nerve. Draw a typical intercostal nerve with its branches What do the branches supply? Do any branches cross over the midline to supply the other side? Draw a cross section of a rib with the intercostals muscles and neurovascular bundle. How are the muscles arranged? What are the indications to block the intercostals nerve? Where would you do it? And how? What are the complications?

How do you prevent LA toxicity? What is it specifically you are worried about? Are there any drugs that can be used to minimize this risk?

Why do you get a pneumothorax? How can you prevent it?

Describe the place of local analgesic nerve blocks during anaesthesia for cholecystectomy.

Describe the anatomy of the caudal space. What are the indications for analgesia administered by this route?

Describe the anatomy of the diaphragm. Which factors in anaesthetic practice affect its function?

Describe the anatomy of the first rib. Outline the technique for subclavian vein catheterisation.

Describe the anatomy of the 9th intercostal nerve. What complications may arise following intercostal nerve block?

Describe the prevention and treatment of the main complications of extradural analgesia using local analgesia.

Obsetrics

Outline your management of a fit primagravida who suffers inadvertent dural puncture with a 16 gauge Tuohy needle during attempted epidural for pain relief in the first stage of labour (cervix 4 cm dilated). Outline the possible reasons for the reduction, over the last decade, of maternal mortality associated with anaesthesia

List the pathophysiological and clinical features of HELLP syndrome. What are the diagnostic laboratory findings and the priorities in management?

Write short notes, with reasons, on your anaesthetic management of emergency Caesarean section for cord prolapse in a fit 21 year old primagravida

What are the advantages of retaining motor power in a woman having an epidural for a normal labour? How can this be achieved and what would you check before allowing the woman to get out of bed?

What is the differential diagnosis of persistent headache in the puerperium of a woman who has undergone a regional anaesthetic technique? Describe the distinguishing clinical features of each cause

What is an appropriate intervertebral space at which to insert a spinal needle to administer a subarachnoid anaesthetic for a Caesarean section? Give your reasons and describe how you would locate the space

When obtaining consent for an epidural for a primigravida in labour, what complications do you mention? Quote their incidence if known. What can be done to reduce the likelihood of these problems

List the three commonest causes of direct maternal deaths in the United Kingdom. What anatomical and physiological changes of pregnancy affect your ability to resuscitate a woman who has suffered cardiovascular collapse at full term?

What potential problems and risks do you consider when planning the anaesthetic management of the delivery of twins

What advice, for and against, would you give a primagravida who is asking if she might eat and drink during her labour? Give reasons.

Define primary postpartum haemorrhage (10%)
List the pharmacological agents that may be used postpartum to reduce uterine atony and any precautions with their use. (50%)
Outline the management of a significant primary postpartum haemorrhage. (40%)

Outline the possible reasons for the reduction, over the last decade, of maternal mortality associated with anaesthesia

List the indications and contraindications for Transcutaneous Electrical Nerve Stimulation (TENS)? What does the patient need to know when using a TENS machine

Cardiac

What is your choice of anaesthesia for pericardectomy in constrictive pericarditis? Give reasons for your choice.

The first patient on your operating theatre list tomorrow morning has an implanted (permanent) cardiac pacemaker. List, with reasons, the relevant factors in your preoperative assessment.
What are the postoperative problems in the first 24 hours after coronary artery bypass graft? How are they prevented

List, with reasons, the factors which affect the incidence of perioperative myocardial infarction

What are the principles of adult cardio-pulmonary bypass? What are the common complications of this procedure?

How do you confirm that a double-lumen endobronchial tube has been placed correctly? Outline the possible complications associated with the use of this equipment.

Classify the types of heart block. Outline appropriate treatment in the intraoperative period

A patient who has undergone a heart transplant requires non-cardiac surgery. What problems may this present for the anaesthetist?

What are the possible deleterious consequences of cardiopulmonary bypass when used in coronary artery surgery? How may these be reduced?

A patient with aortic stenosis presents for non-cardiac surgery. What are the clinical features of aortic stenosis and how would preoperative investigations influence your perioperative management?

What are the risks and benefits of thoracic epidural anaesthesia/analgesia for coronary artery surgery?

Outline the pathology of acute coronary syndromes. What pharmacological treatments are available for patients with an acute coronary syndrome

Describe the preoperative assessment and preparation specific to an adult patient who requires a thoraco-abdominal oesophagectomy. Describe your anaesthetic plan for this operation

List the causes of perioperative atrial fibrillation. What are the dangers of acute onset atrial fibrillation? How would you manage acute atrial fibrillation in the postoperative period?

A patient on the ICU, who had cardiac surgery completed 3 hours ago, is still intubated.
What clinical features might suggest the development of acute cardiac tamponade? (55%)
How might you confirm the diagnosis? (5%)
Outline your management of acute cardiac tamponade? (40%)

Paediatrics

What are the choices for postoperative analgesia for a child aged 4 years presenting for repair of an inguinal hernia as a day case? State briefly the advantages and disadvantages of each method.

Describe your procedure for cardiac life support in a child aged five years.

Outline the anaesthetic management of a 2 year old child who is scheduled for therapeutic bronchoscopy following inhalation of a foreign body 2 days ago. The child does not exhibit any signs of upper airway obstruction

What is the anaesthetic management of pyloric stenosis in a 6 week old child?

Describe your procedure for cardiac life support of a child aged 5 years

A ten week old male infant weighing 3.5 kg is scheduled for inguinal hernia repair. He was delivered prematurely at thirty-four weeks. List the risk factors and state how these can be minimised.

Outline the early management of a one year old child with 25% burns caused by scalding

A ten week old male infant weighing 3.5 kg is scheduled for inguinal hernia repair. He was delivered prematurely at thirty-four weeks. List the risk factors and state how these can be minimised

A 4 year old child who has been knocked unconscious by a blow from a cricket bat arrives at a paediatric neurosurgical centre. After initial appropriate management, a CT scan shows an extradural haematoma. There are no other injuries. Discuss the subsequent management.

You are called to the A and E department to review a 4 year old child who requires intubation. She has a clinical diagnosis of meningococcal sepsis. She has reduced consciousness and a petechial rash. Describe your immediate management.

Outline, with reasons, your perioperative management of an otherwise healthy 4 year old admitted for tonsillectomy

You are asked to anaesthetise a 5-year-old child (weight 20 kg) for an emergency appendicectomy. Describe in detail the induction of anaesthesia with special reference to:-
Fluid management (20%)
The airway (50%)
Drug management, including doses (30%)

A one day old term neonate has arrived at your regional paediatric intensive care unit. A congenital diaphragmatic hernia has been diagnosed. The baby is already intubated and receiving artificial ventilation. Outline, with reasons the principles of preoperative management.

Describe the anaesthetic management of a penetrating eye injury in a screaming 5 year old child.

Physics

List, with a brief statement on the effectiveness of each one, the means available for detecting awareness during anaesthesia.

How does a rotameter flowmeter work? Describe its advantages and limitations

Describe in detail how you would accurately measure a patient’s peak expiratory flow rate. What factors may give rise to erroneous readings

What are the physical principles of the capnograph? Discuss the applications of capnography in anaesthetic practice Define capnography. Draw and label a normal capnograph trace. Why is capnography useful during general anaesthesia? Give examples of abnormal traces and their causes. How may it be calibrated?

List, with a brief statement on the effectiveness of each one, the methods described for detecting awareness during anaesthesia

Outline the methods of estimation of arterial pCO₂ and their limitations

Describe the features of the anaesthetic machine which are intended to prevent the delivery of a hypoxic mixture to the patient.

Describe the circle system for anaesthesia.

Describe the principles involved in pulse oximetry. What are its limitations in clinical practice What are the sources of error in a pulse oximeter?

Define pressure. List the methods available for measuring systemic arterial blood pressure. Outline the principles involved in one of the methods listed.

What information can be obtained from measuring central venous pressure?

What arrangements are required for an adult head injured patient during transfer to a neurosurgical unit?

Physiology

What immunological consequences may result from homologous blood transfusion?

Draw the following diagrams (with values): A spirometer trace showing normal lung volumes, FEV1/FVC graphs and flow-volume loops. How are these altered by the following diseases: asthma, emphysema, pulmonary fibrosis, chest wall restriction and respiratory muscle disease1

Draw clotting cascade.What is the role of the platelets? What is the importance of tissue factor?

Fibrinolytic system

Your patient in recovery has a high CO2. What are its implications? Will it cause hypoxia? How? Can you write and explain the alveolar gas equation. What happens according to the equation if the patient is hypercarbic? What is R? What is its value? Is it constant? What does it depend on? List the common causes of increased CO2 Draw a curve relating alveolar ventilation to PACO2 Can you equate alveolar CO2 to arterial CO2? What is the rationale? Can you equate alveolar O2 to arterial O2? What is the rationale? What is A-a difference? When does this gap widen? What is a shunt? Give me some examples.

What is pulmonary surfactant? Discuss its production in the lung, mechanism of action and function. What would be the effect of insufficient pulmonary surfactant?

Define contractility. Outline the methods available to the clinician to assess myocardial contractility in the perioperative period.

Write brief notes on the physiological responses that constitute the stress response to surgery.

What is meant by 'oxygen flux'? What factors affect it and what therapeutic measures increase it?

What are the adverse effects of intermittent positive pressure ventilation? How would you minimise them?

Describe the endocrine and metabolic responses to major surgery. How does anaesthesia affect them?

What is physiological dead space? What factors affect it?

What mechanisms are involved in anaphylactic reactions? How would you manage a patient showing signs of such a reaction?

How does the physiology of children aged 1 year differ from that of adults?

What factors affect cerebral blood flow? Briefly state their importance in relation to anaesthesia within 12 hours of head injury.

Describe the physiological effects of hypercarbia.

Describe the conducting system of the heart. How may abnormalities of cardiac conduction be revealed by the electrocardiogram?

What are the causes and effects of hypothermia?

Pharmacology

How would you manage a case of accidental intra-arterial injection of thiopentone in the upper limb?

What are the disadvantages of nitrous oxide in clinical practice

Outline the clinical features and management of bupivacaine toxicity

You are asked to investigate the effectiveness of a new anti-emetic agent. Briefly outline the priniciples which should guide the design of such a study.

