Anesthesia Key

B. Define the following terms with respect to nerve injury (3 marks)

Nerve injury	Definition
Neuropraxia (1 mark)	——————-
Axonotmesis (1 mark)	——————-
Neurotmesis (1 mark)	——————-

C. Describe the clinical features of the following nerve palsies (12 marks)

Nerve affected	Common mechanism of injury (4 marks)	Sensory and motor deficits (8 marks)
Lateral cutaneous nerve of thigh	1.	1.————————– 2.————————–
Obturator nerve	1.	1.————————– 2.————————–
Common peroneal nerve	1.	1.————————– 2.————————–
Femoral nerve	1.	1.————————– 2.————————–

D. List the 3 features suggestive of epidural abscess (1 mark)

E. What are the priorities in management of a suspected epidural abscess? (2 marks)

A. Define delirium (1 mark)

Total 20 marks

Question 2

A nurse on the intensive care unit (ICU) has asked you to review a 69-year-old man. He is currently intubated as part of the management of an episode of urosepsis. He had been improving over the last 24 hours. However, he has now become restless and agitated. He has no history of alcohol excess but smokes 20 cigarettes a day.

B. Briefly describe 2 different presentations of delirium (2 marks)

C. List 4 patient risk factors for delirium (4 marks)

D. List 2 iatrogenic risk factors for delirium associated with hospital admission (2 marks)

E. What scoring systems can be used to diagnose delirium in the ICU? (2 marks)

F. List the 4 components of the CAM-ICU delirium screening tool (4 marks)

G. You are investigating and treating the patient’s underlying medical problems.

List the non-pharmacological (3 marks) and pharmacological (2 marks) options for treating this patient’s delirium.

Non-pharmacological

Pharmacological

A. What are the advantages of recommending spinal anaesthesia in this case? (3 marks)

Total 20 marks

Question 3

A 79-year-old man requires transurethral resection of prostate (TURP) for benign prostatic hyperplasia. He has a history of chronic obstructive pulmonary disease (COPD) and angina.

B. a) What is the most commonly used irrigation fluid for TURP surgery in the UK? (1 mark)

b) Briefly describe 2 properties of this fluid which are not ideal? (2 marks)

C. List 5 features of an ideal bladder irrigation fluid for use during TURP (5 marks)

1.————————–

2.————————–

3.————————–

4.————————–

5.————————–

D. The patient becomes unwell during surgery. You suspect TURP syndrome

What features of established TURP syndrome may be apparent? (4 marks)

CNS

(2 marks)

CVS

(2 marks)

E. You check the patient’s urea and electrolytes. What is the most likely biochemical abnormality? (1 mark)

F. Describe 4 measures which are in place to reduce the incidence of TURP syndrome in theatre (4 marks)

A. List the general criteria that a patient must meet to have surgery as a day case (3 marks)

Total 20 marks

Question 4

A 75-year-old man with type 2 diabetes presents to day surgery for elective inguinal hernia repair. He takes metformin and gliclazide daily, and Lantus 80u at night. He also takes enalapril for hypertension and has a glyceryl trinitrate (GTN) spray that he uses a few times per week.

B. List the criteria specific to this patient that must be met for day case surgery (3 marks)

C. Give 3 surgical considerations for the operation to be done as day case surgery (3 marks)

D. His HbA1c was last checked 2 weeks earlier and was 75mmol/L (9%)

a) What does this value represent at a cellular level? (1 mark)

b) What does this process represent at a clinical level? (1 mark)

c) How long does it take to see any change in HbA1c? Why is this? (1 mark)

E. Should his surgery proceed? State why (2 marks)

Please answer Yes or No next and give one reason to support your answer.

F. List 2 pros and 2 cons of a spinal anaesthetic for this type of patient? (2 marks)

Pros

Cons

G. How would you manage his diabetes in the preoperative period? Give specific advice regarding medication (4 marks)

A. What is the patient’s Glasgow Coma Scale (GCS) (1 mark), and the SAH grade according to the World Federation of Neurosurgeons Scale (WFNS)? (1 mark)

Total 20 marks

Question 5

A 37-year-old female presents to the emergency department with sudden onset of headache. Computed tomography (CT) head indicates subarachnoid haemorrhage (SAH). You are asked to review the patient and on examination find their eyes closed, moaning and groaning, and withdrawing from pain. There is no obvious motor deficit. Pupils are equal and reactive.

B. List 5 indications for tracheal intubation following acute SAH (5 marks)

1.————————–

2.————————–

3.————————–

4.————————–

5.————————–

C. The patient is transferred to a neurosurgical unit. A subsequent CT angiogram reveals a wide-necked aneurysm in the Circle of Willis. Name the arteries in the Circle of Willis figure here (5 marks)

1.————————–

2.————————–

3.————————–

4.————————–

5.————————–

D. The patient has a craniotomy for clipping of aneurysm and recovers well; 4 days later she develops a new hemiparesis. What is the definition of a delayed neurological deficit (DND)? (1 mark)

E. List 4 complications which may contribute to DND? (4 marks)

F. In the neurosurgical ICU, the patient’s mean arterial blood pressure is 82mmHg and intracranial pressure is 12mmHg. Calculate the cerebral perfusion pressure (1 mark)

G. What therapies are available to improve cerebral blood flow due to vasospasm following SAH? (2 marks)

Total 20 marks

Question 6

You are allocated to deliver anaesthesia for electroconvulsive therapy (ECT). The list is located in the psychiatry unit.

