Wednesday, May 28, 2008


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.

-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

Saturday, May 24, 2008

The Home Straight

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:

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

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 ( 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.


Friday, May 2, 2008


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:

-Investigations (Observations, Bloods, ABGs, ECG, CXR, Other X-rays, Echo, PFTs etc)

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


-Disposal (Recovery, HDU/ITU, ward)
-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

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