What are the main point that you would include in a patient information leaflet that you would submit to support an application to your local ethics committee to study a new non-depolarising muscle relaxant?

What are the therapeutic uses of magnesium and how does it work?

Draw a nephron with its blood supply. Where and how do the following exert their effects: loop diuretics, thiazide diuretics and aldosterone antagonists?

Write a guideline for reducing and treating postoperative nausea and vomiting.

Discuss the reasons for and against the use of nitrous oxide in anaesthetic practice.

What is the mode of action of epidural opioids? Discuss the relative merits of epidural fentanyl and morphine.

List the patterns of peripheral nerve stimulation that may be used to monitor non-depolarising neuromuscular blockade during anaesthesia. How is each used in clinical practice?

What are the functions of cyclo-oxygenase (COX) enzymes? How are the side-effects of non-steroidal anti-inflammatory drugs related to inhibition of these enzymes?

Describe how and why a vaporiser delivering desflurane is different from one delivering isoflurane

Relate the clinical use of thiopentone and propofol to their pharmacological properties

Outline the pharmacology and clinical use of low molecular weight heparins for prophylaxis against deep vein thrombosis

List the classes, with an example of each, of a) anticoagulants (20%) and b) antiplatelet drugs (20%) in current clinical practice.
How would you minimise the incidence of bleeding and haematoma formation associated with epidural anaesthesia in patients taking each of these drugs? (60%)

What are the endocrine causes of secondary hypertension? (25%)
What is the pharmacological management of each of these endocrine conditions? (35%)
State the mechanism of action of each drug. (40%)

Benzodiazepine action how do they act. GABA recetor. Midazolam: Effects/ Side effects/Uses

Continuous infusion

Context sensitive half life define

Describe the synthesis of 5 hydroxy tryptamine Where is it present? What are its functions? How is it metabolized? What is carcinoid? Where is it found? Small intestine. Which part of small intestine? How does a carcinoid present? Why don’t u get carcinoid syndrome when the tumor is localized to the gut? When do you get carcinoid syndrome and why? What is LSD? What is its relationship to serotonin? Do you know any 5 HT receptors? How many subtypes are there? Are there any drugs you know which act at these receptors? List them. What are their uses?

Compare the electrolyte content and osmolality of 0.9% sodium chloride (normal saline) and compound sodium lactate solution (Hartmann’s). (40%)
Why might compound sodium lactate solution be a better crystalloid replacement fluid than 0.9% sodium chloride? (40%)
Explain the effects of a large infusion of 0.9% sodium chloride on acid-base balance and electrolytes. (20%)

What are the adverse affects of oxygen therapy?

Describe the desirable and undesirable effects of nitrous oxide.

What properties do you consider ideal for a neuromuscular blocking agent?

Compare the cardiovascular effects of desflurane, sevoflurane and isoflurane.

Discuss the mechanism of action and use of spinal opioids.

What are the effects of an overdose of tricyclic antidepressant drugs?

Compare and contrast gelatin-based plasma substitutes and Hartmann's solution.

Long Cases

2007-12-02T12:58:00.001Z

Again difficult to classify but useful to have as one document for printing:

A 75-year-old female presents for elective fixation of C3 and C5. She has a history of rheumatoid arthritis. Over the past 6 months she has complained of weakness in the right leg and both hands.

Drugs
Diclofenac and prednisolone.

Observations and examination
Blood pressure: 190/80 mmHg
Heart rate: 84/min
Lung function test: Reduced FRC and FEV1 to about 45% predicted. She also has a restrictive picture
Full blood count: Mild anaemia and elevated mean cell volume
Arterial blood gases: Mild respiratory alkalosis; nothing significant
Urea and electrolytes: Elevated urea; no other derangements
Chest X-ray: Hyperinflated, right basal consolidation, trachea deviated to the right side

Questions
1. Summarise the case.
2. What are the anaesthetic considerations in rheumatoid arthritis?
3. Give a detailed analysis of investigations, especially the chest X-ray.
4. What would be your anaesthetic management?
5. What drugs would you give the patient?
6. Discuss your airway management, giving detailed discussion of asleep fibreoptic intubation.
7. Discuss the positioning considerations.
8. What blood pressure would you be happy with intraoperatively?
9. Describe your fluid management for this patient.
10. How would you extubate this patient? What postoperative respiratory support should be given?
11. Discuss high-dependency unit/intensive care unit care.

A male in his 60s presents with a strangulated hernia for urgent surgery. He has known atrial fibrillation (AF) and hypertension. He has not been taking his medication. His ECG shows fast AF (150 bpm), with ischaemic changes. There are mild signs of heart failure on the chest X-ray. He is asymptomatic.

Questions
1. Discuss his preoperative optimisation.
2. Discuss his anaesthetic management.

You see a 70-year-old man 4 days after he has undergone abdominal aortic aneurysm repair. His past medical history includes a transient ischaemic attack, non-insulin-dependent diabetes mellitus, hypertension and shortness of breath on exertion. A chest X-ray shows pulmonary oedema, cardiomegaly and right lower lobe collapse with tracheal deviation. An ECG shows new atrial fibrillation (AF) with ischaemia.

1. Discuss AF management in the intensive care unit.
2. What are the possible causes of AF?
3. What other ways do you know to identify AF?
4. What drugs would you administer?

A 70-year-old male presents 4 days postoperatively, following elective abdominal aortic aneurysm repair, now in the intensive care unit with respiratory distress.

Past history:
Ischaemic heart disease
NIDDM
Osteoarthritis, with limited exercise tolerance
Hypertension
Peripheral vascular disease

Drugs:
NSAIDs
Amlodipine
prn glyceryl trinitrate

Examinations:
ECG: two ECGs presented; the first showed normal sinus rhythm, the second showed fast atrial fibrillation.
Chest X-ray: diffuse haziness, increased at right base.

Blood results:
Urea: 14 mmol/L
Creatinine: 170 µmol/L
Arterial blood gases:
PaO₂ 11 kPa
PaCO₂ 6.5 kPa
Bicarbonate: normal

Questions:
1. Why is this patient in respiratory distress?
2. What are the causes of raised hemidiaphragm?
3. What is your interpretation of the arterial blood gas results?
4. Discuss the ECG results, comparing the two ECGs.
5. What are the causes of atrial fibrillation?
6. How would you manage atrial fibrillation:
a) if blood pressure is stable?
b) if blood pressure is unstable?
7. How would you manage his respiratory distress?
8. What are the causes of renal dysfunction?
9. Discuss your perioperative management of the patient if he was on your list.
10. Would he benefit from preoptimisation?

You are presented with a 70-year-old man 4 days postoperatively after an abdominal aortic aneurysm repair. He has a complicated past medical history, which is as follows:

- Hypertension 1991
- Transient ischaemic attack (TIA) 1997
- Type 2 diabetes 1998
- Shortness of breath on exertion (SOBOE) 2000

He has presented to A+E with sudden onset shortness of breath. You, as the ITU registrar, are called down to assess him. His chest X-ray has shown pulmonary oedema, cardiomegaly and right lower lobe collapse with tracheal deviation. His ECG has shown atrial fibrillation (AF) with myocardial ischaemia.

QUESTIONS

1. Please talk in depth about the management of AF in intensive care.
2. Which drugs would you use to treat his AF?
3. What are the causes of AF?
4. How would you identify the causes in this situation?
5. How would you manage this case?

36y male with neurofibromatosis presents with convulsions he also had right sided homonymous hemianopia for last few weeks. He is a smoker and alcoholic. O/E consious, appropriate, no focal neurology other than the eye sight. PR 56/min BP 140/90mmHg.ECG- Right axis deviation, Up slurring of ST in V4&V5.CXR-RUL collapse consolidation and a well circumscribed mass in the midzone. FBC Unremarkable except MCV89 BioChem Unremarkable except high ALP. CT posterior cranial fossa tumour looks malignant. Neurosurgeons want to do a craniotomy

Questions

1.Summarise

2. Planned/ Emergency

3.Differential diagnosis Lung mets/ Nerofibromatosis

4.what is the % of Nerofibromatosis becoming malignant

5.What is R/homonymous hemianopia

6.Alcohol intake what is the recommendation

How much is a unit of alcohol

7.ECG description

8.CXR description

9.Why MCV high/ Causes of high MCV

10.Why ALP high in this Pt normal billirubin

11.What other investigation you need

12. Will you proceed with the case

13. Principal of neurosurgery

14.What is the position for this surgery

Middle aged Downs man for cataract, very anxious, has ASD, loud P2, XRC with prominent pulmonary veins, ECG with RAd and Rt sided strain, patient SOB.

1. summary

2.how would you proceed

3.how would cardiologist treat (diuretics)

4. how would you manage GA?

34 year old female presents for an elective thyroidectomy. 3 yrs ago she presented with palpitations, heat intolerance and anxiety. She was diagnosed as Graves disease and treated with radioiodine which was ineffective. She subsequently became pregnant and now has presented for surgery. She has a small goiter and a lid lag. She is on carbimazole, combined OCP. ECG – WPW syndrome . FBC – increased WCC and neutrophil. U+E – norma.l TFTs – raised T4 and low TSH. Thyroid scintigram – right lobe bigger than left. Some hypoechoic areas interspersed within normal areas. Post op inv – low Ca, low albumin

Summarise the case

What are the common indications for thyroidectomy? – hyperthyroid with failed medical management, goiter and malignancy

What are the features of Graves’s disease?

Why do they get eye signs? Will it get corrected after thyroidectomy?

Why do they get heat intolerance?

What is lid lag?

What do you think about blood results? What is the reason for raised WCC with neutrophilia? You have screened her for infection and the screen is negative. What else would you think of?

Tell about the ECG

Tell me about the thyroid function tests? What is TSH? Why is it raised? Where is secreted from? How is its secretion controlled?

What do you think about the thyroid scintigram? What do they use in this test? What are hot and cold spots? How do they appear in a normal person, in a person with hyperthyroidism and a person with malignancy?

What is radio iodine? How does it help in Graves disease? How is it different from lugol’s iodine? How does carbimazole work? What are you worried about in a patient on carbimazole?