A. What is the definition of remote site anaesthesia? (2 marks)

B. Briefly describe 3 main goals of anaesthetic technique specific to ECT? (3 marks)

C. Describe the cardiovascular response to ECT? (5 marks)

1.————————–

2.————————–

3.————————–

4.————————–

5.————————–

D. How can seizure activity be altered by anaesthetic technique? (4 marks)

E. Describe the role of muscle relaxation during ECT? Include an example (2 marks).

F. A 73-year-old woman is pre-assessed for consideration of possible ECT. Her medical history is severe depression. Her current drug history includes phenelzine. What class of drug is phenelzine? (2 marks)

G. Describe the clinical significance of phenelzine to anaesthesia (2 marks)

Total 20 marks

Question 7

A 76-year-old lady presents to the preoperative assessment clinic prior to a right total hip replacement. The nursing staff are concerned regarding her frailty.

A. What are the 2 main models to describe frailty? (2 marks)

B. What are the risk factors for frailty? (9 marks)

1.————————–

2.————————–

3.————————–

4.————————–

5.————————–

6.————————–

7.————————–

8.————————–

9.————————–

C. Give an example of a tool that can be used to assess frailty? (1 mark)

D. What is prehabilitation? (2 marks)

E. What are the 4 main components of the multimodal approach to prehabilitation? (4 marks)

F. What are the potential outcome benefits of prehabilitation? (2 marks)

A. Describe the principles of using an IABP (4 marks)

Total 20 marks

Question 8

A 64-year-old man has refractory left ventricular failure following a myocardial infarction. The next step in his management is to insert an intra-aortic balloon pump (IABP).

B. Complete the table that follows, listing the haemodynamic effects of an IABP on the aorta, heart, and coronary blood flow (6 marks)

	Haemodynamic effects
Aorta (2 marks)	1.————————– 2.————————–
Heart (3 marks)	1.————————– 2.————————– 3.————————–
Coronary artery blood flow (1 mark)	1.

C. List 4 contraindications to IABP insertion (4 marks)

D. List 6 early complications of IABP insertion (6 marks)

1.————————–

2.————————–

3.————————–

4.————————–

5.————————–

6.————————–

Total 20 marks

Question 9

A 26-year-old lady breaks her ankle dancing in a nightclub. She has open reduction and internal fixation of fibula the following day which proceeds uneventfully.

At review 16 weeks later, she reports persisting severe pain in the ankle. The orthopaedic surgeon queries complex regional pain syndrome (CRPS) and refers her to the pain clinic.

A. What is the definition of CRPS? (3 marks)

B. List the signs and symptoms associated with CRPS (4 marks)

	Signs/ Symptoms
Sensory (1 mark)
Motor (1 mark)
Sudomotor (1 mark)
Vasomotor (1 mark)

C. What are the criteria required for diagnosis of CRPS? (5 marks)

1.————————–

2.————————–

3.————————–

4.————————–

5.————————–

D. Briefly describe 4 principles of management of CRPS (8 marks)

A. List 4 common clinical features of paediatric pyloric stenosis (4 marks)

Total 20 marks

Question 10

A 2-month-old baby is listed for pyloromyotomy. He was born at term gestation by spontaneous vaginal delivery. He has no other significant medical history.

B. State the classic electrolyte imbalance (1 mark) and briefly describe its pathophysiology (2 marks)

C. What are the priorities for preoperative optimization? (3 marks)

D. List 5 important anatomical features in the airway of a child of this age (5 marks)

1.————————–

2.————————–

3.————————–

4.————————–

5.————————–

E. Briefly describe the steps required to induce anaesthesia in this patient in the anaesthetic room? (4 marks)

F. What postoperative monitoring is required? (1 mark)

Total 20 marks

Question 11

A 74-year-old female patient requires open reduction and internal fixation (ORIF) for fractured shaft of humerus. She takes morphine for arthritis and you decide to perform a brachial plexus block.

A. She is concerned about having a needle near her neck. Give 4 general principles required for consent to be informed (4 marks)

B. What is the best approach to the brachial plexus for arm surgery such as this? Give a reason for your answer (3 marks)

C. List 4 precautions you would take to ensure safe and accurate placement of the block before beginning the procedure (4 marks)

D. What are the advantages of ultrasound-guided blocks compared to the traditional nerve stimulator approach? (5 marks)

1.————————–

2.————————–

3.————————–

4.————————–

5.————————–

E. On the diagram to follow, please label the following (3 marks)

a) inferior trunk

b) median nerve

c) medial cord

Reproduced from Principles and Practice of Regional Anaesthesia (4 ed.), Graeme McLeod, Colin McCartney, and Tony Wildsmith, Figure 17.1. Copyright Oxford University Press, 2012. Reproduced with permission of the Licensor through PLSclear.

F. Which nerve is most commonly damaged in the perioperative period? (1 mark)

Total 20 marks

Question 12

A 32-year-old woman requires temporomandibular joint (TMJ) arthrocentesis under general anaesthesia. She has no other significant medical history.

A. What are the symptoms of TMJ dysfunction? (4 marks)

B. On preoperative assessment the patient has mouth opening measured at 2cm. You plan a fibreoptic intubation (FOI) via the nasal route.

What factors would influence whether the nasal FOI was undertaken with the patient awake or under general anaesthesia? (6 marks)

	Factors
Awake FOI (3 marks)	1.————————– 2.————————– 3.————————–
Asleep FOI (3 marks)	1.————————– 2.————————– 3.————————–

Factors

Awake FOI

(3 marks)

Asleep FOI

(3 marks)

C. Describe what premedication may be considered to improve the subsequent intubating conditions, include examples (3 marks)