Anesthesia Key

D. What are the special considerations within the anaesthetic management of this patient for trans-sphenoidal hypophysectomy that you would consider in your preoperative assessment? (5 marks)

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E. The surgeon asks you to facilitate a bloodless field. What can you do to help? (2 marks)

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F. You plan to awaken and extubate the patient immediately at the end of the procedure. What homeostatic variables must be achieved to facilitate this? (3 marks)

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G. You plan to place the patient in high dependency unit (HDU) postoperatively. What specific management should be instituted for this patient as an adjunct to standard HDU care? (3 marks)

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Total 20 marks

Question 2

A 39-year-old female is listed for deep inferior epigastric perforator (DIEP) breast reconstruction. Her only medical history is breast cancer.

A. Outline the 2 main categories of autologous flap blood supply used in plastic surgery (2 marks)

B. What are the physical determinants of blood flow through a flap? (4 marks). State their relationship to one another (1 mark)

C. What non-standard monitoring is considered appropriate for this procedure? (3 marks)

D. What are the intraoperative physiological goals targeted to improve the chances of flap survival? (6 marks)

1.———————

2.———————

3.———————

4.———————

5.———————

6.———————

E. In recovery there are concerns regarding the perfusion of the flap.

How can flap perfusion be assessed clinically at the bedside in the postoperative period? (4 marks)

A. List 5 other specific indications for TIVA (5 marks)

Total 20 marks

Question 3

A 67-year-old man is scheduled for laryngoscopy and biopsy for suspected carcinoma. The surgeon has requested a tubeless field so you have therefore decided to use total intravenous anaesthesia (TIVA).

1.———————

2.———————

3.———————

4.———————

5.———————

B. You are using a target-controlled infusion (TCI) of propofol.

Outline the key components of a TCI device (4 marks)

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C. List 2 pharmacokinetic adult models used for propofol (2 marks)

D. Describe the three-compartment pharmacokinetic model for propofol (5 marks)

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E. Describe how a TCI device ensures a steady state concentration of a drug (4 marks)

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Total 20 marks

Question 4

You and your consultant are about to perform brainstem death testing on a 64-year-old woman in the intensive care unit (ICU).

A. List 4 ‘red flags’ when diagnostic caution is advised for brainstem death testing? (4 marks)

B. Describe how you would perform the apnoea test as part of the brainstem death testing? (6 marks)

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C. You have completed both sets of brainstem death tests, confirmed death by neurological criteria and spoken with the family. The patient is going to proceed to organ donation. She currently has an arterial blood pressure of 84/39mmHg and a central venous pressure (CVP) of 3cmH₂O.

Outline your cardiovascular targets for this patient to maximize donor potential (3 marks)

Heart rate range (bpm) (1 mark)
Mean arterial pressure range (mmHg) (1 mark)
CVP range (mmHg) (1 mark)

D. How would you achieve these cardiovascular targets? (2 marks)

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E. This patient has a urine output of over 400ml/hour.

What biochemical features would confirm the diagnosis of diabetes insipidus? (2 marks)

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F. Outline your management of the main endocrine abnormalities that occur after brainstem death (3 marks)

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Total 20 marks

Question 5

A 32-year-old woman attends for pelvic laparoscopy. She weighs 70kg and her body mass index (BMI) is 35. Her medical history is severe reflux. She had generalized muscular ache following administration of suxamethonium during a previous anaesthetic. Her medication is omeprazole 20mg bd and the oral contraceptive pill. You decide to use rocuronium to facilitate intubation.

A. Give 5 other advantages of using rocuronium instead of suxamethonium for a rapid sequence induction (5 marks)

1.———————

2.———————

3.———————

4.———————

5.———————

B. What dose of rocuronium would you use for a rapid sequence induction in this patient? (1 mark)

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C. Describe the pharmacodynamic principle which accounts for rocuronium’s more rapid onset of action when compared to vecuronium? (2 marks)

D. Give 2 processes by which the effects of rocuronium can be terminated at the end of the procedure (2 marks)

E. Explain the pharmacology of each method (4 marks)

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Process 1

Process 2

F. What dose of sugammadex would you precalculate for immediate reversal of rocuronium in the event of a failed intubation in this patient? (1 mark)

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G. 30 minutes later in the recovery room the patient is hypotensive and is to return to theatre with suspected intra-abdominal bleeding.

Give 3 drug options available to facilitate laryngoscopy conditions during repeat intubation (3 marks)

H. What postoperative advice would you give to this patient regarding their administration of sugammadex? (2 marks)

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Total 20 marks

Question 6

A company representative attends your department one lunchtime to showcase their new ultrasound machine.

A. Give 4 examples each of diagnostic and therapeutic uses of ultrasound in anaesthetic and critical care practice? (8 marks)

Diagnostic

Therapeutic

B. What is the Doppler effect? (2 marks)

C. Give 2 applications of the Doppler effect used in echocardiography? (2 marks)

D. What information can echocardiography provide in a haemodynamically unstable patient? (8 marks)

1.———————

2.———————

3.———————

4.———————

5.———————

6.———————

7.———————

8.———————

Total 20 marks

Question 7

A 59-year-old woman has presented with gradual onset leg weakness and now has difficulty walking. She is normally fit and well but had a self-limiting episode of gastroenteritis 3 weeks ago. She takes no regular medication.

A. List the classic clinical features of Guillain-Barré syndrome (GBS) (5 marks)

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B. What specific investigations, with their findings, would support a diagnosis of GBS? (6 marks)

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C. The patient is admitted to HDU and she is investigated for suspected GBS. However, over the last 48 hours she develops symmetrical arm weakness as well. Today she is struggling to cough and swallow and her respiratory rate has increased to 32 breaths/min. Her PaO₂ is 8.9kPA on 70% oxygen.