What more information do you want about this patient before proceeding to surgery?

Why do you refer these patients to the ENT surgeon? Tell me about vocal cord palsies.

Would you anaesthetize this patient now? Are you sure you want to postpone this lady who has been admitted 48 hrs previously? She is already on 60 mg /day of carbimazole? How else could you control her thyrotoxicosis?

What physical factors would affect your anaesthetic management? (Obesity, hoarseness, dyspnoea on supine, dysphagia)

She had her surgery and is in recovery and she develops resp distress. What are the causes?

How will you manage a wound hematoma?

What is carpopedal spasm? Why does it occur post thyroidectomy?

A 68 year old gentleman presents for elective abdominal aortic aneurysm surgery. Hypertensive for the past 10 years. History of angina - past 2 years. On enalapril, frusemide isosorbide. Had chest pain 2 months ago. No evidence of myocardial infarction on investigation.

On examination

BP - 160/90 mmHg

Jugular venous pressure not raised

Rales on auscultation, both bases

Liver just palpable below the right costal margin

Investigations: Positive findings

White cell count = 12,000/ml

Creatinine - 170 micromol/L

Potassium - 3.2 mmol/L

ECG - T wave inversion v3 - v6, avF

X-Ray chest - mild cardiomegaly

QUESTIONS

Summarise the case.

Do you think his blood pressure is adequately controlled?

What is enalapril/how does it act/what are its side-effects?

What do you think his chest pain was due to (give a differential diagnosis)?

What are the implications if the chest pain had been due to myocardial infarction?

What do you think about his potassium level/why is it low/do you think it is acute/will you correct it before surgery/how will you correct it/what happens if you do not correct it?

Will you be happy to go ahead with the anaesthetic?

What further investigations will you do/why?

How will an echocardiogram help?

Do you think he is in heart failure/does he have a chest infection?

Differential diagnosis for hepatomegaly

What do you find in his ECG?

Did you determine the axis of the heart?

Is there any evidence of MI in the past?

What are the findings on the chest X-ray/how do you say the film is PA view/how did you determine that there is cardiomegaly/how do you measure CT ratio?

What will be your anaesthetic management

Why did you choose to do an epidural

Will you be concerned about something (heparin) that you will be giving intraoperatively?

What are the benefits (of the epidural)?

What will you give in your epidural?

What monitoring will you undertake and why?

59 year old man for transurethral resection of the prostate

Ex-smoker, 20 cigarettes/day

Had 'shadow on lung' 2 years ago

Treated with radiotherapy and drugs - no further information available

Now coughing up blood

Diabetic

Drugs - glibenclamide 5 mg daily

On examination:

1.75 m

72 kg

Pulse: 80/min
BP: 150/90 mmHg
Respiratory rate: 20/min

Chest:
- trachea deviated to right

- bronchial breathing and reduced breath sounds heard in the right upper chest

Abdomen:
- 10 cm bladder palapable

Investigations:

Hb	16.0 g/dl
WBC	7.1 x 10⁹/L
Platelets	271 x 10⁹/L
MCV	normal
Differential	normal
Na	135 mEq/L
K	3.5 mEq/L
Urea	14.6 mmol/L
Creatinine	237 umol/L
Glucose	11 mmol/L
CXR	No cardiomegaly Trachea deviated to right Right upper zone shadowing and loss of volume on right

Lung function tests:

	Predicted	Measured
FEV₁	3.06 L	1.62 L
FVC	4.18 L	3.18 L
FEV₁/FVC	69%	51%
PEFR	533 L/min	250 L/min

QUESTIONS

- Summarise the problems.

- Summarise the positive findings on examination.

- Does a BP of 150/90 mmHg bother you?

- Comment on the investigations.

- How would the raised urea and creatinine affect your management? (Give an example)

- What do you think of a blood glucose of 11 mmol/L?

- What does the CXR show and what is the differential diagnosis?

- Do the lung function tests show a restrictive picture?

- What else would you ask for regarding the lung function tests?

- Would you be happy to anaesthetise this patient now?

- What premedication would you prescribe and why?

- What is your management of his diabetes?

- What anaesthetic would you give and why?

- How would you perform spinal anaesthesia?

A 52 year old male presents electively for transurethral resection of the prostate. He has a history of non-insulin-dependent diabetes, and 2–3 months ago underwent chemotherapy and radiotherapy for 'a shadow on the lung'. He has been a life-long smoker, and recently had an episode of haemoptysis. He is currently taking glibenclamide 5 mg once daily.

On examination

– He is of average build
– Respiratory signs: respiratory rate: 18/min; trachea is deviated to the right; bronchial breathing can be heard in the right upper zone
– Cardiovascular signs: pulse: 80 bpm; blood pressure: 130/90 mmHg
– Gastrointestinal signs: palpable enlarged bladder

Investigations
- Haemoglobin 16 g/dl
- White blood cell count: 8 X 10⁶/ml
- Platelets: normal
- Urea 18: mmol/L
- Creatinine 180 µmol/L
- Na+ and K+: normal
- Liver function tests: normal
- Chest X-ray: right upper lobe collapse
- Pulmonary function tests: FEV1 1.9 L; FVC 3.75 L
- FEV/FVC ratio 0.53

1. Present the salient features of this case.
2. Describe the features of prostatic hypertrophy.
3. Describe the features of renal failure.
4. How might carcinoma of the prostate be diagnosed and treated?
5. Why might this patient have right upper lobe collapse?
6. Why might this patient have a raised haemoglobin level and what is the mechanism for this?
7. Describe the relevance of the lung function results.
8. How might this patient's chest condition be optimised prior to surgery?
9. How would you anaesthetise this man?
10. What are the options for controlling a diabetic patient's glucose perioperatively?
11. Describe the types of oral hypoglycaemic agents available.
12. How would you assess a diabetic patient preoperatively?

A 24 year old male, who is a known drug addict, has recently been admitted to medical ward. He was found unconscious at home with a history of ?heroin overdose. His conscious level improved with 200 mcg naloxone and he became agitated, with a Glasgow Coma Scale of 14. He is complaining of being unable to feel his legs and of generalised weakness. His blood pressure is 80/40 mmHg and his peripheries are cool. He has a past history of depression and alcohol abuse.

Investigations:

Arterial blood gases post-naloxone on air:	pO2	8.0 kPa
	pCO2	6.0 kPa
	pH	7.2
	HCO₃^-	20 mmol/L

Urea and electrolytes	Na	131 mEq/L
	K	7.8 mEq/L
	Ur	13.0 mmol/L
	Cr	331 umol/L
	CK	50,000 IU

ECG Rate 50 bpm sinus (abnormal intermittent p waves) Broad QRS peaked T waves

CXR CVP line in situ. Bilateral diffuse shadowing. R middle lobe collapse. No pneumothorax.

- Summarise the case.

- What may have made him unconscious other than heroin?

- What other drugs may he have taken?
- How would you determine this?

- What does the ECG show?

- Why can't he feel his legs and why is he weak?

- What may the cause of his raised K+ and his renal impairment?

- What is rhabdomyolsis and how does it cause renal failure?
- Why may he have it?

- How would you resuscitate him?

- How would you treat the K+ acutely and subsequently?

- What is the difference between haemofiltration and dialysis?
- How do they work, and which one would you use in this case, given the choice, and why?

A 64 year old man is undergoing right total hip replacement.
- He gives a history of asthma and chest pain.
- He is taking oxitropium bromide.

- He has been hospitalised 3 times for chest pain.
- The last hospitalisation was 6 months ago.
- He has a history of deep vein thrombosis after a previous operation and took Warfarin, which was stopped 3 months ago.
- He also has history of hiatus hernia, diagnosed after oesophagoscopy.

Examination

- He is moderately obese; his weight is 95 kg, his height is 1.65 cm.

- Apart from bilateral basal crepitations and diffuse wheezing, all over both lung fields are normal; first and second heart sounds normal, apex beat is not displaced.
- Blood pressure is 140/90 mmHg.

- Full blood count - NAD

- Lung function test - FEV1 - 65% of predicted value. FEV1/FVC - 50%. PEFR - 70% of predicted value.

- ECG - Bifacicular block. Inverted T waves in Leads 1, AVL, V1 to V4.

- CXR - shows minimal basal effusion. Lungs are not hyperinflated.

1. Summarise the case

2. Interpret the data

3. What further investigation would you carry out?

4. How would you anaesthetise this patient?

5. How would you prevent DVT?

His ECG showed widened QRS complexes and a normal axis but did not show the classical signs of right bundle branch block.

His chest X-ray showed flattened hemidiaphragms. He had a normal cardiothoracic ratio, and his lung function tests revealed an obstructive picture. The patient’s blood tests were all normal, with a haemoglobin level of 15 g/dl.

1. Summarise the main issues regarding this case.
2. What other investigations would you undertake?
3. Which cardiovascular investigations should be carried out?
4. What can you glean from the patient’s baseline arterial blood gases?
5. Would you refer this patient to a cardiologist?
6. What can you say about the patient’s blood pressure, and how would this affect your treatment?
7. What other information would you need from his lung function tests?
8. What would you be concerned about in the full blood count?
9. What is the mechanism of the development of polycythaemia in such patients?
10. How should this patient be optimised, for example in terms of preventing DVTs?
11. How would you treat the patient’s hiatus hernia?
12. Would you anaesthetise him by general or regional anaesthesia? Why?
13. Discuss the patient’s postoperative care.

A patient presents for a radical nephrectomy for malignancy. He has a history of chronic obstructive pulmonary disease, ischaemic heart disease, a pacemaker and requires haemodialysis.

Investigations
Full blood count, urea and electrolytes, chest X-ray, ECG, echocardiogram, pulmonary function tests

What is the transfer factor? (discussion re: the pulmonary function tests)
How would you assess this patient's volaemic status?
Would you consider an epidural? Discuss the pros vs cons
How would you optimise this patient preoperatively?

A 62 year old male with significant cardiovascular and respiratory disease presents for right total hip replacement. He has previously been admitted several times with chest pain, which has been relieved by glyceryl trinitrate (GTN), but he continues to smoke 30 cigarettes a day. He is also obese, and has a hiatus hernia, decreased exercise tolerance and a past history of deep vein thrombosis (DVT). On examination, his blood pressure is 140/85 mmHg, and he has bilateral inspiratory crackles. His ECG showed widened QRS complexes and a normal axis but did not show the classical signs of right bundle branch block. His chest X-ray showed flattened hemidiaphragms. He had a normal cardiothoracic ratio, and his lung function tests revealed an obstructive picture. The patient’s blood tests were all normal, with a haemoglobin level of 15 g/dl.

QUESTIONS

1. Summarise the main issues regarding this case.

2. What other investigations would you undertake?

3. Which cardiovascular investigations should be carried out?

4. What can you glean from the patient’s baseline arterial blood gases?

5. Would you refer this patient to a cardiologist?

6. What can you say about the patient’s blood pressure, and how would this affect your treatment?

7. What other information would you need from his lung function tests?

8. What would you be concerned about in the full blood count?

9. What is the mechanism of the development of polycythaemia in such patients?

10. How should this patient be optimised, for example in terms of preventing DVTs?

11. How would you treat the patient’s hiatus hernia?

12. Would you anaesthetise him, by general or regional anaesthesia? Why?

13. Discuss the patient’s postoperative care.

You are presented with a 7 year old male child with acute painful swelling in the left scrotum, vomiting and torsion of the testes. He has had a cough and been wheezing for 3 days. He had his last meal 4 hours ago. He has been asthmatic for the past 3 years and is currently taking salbutamol and beclomethasone inhalers.

On examination:

The child is found to be very anxious and in pain. He is mildly dehydrated, and weighs 19 kg.

Respiratory signs

– Respiratory rate: 28/min
– Left lower zone: air entry decreased
– Percussion note decreased
– Bilateral rhonchi
– Abdominal examination: scrotum – nothing abnormal detected

Cardiovascular signs

– Heart rate: >120 bpm
– Blood pressure: 110/60 mmHg
– Auscultation: nothing abnormal detected

The result of investigations are as follows:

– Haemoglobin: 10.6 g/dl
– White blood cell count: 14,600/ml
– Neutrophil count: 80 x 10⁶ ml (Normal range 2-7)
– lymphocyte count: 20 x 10⁶ ml (Normal range 1.5-4)
– Packed cell volume: 40%

Other investigations carried out:

– Chest X-Ray
– Urea and electrolytes
– Na+
– K+
– Creatinine

1. Summarise the patient and identify the problems associated with this case.
2 Give the differential diagnosis.
3. Discuss childhood asthma.
4. How do you assess severity of asthma?
5. Comment on investigations.
6. How would you manage this child?
7. How would you anaesthetise this child?

A 68-year-old man has an implanted pacemaker and a past history of angina-like chest pain. He also has chronic obstructive pulmonary disease but maintains that he can climb stairs and has a reasonably active life. He has been smoking 20 cigarettes a day for many years. He is scheduled for an elective right nephrectomy for renal cell carcinoma and has recently undergone haemodialysis. He is on perindopril 20 mg once daily, frusemide 500 mg once daily and aspirin 75 mg twice daily. On examination, he has pitting pedal oedema and is wheezing.

Biochemistry– Na+: 138 mEq/L
– K+: 3.5 mEq/L
– Cl–: 110 mEq/L
– Urea: 30 mmol/L
– Creatinine: 524 µmol/L
– Liver function tests: within normal limits (WNL)

Haematology

– Haemoglobin: 7.5 g/dl
– Haematocrit: 25%
– Platelet count: 227 X 10⁶
– White blood cell count: 5.5 X 10⁶

Pulmonary function tests
– FEV1: 1.8 L
– FEV1/FVC: 55%
– TLCO Within normal limits
– Flow–volume loop: an obstructive pattern loop was provided

Chest X-ray findings
– Implanted pacemaker
– Chronic venovenous haemofiltration (CVVH)
– Right subclavian lines
– Right internal jugular vein central line
– Cardiac/pulmonary fields within normal limits

ECG findings
– Completely paced rhythm 60/min
– Left axis deviation
– Wide QRS complexes >3 mm
– ST elevation with tall T waves in V2-V5

1. Summarise the case
2. What physiological system should be discussed here?
3. The surgeon wants to operate immediately for fear of metastasis if postponed – would you anaesthetise? If not, why not? When would you deem it appropriate to operate? What more information do you require?
4. Discuss the results of all of the investigations above
5. What would be your anaesthetic plan?

An 81-year-old woman presents to the Accident & Emergency Department following a fall, in which she sustained a supracondylar fracture of the right humerus. She is breathless, with a respiratory rate of 20 breaths per min, a blood pressure of 110/70 mmHg, and is in pain. She underwent local excision and radiotherapy for a mass in the right breast a few years previously. She is hypertensive and hypothyroid, and is currently on atenolol 50 mg and thyroxine 100 mcg. Investigations show the following results:

Weight: 50 kg
Height: 1.50 m
Chest X-ray: right pleural effusion
ECG: Sinus rhythm, with borderline left ventricular hypertrophy
Haemoglobin: 9.9 g/dl
White blood cells: 10.3 ? 106/ml
Na+ 131 (135–145) mEq/L
urea 7.5 mmol/l (3.5–6.5)
BM 7.5 random

Questions
1) Summarise the patient’s condition.
2) Why is she breathless?
3) Present her chest X-ray
4) Describe the ECG findings.
5) Would you drain the effusion?
6) How would you drain the effusion?, describe your technique.
7) Why is the patient anaemic?
8) What do the biochemical values tell you?
9) How would you proceed from here? Would you carry out any further investigations?
10) What are the risks associated with regional anaesthesia (interscalene)?
11) Would you give this patient a general anaesthetic?
12) What r the features of hypothyroidism?
13) How would you treat a thyroid coma?

A 60-year-old woman presents for multiple dental extractions. She underwent an open mitral valvotomy 40 years ago. She is currently on warfarin, digoxin and frumil. She also has a history of shortness of breath on exertion and is short of breath when lying flat. On examination, her observations are normal and her chest is clear. She has a normal body mass index. A diastolic murmur is detected. Her blood results, urea and electrolytes, and full blood count are all normal, and her international normalised ratio is 2.5. Her ECG shows atrial fibrillation (rate controlled). Her chest X-ray shows cardiomegaly, an enlarged left atrium and evidence of pulmonary oedema.

1. Discuss the patient’s blood results and investigations.
2. Discuss any evidence of mitral dysfunction.
3. Discuss the pathophysiology of mitral valve disease.
4. Discuss how you would assess cardiovascular status.
5. What further investigations would you perform?
6. Discuss antibody prophylaxis.
7. Discuss preoperative optimisation in this patient.
8. Discuss how you would correct this patient’s abnormal coagulation.
9. How would you assess the patient’s airway?
10. Discuss the conduct of anaesthesia.
11. Discuss how you would extubate the patient (bearing in mind her shortness of breath when lying flat, and implications for airway safety).

A 79-year-old female presents with lower abdominal pain, nausea and vomiting of 24 hours’ standing. She is admitted onto a ward and treated with analgesics and fluids, but the pain is still present. She underwent hemithyroidectomy 2 years ago and now, on examination, a large goitre is found with inspiratory stridor, although the patient is not in acute distress. The surgeon wants to take her to theatre to see if there is a large bowel obstruction.
Medication: thyroxine and aspirin

Observations/examination
Temperature: high
Pulse: 95 bpm
Blood pressure: 140/85 mmHg
Respiratory rate: 24 breaths/minute
Pulmonary artery: massive distension

Investigations
Haemoglobin: 15.2 g/dl
White blood cell count: 18.2 x 109/L
MCV: below normal
Amylase: <200>

1. Summarise the case.
2. What is the differential diagnosis for lower abdominal pain?
3. What fluids might this woman have received on the ward? What are the normal fluid requirements?
4. What are third space losses?
5. What is the composition of Hartmans solution and saline?
6. What are the disadvantages of using excessive saline?
7. Clinically, how can you judge that she is adequately resuscitated?
8. Would you carry out CO monitoring? Can you do this in an awake patient?
9. What blood investigations would you perform?
10. Is her haemoglobin elevated because of dehydration or is it pathological?
11. From the investigations, do you think she is adequately hydrated?
12. What can you tell from her ECG?
13. What can you tell from her chest X-ray?
14. What is the cause of mediastinal widening in this case?
15 What further investigations would you like to carry out?
16. What would be your general anaesthetic plan?
17. Would you use inhalational or intravenous induction?
18. What are the advantage and disadvantages for each?
19. For maintenance of anaesthesia, would you use total intravenous anaesthesia or inhalational anaesthesia?
20. What are the advantages and disadvantages for each?
21. What invasive and non-invasive monitoring would you perform?
22. What pain relief would you administer?
23. Would you give the patient an epidural?

A 74-year-old lady presents for an elective cataract surgery but refuses a local anaesthetic technique.

Past history
Myocardial infarction 6 years ago
Mastectomy >6 years ago
She was admitted last year with a mottled and painful white upper limb, which got better towards the evening, required admission.
She is now breathless on exertion.
Drugs
Frumil: Frusemide 40 mg/Amiloride
Digoxin: 125mcg
Warfarin: 8mg
Weight 51 kg

Blood results
Haemoglobin: 11.5 (lab range 13-15) g/dl)
Red blood cell count: lower side of normal
White cell count: normal
INR: 1.6 (Th. Range 2.0-4.0)
Na⁺: 142 mEq/L
K⁺: 5.5 (Range 3.5-5.0) mEq/L
Urea 10.0 mmol/L
Creatinine: 140 (range up to 120) µmol/L

Observations/examination
Pulse: 80/min, irregular
Blood pressure: 170/80 mmHg
Cardiovascular system: Pansystolic murmur at apex
Low-pitched diastolic murmur at apex
Apex beat slightly lateral to mid-axillary line
Respiratory system: Bilateral fine basal crepitations
Respiratory rate: 16/min
ECG: atrial fibrillation, severe left ventricular hypertrophy (LVH), heart rate <100>

A patient presents for dental clearance. He is on multiple drugs: a tricyclic antidepressant, lithium, an atypical antipsychotic agent and a calcium channel blocker for hypertension. He lives alone, has an unkempt appearance, and has dry mouth and tremor.