You decide she needs ventilatory support.

What specific modifications would you make to your induction and intubating technique for this patient? (2 marks)

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D. You intubate without incident. She is now ventilated and fully monitored, with an arterial and central line, in ICU.

Outline your ongoing specific (2 marks) and supportive management (5 marks) for this patient.

Specific

A. You suspect an immediate life-threatening thoracic injury. List 5 treatable causes of this found on primary survey (5 marks)

Supportive

1.———————

2.———————

3.———————

4.———————

5.———————

Total 20 marks

Question 8

You receive a trauma call to the ED. A 22-year old man was the driver of a car involved in a high-speed road traffic collision. He has multiple injuries.

1.———————

2.———————

3.———————

4.———————

5.———————

B. What immediate diagnostic imaging is appropriate for diagnosing chest trauma? (2 marks)

C. Primary survey is now complete. The patient is breathing spontaneously but not moving his arms or legs. A C5 cervical spine injury is suspected.

What are the clinical features on examination of an acute C5 cervical spine injury? (5 marks)

1.———————

2.———————

3.———————

4.———————

5.———————

D. Describe the specific modifications to airway management during a rapid sequence induction of anaesthesia for this patient (4 marks)

E. One month later the patient is transferred to a spinal injuries unit.

Briefly describe these clinical syndromes resulting from spinal cord injury (4 marks)

Syndrome

Description

Anterior spinal artery syndrome

(2 marks)

Brown-Séquard syndrome

(2 marks)

Total 20 marks

Question 9

You are to anaesthetise a 78-year-old woman for an elective right total hip replacement. She weighs 51kg and has a past medical history including stable angina, hypertension, chronic obstructive pulmonary disease (COPD), and peripheral vascular disease. You plan a spinal anaesthetic with a target-controlled infusion of propofol (TCI) for deep sedation.

A. Define inadvertent perioperative hypothermia (IPH)? (1 mark)

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B. This patient’s temperature on arrival in the theatre suite is 35.4°C.

List 5 risk factors for the development of IPH in the general patient? (5 marks)

1.———————

2.———————

3.———————

4.———————

5.———————

C. Describe in detail 4 major consequences and the associated pathophysiology of IPH that may impact the morbidity and mortality of patients (8 marks)

Major consequence of IPH (4 marks)	Pathophysiology (4 marks)
—————–	—————–
—————–	—————–
—————–	—————–
—————–	—————–

D. Outline your management of this patient’s temperature before and during surgery (6 marks)

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Total 20 marks

Question 10

A 32-year-old woman, Para 2 + 0 is having a caesarean section under spinal anaesthesia.

The baby and placenta have been delivered successfully but there is ongoing bleeding of approximately 800mls so far.

A. List the 4 main causes of primary postpartum haemorrhage (PPH) (4 marks)

B. Complete the table of drugs used to treat uterine atony as directed. Give their doses and routes of administration. List their mechanisms of action and common side effects (12 marks)

Drug	Doses and routes of administration	Mechanism of action	Side effects
Oxytocin (3 marks)
Ergometrine (3 marks)
Carboprost (3 marks)
Misoprostol (3 marks)

C. Despite the appropriate administration of uterotonics over the last 20 minutes and administration of 2L of crystalloid, the bleeding is ongoing with blood loss now at 1.5L.

Outline the next steps in your management of this patient (4 marks)

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Total 20 marks

Question 11

A 6-year-old girl requires elective tonsillectomy. She has no significant medical history.

A. Briefly describe 2 indications for paediatric tonsillectomy (2 marks)

B. Regarding the choice of airway technique for this case, what are the advantages of each below? (6 marks)

	Laryngeal mask airway (LMA) (3 marks)	Tracheal Intubation (3 marks)
Advantages	1.——————— 2.——————— 3.———————	1.——————— 2.——————— 3.———————

C. She re-presents as an emergency 12 hours postoperatively with bleeding from the tonsillar bed. The ears, nose and throat (ENT) surgeon wishes to expedite her return to theatre.

List 4 clinical challenges pertaining to this case (4 marks)

D. Compare the advantages and disadvantages of the anaesthetic induction techniques for this child (8 marks)

	Gas induction (4 marks)	Rapid sequence IV induction (4 marks)
Advantages	1.	1.——————— 2.———————
Disadvantages	1.——————— 2.——————— 3.———————	1.——————— 2.———————

Total 20 marks

Question 12

A 74-year-old female requires laparoscopic cholecystectomy. She has no past medical history. Preoperative assessment reveals she is a current long-term smoker. You suspect she should be diagnosed with COPD.

A. Name 3 of the clinical features of COPD? (3 marks)

B. You request pulmonary function tests (PFTs) to assess severity. What features on PFTs are characteristic of COPD? (2 marks)

C. The PFTs indicate severe COPD. What other investigations should be considered in a patient with severe COPD and why? (4 marks)

Investigation	Reason for Investigation
	———————
	———————
	———————
	———————

Note: Need to have correct test and reasoning to get each full mark.

D. You decide to refer the patient for a respiratory opinion before surgery. List 6 possible treatment modalities that are considered for optimization of this patient? (6 marks)

1.———————

2.———————

3.———————

4.———————

5.———————

6.———————

E. The patient is optimized and listed for theatre. The airway pressure is high during laparoscopy and the patient is difficult to ventilate.

Describe the mechanism of intrinsic positive end expiratory pressure (PEEPi) (1 mark)

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F. Briefly describe 2 ways in which PEEPi can be recognized on a ventilator (2 marks)

G. What strategies can be used to reduce airway pressures in this patient, assuming a patent airway and normal equipment function? (3 marks)