Observations/examination
ECG: essentially normal.
Chest X-ray: borderline cardiomegaly.
Full blood count: normal, degree of chronic renal failure.
Lithium level: upper limit of normal.

1. How appropriate is the patient for a day-case procedure?
2. Discuss the patient’s medications and their respective side-effects and interactions with anaesthesia.
3. What do his results suggest?
4. What further investigations are needed?

A 56-year-old coal miner requires sigmoid colectomy for carcinoma. He has a home nebuliser. His FEV1 is 0.68 litres, and he has 3% reversibility with salbutamol.

Observations/examination
Shortness of breath 50 yards.
Wheezy chest
Respiratory rate 30/min
Non-productive cough
Chest X-ray: bullous lung disease and prominent pulmonary arteries
ECG: normal
Saturations: 93% on air. PO2 12 kPa; PCO2 4.5 kPa
No FBC
No electrolytes

Drugs
He is currently taking 2.5 mg prednisolone (the dose was recently reduced)

Questions
1. Summarise the case.
2. What are the main issues?
3. How would you optimise this patient preoperatively?
4. What is the likely cause of his COPD?
5. Present the chest X-ray.
6. What are the chest X-ray findings in pulmonary hypertension?
7. Present the ECG.
8. What ECG findings might you find?
9. What are the ECG changes seen in heart strain (left and right)?
10. What are the criteria for pathological Q waves?
11. What is respiratory failure?
- Give blood gas definitions of type 1 and 2 respiratory failure
12. What are blue bloaters and pink puffers?
- Which is this patient?
13. How would you anaesthetise this man?

Short Cases

2007-12-02T12:56:00.001Z

Difficult to classify them in topics but useful as a list to print out:

Discuss the anaesthetic management of a 3-year-old child who has inhaled a peanut.

Describe the ECG pattern of a 2:1 block.
- What are the causes of 2:1 block?
- What problems are associated with this condition?
- Discuss the perioperative management and types of pacing.

A 19-year-old presenting for surgery is found to be positive for sickle cell disease. How would this affect your anaesthetic management?
- Discuss sickle cell disease

How does a pulse oximeter work?

Describe the anatomy of the femoral nerve.
- What are the indications for blockade?
- Describe the methods of blockade.

What are the causes and effects of hypercapnia postoperatively?

Compare and contrast sevoflurane and desflurane.

You are asked to interpret a chest X-ray showing tension pneumothorax.
- could the chest X-ray give any indication of the cause?

Discuss the differential diagnosis of subacute lower limb weakness.
- Discuss the diagnosis and management of Guillan barre in the intensive care unit.

A 20-year-old Down’s syndrome patient with a mental capability of a 5-year-old child is admitted with a white, pulseless lower limb. He also has patent ductus arteriosus with Eisenmenger’s syndrome. Discuss your detailed management.

74yo Ruptured aortic aneurysm while in the ward

What will you do now? How do you resuscitate circulation?

What will you do?

How much blood will you request. How much will you resuscitate? How do you proceed?

Where will you anaesthetise? Take me through the process?

What induction agent will you use? Difference between Ketamine and Etomidate? What monitoring will you use?

Do you need arterial line to start the case. How do you monitor clotting?

What is the principal of thrombo elastogram

When do you expect problems

How do you treat intra operative hypertension

26y Thoroscopic Sympathectomy for hyperhydrosis

What do you see in the CXR- Pneumothorax

What else do you see- Subcutaneous emphysema

How to detect pneumothorax on the table? What do you do immediately? How do you insert chest drain? Where do you insert? Do you apply suction?

25yo Mytonica Dystrophica

What are features? Mode of inheritance? Onset? What are the problems for anaesthetists?

What is the principal of anaesthetic management? What is pathology associated

Failed needle thoracocentesis for tension pneumothorax XRC

diagnosis, reasons for failure, what would you do next?

IVDU for operation

Prone position- all routine questions

SUX APNEA

A 8 year old boy who had an emergency appendicectomy is not breathing at the end of the procedure

What is ur differential diagnosis?

How would you proceed?

What would u use first – naloxone or nerve stimulator? Why?

What patterns of nerve stimulation will u use? Why?

What if there is no response to TOF?

What is the difference between TOF,DBS and tetanus?

The last dose of muscle relaxant was given 60 min ago and there is no response to TOF or DBS. What are the things you will consider?

What is sux apnea?

How will u manage it?

Are there any methods to hasten recovery? Would u use them?

Where will you recover the patient?

The patient is now fully recovered. How will u confirm ur diagnosis?

What is dibucaine no?

What atypical variants of sux gene do you know?

JEHOVAH’S WITNESS

What are the principles of management?

What will they accept and not accept?

What is ur target Hb preoperatively? How will u achieve it? Other than iron, erythropoeitin what else would you use?

What steps can u use to minimise blood loss?

What is ur post op management?

When would u consider hyperbaric oxygen therapy?

If you have a 13 year old boy, how will u proceed?

If the child is Gillick competent and refuses blood transfusion what will u do?

RHEUMATOID ARTHRITISC

spine X ray showing atlanto axial subluxation. ? compression of C3 and posterior fixation of C3-5

Tell me ur findings

This is the C spine X ray of a 66 female with rheumatoid arthritis who has intermittent stridor

How will u differentiate between asthma and stridor?

When is stridor predominant- inspiration or expiration? Why?

Are the C spine findings significant?

How would you secure the airway in this lady?

What are the problems of awake fibreooptic in this lady?

Would you consider gas induction?

Which gas would you use? Why?

1. Discuss infantile pyloric stenosis:
– What is the age distribution/sex distribution/population group most commonly affected?
– What is the pathology?
– What are the signs and symptoms?
– How would you assess a 10 week old child with pyloric stenosis?
– How would you assess the degree of dehydration?
– What are the biochemical abnormalities?
– At what stage would you be prepared to proceed with the anaesthetic?
– How would you anaesthetise the child?
– How would you ventilate the child intraoperatively (mode, rate etc)?
– How would you provide analgesia?
– what postoperative problems might you encounter?

2. You are presented with an intravenous drug abuser:
– What are the problems you might encounter?
– What precautions would you take?
– What would you do in the case of a needle stick injury?
– What measures would you take if blood spills onto the floor and the anaesthetic machine?
– How would you anaesthetise a patient who has injected himself in the femoral artery and is scheduled to have a debridement of his leg?
– What would be your choice of anaesthetic, and what problems might you encounter?
– How would you manage postoperative analgesia if the patient is a heroin addict?

3. A patient who is a known epileptic, taking phenytoin, presents for abscess drainage in his abdomen. You are shown his ECG (2:1 block).
– Is the ECG normal? If not, what is the problem? How is the action potential affected?
– How does phenytoin cause this problem? What does it do to the action potential?
– What investigations would you perform? (measure phenytoin levels/electrolytes)
– Would you anaesthetise the patient?
– What would you do if it were an emergency?
– What problems might you encounter, and what precautions would you take?

What is trigeminal neuralgia?
– What treatments can be given?
– Describe the anatomy of trigeminal ganglion block.
– What dose/volume of glycerol should be given?
– How would you perform a microvascular decompression?

A 23 year old female with severe asthma presents for elective nasal polypectomy. She is currently on inhaled and oral steroids and large doses of inhaled salbutamol. You are shown her ECG (shows atrial flutter with 3:1 block).

– Describe the features of the ECG.
– How is the axis calculated?
– Why might the patient be in atrial flutter?
– How do beta-2 agonists work (beyond the G protein level)?
– How would you treat her, and when would you anaesthetise her?

A 25 year old female presents for thymectomy for myasthenia gravis.

1. What is myasthenia gravis?
2. Tell me as much as you know about it
3. How is it diagnosed? (include EMG)
4. What is edrophonium?
5. How does it work?
6. What dose should be used?
7. What are the symptoms?
8. How would you anaesthetise her?

A 16 year old girl with Down syndrome presents for dental conservation as a day case.

1. Outline the problems you might encounter.
2. What are the specific problems associated with Down syndrome?
3. What premedication would you give and why?
4. What anaesthetic would you give and why?

A 13 year old child presents with Guillain Barré syndrome. He has a history of 10 days of malaise, fatigue and weakness.
– What are the treatment options? (discuss plasmaphoresis versus intravenous immunoglobulin)
– You are shown his chest X-ray; describe the features. (discuss pneumomediastinum)

A patient with end-stage renal failure presents for interval appendicectomy
– Discuss the management pre-, intra- and postoperatively

A patient presents with a C2 fracture/dislocation.
– Discuss the anaesthetic management for the repair of acute cervical fracture.

A patient with a 1-month history of anaphylaxis during general anaesthesia now presents for an evacuation of retained products of conception procedure (ERPC).
– Discuss the anaesthetic management of this patient.
– Discuss the investigations for anaphylaxis postoperatively.

A 23 year old woman with Down syndrome presents with a pale, painful right leg.

1. What is the likely diagnosis?
2. What is Eisenmenger's syndrome?
3. What are the problems with anaesthetising a Down syndrome patient?
4. What would the surgeon want to do?
5. What type of anaesthesia would you choose?

You are shown the chest X-ray of a 26 year old female who has undergone a thoracic sympathectomy by the transaxillary approach. This shows:
– An endotracheal tube in situ (flexometallic)
– Pneumomediastinum (air around the heart and great vessels)
– A globular cardiac silhouette

1. What is likely to be the diagnosis?
2. How would you manage the patient?

A patient presents with interpleural block.

1. What are the indications?
2. Describe the procedure you would perform, in terms of the site, position and type of needle, and the catheter used. What would be the relation of the needle to the rib, which space would you choose?
3. What would be your choice of anaesthetic?
4. What volume of anaesthetic would you administer? What rate of infusion would you choose?
5. What complications might you encounter?

Your Examiner describes a patient in the accident and emergency department with features of a tension pneumothorax.

1. How would you treat the patient?
2. Draw the arrangement of a chest drain bottle.
3. How far does the tube go in the water and why is this?
4. Why is the bottle so large?
5. How long should the tubing be?
6. Why should the drain not be lifted above the patient?
7. Draw the arrangement of bottles used to drain a haemothorax and suction.
8. What would you do if the drain stops swinging/bubbling?

A 21 year old primiparous Afro-Caribbean woman presents with an unbooked pregnancy of 31 weeks’ gestation. She is admitted onto the labour ward with foetal distress and her blood test results are:
– Sickledex positive
– Haemoglobin: 9.2 g/dL
– Mean cell volume: 60 fL

1. What problems might you encounter?
2. What is fL the abbreviation for?
3. How would you interpret the blood test results?
4. What are the important things to consider in sickle cell disease?
5. How would you anaesthetise the patient for an immediate emergency Caesarean section?

Eight hours later you are called to see the patient on the ward. She is complaining of pleuritic chest pain and has a raised respiratory rate and a tachycardia. Her oxygen saturation (SpO2) is 89% and her haemoglobin is now 6.5 g/dL ,with a reticulocyte count of 16%.

What do these signs and symptoms suggest to you, and how would you manage the patient?

You are asked to anaesthetise a fit 3 year old boy for a circumcision as a day case.
1. Is this an appropriate patient for day case surgery?
2. Would you anaesthetise a 1 year old child as a day case?
3. What is your lower cut-off age for day case surgery?
4. What premedication would you give?
5. What anaesthetic would you give and why?
6. How would you administer analgesia?
7. How exactly would you perform the local block that you have chosen?
8. How would you anaesthetise this 3 year old child for a circumcision?
9. Under what circumstances would you consider deferring the operation?
10. What kinds of regional blocks might you consider?
11. How would you perform a penile block/caudal?
12. What would be your choice of local anaesthetic and how much would you use?
13. What postoperative analgesia would you prescribe, and at what dose?

A young man presents to the accident and emergency department with an acute onset of dyspnoea. 1. What course of action would you take?
2. What are the likely causes of this presentation?
3. How would you differentiate between a flail chest and a pneumothorax?
4. Describe how a chest drain is inserted.
5. How far beneath the water must the tube be placed?
6. What is the significance of the depth of the under-water seal?

What are the indications for a lumbar sympathectomy?
How would you perform this procedure?
What are the contraindications to a lumbar sympathectomy?
What substances would you inject and at what doses?
What strength of alcohol might you use?

What do you understand by the term 'total intravenous anaesthesia'?
What sort of patients would be suitable for such a technique, and for what sort of procedures?
Which agents would you use?
What is the half-life of propofol?
What are its advantages and disadvantages?

What are the different reasons for being called to recovery?
What are the causes of low blood pressure in recovery
How would you approach the problem?

Discuss the management of acute severe asthma

Discuss the causes and prevention of secondary brain insult

You are presented with an 80-year-old woman with diabetes mellitus and a touch of indigestion on climbing stairs.
Describe her preoperative assessment and perioperative management for cataract surgery.

Describe the control of blood pressure, both in the immediate and long term.

Discuss the management of a 45-year-old female presenting with a perforated appendix and a blood glucose level of 23 mmol/L. She has been unwell for a week, and the surgeons want to take her to theatre as quickly as possible.

How would you manage an unanticipated difficult airway? Compare your management to the situation where a difficulty is expected.

How would you manage an elderly patient presenting for a quick excision biopsy of a lump in his throat? You notice that he is quite hoarse when you see him.

How would you manage a primiparous woman, presenting for a Caesarean section, who is short of breath at rest? You notice that her booking blood pressure was at least 20 mmHg lower than its present value.

What neurosurgical complications do you know of? Select one complication and describe how you would manage it.

A 10-week-old female infant weighing 3.5 kg is scheduled for inguinal hernia repair. She was delivered prematurely at 34 weeks. List the risk factors and state how these can be minimised.

Discuss the perioperative management of a young patient undergoing removal of a phaeochromocytoma.

How would you manage a patient with 45% burns and smoke inhalation postoperatively on the intensive care unit?

A 50-year-old male presents for an open cholecystectomy. He is a known epileptic.
- What are the anaesthetic problems?
- Describe the classifications of epilepsy.
- What drugs are used in the management of the various forms of epilepsy?
- What are the side-effects associated with these drugs?
- What are the implications of anaesthetic drugs for this patient?
- How would you anaesthetise an epileptic patient?

You are shown an ECG; read this systematically.
The diagnosis in this case is of inferior lateral myocardial infarction
(MI) (how would you calculate the axis?). The patient in question is a 55-year-old male who had an MI 4 years ago. He did not have any chest pain at that time.
- What drugs is the patient likely to be on?
- How would you assess this patient?
- What are the symptoms of congestive cardiac failure?
- Differentiate between right heart / left heart symptoms
- Discuss beta blockade.

A 50-year-old woman presents 4 weeks after receiving an epidural steroid injection for chronic back pain. She is now experiencing severe back pain and perineal numbness.
- How would you proceed?
- What are the likely causes of her discomfort?
- What are the markers of infection?
- What further investigations would you carry out?

A female patient has had an anaphylactic reaction. You have dealt with the initial crisis.
- What further action would you take?
- Who should perform the skin prick testing?
- If the same patient were to present for appendicectomy before these test have been carried out, how would you manage this?
- What is the evidence for premedicating with an antihistamine in these circumstances?
- Which induction agent is least likely to cause anaphylaxis?
- How would you recognise anaphylaxis if the patient is anaesthetised?
- If this patient were to present for a leg operation (e.g. for debridement) rather than an appendicectomy, how would you anaesthetise her?

A 36-year-old female with a history of ulcerative colitis presents with toxic megacolon.
- What are the problems you might encounter?
- What investigations would you request?
- What drugs are such patients commonly taking?
- What problems might be caused by these drugs?
- How would you anaesthetise this patient?
- What drugs would you avoid in this type of patient?
- What are the pros and cons of epidural analgesia in such a patient?

A patient presents for a day case laparoscopy.
- How would you provide antiemesis?
- Why is this important?
- Discuss your anaesthetic technique.
- Which volatile anaesthetic is most likely to cause emesis?
- How would you guarantee that emesis is avoided?
- List some antiemetic agents. Where do they act?

You see a 24-year-old woman with antenatal haemorrhage while in labour.
Discuss the causes and management.

You are presented with a case of acromegaly. Discuss the problems of airway management, postoperative care and other associated issues.

You see a patient who has undergone a laparoscopic cholecystectomy. Discuss the issues regarding the use of pneumoperitoneum.

Discuss the causes and physiology of pneumothorax.

Discuss the mechanisms of action of the different classes of anti-hypertensive agents. What are their respective side-effects?

Describe the metabolic pathway of bilirubin and how this can lead to jaundice.
What investigations would you carry out?
Discuss the pathophysiology of pre- and post-hepatic causes of jaundice.

Discuss laminar/turbulent flow and its clinical relevance to anaesthesia.

You are anaesthetising a child for circumcision.
- Discuss how you would carry out a penile block, including details of the method, doses used and nerve roots to be blocked.
- Discuss how you would carry out a caudal block, including the method, doses used , postoperative analgesia and route of administration of analgesia.

How would you assess the severity of a burn?
- Discuss timing of intubation.
- Discuss the method of intubation you would use.

You are to perform a laparoscopic cholycystectomy on a man with right bundle branch block on ECG.
-Interpret the patient’s ECG.
-What is the significance of this condition to his current surgery?
- Discuss the cardiovascular changes that occur with a pneumoperitoneum.

Discuss the following aspects of lasers:
- Their mechanisms of action
- The various types
- Safety issues
- Precautions

Discuss the anatomy of the sciatic nerve, including: Nerve roots, course, branches
- Discuss the following blocks, including use of the nerve stimulator:
- Femoral nerve block
- Three-in-one block
- Obturator nerve block

Discuss the following:
- Drug tolerance
- Drug dependence
- Opiate dependence (including how to deal with intravenous drug addicts)
- Opiate withdrawal

Concerning the pulmonary artery catheter:
- Draw a trace
- Discuss the uses
- Discuss measurements and causes of inaccuracies
- Cardiac output measurement

While administering an epidural for analgesia in a woman in labour with a 16-gauge Tuohy needle, a dural tap occurs.
- What are the reasons for a patient developing a headache after a dural tap?
- What percentage of patients will develop a postdural puncture headache (PDPH)?
- What are the risk factors which predispose to PDPH?
- What would be your further management?
- Would you administer another epidural or insert a spinal catheter?
- What are the advantages and disadvantages of these two techniques?
- Are there any other problems associated with the spinal catheter?
- How would you diagnose Cauda equina syndrome?
- What are the characteristics of PDPH?
- How is it treated?
- Can you use caffeine therapy in a woman who is breast-feeding?
- Would you use an epidural blood patch?
- At what stage would you administer this?
- How is this administered?
- Will you repeat it?
- How would you advise the woman about her future pregnancy?
- Is a future epidural likely to be as good/bad as this one?

How would you anticipate a difficult intubation?
- Describe the Mallampati classification.
- ? Sensitivity and specificity of MPC and others like Patils, Callders, Wilsons
- What equipment would you keep ready in the operating theatre?
- What types of blades would you have ready?
- How would you manage a patient who can be ventilated but cannot be intubated?

A patient in the recovery room, who has undergone a hysterectomy, is confused.
- What is your differential diagnosis and management?
- What are the usual causes for this (including drugs)?
- The patient is hypotensive and tachycardic; how would you manage this?
- Her ECG shows supraventricular tachycardia. How will you manage this?

For the treatment of a fractured wrist, discuss the use of Biers block, brachial plexus block, haematoma block and general anaesthesia with rapid sequence induction.

A patient presents for flexible laryngoscopy; discuss preoperative assessment, microlaryngeal tubes, laser tubes, rigid scopes and maintenance of anaesthesia.

Discuss the anaesthetic management of a 3-year-old child who has inhaled a peanut.

Describe the ECG pattern of a 2:1 block.
- What are the causes of 2:1 block?
- What problems are associated with this condition?
- Discuss the perioperative management and types of pacing.

A 19-year-old presenting for surgery is found to be positive for sickle cell disease. How would this affect your anaesthetic management?
- Discuss sickle cell disease

How does a pulse oximeter work?

Describe the anatomy of the femoral nerve.
- What are the indications for blockade?
- Describe the methods of blockade.

What are the causes and effects of hypercapnia postoperatively?

Compare and contrast sevoflurane and desflurane.

An 8 year old girl fails to breathe after appendicectomy.
- What are the possible causes?
- How could you tell if this was due to muscle relaxants?
- What might you see with a nerve stimulator?
- What is a phase 1 block?
- What is a phase 2 block?
- What type of drug is dibucaine?
- What are normal and abnormal dibucaine numbers?
- Discuss the genetics of suxamethonium apnoea.
- For how long would this patient be apnoeic?
- How would you treat the patient?

You are shown an X-ray of a fractured mandible.
- Present the X-ray.
- Surgeons tell you to take the patient to the operating theatre within the hour. What will you do?
- What would make this case an emergency?
- How would you anaesthetise the patient?
- What are the Difficult Airway Society guidelines with respect to gas induction?
- How would you go about this procedure?
- What might be your major concerns?
- What antiemetics would you use?

A 23-year-old primigravida requires emergency lower segmental caesarean section (LSCS).
- It is a grade 1 category section, what would you do?
- What are the different grades of LSCS?
- Discuss the advantages and disadvantages of general anaesthesia versus spinal anaesthesia.
- Discuss the preoperative assessment en route to theatre with the patient in the left lateral position and receiving oxygen
- Discuss appropriate premedication
- Discuss the techniques for rapid sequence induction of anaesthesia.
- Discuss spinal anaesthesia and the doses that are used.
- Why is thiopentone used for rapid sequence induction?
- Which volatile anesthetics do you use and why?
- What is you opinion of the use of desflurane?

What are the safety features of the modern anaesthetic work station?
- Describe what you know about vaporisers.
- Discuss the use of plenum and draw-over vaporisers. Have you ever used a draw-over vaporiser?
- Discuss the Interlink 25, hypoxic guards, and Richie whistles.

Draw a cross-section of the spine at C6.

How do antiemetics work?
- What receptor types are found at each area?
- Where are the CRTZ, and the VC?
- What antiemetics do you use?
- Describe the mechanism of action of dexamethasone.

What is the stress response?

Basic Sciences Viva

2007-12-02T12:46:00.001Z

Here are some Basic sciences questions from AnaesthesiaUK but arranged in one document.

Define osmosis.

Explain the difference between osmolality and osmolarity.
- What is the importance clinically?

What are Starling’s forces?
- Give the equations and draw a diagram to illustrate.

Describe the anatomy of the pleura, including:
- The innervation.
- The blood supply
- Clinical application: how would you carry out an intrapleural block?

Regarding catecholamines:
- Describe the biochemical pathways and sites of formation.
- Describe the actions of noradrenaline, adrenaline and dopamine.
- Describe the signs, symptoms, and management of phaeochromocytoma.

Describe the physiology of aortic cross-clamping.
- What are side-effects?
- Describe the attenuation techniques.
- Describe spinal, cardiac and renal protection techniques and evidence for their efficacy.

Define Laminar flow/ Turbulant flow

Hagen Poiseulle’s formulae

Factors affecting turbulent flow & how. What is the relevance to anaesthetist? Reynolds number

Variable orifice flow meter. Principle and relevance

Diathermy

physiology/pharmac- ICT/ how different anaesthetic agents affect ICT?

Organ donation issues, neonates?

What are the ways of monitoring the inhalation agents?

Do you know what methods are used in your hospital to monitor inhalation agents?

What is infrared? Tell me how the infrared method works?

How can you be sure that your monitor is accurate?

How will you calibrate this equipment?

Tell me about the piezo electric method

How will you make the crystal vibrate?

Is the frequency important?

Tell me about mass spectrometry

How do you identify the gases as they exit the mass spectrometer?

Flow-volume loop
Draw a normal flow-volume loop.
Draw this in the case of an obstructive lung disorder.
Draw this in the case of a restrictive lung disorder.
Draw this in the case of an upper airway obstruction (e.g. laryngeal).
How is flow measured?

Hospital gas supplies
Draw and describe an oxygen tank.
Describe the liquid, pressure and temperature
Evaporating grid?
In the cylinder: what should be the pressure? What volume of oxygen should it contain and what state should it be in?
What type of valve is found on the cylinder?
From what material is the cylinder made?

Describe the properties of a nitrous oxide tank, in terms of: the manifold, pressure and state?
In the cylinder: what should be the values for pressure, volume and filling ratio?
From what material is the cylinder made?
What is the air source?
What is the air pressure?
What is the difference between an air supply used for anaesthesia and one used for other purposes?

Anaesthesia and the kidneys
Draw a normal nephron; show what gets absorbed and where.
What is the effect of anaesthesia on renal function?
What drugs or gases used by anaesthetists might precipitate acute renal failure?

Larynx
Draw a diagram of the larynx.
Describe the sensory and motor nerve supply.
Describe the actions of the laryngeal muscles.
Describe nerve block for the larynx.
Describe the post-surgical and non-surgical causes of stridor.

Discuss the cytochrome p450 superfamily of enzymes; how do they affect anaesthetic drugs and what are the effects of genetic differences between individuals?

Discuss the strategies for avoiding the necessity of a blood transfusion in a patient.

Describe the anatomy of the caudal space, and discuss caudal block.

Discuss hyperbaric oxygen therapy.

One-lung ventilation (OLV):

What are the indications for OLV?
What are the physiological mechanisms/causes of hypoxaemia with intrathoracic surgery?
How should hypoxaemia on OLV be treated?
How would you apply continuous positive airway pressure (CPAP) to the non-dependent lung?
How could the surgeon assist in applying CPAP?

Answer the following questions on electricity:

What is Ohm’s law?
– What is the difference between direct (DC) and alternating current (AC)?
– Draw a diagram demonstrating the differences between AC and DC.
– Does Ohm’s law apply to AC or DC?
– Is the mains supply AC or DC?
– What is mains current frequency?
– Is the mains current frequency safe?
– If the answer to the previous question is “no”, why is it used?
– Discuss the problem of leakage current. By what mechanisms might a patient suffer?

Discuss the safety features of the anaesthetic machine.

Compare sevoflurane and isoflurane.

Describe the sympathetic supply of the eye.

Discuss the management of carbon monoxide poisoning.

What is meant by laminar/turbulent flow?

What is the Hagen-Poiseuille equation?
What is Reynolds number?
Describe the use of the above concepts in medicine.

Define the following terms:

Log dose–response curve
Agonist
Antagonist
Therapeutic index
Partial agonist

List the various types of antagonists.

Compare morphine and buprenorphine.

Describe the structure and function of the acetylcholine receptor.

Describe the oxygen dissociation curve in different types of hypoxia.

Intercostal nerves

List the branches.

Where are they located? (i.e. between which intercostal muscles?)

Where do they arise from?

Why are the 1st, 2nd and 12th intercostal nerves different?

Which nerve supplies the skin over the back?

Describe the nerve supply to the diaphragm.

How is an intercostal nerve block performed (site, volume etc.)?

Describe the location and arrangement of the neurovascular nerve bundle.

When an intercostal nerve block is performed, where and how does the local anaesthetic spread?

What are the complications of an intercostal nerve block?

Adrenaline:

What receptors does it act on?

Where is it secreted from?

How is it metabolised?

How is it synthesised?

Why is it used in local anaesthesia?

What are the systemic effects of adrenaline?

Discuss the physics of ultrasound.
- How is it generated?
- What is the frequency used?
- Are the waves sent continuously?
- What is the Doppler effect?
- What does it measure?
- Describe the uses of ultrasound.
- Describe the various types of echocardiography
- What are their uses?
- How would you measure cardiac output using echocardiography?
- What are the other uses of ultrasound?

Describe the factors that influence intraocular pressure (IOP).
- What is rate of production of aqueous humour?
- Where is it produced?
- Describe the drainage of the aqueous humour, and the use of mydriatics and miotics.
- What are the effects of drugs on IOP?
- What are the effects of suxamethonium on IOP?
- What is sulphur hexafluoride (SF6), and what are its implications for the anaesthetist?

Draw a sketch illustrating the elimination of thiopentone.
- How many compartments is it distributed into?
- What is its alpha half-life, beta half-life, elimination half-life?
- What are its apparent volume of distribution and clearance values?
- To what extent is it protein bound?
- How is it metabolised?
- What is the half-life of pentobarbitone?
- Describe the pharmacodynamics of thiopentone.
- What is its mechanism of action?
- Following thiopentone administration, which decreases first: cerebral metabolic rate or cerebral blood flow?
- What are the implications of using thiopentone in patients with hypovolaemia?
- What are the effects of thiopentone on the respiratory system?
- What are the effects of thiopentone on the renal system?
- How does thiopentone lead to porphyria?
- What is the pH of thiopentone and why is it stored with nitrogen?
- Why does it smell of garlic?

How would you assess the nutrition of patients in the intensive care unit?
- What is the average calorific requirement of a 70 kg adult?
- How would you provide this?
- Which type of foodstuff is best to administer, and why?
- How much carbohydrate and protein should be given?
- What is immunonutrition?
- What else would you give such patients?
- What trace elements would you provide?

Discuss the physical principles underlying haemofiltration and haemodialysis.
- What are the qualities of an ideal membrane?
- What factors affect the amount of fluid you can remove from a patient?
- What else, besides metabolic toxin removal, can haemofiltration be used for?
- What are the complications of haemodialysis?

Describe the innervation of the inguinal area.
- How would you perform a block?

What are the physical properties of nitrous oxide?
- How is it made?
- What is the second gas effect?
- What are the advantages and disadvantages of using nitrous oxide?

Discuss the physiology of muscle contraction (including the interaction of actin and myosin).
- Discuss the incidence, genetics, features, and reasons for muscle features of myotonia.

Describe the physical principles behind magnetic resonance imaging (MRI).
- What are the advantages and disadvantages of MRI compared with computed tomography?
- Which patients are not suitable for MRI and why?
- Where is the MRI scanner usually located in the hospital and why?
- What problems are associated with MRI?

Define drug tolerance.
- Describe the different ways in which tolerance can occur and give examples.

Draw a diagram of the epidural space.
- What is found in this space?

Describe the pathophysiology of diabetic ketoacidosis (DKA).
- What is the anion gap?
- When would you take a patient to theatre with DKA?

Why do you require a scavenging system?
- Can you name any other methods of preventing pollution?
- What are the normal acceptable levels of various anaesthetic gases the theatre environment?
- Is it an international system?
- Name the normal parts of the active and passive scavenging system?
- What are the advantages and disadvantages of each?
- What is the Cardiff inhaler?
- What are its advantages and disadvantages?
- Describe the toxicity associated with nitrous oxide (NO)?
- Give details of how NO causes megaloblastic anaemia and subacute combined degeneration of the spinal cord?

Describe the anatomy of the cervical plexus.
- Describe the technique for performing cervical plexus block for carotid endarterectomy(both superficial and deep).
- What are the complications of performing this block?
- Describe local anaesthetic toxicity.
- What are the maximum doses that can be used for local anaesthetics?
- What level of bupivacaine causes convulsions?
- What are the advantages and disadvantages of performing carotid endarterectomy with the patient asleep and under local anaesthetic?

What are the effects of the following anaesthetic drugs on cerebral blood flow (CBF)?
- Premedication with benzodiazepines.
- Opiates.
- Induction agents.
- Volatile agents.
- Muscle relaxants.
- What other factors affect CBF?
- Draw a graph of mean arterial pressure/O2/CO2 and CBF.
- Describe ways of reducing intracerebral pressure intraoperatively and postoperatively.
- Describe the mechanism of action of drugs such as mannitol and acetazolamide.

Describe the mechanism of blood clot formation when a blood vessel is injured.
- What other protective mechanisms are triggered?
- What mediators are released?
- What is Virchows triad?
- Draw a flow chart showing the sequence of events from platelet activation through to clot formation.
- What mediators are released by the platelets?
- Show on this chart where heparin works.
- Which patients will be at high risk for deep vein thrombosis (DVT)?
- How can DVT be prevented, pharmacologically and non-pharmacologically?
- How effective are calf compressors (give a percentage)?
- What is the mechanism of action of heparin, low-molecular weight heparin (LMWH), warfarin and protamine?
- What is the difference between heparin and LMWH?

Discuss the physics of MRI.

Discuss the anatomy of the ulnar nerve.

Discuss the oxygen dissociation curve for normal haemoglobin.
- How does this change in the case of sickle cell haemoglobin?
- Discuss the diagnosis of sickle cell disease.

Discuss the classification of opioid receptors, and their endogenous ligands.

Recharged & Ready To Go

2007-12-02T12:37:00.000Z

It really is true - revising anatomy has been a pleasure this last week.........by the pool, with no clouds in the sky, in the 27 degree heat, watching the Red Sea glimmer. OK, enough of all that. I decided to take some basic science stuff with me to revise whilst I was on holiday in Sharm el Sheikh. The first couple of days didn't go very well, what with snorkelling, lunch and listening to music and playing tennis, but after that I managed to do some excellent reading! I took Simon Bricker's "The Anaesthesia Science Viva Book" and managed to get through his anatomy and physiology chapters which were all concise and highly readable. The only thing I'm going to add is a set of diagrams made from my primary revision to the relevant pages. I find anatomy easier to learn from diagrams than paragraphs, and this does extend to some physiology principles.
Having finished cardiothoracic anaesthesia (the first time round - so many more to go!), I'm due to start paeds revision this week in the grand scheme, but am rostered to be on Chronic Pain at work, so may have a crack at that instead.

Stalling

2007-11-19T09:24:00.000Z

After making some an encouraging start, I'm stuttering again. I had a particularly heavy set of obstetric nights and wasn't able to work on any of those shifts. Then we went to Devon for the weekend where there were little people, long walks and the occaisional beer (a bad combination for work!). Next week, I'm off to Egypt to relax for the week, but have made a decision to relearn some basic science stuff from the Primary whilst there. So, all the old favourites such as West, Peck & Hill, and Parbrook will be out with me by the pool. If you're going to do something painful in December, at least do it in 30 degrees!

Out Of The Blocks

2007-11-09T13:11:00.000Z

OK, I've finally started working! I revised some cardiac anaesthesia for an hour and a half on Tuesday night, felt very pleased with myself, woke up the next morning and couldn't remember a damn thing. A long way to go....

2007-10-24T18:39:00.000+01:00

Unfortunately, over the last couple of weeks, house-hunting has taken preference. As well as viewing various properties, our house has had to remain in show-home like state i.e. much cleaning and tidying. So not a lot of exam preparation has occurred. My optimistic aim is to start working next week - although I'm still struggling a bit to motivate myself - especially for the evenings. I've managed to get hold of a copy of Core Topics in Pain and have also downloaded the Final syllabus and printed it out. I found it extremely useful during the Primary to have lots of practice questions grouped together by topic, so that when I came around to revising a specific subject, I could practice the relevant questions to supplement my knowledge. I've decided to do the same with the Final. Past Exam papers can be downloaded from the RCOA website here, and I copied and pasted all the questions from the exam section of AnaesthesiaUK here and here, and then organised them by topic. It was an exceptionally tedious process but I know it will help me in the long run. I have decided upon a plan of action - I've nearly completed my Cardiac & Paediatric Rotation, so will start revising both of those as they are relatively fresh. Then I'm going to move onto Obstetrics, as I seem to be on a permanent Maternity run at present! I also think I'm going to do practice MCQs and SAQs as I go. T minus 4 days to go!!

Bulletins & Articles

2007-10-05T11:40:00.000+01:00

Whilst wrestling with mortgage lenders on the phone and listening to the inevitable "your call is important to us", I started downloading various articles and bulletins which have been extremely useful in preparing for the Final in the past. Excellent material is found both in the Bulletins of the RCOA (back-issues can be downloaded from here), and also from the Continuing Education in Anaesthesia, Critical Care & Pain journals. To download back-issues of these, go to the archive; you will need to register if you haven't done so already using the subscription number that came with your BJA subscription when you first joined the RCOA. Go to My Account in the top left-hand corner of the archive page and fill in your details. Then, go back to the archive page and download the issues you require. I downloaded all the articles in pdf form from 2001-2005 that I didn't have and sorted them into subject. The plan will be to print them all out and make a folder which I can take to work and read during (really long lists) tea breaks!

Books Books Books

2007-09-27T20:06:00.000+01:00

My Amazon delivery arrived in a big box today, followed by the book I bought on eBay. A week ago I ordered 'The Royal College of Anaesthetists Guide to the FRCA examination The Final'. As with the Primary, apparantly a number of questions from this publication appear in the exam, therefore a must-have. It arrived yesterday. I piled them all up neatly in the study (actually the second bedroom - to be negotiated!) and then watched TV with some wine! No point in opening them just yet. As quite a few of my fellow Registars at the enormous teaching hospital are also taking the exam, I thought I would be sneaky and have booked some study leave for April next year (and very tentatively June as well!).

Keen as mustard

2007-09-23T14:16:00.000+01:00

Either I'm naiive or I can't quite remember the complete torture that I went through for the Primary just under a year ago. I feel quite optimistic and keen to get started with the revision at the moment. I think it is because now as a registrar I am more confident in my skills to give an anaesthetic, but still realise how little theory I know/have forgotten!

As far as I'm concerned, the most obvious way to start is to buy lots of books. Worked for me last time. I checked out the recommended list here on AnaesthesiaUK and then took a trip into Central London to Waterstones on Gower St to browse through the selection. I find it easier to look at the books in hard copy before deciding whether to buy them.

I have already acquired:

"The Anaesthesia Science Viva Book" Simon Bricker
"Short Answer Questions in Anaesthesia" Geoffrey Rushman

I got a copy of "Anaesthesia & Critical Care" Chris Dodds & Neil Soni from eBay for a tenner.

Then I placed the following order with Amazon:

"Companion to Clinical Anaesthesia Exams (FRCA Study Guides)"Charlie Corke
"The Clinical Anaesthesia Viva Book"Simon J. Mills
"Short Answer Questions and MCQs in Anaesthesia and Intensive Care"Peter Murphy
"FRCA: MCQs for the Final FRCA: Saunders Self Assessment Series: MCQs for the Final FRCA (FRCA Study Guides)"Karen Henderson
"Practice MCQ's for the Final FRCA (FRCA Study Guides)"Jon Hardman
"Short Answer Questions in Anaesthesia"Simon Bricker;
"Final F.R.C.A.: Short Answer Questions"J. Nickells
"Clinical Notes for the FRCA (FRCA Study Guides)"Charles Deakin
"Final FRCA: Multiple Choice Questions (FRCA Study Guides)"Michael D. Brunner
"QBase Anaesthesia: MCOs for the Final FRCA v. 5"Edward Hammond
"MCQs for the Final FRCA"Khaled Elfituri
"MCQ's in Anaesthesia (FRCA Study Guides)"A. Ganado
"QBase Anaesthesia: MCQs for the Anaesthesia Final FRCA v. 2 (QBase)"Mark Blunt

A bargain at £320!

In the beginning.....

2007-09-23T13:57:00.000+01:00

Not content with potentially moving house at the end of this year, I have decided to take the Final FRCA examination in April/June next year. One of the main reasons for this is the excellent teaching I have thus far received since starting as a registrar at the enormous teaching hospital! I am also trying to stick to my mantra that no matter what, I would not still be taking exams when I turned 30! Having written a guide to passing the Primary FRCA (found here), it was suggested by the good team at AnaesthesiaUK that I might like to produce a similar guide to the Final. I thought that rather than write it retrospectively as I had done previously, I would give a blow-by-blow account of the whole event. After all, I thought, there's plenty of time - the exam's not until April.

Then I remembered my Primary preparation.....and talked to a few people.......and glimpsed at the syllabus. We're looking at a good five to six months revision again. OK, I can start revising in November; that's still five weeks away. But I need the mental preparation time, the timetable-making, the textbook-buying, the study-leave booking, the girlfriend-preparing for the mental torture and anguish that lies ahead. All of a sudden, there was a lot to do!